急性Standford A型主动脉夹层患者行去分支杂交手术后CRRT危险因素分析及预测模型建立

Risk factors analysis and prediction model establishment of continuous renal replacement therapy after hybrid debranching surgery in patients with acute Standford type A aortic dissection

目的分析急性Standford A型主动脉夹层(ATAAD)患者急诊行主动脉弓部去分支杂交手术后连续性肾脏替代治疗(CRRT)的危险因素,并建立预测模型。方法对354例ATAAD急诊行主动脉弓部去分支杂交手术患者进行回顾性分析,根据术后是否行CRRT分为CRRT组(40例)与非CRRT组(314例)。收集患者一般资料、既往病史、术前实验室检查、术前是否有心包积液、夹层是否累及肾动脉、术中资料、术中血制品输注情况、术后7 d血肌酐水平。对术前和术中相关变量进行单因素及多因素回归分析,探究ATAAD患者术后CRRT的独立危险因素,构建列线图模型。用Bootstrap法行内部验证,通过C指数(C‑index)、Calibration校准曲线及决策曲线分析(DCA)分别评估模型的区分度、一致性及临床实用性,绘制受试者操作特征(ROC)曲线并计算曲线下面积(AUC)。结果354例ATAAD患者有40例(11.3%)术后行CRRT。与CRRT组比较,非CRRT组患者肾病史、术前合并心包积液、夹层累及肾动脉比例较低(均P<0.05),高敏肌钙蛋白T、N端B型钠尿肽前体、肌酸激酶同工酶、肌红蛋白、血肌酐、血尿素氮水平较低(均P<0.05),血小板计数较高(P<0.05),凝血酶原时间、D‑二聚体较低(均P<0.05),术中体外循环前和手术结束时乳酸水平较低(均P<0.05),手术时间较短(P<0.05),术中血小板输注>1个治疗量比例较低(P<0.05);两组患者其余指标差异无统计学意义(均P>0.05)。术前肌红蛋白[比值比(OR)1.001,95%置信区间(CI)1.001~1.002]、术前血肌酐[OR 1.016,95%CI 1.010~1.023]、术前心包积液[OR 5.658,95%CI 2.322~13.787]、手术结束时乳酸[OR 1.241,95%CI 1.075~1.371]、术中输注血小板>1个治疗量[OR 9.876,95%CI 1.811~53.863]是ATAAD患者行主动脉弓部去分支杂交手术后CRRT的独立危险因素(P<0.05)。建立的预测模型C‑index为0.891(95%CI 0.845~0.937),Calibration校正曲线中预测结果与实际结果相关性良好,平均绝对误差为0.027,ROC曲线的AUC为0.891(95%CI 0.845~0.937),该模型表现出良好的区分度和一致性,DCA显示阈值概率在4%~67%时该模型具有较好的临床实用性。结论术前肌红蛋白水平、术前血肌酐水平、术前心包积液、手术结束时乳酸水平、术中输注血小板>1个治疗量是ATAAD患者急诊行主动脉弓部去分支杂交手术后CRRT的独立危险因素,建立的列线图模型具有较好的预测效能。

Objective To analyze the risk factors of continuous renal replacement therapy(CRRT)in patients with acute Standford type A aortic dissection(ATAAD)after emergency surgery for hybrid aortic arch debranching and construct a predictive model.Methods Retrospective analysis was performed on 354 patients with ATAAD who underwent emergency surgery for hybrid aortic arch debranching.According to whether CRRT was performed after surgery,the patients were divided into two groups:a CRRT group(n=40)and a non‑CRRT group(n=314).Their general information,medical history,preoperative laboratory examination,preoperative pericardial effusion,renal artery involvement in aortic dissection,intraoperative data,intraoperative blood product infusion,and serum creatinine level on postoperative day 7 were collected.Univariate and multivariate regression analyses were conducted on preoperative and intraoperative variables,in order to identify the independent risk factors for postoperative CRRT in ATAAD patients.Then,a nomogram was established.The Bootstrap method was used for internal validation.The concordance index(C‑index),calibration curve,and decision curve analysis(DCA)were used to evaluate the discrimination,consistency,and clinical practicability of the model,respectively.A receiver operating characteristic(ROC)curve was plotted and the area under curve(AUC)was calculated.Results Among 354 patients with ATAAD,40(11.3%)underwent CRRT after surgery.Compared with the CRRT group,the non‑CRRT group showed decreases in the proportions of renal disease history,preoperative pericardial effusion and renal artery involvement in aortic dissection(all P<0.05),reductions in the levels of high‑sensitivity troponin T,N‑terminal B‑type natriuretic peptide,creatine kinase isoenzyme,myoglobin,serum creatinine and blood urea nitrogen(all P<0.05),increases in the platelet count(P<0.05),decreases in the prothrombin time and D‑dimer(both P<0.05),decrease in the lactic acid level before and after cardiopulmonary bypass(both P<0.05),reduction in the operation time(P<0.05),and decreases in the percentage of intraoperative platelet transfusion>1 therapeutic dose(P<0.05).There was no statistical difference in other indicators between the two groups(all P>0.05).Preoperative myoglobin[odds ratio(OR)1.001(95%confidence interval(CI)1.001,1.002)],preoperative serum creatinine[OR 1.016(95%CI 1.010,1.023)],preoperative pericardial effusion[OR 5.658(95%CI 2.322,13.787)],lactic acid at the end of surgery[OR 1.241(95%CI 1.075,1.371)],intraoperative platelet transfusion>1 therapeutic dose[OR 9.876(95%CI 1.811,53.863)]was independent risk factors for CRRT in ATAAD patients after hybrid aortic arch debranching(P<0.05).The C‑index of this model was 0.891(95%CI 0.845,0.937).The predicted results in the calibration curve correlated well with the actual results,with a mean absolute error of 0.027.The AUC of the ROC curve was 0.891(95%CI 0.845,0.937)and the model demonstrated good discrimination and consistency.DCA analysis showed that the model had good clinical utility when the probability threshold was 4%−67%.Conclusions Preoperative myoglobin,preoperative serum creatinine,preoperative pericardial effusion,lactic acid level at the end of surgery and intraoperative platelet transfusion>1 therapeutic dose are independent risk factors for CRRT in ATAAD patients after emergency surgery for hybrid aortic arch debranching and the established nomogram has good predictive efficiency.