急性Stanford A型主动脉夹层术后急性肾功能损伤的危险因素分析
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摘要
目的分析急性Stanford A型主动脉夹层术后急性肾功能损伤(AKI)的危险因素。方法回顾性分析青岛市市立医院2010年9月至2017年9月间220例Stanford A型主动脉夹层手术患者的资料。平均年龄(52.3±8.7)岁,男162例(73.6%)、女58例(26.4%)。按患者术后是否发生AKI分2组:发生AKI者40例(A组),其中男29例、女11例,平均年龄(54.6±9.2)岁;未发生AKI者180例(B组),男133例、女47例,平均年龄(48.5±7.9)岁。对两组患者围术期多项指标进行单因素和多因素分析。结果住院死亡12例(5.5%),发生AKI组患者死亡7例(17.5%),未发生AKI组患者死亡5例(2.8%)。单因素分析显示,两组患者年龄、术前血清肌酐值、术前白细胞水平、欧洲心血管手术危险因素评分、体外循环时间、深低温停循环(DHCA)时间、主动脉根部处理、主动脉弓置换、术中及术后24 h输注红细胞量、术后机械通气时间、ICU滞留时间、住院时间、院内死亡率等方面差异有统计学意义。多因素分析显示,术前血清肌酐值、术前白细胞水平、体外循环时间和术中及术后24 h输注红细胞量是术后AKI的独立危险因素。结论术前血清肌酐值、术前白细胞水平、体外循环时间和术中及术后24 h输注红细胞量是急性Stanford A型主动脉夹层术后急性肾功能损伤的独立危险因素。临床上可以根据上述危险因素采取相应的预防措施,保护肾脏功能,降低围术期死亡率。
Objective To identify the predictors of postoperative acute kidney injury in patients undergoing surgery for Stanford type A acute aortic dissection. Methods A total of 220 patients who underwent surgery for type A acute aortic dissection in Qingdao Municipal Hospital from September 2010 to September 2017 were divided into two groups including a group A and a group B based on whether acute kidney injury occurred or not after surgery. There were40 patients with 29 males and 11 females with the mean age of 54.6±9.2 years in the group A, 180 patients with 133 males and 47 females with the mean age of 48.5±7.9 years in the group B. Univariate and multivariate analyses(logistic regression) were used to identify the predictive risk factors. Results Overall in-hospital mortality was 5.5%. In univariate analysis, there were statistically significant differences with respect to the age, preoperative creatinine, preoperative white blood cell, the European system for cardiac operative risk evaluation(EuroSCORE), total cardiopulmonary bypass(CPB)time, deep hypothermic circulatory arrest(DHCA) time, arch replacement, red blood cell transfusion intraoperative and in 24 hours postoperatively, postoperative mechanical ventilation time, ICU stay duration, hospital stay duration and in hospital mortality. Multivariate logistic analysis showed that preoperative creatinine, preoperative white blood cell, CPB time, and red blood cell transfusion intraoperative and in 24 hours postoperatively were the independent predictors for postoperative acute kidney injury. Conclusion The incidence of acute kidney injury is high after surgery for acute Stanford type A aortic dissection. It can be predicted based on above factors, for patients with these risk factors, more perioperative care strategies are needed in order to induce the incidence of acute kidney injury.
Objective To identify the predictors of postoperative acute kidney injury in patients undergoing surgery for Stanford type A acute aortic dissection. Methods A total of 220 patients who underwent surgery for type A acute aortic dissection in Qingdao Municipal Hospital from September 2010 to September 2017 were divided into two groups including a group A and a group B based on whether acute kidney injury occurred or not after surgery. There were40 patients with 29 males and 11 females with the mean age of 54.6±9.2 years in the group A, 180 patients with 133 males and 47 females with the mean age of 48.5±7.9 years in the group B. Univariate and multivariate analyses(logistic regression) were used to identify the predictive risk factors. Results Overall in-hospital mortality was 5.5%. In univariate analysis, there were statistically significant differences with respect to the age, preoperative creatinine, preoperative white blood cell, the European system for cardiac operative risk evaluation(EuroSCORE), total cardiopulmonary bypass(CPB)time, deep hypothermic circulatory arrest(DHCA) time, arch replacement, red blood cell transfusion intraoperative and in 24 hours postoperatively, postoperative mechanical ventilation time, ICU stay duration, hospital stay duration and in hospital mortality. Multivariate logistic analysis showed that preoperative creatinine, preoperative white blood cell, CPB time, and red blood cell transfusion intraoperative and in 24 hours postoperatively were the independent predictors for postoperative acute kidney injury. Conclusion The incidence of acute kidney injury is high after surgery for acute Stanford type A aortic dissection. It can be predicted based on above factors, for patients with these risk factors, more perioperative care strategies are needed in order to induce the incidence of acute kidney injury.
引文
1生伟,池一凡,牛兆倬,等.急性Stanford A型主动脉夹层术后ICU监护时间延长的危险因素分析.中国胸心血管外科临床杂志,2016, 23(5):434-439.
2 Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network:report of an initiative to improve outcomes in acute kidney injury. Crit Care, 2007,11:R31.
3 Palomba H, de Castro I, Neto AL et al. Acute kidney injury prediction following elective cardiac surgery:AKICS Score. Kidney Int, 2007, 72:624-631.
4敬毅,刘建平,夏洪韬,等.Stanford A型主动脉夹层术后急性肾功能衰竭的救治分析.中国医药指南,2015,13(20):14-15.
5 Wang X, Ren HM, Hu CY, et al. Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection. J Geriatr Cardiol, 2016,13(8):679-684.
6 Tribuddharat S, Sathitkarnmanee T, Ngamsaengsirisup K, et al.Validation of open-heart intraoperative risk score to predict a prolonged intensive care unit stay for adult patients undergoing cardiac surgery with cardiopulmonary bypass. Ther Clin Risk Manag, 2018, 14:53-57.
7 Moreira R, Jacinto T, Neves P, et al. Predictors of acute kidney injury in the postoperative period of cardiac surgery associated with cardiopulmonary bypass. Rev Port Cir Cardiotorac Vasc,2017, 24(3-4):154.
8 Caputo M, Mokhtari A, Miceli A, et al. Controlled reoxygenation during cardiopulmonary bypass decreases markers of organ damage, inflammation, and oxidative stress in single-ventricle patients undergoing pediatric heart surgery. J Thorac Cardiovasc Surg, 2014, 148(3):792-801.
9 Korotcova L, Kumar S, Agematsu K, et al. Prolonged white matter inflammation after cardiopulmonary bypass and circulatory arrest in a juvenile porcine model. Ann Thorac Surg, 2015, 100(3):1030-1037.
10 Floh A A, Nakada M, La Rotta G, et al. Systemic inflammationincreases energy expenditure following pediatric cardiopulmonary bypass. Pediatr Crit Care Med, 2015,16(4):343-351.
11 Floh AA, Manlhiot C, Redington AN, et al. Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg, 2015,150(3):498-504.
12杨艳丽,马骏.老年患者体外循环心脏手术后急性肾功能损伤及预后危险因素.中国医药,2017,12(8):1205-1208.
13文质斌,崔晓光.体外循环相关急性肾损伤的研究进展.现代医学,2016, 44(1):147-150.
14 Del Porto F, di Gioia C, Tritapepe L, et al. The multitasking role of macrophages in Stanford type A acute aortic dissection.Cardiology, 2014, 127(2):123-129.
15 Anzai A, Shimoda M, Endo J, et al. Adventitial cxcl 1/g-csf expression in response to acute aortic dissection triggers local neutrophil recruitment and activation leading to aortic rupture.Circ Res, 2015, 116(4):612-623.
16庞秀慧,何亮,社宇奎,等.Stanford B型主动脉夹层术前发生全身炎症反应综合征的多因素Logistic回归分析.国际外科学杂志,2016, 43(6):375-378.
17 Takahashi T, Hasegawa T, Hirata N, et al. Impact of acute kidney injury on in-hospital outcomes in patients with DeBakey typeⅡacute aortic dissection. Am Cardiol, 2014, 113(11):1904-1910.
18廖刃,刘进.围手术期血液管理:由限制性输血走向个体化输血.中华医学杂志,2014, 94(7):481-482.
19戴萍,车辑,张卫梅,等.心脏瓣膜置换术患者应用改良贮存式自体输血和异体输血的效果比较.临床输血与检验,2014, 16(2):142-145.
20 Moskowitz DM, McCullough JN, Shander A, et al. The impact of blood conservation on outcomes in cardiac surgery:is it safe and effective? Ann Thorac Surg,2010, 90:451-458.
21黄初生,周慧,覃家锦,等.白细胞滤过在体外循环中应用的Meta分析.医学信息,2014,27(5):152-154.
2 Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network:report of an initiative to improve outcomes in acute kidney injury. Crit Care, 2007,11:R31.
3 Palomba H, de Castro I, Neto AL et al. Acute kidney injury prediction following elective cardiac surgery:AKICS Score. Kidney Int, 2007, 72:624-631.
4敬毅,刘建平,夏洪韬,等.Stanford A型主动脉夹层术后急性肾功能衰竭的救治分析.中国医药指南,2015,13(20):14-15.
5 Wang X, Ren HM, Hu CY, et al. Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection. J Geriatr Cardiol, 2016,13(8):679-684.
6 Tribuddharat S, Sathitkarnmanee T, Ngamsaengsirisup K, et al.Validation of open-heart intraoperative risk score to predict a prolonged intensive care unit stay for adult patients undergoing cardiac surgery with cardiopulmonary bypass. Ther Clin Risk Manag, 2018, 14:53-57.
7 Moreira R, Jacinto T, Neves P, et al. Predictors of acute kidney injury in the postoperative period of cardiac surgery associated with cardiopulmonary bypass. Rev Port Cir Cardiotorac Vasc,2017, 24(3-4):154.
8 Caputo M, Mokhtari A, Miceli A, et al. Controlled reoxygenation during cardiopulmonary bypass decreases markers of organ damage, inflammation, and oxidative stress in single-ventricle patients undergoing pediatric heart surgery. J Thorac Cardiovasc Surg, 2014, 148(3):792-801.
9 Korotcova L, Kumar S, Agematsu K, et al. Prolonged white matter inflammation after cardiopulmonary bypass and circulatory arrest in a juvenile porcine model. Ann Thorac Surg, 2015, 100(3):1030-1037.
10 Floh A A, Nakada M, La Rotta G, et al. Systemic inflammationincreases energy expenditure following pediatric cardiopulmonary bypass. Pediatr Crit Care Med, 2015,16(4):343-351.
11 Floh AA, Manlhiot C, Redington AN, et al. Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg, 2015,150(3):498-504.
12杨艳丽,马骏.老年患者体外循环心脏手术后急性肾功能损伤及预后危险因素.中国医药,2017,12(8):1205-1208.
13文质斌,崔晓光.体外循环相关急性肾损伤的研究进展.现代医学,2016, 44(1):147-150.
14 Del Porto F, di Gioia C, Tritapepe L, et al. The multitasking role of macrophages in Stanford type A acute aortic dissection.Cardiology, 2014, 127(2):123-129.
15 Anzai A, Shimoda M, Endo J, et al. Adventitial cxcl 1/g-csf expression in response to acute aortic dissection triggers local neutrophil recruitment and activation leading to aortic rupture.Circ Res, 2015, 116(4):612-623.
16庞秀慧,何亮,社宇奎,等.Stanford B型主动脉夹层术前发生全身炎症反应综合征的多因素Logistic回归分析.国际外科学杂志,2016, 43(6):375-378.
17 Takahashi T, Hasegawa T, Hirata N, et al. Impact of acute kidney injury on in-hospital outcomes in patients with DeBakey typeⅡacute aortic dissection. Am Cardiol, 2014, 113(11):1904-1910.
18廖刃,刘进.围手术期血液管理:由限制性输血走向个体化输血.中华医学杂志,2014, 94(7):481-482.
19戴萍,车辑,张卫梅,等.心脏瓣膜置换术患者应用改良贮存式自体输血和异体输血的效果比较.临床输血与检验,2014, 16(2):142-145.
20 Moskowitz DM, McCullough JN, Shander A, et al. The impact of blood conservation on outcomes in cardiac surgery:is it safe and effective? Ann Thorac Surg,2010, 90:451-458.
21黄初生,周慧,覃家锦,等.白细胞滤过在体外循环中应用的Meta分析.医学信息,2014,27(5):152-154.