术前血尿酸水平对心脏手术术后急性肾损伤发生的影响
|
摘要
目的:探讨心脏手术患者术前血尿酸水平对术后急性肾损伤(acute kidney injury,AKI)发生的影响。方法:回顾性收集2016年6月1日至2016年12月31日复旦大学附属中山医院接受心脏手术的1 722例患者的临床资料。AKI诊断按照KDIGO定义和分期。高尿酸血症定义为血尿酸>360μmol/L(女性)、>420μmol/L(男性和绝经后女性)。采用Logistic回归分析影响心脏手术患者术后AKI的危险因素。结果:1 722例患者中高尿酸血症患者为527例(30.6%)。患者术后总体AKI发病率为35.5%(n=611),高尿酸组术后AKI发病率显著高于正常尿酸组(43.6%vs 31.9%,P<0.001),危重AKI发病率显著高于正常尿酸组(10.1%vs 6.3%,P=0.006),高尿酸组患者住ICU天数显著多于正常尿酸组(P<0.001),住院费用显著高于正常尿酸组(P<0.001),两组的肾脏替代治疗(RRT)率、住院天数、AKI死亡率和总体死亡率差异无统计学意义。亚组分析显示,在eGFR≥60 mL/(min·1.73 m~2)亚组中,高尿酸组AKI发病率显著高于正常尿酸组(40.8%vs 31.5%,P=0.001),在eGFR<60 mL/(min·1.73 m~2)亚组中,两组的AKI发病率差异无统计学意义。Logistic多因素回归分析显示,心脏手术后AKI发病的独立危险因素包括男性、年龄(每增加1岁)、高血压、糖尿病、NYHA>Ⅱ级、术前eGFR<60 mL/(min·1.73 m~2)、高尿酸血症、主动脉瘤手术、术中体外循环时间(每增加1 h)。结论:高尿酸血症患者术后AKI发病率显著升高,高尿酸血症是心脏术后AKI发病的独立危险因素之一。
Objective: To investigate the effect of preoperative serum uric acid on the risk of acute kidney injury(AKI) in the patients undergoing cardiac surgery. Methods: Clinical data of the patients underwent cardiac surgery in Zhongshan Hospital of Fudan University from June 1 st, 2016 to December 31 th, 2016 were collected, including age, sex, height, weight, comorbidity, blood and urine routine, kidney function, electrolytes, blood glucose tests, etc. AKI was defined and staged according to the Kidney Disease: Improving Global Outcomes(KDIGO) criteria. Hyperuricemia is defined as serum uric acid > 360 μmol/L(female) and > 420 μmol/L(men and postmenopausal women). Logistic regression analysis was applied to analyze the risk factors for postoperative AKI. Results: A total of 1 722 patients were included, among whom, 527 patients were diagnosed with hyperuricemia(30.6%). The overall AKI incidence was 35.5%(n=611). The percentage of AKI patients with hyperuricemia was significantly higher than those with normal serum uric acid(43.6% vs 31.9%, P<0.001), and the rate of critical AKI was significantly higher(10.1% vs 6.3%, P=0.006) than those with normal serum uric acid. The duration of ICU in patients with hyperuricemia was significantly longer than that in patients with normal uric acid(P<0.001). The hospitalization cost of the hyperuricemia group was also significantly higher than that of the normal uric acid group. There was no statistical difference in renal replacement treatment(RRT), hospitalization time, AKI mortality, and overall mortality between the two groups. In subgroup analysis, hyperuricemia patients with eGFR ≥60 mL/(min·1.73 m~2) represented a significantly higher rate of AKI than those with normal uric acid(40.8% vs 31.5%, P=0.001). There was no statistical difference between two groups in the eGFR <60 mL/(min·1.73 m~2) group. Multivariate regression analysis showed that independent risk factors for AKI after cardiac surgery included male, age(for every additional year), hypertension, diabetes, NYHA>Ⅱ, preoperative eGFR<60 mL/(min·1.73 m~2), hyperuricemia, aortic aneurysm surgery, and intraoperative extracorporeal circulation time(for every additional hour). Conclusions: The incidence of AKI in patients with hyperuricemia might increase significantly after surgery. Hyperuricemia might be regarded as an independent risk factor of AKI following cardiac surgery.
Objective: To investigate the effect of preoperative serum uric acid on the risk of acute kidney injury(AKI) in the patients undergoing cardiac surgery. Methods: Clinical data of the patients underwent cardiac surgery in Zhongshan Hospital of Fudan University from June 1 st, 2016 to December 31 th, 2016 were collected, including age, sex, height, weight, comorbidity, blood and urine routine, kidney function, electrolytes, blood glucose tests, etc. AKI was defined and staged according to the Kidney Disease: Improving Global Outcomes(KDIGO) criteria. Hyperuricemia is defined as serum uric acid > 360 μmol/L(female) and > 420 μmol/L(men and postmenopausal women). Logistic regression analysis was applied to analyze the risk factors for postoperative AKI. Results: A total of 1 722 patients were included, among whom, 527 patients were diagnosed with hyperuricemia(30.6%). The overall AKI incidence was 35.5%(n=611). The percentage of AKI patients with hyperuricemia was significantly higher than those with normal serum uric acid(43.6% vs 31.9%, P<0.001), and the rate of critical AKI was significantly higher(10.1% vs 6.3%, P=0.006) than those with normal serum uric acid. The duration of ICU in patients with hyperuricemia was significantly longer than that in patients with normal uric acid(P<0.001). The hospitalization cost of the hyperuricemia group was also significantly higher than that of the normal uric acid group. There was no statistical difference in renal replacement treatment(RRT), hospitalization time, AKI mortality, and overall mortality between the two groups. In subgroup analysis, hyperuricemia patients with eGFR ≥60 mL/(min·1.73 m~2) represented a significantly higher rate of AKI than those with normal uric acid(40.8% vs 31.5%, P=0.001). There was no statistical difference between two groups in the eGFR <60 mL/(min·1.73 m~2) group. Multivariate regression analysis showed that independent risk factors for AKI after cardiac surgery included male, age(for every additional year), hypertension, diabetes, NYHA>Ⅱ, preoperative eGFR<60 mL/(min·1.73 m~2), hyperuricemia, aortic aneurysm surgery, and intraoperative extracorporeal circulation time(for every additional hour). Conclusions: The incidence of AKI in patients with hyperuricemia might increase significantly after surgery. Hyperuricemia might be regarded as an independent risk factor of AKI following cardiac surgery.
引文
[ 1 ] XU J,JIANG W,FANG Y,et al.Management of cardiac surgery-associated acute kidney injury[J].Contrib Nephrol,2016,187:131-142.
[ 2 ] WANG Y,FANG Y,TENG J,et al.Acute kidney injury epidemiology:from recognition to intervention[J].Contrib Nephrol,2016,187:1-8.
[ 3 ] 许佳瑞,滕杰,方艺,等.心脏手术患者急性肾损伤危险因素及预后的前瞻性队列研究[J].中华内科杂志 2012,51(12):943-947.
[ 4 ] XU J R,ZHU J M,JIANG J,et al.Risk factors for long-term mortality and progressive chronic kidney disease associated with acute kidney injury after cardiac surgery[J].Medicine (Baltimore),2015,94(45):e2025.
[ 5 ] FATHALLAH-SHAYKH S A,CRAMER M T.Uric acid and the kidney[J].Pediatr Nephrol,2014,29(6):999-1008.
[ 6 ] XU X,HU J,SONG N,et al.Hyperuricemia increases the risk of acute kidney injury:a systematic review and meta-analysis[J].BMC Nephrol,2017,18(1):27.
[ 7 ] SUSIC D,FROHLICH E D.Hyperuricemia:a biomarker of renal hemodynamic impairment[J].Cardiorenal Med,2015,5(3):175-182.
[ 8 ] LI L,YANG C,ZHAO Y,et al.Is hyperuricemia an independent risk factor for new-onset chronic kidney disease?A systematic review and meta-analysis based on observational cohort studies[J].BMC Nephrol,2014,15:122.
[ 9 ] ISHANI A,XUE J L,HIMMELFARB J,et al.Acute kidney injury increases risk of ESRD among elderly[J].J Am Soc Nephrol,2009,20(1):223-228.
[10] PANNU N,JAMES M,HEMMELGARN B R,et al.Modification of outcomes after acute kidney injury by the presence of CKD[J].Am J Kidney Dis,2011,58(2):206-213.
[11] 中国医师协会肾脏内科医师分会.中国肾脏疾病高尿酸血症诊治的实践指南(2017版)[J].中华医学杂志 2017,97(25):1927-1936.
[12] OKURA T,HIGAKI J,KURATA M,et al.Elevated serum uric acid is an independent predictor for cardiovascular events in patients with severe coronary artery stenosis:subanalysis of the Japanese Coronary Artery Disease (JCAD) Study[J].Circ J,2009,73(5):885-891.
[13] KIM S Y,GUEVARA J P,KIM K M,et al.Hyperuricemia and coronary heart disease:a systematic review and meta-analysis[J].Arthritis Care Res (Hoboken),2010,62(2):170-180.
[14] RONCAL CA,MU W,CROKER B,et al.Effect of elevated serum uric acid on cisplatin-induced acute renal failure[J].Am J Physiol Renal Physiol,2007,292(1):F116-F122.
[15] KHOSLA U M,ZHARIKOV S,FINCH J L,et al.Hyperuricemia induces endothelial dysfunction[J].Kidney Int,2005,67(5):1739-1742.
[16] YU M A,SANCHEZ-LOZADA L G,JOHNSON R J,et al.Oxidative stress with an activation of the renin-angiotensin system in human vascular endothelial cells as a novel mechanism of uric acid-induced endothelial dysfunction[J].J Hypertens,2010,28(6):1234-1242.
[17] ZHOU Y,FANG L,JIANG L,et al.Uric acid induces renal inflammation via activating tubular NF-kappaB signaling pathway[J].PLoS One,2012,7(6):e39738.
[18] KANG D H,NAKAGAW A T,FENG L,et al.A role for uric acid in the progression of renal disease[J].J Am Soc Nephrol,2002,13(12):2888-2897.
[19] VERZOLA D,RATTO E,VILLAGGIO B,et al.Uric acid promotes apoptosis in human proximal tubule cells by oxidative stress and the activation of NADPH oxidase NOX 4[J].PLoS One,2014,9(12):e115210.
[ 2 ] WANG Y,FANG Y,TENG J,et al.Acute kidney injury epidemiology:from recognition to intervention[J].Contrib Nephrol,2016,187:1-8.
[ 3 ] 许佳瑞,滕杰,方艺,等.心脏手术患者急性肾损伤危险因素及预后的前瞻性队列研究[J].中华内科杂志 2012,51(12):943-947.
[ 4 ] XU J R,ZHU J M,JIANG J,et al.Risk factors for long-term mortality and progressive chronic kidney disease associated with acute kidney injury after cardiac surgery[J].Medicine (Baltimore),2015,94(45):e2025.
[ 5 ] FATHALLAH-SHAYKH S A,CRAMER M T.Uric acid and the kidney[J].Pediatr Nephrol,2014,29(6):999-1008.
[ 6 ] XU X,HU J,SONG N,et al.Hyperuricemia increases the risk of acute kidney injury:a systematic review and meta-analysis[J].BMC Nephrol,2017,18(1):27.
[ 7 ] SUSIC D,FROHLICH E D.Hyperuricemia:a biomarker of renal hemodynamic impairment[J].Cardiorenal Med,2015,5(3):175-182.
[ 8 ] LI L,YANG C,ZHAO Y,et al.Is hyperuricemia an independent risk factor for new-onset chronic kidney disease?A systematic review and meta-analysis based on observational cohort studies[J].BMC Nephrol,2014,15:122.
[ 9 ] ISHANI A,XUE J L,HIMMELFARB J,et al.Acute kidney injury increases risk of ESRD among elderly[J].J Am Soc Nephrol,2009,20(1):223-228.
[10] PANNU N,JAMES M,HEMMELGARN B R,et al.Modification of outcomes after acute kidney injury by the presence of CKD[J].Am J Kidney Dis,2011,58(2):206-213.
[11] 中国医师协会肾脏内科医师分会.中国肾脏疾病高尿酸血症诊治的实践指南(2017版)[J].中华医学杂志 2017,97(25):1927-1936.
[12] OKURA T,HIGAKI J,KURATA M,et al.Elevated serum uric acid is an independent predictor for cardiovascular events in patients with severe coronary artery stenosis:subanalysis of the Japanese Coronary Artery Disease (JCAD) Study[J].Circ J,2009,73(5):885-891.
[13] KIM S Y,GUEVARA J P,KIM K M,et al.Hyperuricemia and coronary heart disease:a systematic review and meta-analysis[J].Arthritis Care Res (Hoboken),2010,62(2):170-180.
[14] RONCAL CA,MU W,CROKER B,et al.Effect of elevated serum uric acid on cisplatin-induced acute renal failure[J].Am J Physiol Renal Physiol,2007,292(1):F116-F122.
[15] KHOSLA U M,ZHARIKOV S,FINCH J L,et al.Hyperuricemia induces endothelial dysfunction[J].Kidney Int,2005,67(5):1739-1742.
[16] YU M A,SANCHEZ-LOZADA L G,JOHNSON R J,et al.Oxidative stress with an activation of the renin-angiotensin system in human vascular endothelial cells as a novel mechanism of uric acid-induced endothelial dysfunction[J].J Hypertens,2010,28(6):1234-1242.
[17] ZHOU Y,FANG L,JIANG L,et al.Uric acid induces renal inflammation via activating tubular NF-kappaB signaling pathway[J].PLoS One,2012,7(6):e39738.
[18] KANG D H,NAKAGAW A T,FENG L,et al.A role for uric acid in the progression of renal disease[J].J Am Soc Nephrol,2002,13(12):2888-2897.
[19] VERZOLA D,RATTO E,VILLAGGIO B,et al.Uric acid promotes apoptosis in human proximal tubule cells by oxidative stress and the activation of NADPH oxidase NOX 4[J].PLoS One,2014,9(12):e115210.