急性A型主动脉夹层患者肾损伤与超重的相关性研究
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摘要
目的:心外科术后出现的急性肾损伤(AKI)是与不良预后紧密相连的严重并发症。由于研究人群的选择性偏差及不同AKI诊断标准的干扰,因此我们对主动脉A型夹层患者常温停循环下行紧急主动脉弓部手术出现AKI的发生率及危险因素进行研究分析。方法:该项研究为单中心回顾性研究,自2015年12月至2017年4月,北京安贞医院115例因急性主动脉A型夹层行紧急主动脉弓部替换手术患者。人口统计学资料、化验结果、及术前数据均来自数据库。AKI诊断标准依据全球改善肾脏病预后组织所制定指南。结果:61例患者(53.0%)出现术后AKI,处于指南中所描述第一阶段23例患者,处于第二阶段11例患者,位于第三阶段27例患者。经单因素Logistic回归分析:AKI的独立危险因素为手术时间(OR=1.31,95%CI:1.05～1.64,P=0.018); BMI增加(OR=1.17,95%CI:1.05～1.31,P=0.006)。结论:依据全球改善肾脏病预后组织所制定指南为术后AKI危险因素为超重及手术时间延长。因此对于主动脉A型夹层的超重患者术后应积极预防AKI。
Objective: Acute kidney injury(AKI)after cardiac surgery is a significant complication associated with adverse outcomes. However, the result of previous studies may be confounded by heterogeneous patient selection and variable definitions of AKI. Thus, we investigated the incidence and risk factors of AKI after urgent aortic arch surgery with moderate hypothermic circulatory arrest for acute type A aortic dissection. Methods: This was a single-center retrospective study including 115 consecutive patients undergoing urgent aortic arch surgery for acute type A aortic dissection between December 2015 and April 2017 at Beijing Anzhen Hospital. Demographics, laboratory data and perioperative data were obtained from a collected database. AKI was defined according to the kidney disease improving global outcomes criteria. Results: Sixty-one patients(53.0%) developed postoperative AKI: 23 had Kidney Disease Improving Global Outcomes stage 1, 11 had stage 2, and 27 had stage 3. Univariate logistic regression analysis showed that patients in the AKI group suffered more serious and complicated postoperative outcomes. A logistic regression analysis identified the following two independent risk factors for AKI: duration of operation OR=1.31,95% CI:1.05-1.64, P=0.018)and increased body mass index(OR=1.17,95% CI:1.05-1.31,P=0.006). Conclusions: Overweight and prolonged duration of operation were independent risk factors for AKI based on the Kidney Disease Improving Global Outcomes criteria. More attention should be paid to preventing AKI in overweight patients with acute type A aortic dissection.
Objective: Acute kidney injury(AKI)after cardiac surgery is a significant complication associated with adverse outcomes. However, the result of previous studies may be confounded by heterogeneous patient selection and variable definitions of AKI. Thus, we investigated the incidence and risk factors of AKI after urgent aortic arch surgery with moderate hypothermic circulatory arrest for acute type A aortic dissection. Methods: This was a single-center retrospective study including 115 consecutive patients undergoing urgent aortic arch surgery for acute type A aortic dissection between December 2015 and April 2017 at Beijing Anzhen Hospital. Demographics, laboratory data and perioperative data were obtained from a collected database. AKI was defined according to the kidney disease improving global outcomes criteria. Results: Sixty-one patients(53.0%) developed postoperative AKI: 23 had Kidney Disease Improving Global Outcomes stage 1, 11 had stage 2, and 27 had stage 3. Univariate logistic regression analysis showed that patients in the AKI group suffered more serious and complicated postoperative outcomes. A logistic regression analysis identified the following two independent risk factors for AKI: duration of operation OR=1.31,95% CI:1.05-1.64, P=0.018)and increased body mass index(OR=1.17,95% CI:1.05-1.31,P=0.006). Conclusions: Overweight and prolonged duration of operation were independent risk factors for AKI based on the Kidney Disease Improving Global Outcomes criteria. More attention should be paid to preventing AKI in overweight patients with acute type A aortic dissection.
引文
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[7] 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.
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[11] Kuitunen A, Vento A, Suojaranta-Ylinen R, et al.Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Ann Thorac Surg,2006,81: 542-546.
[12] D’Onofrio A, Cruz D, Bolgan I, et al. RIFLE criteria for cardiac surgery-associated acute kidney injury: risk factors and outcomes. Congest Heart Fail,2010,16: S32-36.
[13] Huen SC, Parikh CR. Predicting acute kidney injury after cardiac surgery: a systematic review. Ann Thorac Surg,2012,93: 337-347.
[14] Machado MN, Nakazone MA, Maia LN. Acute kidney injury based on KDIGO (Kidney Disease Improving Global Outcomes) criteria in patients with elevated baseline serum creatinine undergoing cardiac surgery. Rev Bras Cir Cardiovasc,2014,29: 299-307.
[15] Hoste EA, Kellum JA. Acute renal failure in the critically ill: impact on morbidity and mortality. Contrib Nephrol,2004,144: 1-11.
[16] Karkouti K, Wijeysundera DN, Yau TM, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation,2009,119: 495-502.
[17] Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg,2007,32: 255-262.
[18] Bove T, Calabrò MG, Landoni G, et al. The incidence and risk of acute renal failure after cardiac surgery. J Cardiothorac Vasc Anesth,2004,18: 442-445.
[19] Roh GU, Lee JW, Nam SB, et al. Incidence and risk factors of acute kidney injury after thoracic aortic surgery for acute dissection. Ann Thorac Surg,2012,94: 766-771.
[20] Urbanski PP, Lenos A, Bougioukakis P, et al. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a change of paradigm? Eur J Cardiothorac Surg,2012,41: 185-191.
[21] Leshnower BG, Myung RJ, Kilgo PD, et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg,2010,90: 547-554.
[22] Mori Y, Sato N, Kobayashi Y, et al. Acute kidney injury during aortic arch surgery under deep hypothermic circulatory arrest. J Anesth,2011,25: 799-804.
[23] Gaudino M, Luciani N, Giungi S, et al. Different profiles of patients who require dialysis after cardiac surgery. Ann Thorac Surg,2005,79: 825-829.
[24] Prabhakar G, Haan CK, Peterson ED, et al.The risks of moderate and extreme obesity for coronary artery bypass grafting outcomes: a study from the Society of Thoracic Surgeons’ database. Ann Thorac Surg,2002,74: 1125-1130.
[25] Kumar AB, Bridget Zimmerman M, Suneja M. Obesity and post-cardiopulmonary bypass-associated acute kidney injury: a single-center retrospective analysis. J Cardiothorac Vasc Anesth,2014,28: 551-556.
[26] Ahmed MH, Khalil AA. Obesity-related glomerulopathy: another nail in the coffin of the epidemic of end-stage renal disease. J Clin Pathol,2007,60: 582.
[27] Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney Int,2008,73: 538-546.
[28] Thakar CV, Christianson A, Freyberg R, et al. Incidence and outcomes of acute kidney injury in intensive care units: a Veterans Administration study. Crit Care Med,2009, 37: 2552-2558.
[29] Joannidis M, Metnitz B, Bauer P, et al. Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. Intensive Care Med,2009, 35: 1692-1702.
[30] Lopes JA, Fernandes P, Jorge S, et al. Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the Acute Kidney Injury Network classifications. Crit Care,2008,12: R110.
[31] 曹亮,王嵘,金沐,等. 急性A型主动脉夹层术后重度急性肾损伤危险因素分析. 心肺血管病杂志,2018,37:851-865.
[32] Delanaye P, Mariat C, Cavalier E, et al. Errors induced by indexing glomerular filtration rate for body surface area: reductio ad absurdum. Nephrol Dial Transplant,2009, 24: 3593-3596.
[2] Mariscalco G, Lorusso R, Dominici C, et al. Acute kidney injury: a relevant complication after cardiac surgery. Ann Thorac Surg,2011,92: 1539-1547.
[3] Nota H, Asai T, Suzuki T, et al. Risk factors for acute kidney injury in aortic arch surgery with selective cerebral perfusion and mild hypothermic lower body circulatory arrest. Interact Cardiovasc Thorac Surg,2014,19: 955-961.
[4] Kowalik MM, Lango R, Klajbor K, et al. Incidence and mortality-related risk factors of acute kidney injury requiring hemofiltration treatment in patients undergoing cardiac surgery: a single-center 6-year experience. J Cardiothorac Vasc Anesth,2011,25: 619-624.
[5] Englberger L, Suri RM, Greason KL, et al. Deep hypothermic circulatory arrest is not a risk factor for acute kidney injury in thoracic aortic surgery. J Thorac Cardiovasc Surg,2011,141: 552-558.
[6] Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care,2004,8: R204-212.
[7] 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.
[8] Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Inter Suppl,2012,2: 1-138.
[9] Arnaoutakis GJ, Bihorac A, Martin TD, et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg,2007,134: 1554-1560.
[10] Augoustides JG, Pochettino A, Ochroch EA, et al. Renal dysfunction after thoracic aortic surgery requiring deep hypothermic circulatory arrest: definition, incidence, and clinical predictors. J Cardiothorac Vasc Anesth,2006,20: 673-677.
[11] Kuitunen A, Vento A, Suojaranta-Ylinen R, et al.Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Ann Thorac Surg,2006,81: 542-546.
[12] D’Onofrio A, Cruz D, Bolgan I, et al. RIFLE criteria for cardiac surgery-associated acute kidney injury: risk factors and outcomes. Congest Heart Fail,2010,16: S32-36.
[13] Huen SC, Parikh CR. Predicting acute kidney injury after cardiac surgery: a systematic review. Ann Thorac Surg,2012,93: 337-347.
[14] Machado MN, Nakazone MA, Maia LN. Acute kidney injury based on KDIGO (Kidney Disease Improving Global Outcomes) criteria in patients with elevated baseline serum creatinine undergoing cardiac surgery. Rev Bras Cir Cardiovasc,2014,29: 299-307.
[15] Hoste EA, Kellum JA. Acute renal failure in the critically ill: impact on morbidity and mortality. Contrib Nephrol,2004,144: 1-11.
[16] Karkouti K, Wijeysundera DN, Yau TM, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation,2009,119: 495-502.
[17] Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg,2007,32: 255-262.
[18] Bove T, Calabrò MG, Landoni G, et al. The incidence and risk of acute renal failure after cardiac surgery. J Cardiothorac Vasc Anesth,2004,18: 442-445.
[19] Roh GU, Lee JW, Nam SB, et al. Incidence and risk factors of acute kidney injury after thoracic aortic surgery for acute dissection. Ann Thorac Surg,2012,94: 766-771.
[20] Urbanski PP, Lenos A, Bougioukakis P, et al. Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a change of paradigm? Eur J Cardiothorac Surg,2012,41: 185-191.
[21] Leshnower BG, Myung RJ, Kilgo PD, et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg,2010,90: 547-554.
[22] Mori Y, Sato N, Kobayashi Y, et al. Acute kidney injury during aortic arch surgery under deep hypothermic circulatory arrest. J Anesth,2011,25: 799-804.
[23] Gaudino M, Luciani N, Giungi S, et al. Different profiles of patients who require dialysis after cardiac surgery. Ann Thorac Surg,2005,79: 825-829.
[24] Prabhakar G, Haan CK, Peterson ED, et al.The risks of moderate and extreme obesity for coronary artery bypass grafting outcomes: a study from the Society of Thoracic Surgeons’ database. Ann Thorac Surg,2002,74: 1125-1130.
[25] Kumar AB, Bridget Zimmerman M, Suneja M. Obesity and post-cardiopulmonary bypass-associated acute kidney injury: a single-center retrospective analysis. J Cardiothorac Vasc Anesth,2014,28: 551-556.
[26] Ahmed MH, Khalil AA. Obesity-related glomerulopathy: another nail in the coffin of the epidemic of end-stage renal disease. J Clin Pathol,2007,60: 582.
[27] Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney Int,2008,73: 538-546.
[28] Thakar CV, Christianson A, Freyberg R, et al. Incidence and outcomes of acute kidney injury in intensive care units: a Veterans Administration study. Crit Care Med,2009, 37: 2552-2558.
[29] Joannidis M, Metnitz B, Bauer P, et al. Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. Intensive Care Med,2009, 35: 1692-1702.
[30] Lopes JA, Fernandes P, Jorge S, et al. Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the Acute Kidney Injury Network classifications. Crit Care,2008,12: R110.
[31] 曹亮,王嵘,金沐,等. 急性A型主动脉夹层术后重度急性肾损伤危险因素分析. 心肺血管病杂志,2018,37:851-865.
[32] Delanaye P, Mariat C, Cavalier E, et al. Errors induced by indexing glomerular filtration rate for body surface area: reductio ad absurdum. Nephrol Dial Transplant,2009, 24: 3593-3596.