合并急性肾损伤的感染性心内膜炎的临床特点和预后分析
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摘要
目的:探讨合并急性肾损伤(acute kidney injury,AKI)的感染性心内膜炎(infective endocarditis,IE)患者的临床特点,分析此类患者的围术期及预后情况。方法:回顾性分析2002年1月至2018年6月在北京大学第一医院心脏外科就诊的IE患者100例。根据患者术前情况及AKIN标准,分为AKI组和非AKI组,比较两组临床资料和术后并发症的差异,随访对比两组预后情况。结果:AKI组21例和非AKI组79例,总体平均年龄(43.7±15.7)岁,男女比例3∶1,IE患者中AKI的发生率为21%。两组间年龄、性别构成差异无统计学意义。与非AKI组相比,AKI组患者皮疹及下肢水肿的比例更高(P=0.017和P=0.001),尿潜血及尿蛋白阳性率更高(P<0.001),血红蛋白及血清白蛋白水平更低(P<0.001),临床心功能更差(P=0.033)。两组病原菌检出率及病原菌种类差异无统计学意义。除9例患者拒绝手术外,其余91例患者均接受了体外循环下心内直视手术,包括AKI组19例和非AKI组72例。AKI组患者围术期红细胞用量更多(P=0.010),术后呼吸机使用时间及监护室停留时间更长(P=0.028和P=0.003)。以两组患者术前末次肌酐为基准,AKI组新发术后肾功能不全比例更高(P=0.004)。两组患者院内死亡率差异无统计学意义(P=0.463),随访期间两组生存率差异未见统计学意义(P=0.581)。结论:与非AKI组相比,合并AKI的IE患者围术期并发症发生率更高,但两组患者院内死亡率及预后无明显差异。
Objective:To investigate the clinical features and treatment of infective endocarditis(IE)patients with acute kidney injury(AKI),and to compare the adverse complications and outcome with IE patients without AKI.Methods:Clinical data of 100 IE cases in Peking University First Hospital from January 2002 to June 2018 were retrospectively reviewed.The patients were divided into AKI group(n=21) and non-AKI group(n=79) based on the AKI network(AKIN) definition.The clinical data and prognosis were compared between the two groups.Results:The incidence of AKI was 21%.The average age was(43.7 ± 15.7) years,and the ratio of male to female was 3 ∶ 1.There was no significant difference in age and gender between the two groups.Compared with non-AKI group,the AKI group had more rash and lower limbs edema(P=0.017 and P=0.001),higher urine blood and protein positive rate(both P<0.001).Lower hemoglobin and serum albumin level(both P<0.001),worse clinical cardiac function(NYHA Ⅲ-Ⅳ,P=0.033) were found in AKI group compared with non-AKI group.There was no significant difference in microbiologic positive rate and pathogenic bacteria sorts between the two groups.Nine patients refused surgery,and the other 91 cases underwent cardiac surgery with cardiopulmonary bypass under general anesthesia,including 19 cases of AKI group and 72 cases of non-AKI group.The ventilation time and intensive care unit(ICU) stay time were longer in AKI group than in non-AKI group(P=0.028 and P=0.003).AKI group needed more red blood cell transfusion(P=0.010).Using the last serum creatinine before surgery as basic level,there was more new-onset AKI cases in AKI group than in non-AKI group.During the median follow-up time 42 months,there was no significant difference in perioperative and follow-up mortality between the two groups(P=0.463 and P=0.581).Conclusion:More perioperation complications occurred in IE patients with AKI,but no significant difference in in-hospital and follow-up mortality between the AKI and non-AKI groups was observed.
Objective:To investigate the clinical features and treatment of infective endocarditis(IE)patients with acute kidney injury(AKI),and to compare the adverse complications and outcome with IE patients without AKI.Methods:Clinical data of 100 IE cases in Peking University First Hospital from January 2002 to June 2018 were retrospectively reviewed.The patients were divided into AKI group(n=21) and non-AKI group(n=79) based on the AKI network(AKIN) definition.The clinical data and prognosis were compared between the two groups.Results:The incidence of AKI was 21%.The average age was(43.7 ± 15.7) years,and the ratio of male to female was 3 ∶ 1.There was no significant difference in age and gender between the two groups.Compared with non-AKI group,the AKI group had more rash and lower limbs edema(P=0.017 and P=0.001),higher urine blood and protein positive rate(both P<0.001).Lower hemoglobin and serum albumin level(both P<0.001),worse clinical cardiac function(NYHA Ⅲ-Ⅳ,P=0.033) were found in AKI group compared with non-AKI group.There was no significant difference in microbiologic positive rate and pathogenic bacteria sorts between the two groups.Nine patients refused surgery,and the other 91 cases underwent cardiac surgery with cardiopulmonary bypass under general anesthesia,including 19 cases of AKI group and 72 cases of non-AKI group.The ventilation time and intensive care unit(ICU) stay time were longer in AKI group than in non-AKI group(P=0.028 and P=0.003).AKI group needed more red blood cell transfusion(P=0.010).Using the last serum creatinine before surgery as basic level,there was more new-onset AKI cases in AKI group than in non-AKI group.During the median follow-up time 42 months,there was no significant difference in perioperative and follow-up mortality between the two groups(P=0.463 and P=0.581).Conclusion:More perioperation complications occurred in IE patients with AKI,but no significant difference in in-hospital and follow-up mortality between the AKI and non-AKI groups was observed.
引文
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[11]张苑,任鹏涛,杨婧,等.感染性心内膜炎患者临床特征与预后影响因素分析[J].中华医院感染学杂志,2016,26(7):1531-1532.
[12]Ambrosioni J,Hernandez-Meneses M,Téllez A,et al.Hospital clinic infective endocarditis investigators.The changing epidemiology of infective endocarditis in the Twenty-First Century[J].Curr Infect Dis Rep,2017,19(5):21.
[13]Fowler VG Jr,Miro JM,Hoen B,et al.Staphylococcus aureus endocarditis:a consequence of medical progress[J].JAMA,2005,293(24):3012-3021.
[14]Salgado-Pabón W,Breshears L,Spaulding AR,et al.Superantigens are critical for Staphylococcus aureus infective endocarditis,sepsis,and acute kidney injury[J/OL].MBio,2013,4(4),doi:10.1128/m Bio.00494-13.
[15]Wallace SM,Walton BI,Kharbanda RK,et al.Mortality from infective endocarditis:clinical predictors of outcome[J].Heart,2002,88(1):53-60.
[16]Kang DH,Kim YJ,Kim SH,et al.Early surgery versus conventional treatment for infective endocarditis[J].N Engl J Med,2012,366(26):2466-2473.
[17]Chu VH,Park LP,Athan E,et al.Association between surgical indications,operative risk,and clinical outcome in infective endocarditis:a prospective study from the international collaboration on endocarditis[J].Circulation,2015,131(2):131-140.
[18]Mariscalco G,Lorusso R,Dominici C,et al.Acute kidney injury:a relevant complication after cardiac surgery[J].Ann Thorac Surg,2011,92(4):1539-1547.
[19]Pang PY,Sin YK,Lim CH,et al.Surgical management of infective endocarditis:An analysis of early and late outcomes[J].Eur J Cardiothorac Surg,2015,47(5):826-832.
[20]Buchholtz K,Larsen CT,Hassager C,et al.In infectious endocarditis patients mortality is highly related to kidney function at time of diagnosis:A prospective observational cohort study of 231cases[J].Eur J Intern Med,2009,20(4):407-410.
[2]Thakar CV,Worley S,Arrigain,S,et al.Influence of renal dysfunction on mortality after cardiac surgery:Modifying effect of preoperative renal function[J].Kidney Int,2005,67(3):1112-1119.
[3]Shanmugam B,Khalif A,Pati P,et al.Trends in acute kidney injury in patients diagnosed with infective endocarditis:Data from the national inpatient sample from 1999-2014[J].Chest,2017,152(4):A69.
[4]Legrand M,Pirracchio R,Rosa A,et al.Incidence,risk factors and prediction of post-operative acute kidney injury following cardiac surgery for active infective endocarditis:An observational study[J].Crit Care,2013,17(5):R220.
[5]Mylonakis E,Calderwood SB.Infective endocarditis in adults.NEngl J Med,2001,345(18):1318-1330.
[6]Cruz DN,Bagshaw SM,Ronco C,et al.Acute kidney injury:classification and staging[J].Contrib Nephrol,2010,164:24-32.
[7]Slipczuk L,Codolosa JN,Davila CD,et al.Infective endocarditis epidemiology over five decades:a systematic review[J].PLo SOne,2013,8(12):e82665.
[8]Olmos C,Vilacosta I,Fernández-Pérez C,et al.The evolving nature of infective endocarditis in Spain:A population-based study(2003 to 2014)[J].J Am Coll Cardiol,2017,70(22):2795-2804.
[9]Shih CJ,Chu H,Chao PW,et al.Long-term clinical outcome of major adverse cardiac events in survivors of infective endocarditis a nationwide population-based study[J].Circulation,2014,130(19):1684-1691.
[10]Boils CL,Nasr SH,Walker PD,et al.Update on endocarditisassociated glomerulonephritis[J].Kidney Int,2015,87(6):1241-1249.
[11]张苑,任鹏涛,杨婧,等.感染性心内膜炎患者临床特征与预后影响因素分析[J].中华医院感染学杂志,2016,26(7):1531-1532.
[12]Ambrosioni J,Hernandez-Meneses M,Téllez A,et al.Hospital clinic infective endocarditis investigators.The changing epidemiology of infective endocarditis in the Twenty-First Century[J].Curr Infect Dis Rep,2017,19(5):21.
[13]Fowler VG Jr,Miro JM,Hoen B,et al.Staphylococcus aureus endocarditis:a consequence of medical progress[J].JAMA,2005,293(24):3012-3021.
[14]Salgado-Pabón W,Breshears L,Spaulding AR,et al.Superantigens are critical for Staphylococcus aureus infective endocarditis,sepsis,and acute kidney injury[J/OL].MBio,2013,4(4),doi:10.1128/m Bio.00494-13.
[15]Wallace SM,Walton BI,Kharbanda RK,et al.Mortality from infective endocarditis:clinical predictors of outcome[J].Heart,2002,88(1):53-60.
[16]Kang DH,Kim YJ,Kim SH,et al.Early surgery versus conventional treatment for infective endocarditis[J].N Engl J Med,2012,366(26):2466-2473.
[17]Chu VH,Park LP,Athan E,et al.Association between surgical indications,operative risk,and clinical outcome in infective endocarditis:a prospective study from the international collaboration on endocarditis[J].Circulation,2015,131(2):131-140.
[18]Mariscalco G,Lorusso R,Dominici C,et al.Acute kidney injury:a relevant complication after cardiac surgery[J].Ann Thorac Surg,2011,92(4):1539-1547.
[19]Pang PY,Sin YK,Lim CH,et al.Surgical management of infective endocarditis:An analysis of early and late outcomes[J].Eur J Cardiothorac Surg,2015,47(5):826-832.
[20]Buchholtz K,Larsen CT,Hassager C,et al.In infectious endocarditis patients mortality is highly related to kidney function at time of diagnosis:A prospective observational cohort study of 231cases[J].Eur J Intern Med,2009,20(4):407-410.