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中华肾病研究电子杂志

中华肾病研究电子杂志 ›› 2020, Vol. 09 ›› Issue (04) : 159 -165. doi: 10.3877/cma.j.issn.2095-3216.2020.04.003

所属专题： 文献；

论著

心血管手术相关急性肾损伤患者行连续性肾脏替代治疗后的预后因素分析
刘珊1, 邬步云2, 刘康2, 俞香宝2, 朱亚梅2, 邵永丰3, 赵胜3, 邢昌赢2, 毛慧娟2,†()   
  1. 1. 210029　南京医科大学第一附属医院肾内科；222000　连云港市第二人民医院肾内科
    2. 210029　南京医科大学第一附属医院肾内科
    3. 210029　南京医科大学第一附属医院心脏大血管外科
  • 收稿日期:2020-05-07 出版日期:2020-08-28
  • 通信作者: 毛慧娟
  • 基金资助:
    国家自然基金面上项目(81970639); 江苏省教育厅六大人才高峰(WSN-056); 2017年江苏省卫生健康委员会科研项目(H2017023)

Analysis of prognostic factors in patients with cardiac and vascular surgery-related acute kidney injury after continuous renal replacement therapy

Shan Liu1, Buyun Wu2, Kang Liu2, Xiangbao Yu2, Yamei Zhu2, Yongfeng Shao3, Sheng Zhao3, Changying Xing2, Huijuan Mao2,†()   

  1. 1. Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029; Department of Nephrology, Lianyungang Second People′s Hospital, Lianyungang 222000
    2. Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029
    3. Department of Cardiovascular Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029; Jiangsu Province, China
  • Received:2020-05-07 Published:2020-08-28
  • Corresponding author: Huijuan Mao
  • About author:
    Corresponding author: Mao Huijuan, Email:
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引用本文：

刘珊, 邬步云, 刘康, 俞香宝, 朱亚梅, 邵永丰, 赵胜, 邢昌赢, 毛慧娟. 心血管手术相关急性肾损伤患者行连续性肾脏替代治疗后的预后因素分析[J/OL]. 中华肾病研究电子杂志, 2020, 09(04): 159-165.

Shan Liu, Buyun Wu, Kang Liu, Xiangbao Yu, Yamei Zhu, Yongfeng Shao, Sheng Zhao, Changying Xing, Huijuan Mao. Analysis of prognostic factors in patients with cardiac and vascular surgery-related acute kidney injury after continuous renal replacement therapy[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2020, 09(04): 159-165.

目的

探讨心血管手术相关急性肾损伤患者行连续性肾脏替代治疗后不同预后的相关因素。

方法

本研究纳入2015年1月至2018年12月在南京医科大学第一附属医院住院行心血管手术治疗且接受连续性肾脏替代治疗的患者，按90 d是否死亡和90 d内RRT治疗天数(≤14 d，15～90 d，>90 d)将患者分为4组，分析90 d死亡、90 d透析依赖、90 d延迟摆脱透析的相关影响因素。

结果

本研究共纳入210例患者，平均随访400 d。其中90 d死亡114例，90 d生存且14 d内摆脱透析37例，90 d生存15～90 d内摆脱透析46例，90 d生存且透析依赖13例。多因素Cox回归显示：90 d死亡的独立危险因素包括高龄(HR＝1.029，95%CI: 1.013～1.045，P<0.001)、术前血清肌酐低(HR＝0.993，95%CI: 0.987～0.998，P＝0.008)、CRRT前APACHE Ⅱ高评分(HR＝1.043, 95%CI: 1.004～1.084，P＝0.028)、CRRT前SOFA评分高(HR＝1.130, 95%CI: 1.052～1.213，P<0.001)、CRRT前脓毒症(HR＝2.327, 95%CI: 1.591～3.403，P<0.001)、CRRT前过低的舒张压(HR＝0.979，95%CI: 0.963～0.996，P＝0.013)。90 d存活患者透析依赖的独立危险因素包括术前较低的eGFR(HR＝0.962，95%CI: 0.940～0.984，P<0.001)。90 d存活患者中延迟摆脱透析的危险因素有血清白蛋白低(OR＝0.837，95%CI: 0.717～0.977，P＝0.024)、机械通气时间长(OR＝1.434，95%CI: 1.175～1.749，P<0.001)、CRRT前尿量少(OR＝0.739，95%CI: 0.623～0.876，P<0.001)。

结论

心血管手术相关急性肾损伤并行连续性肾脏替代治疗患者中，90 d死亡与高龄、CRRT前疾病的严重程度、脓毒症和过低的舒张压有关；90 d存活患者透析依赖与患者术前较差的肾功能有关；90 d存活患者延迟摆脱透析与血清白蛋白低、机械通气时间长、CRRT前尿量少有关。

关键词: 心血管手术相关急性肾损伤, 连续性肾脏替代治疗, 预后
Objective

To investigate the prognostic factors in patients with cardiac and vascular surgery-related acute kidney injury after continuous renal replacement therapy.

Methods

This study included patients admitted to the First Affiliated Hospital of Nanjing Medical University between January 2015 to December 2018, who underwent major cardiovascular surgery followed by continuous renal replacement therapy (CRRT). The patients were divided into 4 groups according to whether they survived within 90 days and the duration of RRT [≤14 days (rapid cessation), 15-90 days (delayed cessation), and >90 days (dialysis dependence)]. Risk factors for 90-day mortality, 90-day dialysis dependence, and 90-day delayed cessation of dialysis were analyzed.

Results

A total of 210 patients were included in this study, with an average follow-up duration of 400 days. Among them, 114 patients died within 90 days, 37 patients survived with rapid cessation of RRT, 46 patients survived with delayed cessation of RRT, and 13 patients survived with dialysis dependence. Multivariate Cox regression analysis showed that the independent risk factors of 90-day mortality included elder age (HR=1.029, 95%CI: 1.013-1.045, P<0.001), low level of preoperative serum creatinine (HR=0.993, 95%CI: 0.987-0.998, P=0.008), high score by APACHE Ⅱ before CRRT (HR=1.043, 95%CI: 1.004-1.084, P=0.028), high score by SOFA before CRRT (HR=1.130, 95%CI: 1.052-1.213, P<0.001), sepsis before CRRT (HR=2.327, 95%CI: 1.591-3.403, P<0.001), and low level of diastolic blood pressure before CRRT (HR=0.979, 95%CI: 0.963-0.996, P=0.013). The independent risk factors for patients survived with dialysis dependence consisted of low preoperative eGFR (HR=0.962, 95%CI: 0.940-0.984, P<0.001). The risk factors for patients survived with delayed cessation of dialysis were low level of serum albumin (OR=0.837, 95%CI: 0.717-0.977, P=0.024), long duration of mechanical ventilation (OR=1.434, 95%CI: 1.175-1.749, P<0.001), and low level of urine volume before CRRT (OR=0.739, 95%CI: 0.623-0.876, P<0.001).

Conclusion

In patients with cardiovascular surgery-associated acute kidney injury requiring CRRT, 90-day mortality was associated with elder age, severity of disease, sepsis, and low level of diastolic blood pressure before CRRT. Patients survived at 90-day having dialysis dependence were associated with poor preoperative renal function. Patients survived at 90-day having delayed cessation of dialysis were associated with low level of serum albumin, long duration of mechanical ventilation, and low level of urine volume before CRRT.

Key words: Cardiovascular surgery-related acute kidney injury, Continuous renal replacement therapy, Prognosis
表1 患者的基线资料
变量 90 d死亡(n＝114) 90 d生存 P值
快速摆脱透析(n＝37) 延迟摆脱透析(n＝46) 透析依赖(n＝13)
一般资料 ? ? ? ? ?
? 男性[n(%)] 65(57.0) 23(62.2) 35(76.1) 9(69.2) 0.150
? 年龄(岁) 66(55，73) 56(52，70) 55(42，66) 67(60，70) <0.001
? BMI(kg/m2) 22.8(20.8，26.2) 24.6(22.8，26.8) 24.2(21.0，27.8) 25.4(21.7，26.8) 0.148
? 高血压[n(%)] 67(58.8) 23(62.2) 23(50.0) 10(76.9) 0.337
? 糖尿病[n(%)] 18(15.8) 9(24.3) 6(13.0) 5(38.5) 0.123
? Charlson合并症评分 1(0，2) 1(0，2) 1(0，1) 3(1，5) 0.001
? NT-ProBNP(10 ng/L) 164(72，338) 227(95，348) 90(47，153) 547(182，900) 0.002
? 血白蛋白(g/L) 35.5(33.1，33.8) 37.0(35.2，39.0) 35.4(31.8，38.7) 35.2(33.6，37.0) 0.207
? 左心射血分数(%) 62(56，65) 60(50，63) 62(52，65) 59(53，63) 0.289
? 术前血清肌酐(μmol/L) 79(67，98) 82(71，114) 78(66，106) 161(98，222) 0.001
? eGFR [ml/(min·1.73 m2)] 79(61，94) 79(55，98) 90(59，110) 38(21，65) <0.001
手术类型[n(%)] ? ? ? ? 0.016
? 瓣膜 46(40.4) 18(48.6) 17(37.0) 5(38.5) ?
? CABG 19(16.7) 6(16.2) 3(6.5) 5(38.5) ?
? 瓣膜＋CABG 15(13.2) 3(8.1) 2(4.3) 3(23.1) ?
? 主动脉 23(20.2) 9(24.3) 15(32.6) 0(0.00) ?
? 其他 11(9.6) 1(2.7) 9(19.6) 0(0.00) ?
手术信息 ? ? ? ? ?
? 体外循环[n(%)] 94(82.5) 31(83.8) 43(93.5) 8(61.5) 0.045
? 体外循环(min) 158(95，210) 176(123，222) 187(122，236) 108(0，156) 0.026
? 手术时间(min) 376(282，515) 350(280，495) 438(315，540) 280(241，327) 0.009
术后指标 ? ? ? ? ?
? 机械通气(d) 8(4，12) 2(0.5，5.0) 5(2，9) 4(1，5) <0.001
? 降钙素原(ng/ml) 11.2(3.2，32.7) 3.6(1.4，10.6) 10.2(4.3，18.1) 9.8(5.2，13.2) 0.025
CRRT前状态 ? ? ? ? ?
? APACHE Ⅱ评分 20(12，24) 14(10，16) 14(12，17) 14(12，16) 0.001
? SOFA评分 14(11，17) 10(8，12) 12(10，14) 10(9，12) <0.001
? 脓毒症[n(%)] 50(43.8) 4(10.8) 4(8.7) 3(23.1) <0.001
? 明显高钾血症[n(%)] 6(5.2) 1(2.7) 1(2.2) 3(23.1) 0.022
? 血管活性药物评分 24.0(10，41) 4(0，17.5) 12(6.5，37.3) 15(2.5，19) <0.001
? 收缩压(mmHg) 108(98，119) 117(106，125) 114(101，130) 113(101，128) 0.060
? 舒张压(mmHg) 54(48，60) 64(50，72) 60(53，64) 61(54，63) 0.002
? 中心静脉压(mmHg) 14(10，18) 14(12，16) 12(10，14) 11(9，14) 0.025
? 尿素氮(mmol/L) 17(12，28) 17(14，26) 16(13，21) 18(16，24) 0.490
? 血清肌酐(μmol/L) 182(150，259) 240(183，339) 255(197，370) 332(260，361) <0.001
? 入量(100 ml) 32.8(29.0，39.3) 30.0(23.9，35.2) 34.7(26.9，41.8) 30.1(21.3，35.8) 0.016
? 尿量(100 ml) 4.5(1.8，10.6) 9.4(6.1，17.1) 4.4(1.5，7.5) 5.7(3.2.12.7) <0.001
表2 使用Cox回归分析90 d死亡的相关因素(n＝210)
变量 单因素 多因素
HR(95%CI) P值 HR(95%CI) P值
性别(男性) 0.661(0.456～0.959) 0.029 ? ?
年龄(岁) 1.034(1.017～1.051) <0.001 1.029(1.013～1.045) <0.001
体重(kg) 0.979(0.964～0.993) 0.004 ? ?
术前血清肌酐(μmol/L) 0.994(0.990～0.999) 0.020 0.993(0.987～0.998) 0.008
机械通气时间(d) 1.022(1.006～1.038) 0.006 ? ?
CRRT前脓毒症(1/0) 3.086(2.124～4.484) <0.001 2.327(1.591～3.403) <0.001
CRRT前APACHE Ⅱ评分 1.079(1.048～1.111) <0.001 1.043(1.004～1.084) 0.028
CRRT前SOFA评分 1.198(1.130～1.270) <0.001 1.130(1.052～1.213) <0.001
CRRT前收缩压(mmHg) 0.985(0.975～ 0.995) 0.004 ? ?
CRRT前舒张压(mmHg) 0.968(0.952～0.984) <0.001 0.979(0.963～0.996) 0.013
CRRT前血管活性药物评分 1.012(1.007～1.018) <0.001 ? ?
CRRT前24 h入量(100 ml) 1018(1.005～1.031) 0.008 ? ?
表3 使用Cox回归分析90 d存活患者透析依赖的相关因素(n＝96)
变量 单因素 多因素
HR(95%CI) P值 HR(95%CI) P值
年龄(岁) 1.061(1.005～1.119) 0.031 ? ?
术前血清肌酐(μmol/L) 0.010(1.005～1.015) <0.001 ? ?
术前eGFR [ml/(min·1.73 m2)] 0.962(0.940～0.984) <0.001 0.962(0.940～0.984) <0.001
Charlson合并症评分 1.560(1.237～1.967) <0.001 ? ?
手术时间(min) 0.993(0.988～0.998) 0.009 ? ?
明显高钾血症(1/0) 5.460(1.503～19.839) 0.010 ? ?
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