心脏手术后急性肾损伤预测模型的初步建立与验证  

Establishment and validation of a clinical risk model to predict acute kidney injury after cardiac surgery

作　　者：邹周平[1] 姜物华[1,2] 丁小强[1,2,3] 方艺[1,2,3] 许佳瑞[1,2] 姜俊[1] 刘岚[4] 王春生[4] 滕杰[1,2,3] 

机构地区：[1]复旦大学附属中山医院肾脏科,上海200032 [2]上海市肾病与透析研究所 [3]上海市肾脏疾病与血液净化重点实验室 [4]复旦大学附属中山医院心脏外科,上海200032

出　　处：《上海医学》2015年第5期366-372,共7页Shanghai Medical Journal

基　　金：国家十二五支撑计划(2011BAI10B07);上海市科学技术委员会科研计划(12DJ1400201;14DZ2260200)资助项目

摘　　要：目的 初步建立心脏手术后急性肾损伤（AKI）患者发病的预测模型,并进行验证。方法 连续收集2010年5月—2011年1月于复旦大学附属中山医院心外科行冠状动脉旁路移植术（CABG）、非体外循环冠状动脉旁路移植术（OPCAB）、瓣膜手术或瓣膜手术联合CABG的1 394例患者的临床资料。采用2012年KDIGO（kidney disease：improving global outcomes）指南的AKI诊断标准,其中1 067例患者作为模型建立组,对心脏手术后AKI的发病率和危险因素进行统计分析,建立数学预测模型;余300例患者为模型验证组,通过分辨力（ROC曲线的AUC）和校准度（Hosmer-lemeshow拟合优度检验）验证模型的预测价值。结果 模型建立组手术后AKI发病率为20.3%（217/1 067）,肾脏替代治疗（RRT）治疗率为3.5%（38/1 067）,病死率为3.3%（35/1 067）。AKI患者的RRT治疗率为17.5%（38/217）,病死率为13.8%（30/217）。单因素分析结果显示,心脏手术后AKI发病危险因素包括术前因素（男性、年龄、糖尿病、需要治疗的糖尿病、高血压、冠状动脉性心脏病、脑血管病、慢性阻塞性肺疾病、术前7d内行冠状动脉造影检查、纽约心脏病学会心功能分级Ⅲ级及以上、左心室射血分数〈0.5、术前血清肌酐水平、术前肾小球滤过率估算值、术前尿液检查异常）、术中因素（CPB时间、瓣膜手术联合CABG、术中输红细胞悬液〉400mL、术中输血浆〉400mL、术中净入量〉1 200mL）和术后因素／[术后发生低心排综合征、术后中心静脉压〉14cmH2O（1cmH2O=0.098kPa）／]。Logistic逐步回归分析显示,男性（OR=1.645,95%CI为1.142-2.369）、有脑血管病史（OR=5.534,95%CI为3.061-10.006）、瓣膜手术联合CABG（OR=3.511,95%CI为0.827-14.906）、术前血清肌酐水平〉115μmol/L（OR=2.325,95%CI为1.351-4.001）、术前7d内行冠状动脉造影检查（OR=1.609,95%CI为1.147-2.257）、术前纽约心脏病学会心功能分级Objective To establish and validate a risk model to predict acute kidney injury （AKI） after cardiac surgery. Methods Clinical data of 1394 patients undergoing cardiac surgery including coronary artery bypass grafting （CABG）, off pump coronary artery bypass （OPCAB）, valve surgery, CABG with or without valve surgery in the department of cardiac surgery in the Zhongshan hospital, Fudan university between May 2010 and January 2011 were collected. AKI was finally diagnosed according to 2012 Kidney Disease.. Improving Global Outcomes （KDIGO）. Logistic regression was used to analyze the incidence and risk factors of AKI among 1 067 patients, and the other 300 patients were set for validation by means of Hosmer-Lemeshow goodness-of-fit test for the calibration and receiver operation characteristic （ROC） curves with area under ROC curve （AUROC） for the discrimination. Results The incidence of AKI and renal replacement therapy （RRT） after cardiac surgery in the derivation cohort were 20.3% （217/1 067） and 3.5% （38/1 067）, respectively. The mortality of derivation cohort was 3.3% （35/1 067）. Among the AKI patients, the RRT rate was 17.5% （38/217） and the mortality was 13.8% （30/217）. The univariate analysis showed that the risk factors of AKI after cardiac surgery included preoperative （male, age, diabetes, treatment required diabetes, hypertension, coronary heart disease, cerebrovascular disease, chronic obstructive pulmonary diseases, coronary angiography within 7 days, New York Heart Association [NYHA} classification of cardiac function〉Ⅱ, left ventricular ejection fraction〈0.5, baseline serum creatinine [sCr], baseline glomerular filtration rate, and baseline urine abnormity）, intra-operative （cardiopulmonary bypass time, valve surgery plus CABG, intra-operative erythrocyte suspension infusion〉400 mL, intra-operative plasma infusion〉400 mL, and intra-operative net inpuE〉 1 200 mL） and postoperative ones （low cardiac output syndrome [LCOS-], central ve

关 键 词：心脏手术 急性肾损伤 预测模型 危险因素 

分 类 号：R654.2[医药卫生—外科学]