危重患者腹部大手术术后白蛋白水平与急性肾损伤的相关性研究  

Relationship between postoperative immediate serum albumin level and postoperative acute kidney injury after major abdominal surgery in critically ill patients

作　　者：黎伟 李楠[1] 李双玲[1] Li Wei;Li Nan;Li Shuangling(Department of Surgical Intensive Care Unit,Peking University First Hospital,Beijing 100034,China;Department of Internal medicine,Taiyuan Xinghualing District Central Hospital,Taiyuan 030002,Shanxi,China)

机构地区：[1]北京大学第一医院重症医学科,北京100034 [2]太原市杏花岭区中心医院内科,山西太原030002

出　　处：《中华危重病急救医学》2021年第8期955-961,共7页Chinese Critical Care Medicine

基　　金：国家临床重点专科建设项目(2012-649)。

摘　　要：目的探讨危重患者腹部大手术术后即刻白蛋白(ALB)水平与术后急性肾损伤(AKI)的关系。方法采用回顾性队列研究,查阅2017年6月到2018年7月北京大学第一医院重症医学科实施腹部大手术危重患者的电子病例资料,包括术后ALB水平及肾功能等指标。依据改善全球肾脏病预后组织(KDIGO)AKI诊断及分期标准将患者分为术后发生AKI组和术后无AKI组,分析围手术期AKI发生的危险因素,并进行多因素Logistic回归分析;绘制ALB水平预测AKI发生的受试者工作特征曲线(ROC曲线),确定ALB临界值;并绘制患者术后住院时间的Kaplan-Meier生存曲线。结果共363例危重患者实施腹部大手术,有105例(28.9%)术后发生AKI。与术后无AKI组比较,术后AKI组患者年龄更大(t=-2.794、P=0.005),术前合并糖尿病、慢性肾脏病的比例更高(χ^(2)_(1)=4.613、χ^(2)_(2)=5.427,均P<0.05),美国麻醉医师学会(ASA)分级Ⅲ、Ⅴ级的比例更高(χ^(2)=19.444、P<0.001),基线血清肌酐(SCr)、术前脑利钠肽(BNP)水平更高(U_(1)=2.859、U2=2.283,均P<0.05),术前ALB水平更低(t=3.226、P=0.001),术前使用造影剂的比例更高(χ^(2)=7.431、P=0.006),急诊手术、术中使用血管加压药的比例更高(χ^(2)_(1)=4.211、χ^(2)_(2)=4.947,均P<0.05),入ICU 24 h内非肾序贯器官衰竭评分(SOFA)和急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)更高(U=2.233、t=3.130,均P<0.05),术后即刻ALB<32 g/L的比例更高(χ^(2)=7.601、P=0.006)。ROC曲线分析显示,术后即刻ALB预测术后AKI发生的临界值为32 g/L,其敏感度为86.7%,特异度为28.3%。多因素Logistic回归分析显示,ASA分级、术前使用造影剂、基线SCr、术后即刻ALB<32 g/L为危重患者发生AKI的独立危险因素〔优势比(OR)和95%可信区间(95%CI)分别为2.248(1.458~3.468)、2.544(1.332~4.857)、1.018(1.008~1.027)、2.685(1.383~5.212),均P<0.01〕。与术后无AKI组比较,术后AKI组患者ICU实施机械通气的比例更高(χ^(2)=13.635�Objective To investigate the relationship between albumin(ALB)level immediately after major abdominal surgery and postoperative acute kidney injury(AKI)in critically ill patients.Methods A retrospective cohort study was conducted.Patients who accepted the major abdominal surgery admitted to the department of intensive care unit(ICU)of the Peking University First Hospital from June 2017 to July 2018 were enrolled.Clinical data including the postoperative ALB level and renal function were collected.Patients were divided into postoperative AKI group and postoperative non-AKI group according to the AKI diagnosis and staging criteria of Kidney Disease:Improving Global Outcomes(KIDGO).The risk factors of perioperative AKI occurrence were analyzed,and multivariate Logistic regression analysis was performed.The receiver operator characteristic curve(ROC curve)was plotted for the ALB level to predict the occurrence of AKI and to determine the ALB cut-off value.The Kaplan-Meier survival curve of postoperative survival of patients was drawn.Results A total of 363 critically ill patients underwent major abdominal surgery,and 105 patients(28.9%)suffered from AKI.Compared with the non-AKI group,the patients in the AKI group were older(t=-2.794,P=0.005),preoperative proportions of diabetes and chronic kidney disease were higher(χ^(2)_(1)=4.613,χ^(2)_(2)=5.427,both P<0.05),the proportion of American Society of Anesthesiologists(ASA)grades andⅤwas higher(χ^(2)=19.444,P<0.001),baseline serum creatinine(SCr)and preoperative brain natriuretic peptide(BNP)levels were higher(U_(1)=2.859,U2=2.283,both P<0.05),preoperative ALB level was lower(t=3.226,P=0.001),the proportion of preoperative use of contrast media was higher(χ^(2)=7.431,P=0.006),the proportions of emergency surgery and using vasopressor during surgery were higher(χ^(2)_(1)=4.211,χ^(2)_(2)=4.947,both P<0.05),non-renal SOFA score and acute physiology and chronic health evaluation(APACHE)within 24 hours after ICU admission were higher(U=2.233,t=3.130,both P<0.05),and

关 键 词：腹部大手术 急性肾损伤 白蛋白 预后 

分 类 号：R656[医药卫生—外科学]