术前心功能与心脏外科手术后急性肾损伤的相关性研究  

Correlation between preoperative cardiac function and postoperative acute kidney injury after cardiac surgery

作　　者：侯克龙 沈骁 李静[2] 孙芳[2] 邹磊[2] 章淬[2] 穆心苇[2] Hou Ke-long;Shen Xiao;Li Jing;Sun Fang;Zou Lei;Zhang Cui;Mu Xin-wei(Department of Critical Care Medicine,Third Municipal People's Hospital,Bengbu 233000,China;Department of Critical Care Medicine,First Municipal Hospital,Nanjing Medical University,Nanjing 210006,China)

机构地区：[1]蚌埠市第三人民医院重症医学科,233000 [2]南京医科大学附属南京医院(南京市第一医院)重症医学科,210006

出　　处：《临床肾脏病杂志》2021年第10期804-810,共7页Journal Of Clinical Nephrology

摘　　要：目的探讨术前不同心功能与心脏外科术后患者发生急性肾损伤(acute kidney injury, AKI)的相关性以及预后情况。方法本研究为回顾性观察研究,筛选2017年9月至2019年5月期间入住南京医科大学附属南京医院重症医学科的1468例成年心脏外科术后患者。根据NYHA分级标准将患者分为四组,即心功能Ⅰ级、Ⅱ级、Ⅲ级和Ⅳ级,另外,根据测得患者术前氨基末端脑钠肽前体(N-terminal pro-brain natriuretic peptide, NT-proBNP)浓度的四分位数间距(P25、P50、P75)分为4层,即心功能A层、B层、C层和D层,分别比较患者的基本临床资料、术后AKI以及预后情况,多因素逻辑回归分析术后AKI的相关危险因素。结果 1468例成年心脏外科手术后患者有264例发生AKI,总发病率为18.0%。术前心功能分级越高以及NT-proBNP浓度越高的患者,术后AKI发病率越高(分别为12.7%、13.1%、20.7%、35.5%,P<0.001;9.2%、11.2%、16.2%、37.9%,P<0.001),这类患者也更易发生休克、低心排综合征及多器官功能衰竭等并发症,机械通气时间、住院时间及ICU滞留时间也更长,差异均有统计学意义(P<0.05)。多因素逻辑回归分析显示,术前心功能分级(OR=1.43,95%CI:1.36~2.16,P=0.007)、心功能分层(OR=1.64,95%CI:1.54~2.32,P<0.001)、血肌酐、尿酸以及NGAL水平、术中红细胞输注单位量、术后24 h内血乳酸水平是心脏外科术后AKI发生的独立危险因素。NT-proBNP预测术后AKI的受试者工作特征曲线下面积为0.73(95%CI:0.69~0.77,P<0.001)。结论术前心功能分级越高以及NT-proBNP浓度越高的患者心脏术后并发AKI的风险越高,其临床预后越差。因此,这类患者围手术期间应积极纠正贫血、减少失血及输血、改善心功能以及优化容量管理等,以降低术后AKI的发病率。Objective To explore the correlation and prognosis between preoperative cardiac function and postoperative acute kidney injury(AKI)after cardiac surgery.Methods A total of 1,468 adult patients undergoing cardiac surgery were admitted into Intensive Care Unit of First Municipal Hospital from September 2017 and May 2019.According to the classification scheme of New York Heart Association(NYHA),they were divided into four groups of NYHA class Ⅰ,Ⅱ,Ⅲ and Ⅳ.And they were assigned into four levels according to the interquartile range(P25/P50/P75)of preoperative NT-proBNP concentration.General data and clinical outcomes of four groups were compared.And multivariate Logistic regression analysis was utilized for examining the risk factors of postoperative AKI after cardiac surgery.Results Among them, 264 patients(18.0%)developed AKI.These patients with higher preoperative cardiac function classification and NT-proBNP concentration had a higher postoperative incidence of AKI(12.7%,13.1%,20.7%,35.5%,P<0.001;9.2%,11.2%,16.2%,37.9%,P<0.001),a higher risk of postoperative complications(shock, low cardiac output syndrome & multiple organ failure)and longer duration of mechanical ventilation, hospital stay and ICU stay.The above indicators were statistically different(P<0.05).Multivariate Logistic regression analysis revealed that independent risk factors for postoperative AKI:preoperative cardiac function classification(OR=1.43,95%CI:1.36~2.16,P=0.007),preoperative cardiac function stratification(OR=1.64,95%CI:1.54~2.32,P<0.001),serum creatinine, serum uric acid, neutrophil gelatinase-associated lipocalin, intraoperative red blood cell units and postoperative lactate.The area under receiver operating characteristic curve of NT-proBNP for predicting postopeartive AKI was 0.73(95%CI:0.69-0.77,P<0.001).Conclusion Patients with higher cardiac function classification and NT-proBNP concentration have a worse clinical prognosis.For lowering the incidence of postoperative AKI,clinicians should actively correct anemia, reduce blo

关 键 词：心脏功能 心脏外科手术 急性肾损伤 预后 

分 类 号：R654.2[医药卫生—外科学] R692[医药卫生—临床医学]