1113例心脏瓣膜置换手术后急性肾损伤的临床分析

目的 研究不同类型心脏瓣膜置换手术后急性肾损伤（AKI）的发病情况及其危险因素。 方法 采用前瞻性队列研究。收集本院心外科2009年4月1日至2010年3月31日期间进行心脏瓣膜置换手术患者的临床资料,采用多因素回归方法筛选出各类心脏瓣膜置换患者术后发生AKI的危险因素。AKI诊断标准为48 h内Scr上升≥26.4 μmol/L或较基础值增加≥50%;和（或）尿量<0.5 ml?kg-1?h-1达6 h。结果 1113例瓣膜置换手术患者术后AKI发病率为33.24%,AKI患者住院病死率为6.49%,其死亡风险较非AKI患者增加5.373倍 （P < 0.01）。心脏瓣膜置换伴冠脉搭桥手术术后AKI发病率为75.00%,显著高于其它瓣膜置换手术类型（P < 0.01）。多因素非条件Logistic回归分析表明,年龄（每增加10岁）、男性、术中体外循环时间≥120 min以及心脏瓣膜置换合并冠脉搭桥手术是术后发生AKI的独立危险因素,OR值分别为1.455、2.110、1.768和2.994。 结论 AKI是心脏瓣膜置换手术后常见的严重并发症。心脏瓣膜置换合并冠脉搭桥手术术后更容易发生AKI。高龄、男性、术中体外循环时间≥120 min以及心脏瓣膜置换合并冠脉搭桥手术是心脏瓣膜置换术后发生AKI的独立危险因素。     

心肺转流下心脏瓣膜术后急性肾损伤的危险因素分析

目的探讨成人心肺转流(cardiopulmonary bypass,CPB)下心脏瓣膜手术后急性肾损伤(acute kidney injury,AKI)的危险因素。方法回顾性分析1 349例心脏瓣膜手术患者的临床资料,采用多因素Logistic回归分析心脏瓣膜术后AKI的危险因素。结果 1 349例心脏瓣膜手术患者AKI发生率为28.4%,多因素Logistic回归分析显示,每增加1岁(OR=1.05,95%CI 1.03~1.06,P0.001)、糖尿病史(OR=2.11,95%CI 1.22~3.68,P=0.008)、贫血(OR=1.50,95%CI1.05~2.21,P=0.026)、术前血清肌酐(Scr)值每增加1mg/dl(OR=1.01,95%CI 1.01~1.02,P=0.001)、手术时间每增加1h(OR=1.28,95%CI 1.15~1.41,P0.001)、术中输注血浆(OR=1.50,95%CI 1.14~1.97,P=0.004)是心脏瓣膜术后发生AKI的独立危险因素。结论心肺转流下心脏瓣膜术后急性肾损伤的独立危险因素是高龄、糖尿病史、贫血、术前肌酐高、手术时间长以及术中输注血浆。     

Anemia-associated acute kidney injury after cardiac surgery with cardiopulmonary bypass

Objective To investigate the incidence and to evaluate the risk factors of acute kidney injury (AKI) following cardiac surgery with cardiopulmonary bypass (CPB) at general hospitals. Methods A retrospective cohort database study was conducted, involving 233 patients who were scheduled to heart valve surgery or coronary artery bypass grafting (CABG) with CPB technique. Logistic regression was used to screen out the risk factors of AKI after the surgery. Results The study population, with an average age of 57±12 years (age 21 to 83) were investigated, there were 54(23.2%) diabetes patients, 105 (45.1%) hypertension patients, 21 (9%) chronic kidney disease (CKD) patients, and 51 (21.9%) anemia patients. Overall incidence of AKI was 32.2%. The Analysis Result indicates that preoperative CKD, anemia, hypoalbuminemia, left ventricular ejection fraction, intraoperative aortic block time, minimum mean arterial pressure, perioperative infection, and application of vancomycin are risk factors associated with postoperative AKI. Multiariable Logistic regression suggests that basic CKD (OR=9.498, P=0.001), anemia (OR=3.150, P=0.021), the LVEF before surgery (OR=1.733, P=0.045), intraoperative aortic block time (OR=2.227, P=0.026), and white blood cell (OR=3.357, P=0.032) were the independent risk factors of AKI. Conclusions AKI is a common complication following cardiac surgery with CPB. The patients with preoperative renal insufficiency, anemia, long intraoperative aortic block time and higher perioperative white blood cell count are subjected to a higher incidence of AKI. Alleviating patients’ anemia and reducing artery block of extracorporeal circulation time therefore might be potential means to mitigate the risks of AKI after cardiac surgery.     

Role of body mass index on acute kidney injury patients after cardiac surgery

Objective To explore the association between BMI and the risk of developing cardiac surgery associated acute kidney injury (CS-AKI), mortality of AKI and AKI requiring renal replacement therapy (AKI-RRT) after cardiac surgery. Methods Clinical data of patients undergoing cardiac surgery from January 2011 to December 2015 in Zhongshan Hospital of Fudan University were prospectively collected. Patients were divided into four groups according to BMI classification of Chinese population. Adjustment for selection bias was further assessed using propensity score method (PSM) to evaluate the role of BMI in the development of AKI. Results A total of 8442 patients were enrolled, among which 1092 patients successfully matched through PSM. The AKI incidences were respectively 30.3%, 33.3%, 38.6% and 46.8% in four BMI groups (P＜0.01) before PSM. The AKI incidences were respectively 31.9%, 35.2%, 42.5% and 42.9% in four BMI groups (P=0.016) after PSM. The risk of developing AKI increased by 19.9% as the BMI increased per 5 kg/m2 (95%CI: 1.070-1.344, P=0.002). The hospital mortality of patient (overall, AKI, AKI-RRT) in four groups was not statistically different after PSM (P＞0.05), but overweight group always had the lowest mortality. Conclusions BMI is a risk factor for AKI after cardiac surgery, and the AKI incidence increases with increasing BMI in a certain range.     

成人心脏外科手术相关急性肾损伤的研究进展

心脏外科手术相关急性肾损伤(CSA-AKI)是临床危重症之一,致病因素和发病机制复杂,是临床医生面临的巨大挑战。目前预防及处理CSA-AKI尚存在很多争议。本文重点介绍CSA-AKI的研究进展。     

吸入麻醉和静脉麻醉对心脏手术患者术后急性肾损伤的影响

目的 探讨吸入麻醉和静脉麻醉对心脏手术患者术后急性肾损伤(AKI)的影响。方法 选择行择期心肺转流下心脏手术的患者318例,男156例,女162例,年龄18～81岁,BMI 14～35 kg/m²,ASAⅡ—Ⅳ级。随机分为两组：吸入麻醉组(I组)和静脉麻醉组(P组),每组159例。记录术后2 d内AKI发生率。记录AKI分级和肾脏替代治疗(RRT)发生情况,机械通气时间,ICU停留时间,术后住院时间,麻醉诱导前、到达ICU时、术后24、48 h血清肌酐(Scr)、尿素氮(BUN)、胱抑素C、估计肾小球滤过率(eGFR),术后1、2、3 d液体输入量、尿量、利尿剂使用量,术后30 d主要肾脏不良事件和术后6个月死亡率。结果 术后2 d内I组发生AKI 29例(18.2%),P组25例(15.7%),两组差异无统计学意义。I组被诊断为AKI 2级或3级3例(1.9%),其中1例在住院期间接受RRT,P组无一例接受RRT。两组机械通气时间,ICU停留时间,术后住院时间差异无统计学意义。两组不同时点BUN、胱抑素C、eGFR,术后1、2、3 d液体输入量、尿量、利尿剂使用...     

心脏术后尿中性粒细胞明胶酶相关脂质运载蛋白和白细胞介素18与急性肾损伤的关系

目的 探讨接受体外循环心脏手术患者尿中性粒细胞明胶酶相关脂质运载蛋白（NGAL）和尿白细胞介素18（IL-18）与急性肾损伤（AKI）的关系。 方法 根据AKI的诊断标准，将33例体外循环心脏手术的患者分为AKI组及非AKI组，分别留取术前及术后不同时间点的血液和尿液标本，测定Scr、尿NGAL和IL-18水平。 结果 33例中有9例发生AKI，发生率为27.27%。AKI组Scr升高峰值出现在12～48 h内。与术前相比， AKI组术后2 h、4 h尿NGAL及IL-18水平升高，差异有统计学意义（P < 0.01）。与非AKI组比较，AKI组术后各时间点的尿NGAL水平、术后2 h及4 h的尿IL-18水平都较高，差异有统计学意义（P < 0.01）。经尿肌酐（Ucr）校正后，相应时间点的NGAL/Ucr和IL-18/Ucr差异仍有统计学意义（P < 0.01）。术后2 h尿NGAL和尿NGAL/Ucr的界定（cutoff） 值分别在250 µg/L和250 µg/mmol时；术后2 h尿IL-18和尿IL-18/Ucr的界定值分别在1800 ng/L和1800 ng/mmol时，体现出较好的敏感性和特异性。 AKI组术后12 h Scr水平与术后2 h尿NGAL水平呈正相关（r = 0.638，P < 0.05）。结论 体外循环下接受心脏手术的患者AKI发生率较高；术后2 h尿NGAL和NGAL/Ucr、术后2 h尿IL-18和尿IL-18/Ucr当达到一定界定值时，均可作为体外循环下心脏手术后AKI发生的早期诊断参考指标，其中术后2 h尿NGAL/Ucr为250 µg/mmol时更敏感。     

术前高敏C反应蛋白水平与成人心脏手术后急性肾损伤的相关性

目的 分析术前高敏C反应蛋白（hs-CRP）水平与成人心脏手术后急性肾损伤（AKI）的相关性。
方法 本研究为回顾性病例-对照研究。收集2017年1月至2018年12月行开放心脏手术的成年患者病历资料。根据改善全球肾脏病预后组织（KDIGO）标准判断AKI。采用多因素Logistic回归分析评估术前hs-CRP水平>3 mg/L与术后AKI的相关性。
结果 本研究共纳入患者17 339例,术后有5 231例（30.1%）发生AKI。术前hs-CRP>3 mg/L的患者有4 350例（25.1%）。单因素分析显示,AKI患者术前存在hs-CRP>3 mg/L的比例明显高于非AKI患者（30.5% vs 24.8%,P<0.001）。在校正了性别、年龄、既往史、术前心功能、术前肾功能、术中输血情况等因素后,术前hs-CRP>3 mg/L是成人心脏术后发生AKI的独立危险因素（OR=1.145, 95%CI 1.052～1.246,P=0.002）。
结论 术前hs-CRP水平>3 mg/L会增加心脏术后AKI的发生风险。     

Urinary aprotinin as a predictor of acute kidney injury after cardiac surgery in children receiving aprotinin therapy

Proteomic analysis has revealed potential early biomarkers of acute kidney injury (AKI) in children undergoing cardiopulmonary bypass (CPB), the most prominent one with a mass-to-charge ratio of 6.4 kDa. The objective of this study was to identify this protein and test its utility as a biomarker of AKI. Trypsin-digested protein bands were analyzed by tandem mass spectrometry (MS/MS) to identify the protein in urine samples. Surface-enhanced laser desorption/ionization time-of-flight analysis and a functional activity assay were performed to quantify urinary levels in a pilot study of 106 pediatric patients undergoing CPB. The protein was identified as aprotinin. Urinary aprotinin levels 2 h after initiation of CPB were predictive of AKI (for functional assay: 92% sensitivity, 96% specificity, area under the curve of 0.98). By multivariate analysis, the urinary aprotinin level 2 h after CPB was an independent predictor of AKI (beta = 0.001, P < 0.0001). The 2 h urinary aprotinin level correlated with serum creatinine, duration of AKI, and length of hospital stay. We concluded that urinary aprotinin levels 2 h after initiation of CPB predict the development of AKI and adverse clinical outcomes.     

Risk factor for acute kidney injury in patients with chronic kidney disease receiving valve surgery with cardiopulmonary bypass

IntroductionAcute kidney injury (AKI) after cardiopulmonary bypass (CPB) in patients with pre-existing impaired renal function carries deleterious outcomes but is not frequently evaluated. The optimal CPB strategy for preventing AKI in this vulnerable patient group is still controversial.MethodsA total of 156 patients with preoperative estimated glomerular filtration rate (e-GFR) <30 ml/min but not on chronic dialysis receiving valve operation under CPB were included in the present study. Postoperative AKI was defined as KDIGO (Kidney Disease Improving Global Outcomes) stage 3. Hospital mortality and two-year renal function evolution were compared between patients with postoperative AKI and those without AKI. Risk factors for the development of postoperative AKI were also studied.ResultsThe incidence of postoperative KDIGO-3 was high (44.2%). Hospital mortality was higher in the AKI group (30.4%) than in the non-AKI group (8.0%). Among the hospital survivors, renal function deterioration to permanent dialysis at two years was also more common in AKI group (14.5%) than in non-AKI group (4.6%). Univariate logistic regression for postoperative AKI revealed male gender, increased age, height, weight, BSA, and BMI, high preoperative serum creatinine, prolonged CPB duration, and decreased CPB target temperature as risk factors. However, multivariate analysis revealed only high preoperative serum creatinine and decreased CPB target temperature as significant risk factors for postoperative AKI.ConclusionTo prevent postoperative AKI in CKD patients, low CPB target temperature is avoided, especially for those with high preoperative serum creatinine levels.     

输血与心脏移植术后急性肾损伤相关性研究

目的研究围术期输血和心脏移植术后急性肾损伤(acute kidney injury,AKI)的相关性。方法选取2016年1月至2018年12月在广东省人民医院心外科行心脏移植术的67例患者作为研究对象。根据排除标准最后纳入63例患者,其中男53例、女10例,平均年龄(44.3±12.9)岁。将20例心脏移植术后使用连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)的患者作为RT组,另外将没有使用CRRT的43例患者作为非RT组。比较两组患者基线资料、围术期输血资料及临床预后等指标。结果两组术前基线特征基本一致。两组在围术期输注红细胞量和血浆量、术后24 h出血量、是否再次手术探查等方面差异均有统计学意义(P<0.05)。多因素分析发现围术期输注红细胞量是AKI的独立危险因素(OR=1.115)。相关性分析显示肾损伤程度与围术期输注红细胞量呈正相关(r=0.686,P<0.05)。受试者工作特征(ROC)曲线下面积为0.923(95%CI 0.852~0.995,P<0.001)。经ROC曲线计算发现围术期输注红细胞超过18 mL/kg将增加心脏移植术后AKI发生率。结论围术期输血和心脏移植术后AKI密切相关,临床中输血越多肾损伤发生率越高、预后越差,建议可开展多种节约用血措施。     

Platelet-leukocyte aggregates – a predictor for acute kidney injury after cardiac surgery

BackgroundAcute kidney injury (AKI) is one of the most common complications after cardiac surgery. However, effective biomarker used for early diagnosis of AKI has not been identified. Platelet-leukocyte aggregates (PLAs) participate in inflammation and coagulation, leading to vascular lesions and tissue destruction. We designed a prospective study to assess whether PLAs can serve as a good biomarker for early diagnosis of AKI after cardiac surgery.MethodsPatients with rheumatic heart disease scheduled to undergo valve replacement surgery were enrolled. Blood samples were collected at five timepoints as follows: (a) At baseline. (b) At the end of extracorporeal circulation. (c) Arrival at intensive care unit (ICU). (d) Four-hours after the admission to ICU. (e) Twenty hours after the admission to ICU. After collection, the samples were immediately used for PLAs measurement by flow cytometry.ResultsA total of 244 patients were registered, and 15 of them were diagnosed with AKI according to the serum creatinine of KDIGO guidelines. The PLAs levels in AKI group were significantly increased 20 h after surgery (two-way repeated measure analysis of variance, p < 0.01) compared with that at baseline. Patients whose preoperative PLAs were higher than 6.8% showed increased risk of developing AKI (multivariate logistic regression; p = 0.01; adjusted odds ratio, 1.05; 95% confidence interval, 1.01–1.09).ConclusionPLAs is an independent risk factor for AKI after valve replacement among patients with rheumatic heart disease.     

左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

目的探讨左心瓣膜置换术后远期三尖瓣关闭不全(TR)发生的可能机制以及外科治疗方法的选择和结果.方法 56例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人,10例人工瓣膜功能正常(A组)者中行二尖瓣置换(MVR)4例,主动脉瓣、二尖瓣双瓣置换(DVR)6例;46例人工瓣膜功能障碍(B组)者中MVR 36例,主动脉瓣置换(AVR)4例, DVR 6例.在A、B两组中,46例第1次手时三尖瓣未见明显异常,10例第1次手术时已行DeVega三尖瓣成形(TVP),第2次手术时发现缝线断裂3例,缝线撕脱7例.56例TR病人再次手术时9例行三尖瓣替换(TVR),其中6例三尖瓣呈风湿性改变;47例行TVP.结果 TVP和TVR各死亡1例,病死率3.6%.54例获随访,随访时间6～132个月,平均(79.4±34.8)个月.8例TVR病人术后心功能恢复良好,46例TVP者40例为轻度TR,5例出现中度TR,仍需强心、利尿药维持,1例再次出现重度TR.结论左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关.重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠.随访发现部分TVP病人功能性TR仍有逐渐加重趋势.     

A new model to predict acute kidney injury after cardiac surgery in patients with renal insufficiency

ObjectiveTo establish a simple model for predicting postoperative acute kidney injury (AKI) requiring renal replacement therapy (RRT) in patients with renal insufficiency (CKD stages 3–4) who underwent cardiac surgery.MethodsA total of 330 patients were enrolled. Among them, 226 were randomly selected for the development group and the remaining 104 for the validation group. The primary outcome was AKI requiring RRT. A nomogram was constructed based on the multivariate analysis with variables selected by the application of the least absolute shrinkage and selection operator. Meanwhile, the discrimination, calibration, and clinical power of the new model were assessed and compared with those of the Cleveland Clinic score and Simplified Renal Index (SRI) score in the validation group. Results: The rate of RRT in the development group was 10.6% (n = 24), while the rate in the validation group was 14.4% (n = 15). The new model included four variables such as postoperative creatinine, aortic cross‐clamping time, emergency, and preoperative cystatin C, with a C-index of 0.851 (95% CI, 0.779–0.924). In the validation group, the areas under the receiver operating characteristic curves for the new model, SRI score, and Cleveland Clinic score were 0.813, 0.791, and 0.786, respectively. Furthermore, the new model demonstrated greater clinical net benefits compared with the Cleveland Clinic score or SRI score.ConclusionsWe developed and validated a powerful predictive model for predicting severe AKI after cardiac surgery in patients with renal insufficiency, which would be helpful to assess the risk for severe AKI requiring RRT.     

Transapical versus transfemoral approach and risk of acute kidney injury following transcatheter aortic valve replacement: a propensity-adjusted analysis

Background: The aim of this study was to compare the incidence of post-procedural acute kidney injury (AKI) and other renal outcomes in patients undergoing transapical (TA) and transfemoral (TF) approaches for transcatheter aortic valve replacement (TAVR).

Methods: All consecutive adult patients undergoing TAVR for aortic stenosis from 1 January 2008 to 30 June 2014 at a tertiary referral hospital were included. AKI was defined based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Logistic regression adjustment, propensity score stratification, and propensity matching were performed to assess the independent association between procedural approach and AKI.

Results: Of 366 included patients, 171 (47%) underwent TAVR via a TA approach. AKI occurrence in this group was significantly higher compared to the TF group (38% vs. 18%, p?Conclusion: In a cohort of patients undergoing TAVR for aortic stenosis, a TA approach significantly increases the AKI risk compared with a TF approach. However, the TAVR approach did not affect severe renal outcomes or long-term renal function.     

Metabonomics of acute kidney injury in children after cardiac surgery

Acute kidney injury (AKI) is a major complication in children who undergo cardiopulmonary bypass surgery. We performed metabonomic analyses of urine samples obtained from 40 children that underwent cardiac surgery for correction of congenital cardiac defects. Serial urine samples were obtained from each patient prior to surgery and at 4 h and 12 h after surgery. AKI, defined as a 50% or greater rise in baseline level of serum creatinine, was noted in 21 children at 48–72 h after cardiac surgery. The principal component analysis of liquid chromatography/mass spectrometry (LC/MS) negative ionization data of the urine samples obtained 4 h and 12 h after surgery from patients who develop AKI clustered away from patients who did not develop AKI. The LC/MS peak with mass-to-charge ratio (m/z) 261.01 and retention time (t_R) 4.92 min was further analyzed by tandem mass spectrometry (MS/MS) and identified as homovanillic acid sulfate (HVA-SO₄), a dopamine metabolite. By MS single-reaction monitoring, the sensitivity was 0.90 and specificity was 0.95 for a cut-off value of 24 ng/μl for HVA-SO₄ at 12 h after surgery. We concluded that urinary HVA-SO₄ represents a novel, sensitive, and predictive early biomarker of AKI after pediatric cardiac surgery.     

主动脉瓣置换术后人工心脏瓣膜-病人不匹配现象

目的 探讨主动脉瓣置换术后人工心脏瓣膜-病人不匹配(PPM)现象的发生率以及PPM与术后早期血流动力学和病死率的关系.方法 292例主动脉瓣置换手术(AVR)病人,参照人工瓣膜有效开口面积(EOA)和病人的体表面积计算有效开口面积指数(EOAI),EOAI＞0.85 cm2/m2不存在或仅有轻度的PPM;中度PPM 0.65≤EOAI≤0.85 cm2/m2;重度PPM EOAI＜0.65 cm2/m2.超声多普勒测量AVR术后主动脉瓣位平均跨瓣压差和血流速度,比较不同种类瓣膜(机械瓣和生物瓣)和不同大小瓣膜(＞21 mm和≤21 mm)AVR术后PPM发生率以及PPM与术后早期血流动力学、病死率的关系.结果 292例中机械瓣置换术219例,生物瓣置换术73例,两种术后中度PPM发生率分别为6.25%和48.22%(P＜0.01).置换＞21 mm人工瓣膜(191例)和≤21 mm人工瓣膜(101例)术后PPM发生率分别为13.61%和33.66%(P＜0.05).PPM组术后主动脉瓣平均跨瓣压差和平均流速[(26.50±6.25)mm Hg(1 mm Hg=0.133 kPa)和(2.66±0.87)m/s]显著高于非PPM组[(16.75±3.46)mm Hg和(1.58±0.47)m/s,P＜0.01].PPM组和非PPM组的术后早期病死率分别为6.67%和2.16%(P＜0.05).结论 AVR术后PPM现象普遍存在,尤其是置换生物瓣以及小瓣膜(≤21 mm)者.PPM影响术后瓣膜血流动力学,与术后早期病死率密切相关.