三种心脏外科术后急性肾功能衰竭预测模型的临床应用

目的 分析克利夫兰急性肾功能衰竭评分(Cleveland ARF Score)、心脏术后急性肾功能不全评分(acute kidney injury prediction following elective cardiac surgery,AKICS)、简易肾功能指数评分(Simplified Renal Index,SRI score)三种模型在预测心脏术后发生急性肾功能衰竭中的作用,评价三种模型的预测价值.方法 2009年6月至2010年5月,连续收集了行心脏手术并有完整资料的患者504例纳入研究,分别使用Cleveland、AKICS、SRI评分系统进行校准度和分辨力的评价,分析并比较三种评分系统模型对术后发生急性肾功能衰竭的预测价值.结果 504例中术后需要肾脏替代治疗(renal re-placement therapy,RRT) 16例(3.17％),其中6例死亡(37.5％);发生肾功能不全27例(5.36％),经治疗后肾功能恢复正常.应用AKICS模型术后需要RRT治疗11例(2.70％),发生肾功能不全25例(6.13％),模型全组预计发生率3.77％.Cleveland评分术后需要RRT治疗16例(3.17％),发生肾功能不全27例(5.36％),模型全组预计发生率0.99％.SRI评分术后需要RRT治疗15例(3.21％),发生肾功能不全24例(5.13％).与预测结果比较,AKICS模型表现出较好的校准度(P=0.922,x2=0.162),Cleveland模型校准度差异有统计学意义(P=0.026,x2=15.644).Cleveland Score、AKICS、SRI 预测术后急性肾功能衰竭需行RRT治疗的ROC曲线下面积分别为0.695、0.732、0.759,术后肾功能不全的ROC曲线下面积分别为0.711、0.753、0.779.结论 结果显示,SRI模型预测术后RRT治疗及肾功能不全的实际危险度相关性较好.AKICS模型预测术后肾功能不全的实际危险度相关性较好.SRI模型的校准度及分辨能力均较好,可能较适用于评估患者的相对危险度.AKICS模型对于研究设计及选择治疗方案有一定使用价值.     

RIFLE肾功能分级对心脏术后ECMO辅助病人转归的预测意义

目的 探讨RIFLE肾功能分级系统与住院死亡的相关关系,并探讨其对病人转归的预测意义.方法 收集2004年10月至2006年11月40例心脏手术后应用体外膜肺氧合(ECMO)进行支持治疗的成年病人资料,包括术后呼吸机辅助时间、监护室停留时间及转归等.结果 ECMO辅助平均(56.8±44.1)h.32例成功脱离ECMO,脱机率为80%,22例生存出院,总病死率45%.RIFLE分级系统ROC曲线下面积为0.904(95%可信区间0.798～1.010,P＜0.01)与病死率之间有很好的相关性.结论 RIFLE分级系统能够可靠预测ECMO辅助治疗病人的预后及死亡,应用简便、快捷.     

肝移植病人术后急性肾功能衰竭18例临床分析

目的:探讨影响肝移植术后发生急性肾功能衰竭的原因及处理方法。方法:回顾性分析我院91例肝移植病人中发生与未发生术后急性肾功能衰竭病人的临床资料,采用单因素分析和Logistic回归模型进行多因素分析。结果:肾衰组病人1年生存率低于对照组;与术后发生早期急性肾功能衰竭的有关因素包括术前血清肌酐、总胆红素、总手术时间、术中出血量、输血量、术中输液总量、术中尿量。术前血清肌酐高和术中尿量是术后早期急性肾功能衰竭发生的独立影响因素。移植术后发生急性肾功能衰竭的病人ICU留置时间延长,术后住院时间延长,住院费用升高。结论:肝移植术后有较高的急性肾功能衰竭发生率,对术后少尿、血清肌酐水平升高的病人及早实施肾脏替代等治疗能有效降低其发病率和死亡率。     

与术后急性肾衰相关的术前危险因素

急性肾衰是术后严重并发症之一，本文根据几十年来的文献报道，对１０８６５例病人进行统计学分析以明确急性肾衰的相关因素。     

心脏术后多器官功能障碍综合征的防治

目的 总结３０例心脏术后多器官功能障碍综合征（ＭＯＤＳ）病人防治体会。方法 对３０例ＭＯＤＳ病人的临床资料进行了分析,并对ＭＯＤＳ的预防进行了探讨。结果 ２１例心肺功能病人,死亡１例;５例３个系统衰竭病人,死亡４例;４例３个以上系统衰竭病人,全部死亡。总死亡倒数占心脏病人总数的０．９％,占ＭＯＤＳ的３３．３％。结论 提高手术技巧、缩短主动脉阻断时间、正确处理低心排、细致的呼吸系统管理、预防感染、充     

心脏术后急性肾功能衰竭

急性肾功能衰竭是心脏术后常见而严重的并发症 ,是患者死亡率增加的独立危险因素 ,探讨心脏术后发生ARF的危险因素 ,并积极预防和治疗是近年来研究的热点之一 ,本文就心脏术后发生急性肾功能衰竭的相关因素、治疗和预后等问题的临床研究进展作一综述     

心脏术后急性肾功能衰竭

急性肾功能是心脏术后常见而严重的并发症，是患者死亡率增加的独立危险因素，探讨心脏术后发生ARF的危险因素，并积极预防和治疗是近年来研究的热点之一，本文就心脏术后发生急性肾功能衰竭的相关因素、治疗和预后等问题的临床研究进展作一综述。     

心脏手术后急性肾损伤研究进展

急性肾衰竭(acute renal failure,ARF)是心脏手术后常见的并发症之一,与住院时间延长和死亡率增高密切相关.近两年急性肾功能衰竭的概念已被急性肾损伤(acute kidney injury,AKI)所替代,本文就心脏手术后急性肾损伤的研究进展作一综述.     

AKIN标准联合APACHEⅡ和SOFA评分对心脏术后急性肾损伤的预后评估

目的 探讨急性肾损伤网络（AKIN）制定的急性肾损伤（AKI）诊断标准联合急性生理与慢性健康状况评分Ⅱ（APACHEⅡ）和序贯器官衰竭评估（SOFA）评分对心脏术后AKI的预后评估价值。 方法 前瞻性收集2009年4月至8月期间在本院行心脏手术患者的临床资料,采用AKIN标准对心脏术后患者进行AKI诊断和分期;根据患者术后第1个24 h内的生理指标最差值进行APACHEⅡ和SOFA评分,并用受试者工作特征（ROC）曲线和Hosmer-Lemeshow拟合优度检验评价3项评估系统的分辨力和校准力。以Logistic多元回归分析它们对预后的影响。 结果 993例患者中309例术后出现AKI,发病率为31.1%。患者AKI诊断日和首次达AKIN 最高分期日距手术的中位间隔时间分别为1 d和2 d。AKIN 1、2、3期患者的APACHEⅡ及SOFA评分均高于非AKI患者（P < 0.01）,且分值与AKIN分期呈正相关（APACHEⅡ r = 0.37,P < 0.01;SOFA r = 0.42,P < 0.01）。病死率亦随AKIN分期升高而升高。非AKI组、AKIN 1期患者根据APACHEⅡ分值计算所得的校正预计病死率（PDR-A）明显高于实际病死率（P < 0.01）,而AKIN 3期PDR-A则低于实际病死率（P < 0.01）。APACHE Ⅱ、SOFA评分及AKIN分期的ROC曲线下面积（AUC）均>0.8,且Hosmer-Lemeshow拟合优度检验提示模型拟合较好。Logistic多元回归分析显示APACHEⅡ≥19（OR = 4.26）和AKIN 3期（OR = 76.15）是心脏术后患者院内死亡的独立预测指标。 结论 AKIN标准能在心脏术后早期对患者进行AKI诊断和分期,且在一定程度上发挥预后评估的作用。APACHEⅡ和SOFA在术后第1个24 h内的评分能较好区分病情的严重程度。3者作为预测模型均显示了对于整体预后较好的分辨力和校准力,且APACHEⅡ≥19和AKIN 3期是心脏术后患者院内死亡的独立预测指标。需注意APACHEⅡ计算所得的PDR-A与AKIN不同分期组实际病死率相比存在偏差,动态评分可能有助于提高预测准确性。     

联合实施心脏瓣膜置换术和肾移植术治疗心脏瓣膜病合并慢性肾功能衰竭

目的 探讨有心脏手术指征但合并肾功能衰竭的患者的手术治疗途径。方法 为1例患有严重的风湿性心脏瓣膜病（心功能Ⅲ-Ⅳ级）,同时合并慢性肾功能衰竭（血尿素氮19.1mol/L。血肌酐442umol/L)的28岁男性患者,联合实施心脏瓣膜置换术和同种异体肾移植术,术后经过抗心衰、抗排异、纠正水电解质平衡紊乱及抗炎治疗。结果 患者心、肾功能恢复良好（心功能Ⅰ-Ⅱ级,血尿素氮6.8mmol/L,血肌酐70.7umol/L),术后2个月出院。结论 联合手术能够为以往因合并肾衰而不能耐受心脏手术的心脏疾病患者提供一个有效的治疗方案。     

Renji acute kidney injury score is a useful tool to predict acute kidney injury after cardiac surgery

Objective To validate the effect of Renji acute kidney injury score (RAKIS) on predicting patients with acute kidney injury (AKI) after cardiac surgeries, and make comparison with Cleveland score, simplified renal index (SRI) and acute kidney injury following cardiac surgery (AKICS). Methods Patients undergoing open heart surgery from 2008/01/01 to 2010/10/31 in Renji hospital were enrolled, and their scores of those four scoring models were calculated. AKI patients were diagnosed by KDIGO, and those scores of AKI patients and non-AKI patients were compared. Receiver operating characteristic (ROC) curve and area under curve (AUC) were used to decide the predictive values of those models. Results A total of 1126 patients were chosen in this cohort, with the average age of (58.43±14.88) years (rang from 18 to 88). The male to female ratio was 1.47∶1. And 355(31.5%) patients were developed AKI. AKI stage Ⅰ, Ⅱ and Ⅲ were 65.4%, 23.7% and 11.0% respectively. RAKIS was significantly higher in AKI patients than in non-AKI patients (17.5 vs 9.0, P＜0.001). The AUCs of RAKIS to predict AKI, AKI Ⅱ-Ⅲ stages, renal replacement therapy (RRT) and in-hospital death were 0.818, 0.819, 0.800 and 0.784 respectively. The AUCs of Cleveland score and SRI were 0.659 to 0.710, lower than those of RAKIS and AKICS. AKICS had lower value for predicting AKI and AKI Ⅱ-Ⅲ stages (AUC 0.766 and 0.793), but good value in predicting RRT and in-hospital death after surgery (AUC 0.804 and 0.835) as compared with RAKIS. Conclusions RAKIS is valid and accurate in the discrimination of KDIGO defined AKI patients, while for predicting the composite end point, AKICS may be more useful.     

老年心脏手术后急性肾损伤可纠正的危险因素分析

目的 探讨老年心脏手术患者术后急性肾损伤(AKI)可纠正的危险因素,降低其发生率,改善预后.方法 收集广东省人民医院2007年1月至2009年12月年龄≥60岁心脏手术患者的临床资料.以RIFLE标准诊断的AKI为观察终点,术前最后一次血肌酐为基线值.Logistic回归分析确定心脏术后AKI的独立危险因素.结果 457例患者入组,313例(68.5％)术后发生AKI.Logistic回归分析显示,男性、年龄＞ 65岁、高血压、术前估算肾小球滤过率＜60 ml/min、术前尿酸＞450 μmol/L(OR 2.938,95％可信区间1.633 ～5.285)、体外循环＞120 min、机械通气时间延长、术后用血管紧张素抑制酶/血管紧张素受体抑制剂和利尿剂是心脏术后AKI的独立影响因素.结论 术前尿酸＞450 μmol/L是老年心脏手术患者术后AKI可纠正的危险因素.     

急性肾损伤生物学标志物在心脏外科术后的研究进展

急性肾损伤是心脏外科手术后常见的严重并发症,发病率和病死率均较高.血肌酐及尿量作为急性肾损伤的标志物缺乏敏感性,延误了早期有效的治疗.近年来对于诊断急性肾损伤的生物学标志物方面的研究取得了较大进展,有些指标已逐步进入临床研究阶段,其中包括中性粒细胞明胶酶相关脂质运载蛋白、胱抑素C、肾损伤分子-1、白细胞介素-18等.本文旨在对心脏外科术后急性肾损伤早期生物学标志物基础及临床方面的研究进展作一综述.     

Validation of 5 prediction models for acute kidney injury and its outcome after cardiac surgery procedures in Chinese patients

ObjectiveTo assess the clinical usefulness and value of the 5 models for the prediction of acute kidney injury (AKI), severe AKI which renal replacement treatment was needed (RRT-AKI) and death after cardiac surgery procedures in Chinese patients. Methods One thousand and sixty - seven patients who underwent cardiac surgery procedures in the department of cardiac surgery in the Zhongshan Hospital, Fudan University between May 2010 and January 2011 were involved in this research. The predicting value for AKI (AKICS), RRT-AKI (Cleveland, SRI and Mehta score) and death (EURO score) after cardiac surgery procedures was evaluated by Hosmer-Lemeshow goodness-of-fit test for the calibration and area under receiver operation characteristic curve (AUROC) for the discrimination. ResultsThe incidence of AKI was 20.34%(217/1067), and 63.13% of their renal function recovered completely. The incidence of RRT-AKI was 3.56%(38/1067) and the mortality of AKI and RRT - AKI was 9.68%(21/217) and 44.73%(17/38) respectively. The total mortality was 3.28%（35/1067）. The discrimination and calibration for the prediction of AKI of AKICS were low. For the prediction of RRT-AKI, the discrimination and calibration of Cleveland score were high enough, but the predicated value was lower than the real value (1.70% vs 3.86%). The discrimination of Mehta score and the calibration of SRI were low. The discrimination and calibration for the prediction of death of EURO score was low. ConclusionAccording to the 2012 KDIGO AKI definition, none of the 5 models above is good at predicting AKI after cardiac surgery procedures. Cleveland score has been validated to have a proper impact on predicting RRT-AKI after cardiac surgery procedures, but the predicting value is still in doubt. EURO score has been validated to have an inaccurate predicting value for death after cardiac surgery procedures.     

心脏术后低排综合征致急性肾功能衰竭的腹膜透析治疗

目的　探讨腹膜透析对心脏术后低排综合征 (LOS)致急性肾功能衰竭 (ARF)的疗效。方法　 2 4例心脏术后引起LOS合并多脏器功能衰竭 (MSOF)致ARF者 ,因不适合血液透析 (HD) ,于确诊后 2 4小时内进行腹膜透析 (PD)治疗。结果　 12例患者多脏器严重衰竭死亡 ,9例患者PD 3～30天内肾功能恢复 ,3例治疗后病情好转 ,自动出院。结论　心脏术后LOS致MOSF合并有ARF者 ,PD具有较好的治疗效果。     

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。     

成人体外循环心脏手术后急性肾损伤的危险因素分析

目的 探讨成人体外循环心脏手术后急性肾损伤(AKI)的发病情况及危险因素.方法 回顾性分析2006年9月至2011年7月行体外循环心脏手术的成人患者6665例.根据术后是否发生AKI分为两组,AKI组1779例,非AKI组4886例.收集患者临床资料,采用单因素和多因素Logistic回归分析AKI发生的危险因素.结果 AKI组中102例(1.53％)进行了肾脏替代治疗(RRT),院内死亡44例;非AKI组死亡14例,AKI组住院病死率显著高于非AKI组患者(2.47％对0.29％,P＜0.01).多因素Logistic回归分析显示,男性、年龄(每增加10岁)、高血压史、糖尿病史、术前基础血肌酐值≥115μmol/L、术前血尿酸值≥420 μmol/L、术前左心室射血分数＜0.40、术前贫血、手术类型(主动脉瘤手术)、体外循环≥120 min、深低温停循环的应用、术后低血压、术后24 h内输血量≥1000 ml、术后机械通气≥72 h是体外循环心脏术后发生AKI的独立危险因素.结论 AKI是成人体外循环心脏手术后的常见并发症,与术后病死率的增加有关.AKI的发生与多种围手术期危险因素有关,应充分重视这些危险因素的评估和预防.     

肾功能损伤分级系统在成人心脏术后的应用

Objective The aim of this study was to evaluate of adilty of two acute renal failure-specific scoring systenms (the classification by Bellome et al and the AKIN criteria) for predicting hospital mortality after cardiac surgery in adult patients. Methods Between October 1 st 2006 to Decemjber 31 st 2006, 509 adult patients who ungerwent coronary artery bypass grafting (CABG) and/ or valve operation were enrolled in this study. The medical data collection included gender, age, types of operation, perioperative he- modynamic parameters, urine output, biochemical parameters and outcome. Renal function was assessed daily according to the classi- ficatinn by Bellomo and the AKIN criteria, respectively. As references, Acure Physiology and Chronic Health Evaluation(APACHE) Ⅱ and Sepsis-related Organ Failure Assessment (SOFA) score were also calculated. Resuits Three hundred and forty-one patients were male (67.0%), and 168 were female (33.0%), mean age was (56.2±12.0) years old. Tnree hundred and nine patieats un- derwent CABG, 182 underwent valve operation and 18 underwent CABG plus valve operation, Mean duration of ventilation support was (20.4±17.7) houra, and the ICU stay was (1.4±1.0) days. Postoperative hospital stay was (13.8±9.1) days. According to the classification by Bellomo., the highest in-hospital mortality was 52.9% in ARFS group. Mahiplicatinn of in-hospital morality rate was abserved (X2 for trend, P<0.01) in 0.4% (non-ARF), 1.2% (stage 1), 12.0% (stal～ 2) and 32.4% (stage 3) of pa- tients based on the AKIN criteria. By applying the area under the receiver operating characteristic ourve, the classification by Bellomo and the AKIN criteria had good discriminative power. Furthering, multivariate logistic regression analysis verified that the Odds Ratio of the AKIN criteria was 5.478 (P =0.028, 95% Confidence Interval 1.027- 24.856), after adjusting for gender and age. Con- clusion Analytical data confinned good discriminative power of both the AKIN criteria and the classification by Bellomo for predicting hospital mortality of adult postoperative patient with ARF.