DCD供肝肝移植术后早期急性肾损伤相关危险因素分析

目的  分析心脏死亡器官捐献（DCD）供肝肝移植术后早期急性肾损伤（AKI）的相关危险因素。方法  回顾性分析184例DCD供肝肝移植供、受体资料。根据术后早期是否发生AKI分为AKI组和非AKI组,并且对AKI组行AKI分期。比较两组一般资料和术前、术中、术后相关指标的差异。用Kaplan-Meier曲线分析非AKI组和AKI组不同分期累积存活率等预后情况。结果  本研究纳入病例184例,术后早期发生AKI 68例（37.0%）,其中AKI 1期31例,AKI 2期26例,AKI 3期11例,且发生多在术后3 d内。单因素分析结果显示术前白蛋白 < 35 g/L、术前血清钠≤ 137 mmol/L、手术时间>7.5 h、术中出血量>3 000 mL、术中红细胞输注量>15 U、术中尿量≤ 100 mL/h这6项指标为肝移植术后早期发生AKI的危险因素（均为P < 0.05）。Logistic多变量回归分析结果表明术中红细胞输注量>15 U是肝移植术后早期发生AKI的独立危险因素[比值比（OR）1.061,95%可信区间（CI）1.008~1.118,P=0.024]。Kaplan-Meier生存曲线结果表明随着AKI程度不断加重,其累积存活率逐渐降低,差异有统计学意义（均为P < 0.05）。结论  肝移植患者术后早期AKI的发生率较高,且严重程度与受体的短期和长期预后密切相关,术中大量输注红细胞是AKI发生的独立危险因素。     

心脏死亡器官捐献肝移植术后并发急性肾损伤危险因素分析

目的探讨心脏死亡器官捐献(DCD)肝移植术后并发急性肾损伤(AKI)的危险因素。 方法回顾性分析2012年1月至2018年11月宁波市医疗中心李惠利医院肝胆胰外科159例DCD肝移植受者临床资料,根据改善全球肾脏病预后组织临床实践指南中AKI诊断标准将159例受者分为AKI组(34例)和对照组(125例)。采用两独立样本t检验比较两组受者年龄和术前血清白蛋白。采用Wilcoxon符号秩和检验比较两组受者术前终末期肝病模型(MELD)评分、术前体质指数(BMI)、供肝冷/热缺血时间、术中输液量、术中出血量、术中输血量、术中尿量、手术时间、术中去甲肾上腺素总用量及总住院天数。采用卡方检验比较两组受者性别、术前乙型肝炎、术中低血压、术后感染、肝移植术式及术后再次手术情况。将单因素分析中有统计学差异的变量纳入Logistic回归进行多因素分析。P<0.05为差异有统计学意义。 结果肝移植术后AKI发生率为21.4%(34/159)。单因素分析结果表明,AKI组与对照组受者术前MELD评分、术前血清白蛋白、术中输液量、术中出血量、术中尿量、手术时间、术中低血压及术后再次手术差异均有统计学意义(Z＝2.763, t＝－2.250, Z＝2.040, Z＝2.092, Z＝－3.303, Z＝－2.170, χ²＝8.227, χ²＝5.294, P均<0.05)。Logistic回归多因素分析结果显示：术前MELD评分、术前血清白蛋白、术中尿量和手术时间是DCD肝移植术后并发AKI的独立危险因素,差异均有统计学意义(P均<0.05)。 结论DCD肝移植术前应改善受者一般情况,提高围手术期营养水平,术中控制液体出入量,合理使用利尿剂和缩短手术时间,以降低受者术后AKI发生率。     

肝移植术后急性肾损伤的早期诊断

背景 急性肾损伤(acute kidney injury,AKI)为肝移植术后常见严重并发症,其发生威胁患者生存.文献报道AKI发生率差异较大,原因可能与不同研究中AKI的诊断标准不一致有关. 目的 探讨肝移植术后AKI早期诊断的最新进展,以便积极预防、尽早治疗. 内容 综述肝移植术后AKI的常用诊断标准及其发生的相关危险因素,并讨论可能的诊断新指标. 趋向 血肌酐(serum creatinine,Scr)是目前诊断AKI最常用的生物标志物,但近年来研究指出,中性粒细胞明胶酶相关脂质运载蛋白(neutrophil gelatinase-associated lipocalin,NGAL)、肾损伤分子-1(kidney injury molecule-1,KIM-1)、胱抑素C(Cystatin C,Cys-C)等新型生物学标志物或许可替代Scr,成为早期诊断AKI的理想指标.     

Tomita及改良Tokuhashi结合脊柱肿瘤不稳评分在脊柱转移瘤患者治疗决策中的可信度和可重复性研究

目的 :分析Tomita评分结合脊柱肿瘤不稳评分(spinal instability neoplastic score,SINS)和改良Tokuhashi评分结合SINS评分用于脊柱转移瘤患者治疗决策的可信度和可重复性,评价两套评分系统临床运用价值。方法:3名具有一定临床经验的脊柱外科医生对41例脊柱转移瘤患者进行回顾性分析。这3名脊柱外科医生用Tomita评分、改良Tokuhashi评分、SINS评分对每位患者进行评分,并运用改良Tokuhashi结合SINS评分及Tomita结合SINS评分决定患者的治疗方案。间隔20天后对上述病例进行重复分析,分析观察者间一致性和观察者内一致性。结果:Tomita结合SINS评分用于治疗决策时,平均观察者间一致性Kappa值为0.78(0.75~0.81),平均观察者内一致性Cronbach′sα系数为0.79(0.77~0.82)。改良Tokuhashi结合SINS评分用于治疗决策时,平均观察者间一致性Kappa值为0.68(0.65~0.72),平均观察者内一致性Cronbach′sα系数为0.73(0.72~0.75)。有17.9%的患者在两组系统评估后而得出不同治疗方案。结论:Tomita结合SINS评分和改良Tokuhashi结合SINS评分均具有较好的可信度和可重复性。     

肝移植术后急性肾损伤的研究进展

肝移植是终末期肝病的有效治疗方法,近年来由于移植技术的成熟,肝移植手术的数量显著增多,但术后各种急慢性并发症仍是影响患者术后生存质量的主要因素。急性肾损伤(acute kidney injury,AKI)是肝移植术后常见并发症之一,也是肝移植术后患者病死率增高的主要原因之一。本文拟从AKI的诊断标准、致病因素及生物标记物等方面,回顾国内外该领域的研究进展,以提高临床医务人员对肝移植术后AKI的认识,减少术后AKI的发生,改善移植患者的预后。     

Hepatic ischemia reperfusion injury is associated with acute kidney injury following donation after brain death liver transplantation

Donation after cardiac death liver transplant recipients have an increased frequency of acute kidney injury (AKI). This suggests that hepatic ischemia‐reperfusion injury may play a critical role in the pathogenesis of AKI after liver transplantation. The aim of this single‐center study was to determine if hepatic ischemia‐reperfusion injury, estimated by peak peri‐operative serum amino‐transferase (AST), is associated with AKI following donation after brain death (DBD) liver transplantation. A total of 296 patients received 298 DBD liver transplants from January 2007 to June 2011. The incidence of AKI was 35.9%. AKI was a risk factor for chronic kidney disease (P = 0.037) and mortality (P = 0.002). On univariate analysis, peak AST correlated with peak creatinine (P < 0.001) and peak change in creatinine from baseline (P < 0.001). Peak AST was higher in AKI patients (P < 0.001). The incidence of AKI in patients with a peak AST of <1500, 1500–2999 and ≥3000 U/l was 26.1%, 39.8% and 71.2%, respectively (P < 0.001). On multiple logistic regression analysis, peak AST was independently associated with the development of AKI (P < 0.001). In conclusion, hepatic ischemia‐reperfusion injury demonstrates a strong relationship with peri‐operative AKI in DBD liver transplant recipients.     

Role of total hip replacement arthroplasty between transplantation and acute kidney injury

Osteonecrosis of the femoral head is a severely disabling complication of steroid immunosuppression in renal transplant patients. The increased number of patients undergoing transplantation has increased the number of transplant recipients undergoing total hip replacement arthroplasty (THRA). In this study, we retrospectively assessed patients who underwent THRA from May 2004 to February 2014, and evaluated their demographic and clinical characteristics, the results of peri-operative laboratory tests, the amounts of fluids transfused during surgery, and anesthesia time. Our results found that post-operative acute kidney injury (AKI) was significantly associated with transplantation, and transplantation was an independent factor predictive of post-operative AKI, so transplant recipients are at risk for AKI following THRA. Total hip replacement is a safe and effective treatment for transplant recipients and, in view of their limited life expectancy, should be considered at an early stage in their treatment.     

The postreperfusion syndrome is associated with acute kidney injury following donation after brain death liver transplantation

Acute kidney injury (AKI) is frequently observed after donation after brain death (DBD) liver transplantation (LT) and associated with impaired recipient survival and chronic kidney disease. Hepatic ischemia/reperfusion injury (IRI) is suggested to be an important factor in this process. The postreperfusion syndrome (PRS) is the first manifestation of severe hepatic IRI directly after reperfusion. We performed a retrospective study on the relation between hepatic IRI and PRS and their impact on AKI in 155 DBD LT recipients. Severity of hepatic IRI was measured by peak postoperative AST levels and PRS was defined as >30% decrease in MAP ≥1 min within 5 min after reperfusion. AKI was observed in 39% of the recipients. AKI was significantly more observed in recipients with PRS (53% vs. 32%; P = 0.013). Median peak AST level was higher in recipients with PRS (1388 vs. 771 U/l; P < 0.001). Decrease in MAP after reperfusion correlated well with both severity of AKI (P = 0.012) and hepatic IRI (P < 0.001). Multiple logistic regression identified PRS as an independent factor for postoperative AKI (OR 2.28; 95% CI 1.06–4.99; P = 0.035). In conclusion, PRS reflects severe hepatic IRI and predicts AKI after DBD LT. PRS immediately after reperfusion is an early warning sign and creates opportunities to preserve postoperative renal function.     

Strong impact of acute kidney injury on survival after liver transplantation

Acute kidney injury (AKI) is a major complication in orthotopic liver transplantation (OLT). In an evaluation of Acute Kidney Injury Network (AKIN) criteria in liver transplanted patients, we retrospectively analyzed the usefulness of these criteria to predict survival of 193 consecutive patients at a single center who underwent primary OLT for clinical parameters and peak AKI. Postoperative AKI according to AKIN occurred in 60.1% of the patients, namely, stages 1, 2, and 3 in 30%, 13% and 17.1% respectively. Using multivariate logistic regression, AKIN stage 1 and 2 AKI were independently associated with the pre-OLT Model for End-Stage Liver Disease (MELD) score and age, while stage 3 AKI was independently associated with MELD and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. The 28-day and 1-year mortality post-OLT of AKI patients were 15.5% and 25.9% respectively compared with 0% and 3.9% among non-AKI patients (P < .05 for both). The survival rates of non-AKI and stages 1, 2, and 3 AKI subjects were 96%, 85.5%, 84%, and 45.3%, respectively. Cox regression analysis showed independent risk factors for mortality during the first year after transplantation to include post-OLT AKI (12.1; P < .05), post-OLT infection (HR 4.7; P < .01), pre-OLT hypertension (HR 4.4; P < .01) hazard ratio [HR] and post-OLT APACHE II ≥10 (HR 3.6; P < .05). We concluded that AKI as defined by the AKIN criteria is a major complication of OLT linked to a poor outcomes. It remains to be evaluated whether aggressive perioperative therapy to prevent AKI can improve survival among OLT patients.     

肝移植术后急性肾损伤的发生情况及其与预后的关系

Objective To investigate the incidence of acute kidney injury ( AKI) post-orthotopic liver transplant ( OLT ) and its association with prognosis. Methods Data of 28 patients received single OLT in our hospital from 2004 to 2006 were retrospectively analyzed. The incidence of AKI was investigated by new acute kidney injury network (AKIN) criteria. The follow-up was over one year. The prognosis of AKI patients at day 28 and 1 year was evaluated by Kaplan-Meier survival analysis. The association between AKI and prognosis was examined. Results A total of 193 patients were enrolled. The average age was (48.07±10.02) years old. The ratio of male to female was 4:1. One hundred and sixteen (60.1%) patients of post-OLT AKI were found, whose AKI stage 1, 2 and 3 were 50.0%, 21.6% and 28.4% respectively. Ten (8.6%) patients required renal replacement therapy (RRT) after OLT. In AKI post-OLT patients, day 28 and 1 year mortality were significantly higher than those in non-AKI patients (15.5% vs 0, 25.9% vs 3.9%, respectively, both P<0.05). Kaplan-Meier survival analysis showed the 1-year survival rates of AKI stage 1, 2, 3 post-OLT and non-AKI were 84.0%, 81.0%, 42.4% and 90.9%, respectively. The 1-year survival rate of non-AKI was significantly higher than that of AKI stage 1, 2, 3. The 1-year survival rate of AKI stage 3 was significantly lower than that of stage 1 and 2. There was no significant difference between AKI stage 1 and 2. Scr at 1 year post-OLT was significantly higher than that of baseline [（88.35±37.15） vs (73.70±33.88) ?滋mol/L, P<0.05）. The change of Scr value at 1 year compared to baseline in AKI patients was similar to non-AKI patients. However such change in AKI stage 2 and 3 was higher than that in stage 1. Conclusions The incidence of AKI post-OLT is quite high and associated to the poor prognosis in short and long periods. Renal function may decrease gradually which is associated to the AKI stage post-OLTI.     

肝移植术后早期急性肾损伤的危险因素及与预后的关系

目的观察肝移植术后患者早期急性肾损伤(acute kidney injury,AKI)的发生情况,探讨其危险因素及预后影响。 方法回顾性分析2015年10月至2017年11月在南京医科大学第一附属医院肝脏外科进行肝移植术的患者的临床资料。应用改善全球肾脏病预后组织(Kidney Disease: Improving Global Outcomes,KDIGO)2012年修订的AKI诊断和分期标准观察肝移植术后AKI的发生情况,并根据AKI情况将患者分为两组：急性肾损伤和非急性肾损伤组,使用Logistic回归分析患者术后AKI的危险因素。应用Kaplan-Meier生存曲线分析患者术后30 d、90 d及1年的预后。 结果本研究共纳入146例肝移植患者,术后67例发生AKI(45.9%),其中AKI 1期占70.1%,AKI 2期占22.4%,AKI 3期占7.5%;其中7例患者接受肾脏替代治疗(renal replacement therapy,RRT)(10.4%)。相比于非AKI患者及AKI 1期的患者,AKI 2～3期患者30 d及90 d生存率明显下降。多因素Logistic回归分析表明,术前血清肌酐(serum creatinine,Scr)升高、国际标准化比值(international normalized ratio,INR)升高、术后天门冬氨酸氨基转移酶(aspartate aminotransferase,AST)升高及术后24 h血红蛋白降低为AKI发生的独立危险因素,并且基于AST峰值评估的肝脏缺血再灌注损伤(hepatic ischemia-reperfusion injury,HIRI)的严重程度与AKI的发生有关。 结论肝移植术后AKI发生率高,并且与患者短期的预后有关。关注AKI发生的危险因素,有助于进一步采取积极有效的干预措施,对提高肝移植术后预后有着重要的意义。     

Levosimendan in rats decreases acute kidney injury after cardiopulmonary resuscitation by improving mitochondrial dysfunction

BackgroundAcute kidney injury (AKI), the most common complication after cardiac resuscitation, is highly prevalent and harmful. There is increasing evidence that levosimendan can improve cardiac output, increase renal blood flow, and prevent AKI. As a novel calcium sensitizer, levosimendan may exert its protective effect via mitochondria.MethodsRat models of asphyxia-induced cardiac arrest and cardiopulmonary resuscitation (CPR) were set up. Thirty healthy adult male SD rats were randomly divided into CPR group (CPR group, n=10), levosimendan-treated group (levo group, n=10), and sham-operated group (sham group, n=10). Twelve hours after CPR, serum renal function indicators were measured, the kidney injury and mitochondrial morphological changes were observed. Oxygen uptake of the mitochondria, mitochondrial adenosine triphosphate (ATP) and mitochondrial free Ca²⁺ concentration were measured. Oxidative stress-related indicator levels in rat kidney tissues were further detected to analyze the differences in apoptosis rates among these three groups. Mitochondrial optic atrophy 1 (Opa1), dynamin-related protein 1 (Drp1), and apoptosis-related proteins were detected using Western blotting.ResultsCompared with the sham group, the CPR group had a significant increase in renal tissue damage. PAS staining and HE stains confirmed that CPR led to renal histopathological damage and destruction of the mitochondrial structure. Levosimendan improved the histopathological and ultrastructural damages of kidneys. Further analysis revealed that mitochondrial ATP content, NADH dehydrogenase, succinate dehydrogenase/cytochrome C oxidase, superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (CSH-Px) decreased. Free Ca²⁺ concentration and malondialdehyde (MDA) significantly increased (all P<0.05) in the kidney tissues of rats in the CPR group. However, mitochondrial ATP content, NADH dehydrogenase, succinate dehydrogenase/cytochrome C oxidase, SOD, CAT, and CSH-Px increased, whereas free Ca²⁺ concentration and MDA decreased (all P<0.05) in the levo group. The apoptosis rate increased in the CPR group. There were significantly increased levels of Drp1 protein levels, and significantly decreased Opa1 expression (all P<0.05). However, the levo group showed the opposite effects (all P<0.05).ConclusionsLevosimendan can alleviate AKI following CPR, which may be achieved by improving mitochondrial dysfunction and suppressing the mitochondrial apoptosis pathway.     

Potential biomarkers for the early detection of acute kidney injury after percutaneous nephrolithotripsy

This study aims to investigate the role of urinary biomarkers in the determination of the potential risks of renal parenchymal tubular damage in adult patients who underwent percutaneous nephrolithotomy (PNL) with the indication of renal stone. A randomized and prospective controlled study was performed between June and December 2013. We enrolled 29 consecutive patients with renal calculi?>?2?cm and who underwent PNL, as well as 47 healthy control subjects. Urine samples, including 2 h before surgery, 2 and 24 h after surgery were collected from the patient group. Freshly voided urine samples were collected from the control group. Kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-glucosaminidase (NAG), and liver-type fatty acid binding protein (LFABP) levels were measured from these urine samples. The mean KIM-1/Cr value that measured 24 h after the operation was statistically significant, higher than its preoperative (preop) level (p?= 0.045). A significant difference was detected between the mean preop and postoperative (postop) 24 h NAG/Cr values (p?< 0.001). Also, postop 24 h NGAL/Cr levels were statistically significant, higher than its preop levels (p?= 0.013). According to the comparison of preop and postop levels, an increase in LFABP/Cr values secondary to surgical intervention was observed without any statistically significant difference. Besides the LFABP/Cr levels do not change after percutaneous kidney surgery, KIM-1/Cr, NAG/Cr, and NGAL/Cr levels increase postop period, especially at 24 h. Further studies with a larger series and repeated measurements should be performed to clarify if they can be used to demonstrate renal damage after percutaneous surgery or not.     

Early intraoperative iron-binding proteins are associated with acute kidney injury after cardiac surgery

Objectives

Iron regulation is an important modifier of renal ischemia–reperfusion injury, but the role of iron-binding proteins during cardiopulmonary bypass remains unclear. The goal was to characterize iron-binding proteins throughout ischemia–reperfusion injury to determine their association with acute kidney injury development.