肝移植术后早期与晚期急性肾损伤的危险因素

目的探讨肝移植患者术后早期(术后48 h内)和晚期(术后48 h~7 d)急性肾损伤(AKI)发生的危险因素。方法前瞻性收集2018年6月至2020年6月我院SICU收治的256例肝移植患者临床资料,包括基础疾病及术前、术中和术后多个临床变量数据,研究终点为肝移植术后7 d内AKI的发生率,根据AKI的发生情况与发生时间,将患者分为非AKI组(162例)、早期AKI组(65例)和晚期AKI组(29例)。结果①与非AKI组比较,早期AKI组患者术前血肌酐(SCr)及终末期肝病模型(MELD)评分较高,手术时间较长,术中尿量较少,术后谷草转氨酶(AST)和谷丙转氨酶(ALT)水平较高(均P <0.05)。多因素Logistic回归分析显示,术前MELD评分(OR 1.437,95%CI 1.263~1.712,P <0.05)、术中尿量(OR 1.503,95%CI 1.103~2.057,P <0.05)及术后AST水平(OR 1.634,95%CI 1.094~2.215,P <0.05)是早期发生AKI的危险因素。以上三个危险因素联合预测早期AKI发生的AUC为0.816(95%CI 0.752~0.869,P <0.05)。②与非AKI组比较,晚期AKI组患者术前SCr、术后去甲肾上腺素剂量、术后血乳酸水平、FK506血药谷值浓度、术后AST和ALT水平较高(均P <0.05)。多因素Logistic回归分析显示,术后血乳酸水平(OR 1.593,95%CI 1.146~2.072,P <0.05)、FK506血药谷值浓度(OR 1.663,95%CI 1.167~2.204,P <0.05)及脓毒症(OR 2.746,95%CI 1.186~4.837,P <0.05)是晚期发生AKI的危险因素。以上三个危险因素联合预测晚期AKI发生的AUC为0.820 (95%CI 0.745~0.811,P <0.05)。结论肝移植术后早期与晚期发生AKI的危险因素有所不同;术前MELD评分、术中尿量及术后AST水平是早期AKI发生的独立危险因素,而术后血乳酸水平、FK506血药谷值浓度及脓毒症是晚期AKI发生的独立危险因素。

Analysis of risk factors for early and late acute kidney injury after liver transplantation

Objective To investigate the risk factors for acute kidney injury( AKI) after liver transplantation at the early( 48 h after liver transplantation) and late( 48 h to 7 d after liver transplantation) stages. Methods The clinical data of 256 liver transplantation patients admitted to SICU during June 2018-June 2020 were prospectively collected,including underlying diseases,preoperative,intraoperative and postoperative clinical variables. The end point of the study was the occurrence of AKI within 7 days after liver transplantation. According to the occurring time of AKI,the patients were divided into the non-AKI group( 162 cases),early AKI group( 65 cases) and late AKI group( 29 cases). Results①Compared with the non-AKI group,the patients in the early AKI group had higher preoperative serum creatinine( SCr) and model for end-stage liver disease( MELD) score,longer operative time,less intraoperative urine volume,and higher postoperative AST and ALT levels( all P <0. 05). Multivariate Logistic regression analysis suggested that preoperative MELD score( OR 1. 437,95% CI 1. 263-1. 712,P < 0. 05),intraoperative urine volume( OR 1. 503,95% CI 1. 103-2. 057,P < 0. 05) and postoperative AST( OR 1. 634,95% CI 1. 094-2. 215,P < 0. 05) were independent risk factors for early AKI. The AUC of the above three risk factors combined to predict early AKI was 0. 816( 95% CI 0. 752-0. 869,P < 0. 05).② Compared with the non-AKI group,the patients in the late AKI group had higher preoperative SCr,postoperative dose of norepinephrine,serum lactate,trough concentration of FK506,postoperative AST and ALT levels( all P < 0. 05). Multivariate Logistic regression analysis suggested that serum lactate level( OR 1. 593,95% CI 1. 146-2. 072,P <0. 05),trough concentration of FK506( OR 1. 663,95% CI 1. 167-2. 204,P < 0. 05) and sepsis( OR2. 746,95% CI 1. 186-4. 837,P < 0. 05) were independent risk factors for AKI at the late stage. The AUC of the above three risk factors combined to predict late AKI was 0. 820( 95% CI 0. 745-0. 811,P < 0. 05). Conclusions There are different risk factors between early AKI and late AKI after liver transplantation. Preoperative MELD score, intraoperative urine volume and postoperative AST are independent risk factors for early AKI,while postoperative serum lactate level,trough concentration of FK506 and sepsis are independent risk factors for late AKI.