急性主动脉夹层患者入院时血钠水平与其术后30天院内死亡的相关性研究

背景　急性主动脉夹层（AAD）是一种起病急、进展快、病死率高的急性大血管疾病，有研究显示，不同程度的高钠血症患者与其院内死亡有关，但关于入院时血钠水平与AAD患者院内死亡率的关系研究报道较少。目的　探讨AAD患者入院时血钠水平与术后院内死亡率的关系及其院内死亡的影响因素。方法　选取2015年1月至2019年12月于河北医科大学第四医院心外科住院的AAD患者415例。根据入院时血钠水平的四分位数将AAD患者分为Q1组（≤136 mmol/L）、Q2组（137~138 mmol/L）、Q3组（139~140 mmol/L）、Q4组（≥141 mmol/L），并收集AAD患者的基本信息及入院时实验室检查结果，以住院期间全因死亡为观察终点。采用Kaplan-Meier方法分析4组AAD患者术后30 d的累积生存率，采用Cox回归模型分析探讨入院时不同血钠水平AAD患者与其术后院内死亡率的关系以及AAD患者术后院内死亡的影响因素。结果　根据入院时血钠水平将AAD患者分为Q1组114例、Q2组103例、Q3组102例、Q4组96例。4组年龄、Stanford A型比例、Stanford A型死亡率、院内死亡率、尿素氮水平、中性粒细胞计数、单核细胞计数和血氯水平比较，差异均有统计学意义（P<0.05），其中Q4组中性粒细胞计数高于其他3组（P<0.05），Q4组院内死亡率高于Q1组（P<0.05）。4组AAD患者术后30 d生存率比较，差异有统计学意义（χ2=10.994，P=0.012）；其中Q1组生存率与Q3、Q4组比较，差异有统计学意义（χ2=6.282，9.632；P=0.012，0.002）。在未调整的Cox回归模型中，Q3、Q4组的死亡风险分别为2.890〔95%CI（1.264，6.604），P=0.012〕和3.253〔95%CI（1.447，7.312），P=0.004〕；调整年龄、性别后，Q3、Q4组的死亡风险分别为2.825〔95%CI（1.228，6.502），P=0.015〕和3.241〔95%CI（1.441，7.290），P=0.004〕；完全调整模型后，Q3、Q4组的死亡风险分别为3.086〔95%CI（1.242，7.671），P=0.015〕和3.370〔95%CI（1.384，8.204），P=0.007〕。Q2组死亡风险在三个模型中差异均无统计学意义（P>0.05）。多因素Cox回归模型分析结果显示，Stanford A型〔HR=3.634，95%CI（1.638，8.086），P=0.002〕、血糖〔HR=1.077，95%CI（1.025，1.132），P=0.002〕、α-HBDH〔HR=1.001，95%CI（1.001，1.002），P<0.001〕、血钠〔HR=1.068，95%CI（1.029，1.109），P=0.001〕是AAD患者术后院内死亡的影响因素。结论　入院时血钠水平与AAD患者术后院内死亡相关，高水平的血钠可能会增加其术后院内的死亡率。

Association between Admission Serum Sodium and In-hospital Postoperative 30-day Mortality in Acute Aortic Dissection Patients

Background　Acute aortic dissection（AAD）is a macrovascular disease with acute onset，quick progression and high mortality. Studies indicate that the severity of hypersodium is associated with in-hospital death. However，the relationship between admission serum sodium and in-hospital death of patients with AAD remains little known. Objective　To examine whether in-hospital postoperative mortality associates with admission serum sodium，and its associated risk factors in patients with AAD. Methods　Four hundred and fifteen AAD inpatients from Department of Cardiac Surgery，the Fourth Hospital of Hebei Medical University were enrolled during January 2015 to December 2019. General clinical data，and baseline laboratory results were collected. The endpoint was in-hospital all-cause mortality. The Kaplan-Meier estimate was used to compute the in-hospital postoperative 30-day cumulative survival in quartile groups of admission serum sodium（Q1：≤136 mmol/L，Q2：137-138 mmol/L，Q3：139-140 mmol/L，Q4：≥141 mmol/L）. The Cox proportional-hazards model was used to examine the association of admission serum sodium with in-hospital postoperative mortality，and risk factors associated with in-hospital postoperative mortality. Results　Q1-4 groups（n=114，103，102，96）had statistically significant differences in variables involving mean age，prevalence and mortality of Stanford-A AAD，in-hospital mortality，and mean levels of blood urea nitrogen，serum neutrophil count，monocyte count，and chloride（P<0.05）. In particular，Q4 group had much higher mean neutrophil count and in-hospital mortality than other groups（P<0.05）. The survival of in-hospital postoperative 30-day mortality differed significantly across the four quartile groups（χ2=10.994，P=0.012）. The in-hospital postoperative 30-day cumulative survival in Q1 group was statistically different compared with that of Q3 group and Q4 group（χ2=6.282，P=0.012；χ2=9.632，P=0.002）. Cox regression analysis demonstrated that the risk of death was 2.890〔95%CI（1.264，6.604），P=0.012〕 in Q3 group，and was 3.253〔95%CI（1.447，7.312），P=0.004〕 in Q4 group. After adjusting for age and gender，the risk of death in Q3 and Q4 groups was 2.825〔95%CI（1.228，6.502），P=0.015〕 and 3.241〔95%CI（1.441，7.290），P=0.006〕，respectively. After adjusting for all covariates，the risk of death in Q3 and Q4 groups was 3.086〔95%CI（1.242，7.671），P=0.015〕 and 3.370〔95%CI（1.384，8.204），P=0.007〕，respectively. The risk of death in Q2 group changed insignificantly before and after partial or fully adjusting for the covariates（P<0.05）. Multivariate Cox regression analysis revealed that Stanford-A AAD 〔HR=3.634，95%CI（1.638，8.086），P=0.002〕，plasma glucose 〔HR=1.077，95%CI（1.025，1.132），P=0.002〕，α-HBDH〔HR=1.001，95%CI（1.001，1.002），P<0.001〕 and serum sodium〔HR=1.068，95%CI（1.029，1.109），P=0.001〕 were associated with in-hospital postoperative 30-day mortality in patients with AAD. Conclusion　The in-hospital postoperative 30-day mortality may be associated with the serum sodium at admission in AAD patients，and the risk of the former may increase with the elevation of the latter.