合并慢性肾功能不全的冠状动脉粥样硬化性心脏病患者冠状动脉搭桥手术的预后及其影响因素

目的 分析冠状动脉粥样硬化性心脏病（以下简称冠心病）合并慢性肾功能不全（chronic kidney disease，CKD）的患者行冠状动脉旁路移植术（coronary artery bypass grafting，CABG）的预后及其影响因素。方法 收集2007年1月至2018年12月首都医科大学附属北京安贞医院1 056例冠心病合并慢性肾功能不全患者的临床资料，包括术前基本资料、手术过程、围术期合并症、住院费用及出院情况，并完成中远期随访。结果 入组患者术前肌酐浓度为（184.56±145.93） mmol/L，肾小球滤过率为（34.57±12.61） mL·min^-1·1.73m^-2，其中CKD 3期739例、4期226例、5期91例。左主干病变183例（17.3%），平均冠状动脉病变支数（3.02±0.73）支。非体外循环搭桥手术936例（88.6%），平均完成冠状动脉吻合数（2.92±0.82）支。围术期病死率为64例（6.1%），术后发生急性肾衰竭需透析患者83例（7.9%）、二次开胸止血率73例（6.9%）、围术期心肌梗死134例（12.7%）、新发房颤155例（14.7%）。术后随访率为92.2%，随访时间6（1，11）年，长期生存率93.6%，其中全因死亡58例，232例患者随访期间发生主要不良心脑血管事件（main adverse cardiovascular and cerebrovascular events，MACCE），术后新增长期透析患者34例。Logistic分析显示女性、急诊手术、术前透析史、脑梗史、左主干病变与围术期死亡成正相关（P=0.039，0.037，0.020，0.009，0.000），而非体外循环手术与围术期死亡呈负相关（P=0.002）；术前透析史、慢性阻塞性肺病（chronic obstructive pulmonary disease，COPD）史及三酰甘油浓度控制不佳，随访期间发生MACCE的独立危险因素（P=0.016，0.003，0.031）。结论 合并慢性肾功能不全的冠心病患者行搭桥手术的风险高于普通患者，其中女性、急诊手术、术前透析史、脑梗史及左主干病变是患者发生围术期死亡的危险因素，而非体外循环可能是患者围术期恢复的保护性因素。此外，术前透析史、COPD病史及三酰甘油控制不佳则是术后中远期发生MACCE事件的危险因素。

Analyze of long-term prognosis of coronary artery bypass grafting in patients with coronary atherosclerotic and chronic kidney disease

Objective To analyze the prognosis and factors of coronary artery bypass grafting (CABG) in patients with chronic kidney disease(CKD). Methods The clinical data of 1056 patients with chronic kidney disease who underwent CABG in Anzhen Hospital, Capital Medical University from January 2007 to December 2018 were collected,and the long-term follow-up were completed, which included basic perioperative information, surgical procedure, operative complication, and hospitalization costs. Results The level of preoperative creatinine was (184.56±145.93) mmol/L, estimated glomerular filtration rate(eGFR)was (34.57±12.61) mL·min^-1·1.73 m^-2,and the cases of phase 3 to 5 of CKD were 739, 226, and 91 patients, respectively. A total of 183 patients (17.3%) were diagnosed with left main stenosis. The average number of lesion vessels was 3.02±0.73, the proportion of off-pump CABG was 936 (88.6%), and the average graft number were 2.92±0.82. The mortality rate was 6.1% (64 case), and the incidence rate of acute kidney failure, reoperation for stanching, and perioperative myocardial infarction was 83(7.9%), 73(6.9%), and 134(12.7%), and 155(14.7%) respectively. The follow-up rate was 92.2% and the median follow-up time was 6 years (1-11 years). The long-term survival rate was 93.6%,74.7% patients occurred without major adverse cardiac and cerebrovascular events (MACCE), and 58 died from all-cause. Logistics regression analyze showed that the female, emergency surgery, dialysis, cerebral infarction history, and left main stenosis were positively correlated with perioperative death (P=0.039,0.037,0.020,0.009,0.000), whereas off-pump coronary bypass grafting (OPCABG) was negatively correlated with perioperative death (P=0.002). The dialysis history, higher level of triglyceride, and chronic obstructive pulmonary diseases (COPD) were independent risk factors of MACCE (P=0.016,0.003,0.031). Conclusion The risk of CABG procedure in patients with CKD was obviously high. The female, emergency surgery, dialysis, cerebral infarction history, and left main stenosis were independent risk factors of death, whilst OPCABG was protective factor. The dialysis history, higher level of triglyceride, and COPD were independent risk factors of MACCE.