接受不同他汀治疗的冠状动脉旁路移植术后发生急性肾损伤的影响因素分析

目的:对比研究瑞舒伐他汀和阿托伐他汀对冠状动脉旁路移植术（coronary artery bypass grafting，CABG）患者急性肾损伤（acute kidney injury，AKI）发生的影响，并分析CABG术后AKI的影响因素。方法:回顾性收集2014年5月至2020年5月年龄大于18周岁、在山东大学附属临沂市人民医院心脏外科接受CABG术的550例患者为研究对象。根据患者术前是否常规应用瑞舒伐他汀或阿托伐他汀分为瑞舒伐他汀组（ n=322）、阿托伐他汀组（ n=125）和非他汀组（ n=103）。收集患者的人口统计学资料、CABG前后的临床资料和实验室检查结果。比较三组患者的尿素氮（blood urea nitrogen，BUN）、血清肌酐（serum creatinine，Scr）、肌酐清除率（creatinine clearance rate，Ccr）以及术后AKI发生情况；采用单因素分析和二分类Logistic回归分析探讨他汀对CABG术患者发生AKI的影响。 结果:与术前相比，550例患者术后BUN差异无统计学意义（ P>0.05），Scr升高，Ccr降低，差异均有统计学意义（ P<0.01）。瑞舒伐他汀组术后BUN降低，差异有统计学意义（ P<0.01），Scr、Ccr无显著变化（ P>0.05）；阿托伐他汀组术后Scr升高，差异有统计学意义（ P<0.01），BUN、Ccr差异无统计学意义（ P>0.05）；非他汀组术后BUN、Scr升高，Ccr降低，差异均有统计学意义（ P<0.01）。瑞舒伐他汀组和阿托伐他汀组术后BUN、Scr均低于非他汀组，差异均有统计学意义（均 P<0.01）；Ccr高于非他汀组，差异有统计学意义（ P<0.01）。瑞舒伐他汀组BUN、Scr和阿托伐他汀组差异均无统计学意义（ P>0.05），Ccr高于阿托伐他汀组，差异有统计学意义（ P<0.05）。三组间BUN、Scr、Ccr差异有统计学意义（ χ2值分别为48.925、22.677、34.426，均 P<0.01）。550例患者中AKI发生率为15.1%（83/550），其中瑞舒伐他汀组9.6%（31/322），阿托伐他汀组16.0%（20/125），非他汀组31.1%（32/103）。瑞舒伐他汀组和阿托伐他汀组AKI发生率均低于非他汀组，差异有统计学意义（ χ2值分别为28.412、7.282， P<0.01）。多因素回归分析发现高血压病史（ OR=3.555，95% CI：1.959~6.451， P<0.01）、NHYA心功能Ⅲ/Ⅳ（ OR=2.438，95% CI：1.187~5.008， P=0.015）、血清肌酐水平升高（ OR=1.018，95% CI：1.003~1.032， P=0.016）、术中采用体外循环（ OR=2.936，95% CI：1.454~5.927， P=0.003）是CABG术后发生AKI的独立危险因素；而术前常规他汀治疗（ OR=0.490，95% CI：0.247~0.974， P=0.042）和血清白蛋白水平（ OR=0.920，95% CI：0.856~0.990， P=0.026）是CABG术后发生AKI的保护因素。 结论:CABG术后发生AKI常见，术前常规应用瑞舒伐他汀或阿托伐他汀以及术前高血清白蛋白水平均可以保护肾功能，降低术后AKI发生率，是CABG术后AKI的保护因素，而高血压病史、NHYA心功能Ⅲ/Ⅳ、术前血清肌酐水平升高、术中采用体外循环是CABG术后发生AKI的独立危险因素。

Analysis of influencing factors of acute kidney injury in coronary artery bypass grafting patients treated with different statins

Objective:To compare the effects of rosuvastatin and atorvastatin on coronary artery bypass grafting (CABG) on the incidence of acute kidney injury (AKI), and assess the independent risk factors of AKI.Methods:We retrospectively collected 550 patients aged 18 years or older who underwent CABG from May 2014 to May 2020. They were divided into the rosuvastatin group ( n=322), atorvastatin group ( n=125) and non statins group ( n=103) according to whether rosuvastatin or atorvastatin was routinely used before operation. Demographic data, clinical data before and after CABG and laboratory results were collected. Blood urea nitrogen (BUN), serum creatinine (Scr), creatinine clearance rate (Ccr) and incidence of postoperative AKI were compared among the three groups. Univariate analysis and binary logistic regression analysis were used to investigate the effect of statins on AKI in patients undergoing CABG. Results:Compared with preoperation, BUN showed no significant change ( P>0.05), while Scr was increased and Ccr was decreased significantly (both P<0.01); BUN in the rosuvastatin group was decreased significantly ( P<0.01), whereas Scr and Ccr had no significant change ( P>0.05); Scr in the atorvastatin group was increased significantly ( P<0.01), but there was no significant difference in BUN and Ccr ( P>0.05). BUN and Scr in the non statins group were increased significantly (both P<0.01), while Ccr was decreased significantly ( P<0.01). After operation, BUN and Scr in the rosuvastatin group and atorvastatin group were significantly lower than those in the non statins group (all P<0.01); Ccr was significantly higher than that in the non statins group ( P<0.01). BUN and Scr were not significantly different between the rosuvastatin and atorvastatin groups ( P>0.05), but Ccr was significantly higher than that in the atorvastatin group ( P< 0.05). There were significant differences in BUN, Scr and Ccr among the three groups ( χ2=48.925, 22.677 and 34.426, all P<0.01). The incidence of AKI among 550 patients was 15.1% (83/550), of which 9.6% (31/322) in the rosuvastatin group, 16.0% (20/125) in the atorvastatin group and 31.1% (32/103) in the non statins group. The incidence of AKI in the rosuvastatin and atorvastatin groups was significantly lower than that in the non statins group ( χ2=28.412, 7.282, P<0.01). Multivariate regression analysis showed that hypertension ( OR=3.555, 95% CI: 1.959-6.451, P<0.01), NHYAⅢ/Ⅳ ( OR=2.438, 95% CI: 1.187-5.008, P=0.015), and increased serum creatinine level ( OR=1.018, 95% CI: 1.003-1.032, P=0.016), and intraoperative cardiopulmonary bypass ( OR=2.936, 95% CI: 1.454-5.927, P=0.003) were independent risk factors for AKI after CABG, while preoperative conventional statin therapy ( OR=0.490, 95% CI: 0.247-0.974, P=0.042) and increased serum albumin level ( OR=0.920, 95% CI: 0.856-0.990, P=0.026) were protective factors for AKI after CABG. Conclusions:The incidence of AKI after CABG is common. Rosuvastatin or atorvastatin and increased preoperative serum albumin level can protect renal function and reduce the incidence of AKI, which are the protective factors of AKI after CABG. The hypertension, NHYAⅢ/Ⅳ, increased preoperative serum creatinine level and cardiopulmonary bypass are the independent risk factors of AKI after CABG.