老年心脏瓣膜术后患者并发急性肾损伤的危险因素分析及其对预后的影响

Risk factors of acute kidney injury after heart valve surgery in elderly patients and their impact on prognosis

摘要:

目的 探讨≥65岁老年患者行心脏瓣膜外科手术后发生急性肾损伤（acute kidney injury，AKI）的危险因素及其对预后的影响。方法 回顾性分析2013年1月至2014年5月在广东省人民医院行心脏瓣膜外科手术的≥65岁老年患者，剔除术前接受肾替代治疗、血肌酐值缺失的病例，记录入选病例的术前、术中及术后临床资料，定期进行电话随访，主要终点为AKI发生率，次要终点为随访死亡率。根据术后是否并发KDIGO标准的AKI分期≥2，分为AKI组和对照组。采用单因素分析和logistic回归多因素分析探索术后AKI的危险因素，采用Kaplan-Meier生存分析显示AKI对随访死亡的影响，采用多因素Cox回归模型分析术后患者随访死亡的危险因素。结果 本研究共纳入225例患者，其中女性110例（58.89%）。AKI（AKI 2~3期）发病率为26.22%（n=59）。AKI组住院死亡率显著高于对照组（13.6% vs. 0.0%，P<0.001）；最长随访时间9年，AKI组随访死亡率显著高于对照组（42.4% vs. 9.6%，P<0.001）。Kaplan-Meier生存分析显示AKI组的随访死亡率显著高于对照组（P<0.001）。单因素及logistic回归多因素分析结果显示，术后AKI的独立危险因素是术前血小板计数较低（OR=0.99，P=0.011）及围术期红细胞输注量较大（OR=1.11，P<0.001）。单因素及多因素Cox回归模型分析结果显示，发生随访死亡的危险因素是术前白蛋白水平低下（HR=0.90，P=0.028）、使用主动脉内球囊反搏（HR=7.38，P=0.003）及并发术后AKI（HR=2.88，P=0.006）。结论 术前血小板计数较低及围术期红细胞输注量较大可增加≥65岁老年患者行心脏瓣膜手术后并发AKI的风险，而术后并发AKI可增加住院死亡率和随访死亡率。

Abstract:

Objective To investigate the risk factors of acute kidney injury（AKI） after heart valve surgery in elderly patients ≥ 65 years old and their effects on prognosis.Methods A retrospective analysis was performed on elderly patients aged 65 years and above who underwent heart valve surgery in Guangdong Provincial People's Hospital from January 2013 to May 2014. The patients who received renal replacement therapy before surgery and whose serum creatinine value was missing were excluded，and the selected cases were recorded. The preoperative，intraoperative，and postoperative clinical data were collected，and regular telephone follow-up was conducted. The primary endpoint was the incidence of AKI，and the secondary endpoint was follow-up mortality. Patients were divided into AKI group and control group according to whether they complicated with stage ≥ 2 AKI. Univariate analysis and logistic regression multivariate analysis were used to explore the risk factors of postoperative AKI，Kaplan-Meier survival analysis was used to show the effect of AKI on follow-up death，and multivariate Cox regression model was used to analyze the risk factors of postoperative follow-up death.Results A total of 225 patients were included in this study，including 110 women（58.89%），and the incidence of AKI was 26.22%（n=59）. The in-hospital mortality in the AKI group was significantly higher than that in the control group（13.6% and 0.0%，P<0.001）. The longest follow-up time was 9 years，and the follow-up mortality in the AKI group was significantly higher than that in the control group（42.4% and 9.6%，P<0.001）. Kaplan-Meier survival analysis showed that the follow-up mortality in the AKI group was significantly higher than that in the control group（P<0.001）. Univariate and logistic regression multivariate analysis showed that the independent risk factors for postoperative AKI were lower preoperative platelet count（OR=0.99，P=0.011） and larger amount of perioperative red blood cell transfusion（OR=1.11，P<0.001）. Univariate and multivariate Cox regression model analysis showed that the risk factors for follow-up death were lower preoperative albumin level（HR=0.90，P=0.028），use of intra-aortic balloon pump（HR=7.38，P=0.003） and postoperative AKI（HR=2.88，P=0.006）.Conclusion Lower preoperative platelet count and larger amount of perioperative red blood cell transfusion might increase the risk of AKI after heart valve surgery in elderly patients ≥ 65 years old，and postoperative AKI could increase in-hospital mortality and follow-up mortality.