Devbhandari Mohan P, Duncan Andrew J, Grayson Antony D, Fabri Brian M, Keenan Daniel J M, Bridgewater Ben, Jones Mark T, Au John
Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, United Kingdom.
Eur J Cardiothorac Surg. 2006 Jun;29(6):964-70. doi: 10.1016/j.ejcts.2006.03.038. Epub 2006 May 3.
As little is known about the impact of non-dialysis-dependent renal dysfunction on short- and mid-term outcomes following coronary surgery we have conducted a large multi-centre study comparing patients with no history of renal dysfunction to those with preoperative renal dysfunction.
Data was prospectively collected on 19,625 consecutive patients undergoing isolated coronary surgery between 1997 and 2003 from four institutions. Sixty-seven patients had a history of dialysis support prior to coronary surgery, and were excluded from the main analysis of the study. The remaining 19,558 patients were divided into two groups based on preoperative serum creatinine level, patients with preoperative renal dysfunction with serum creatinine levels >200 micromol/L without dialysis support and control patients with preoperative serum creatinine levels <200 micromol/L. Case-mix was accounted for by developing a propensity score, which was the probability of belonging to the non-dialysis-dependent renal dysfunction group, and included in the multivariable analyses.
There were 19,172 patients with preoperative serum creatinine levels <200 micromol/L and 386 patients with serum creatinine levels >200 micromol/L without dialysis support. The propensity score included sex, body mass index, co-morbidity factors (respiratory disease, diabetes, cerebrovascular disease, hypertension, and hypercholesterolemia), ejection fraction, left main stem stenosis, emergency status, prior cardiac surgery, off-pump surgery, and the logistic EuroSCORE. After adjusting for the propensity score, patients with preoperative non-dialysis-dependent renal dysfunction had significantly higher in-hospital mortality (adjusted odds ratio 3.0, p < 0.001), stroke (adjusted odds ratio 2.0, p = 0.033), atrial arrhythmia (adjusted odds ratio 1.5, p = 0.003), prolonged ventilation (adjusted odds ratio 2.1, p < 0.001), and post-op stay > 6 days (adjusted odds ratio 2.6, p < 0.001). One thousand one hundred and eighty-three (6.1%) deaths occurred during 58,062 patient-years follow-up. After adjusting for the propensity score, the adjusted hazard ratio of mid-term mortality for non-dialysis-dependent renal dysfunction was 2.7 (p < 0.001).
Patients undergoing coronary surgery with non-dialysis-dependent renal dysfunction have significantly increased perioperative morbidity and mortality. Mid-term survival is also significantly reduced at 5-years.
由于对于非透析依赖性肾功能不全对冠状动脉手术后短期和中期预后的影响知之甚少，我们开展了一项大型多中心研究，比较无肾功能不全病史的患者与术前存在肾功能不全的患者。
前瞻性收集了1997年至2003年间来自四个机构的19625例连续接受单纯冠状动脉手术患者的数据。67例患者在冠状动脉手术前有透析支持史，被排除在本研究的主要分析之外。其余19558例患者根据术前血清肌酐水平分为两组，术前血清肌酐水平>200微摩尔/升且无透析支持的肾功能不全患者以及术前血清肌酐水平<200微摩尔/升的对照患者。通过建立倾向评分来考虑病例组合情况，倾向评分即属于非透析依赖性肾功能不全组的概率，并纳入多变量分析。
有19172例术前血清肌酐水平<200微摩尔/升的患者和386例血清肌酐水平>200微摩尔/升且无透析支持的患者。倾向评分包括性别、体重指数、合并症因素（呼吸系统疾病、糖尿病、脑血管疾病、高血压和高胆固醇血症）、射血分数、左主干狭窄、急诊状态、既往心脏手术、非体外循环手术以及逻辑欧洲心脏手术风险评估系统（EuroSCORE）。在对倾向评分进行调整后，术前非透析依赖性肾功能不全的患者住院死亡率显著更高（调整后的优势比为3.0，p<0.001）、卒中发生率更高（调整后的优势比为2.0，p = 0.033）、房性心律失常发生率更高（调整后的优势比为1.5，p = 0.003）、机械通气时间延长（调整后的优势比为2.1，p<0.001）以及术后住院时间>6天（调整后的优势比为2.6，p<0.001）。在58062患者年的随访期间发生了1183例（6.1%）死亡。在对倾向评分进行调整后，非透析依赖性肾功能不全中期死亡率的调整后风险比为2.7（p<0.001）。
接受冠状动脉手术且伴有非透析依赖性肾功能不全的患者围手术期发病率和死亡率显著增加。5年时中期生存率也显著降低。
