Mehta Rajendra H, Grab Joshua D, O'Brien Sean M, Bridges Charles R, Gammie James S, Haan Constance K, Ferguson T Bruce, Peterson Eric D
Duke Clinical Research Institute, Durham, NC 27715, USA.
Circulation. 2006 Nov 21;114(21):2208-16; quiz 2208. doi: 10.1161/CIRCULATIONAHA.106.635573. Epub 2006 Nov 6.
Estimation of an individual patient's risk for postoperative dialysis can support informed clinical decision making and patient counseling.
To develop a simple bedside risk algorithm for estimating patients' probability for dialysis after cardiac surgery, we evaluated data of 449,524 patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery and enrolled in >600 hospitals participating in the Society of Thoracic Surgeons National Database (2002-2004). Logistic regression was used to identify major predictors of postoperative dialysis. Model coefficients were then converted into an additive risk score and internally validated. The model also was validated in a second sample of 86,009 patients undergoing cardiac surgery from January to June 2005. Postoperative dialysis was needed in 6451 patients after cardiac surgery (1.4%), ranging from 1.1% for isolated CABG procedures to 5.1% for CABG plus mitral valve surgery. Multivariable analysis identified preoperative serum creatinine, age, race, type of surgery (CABG plus valve or valve only versus CABG only), diabetes, shock, New York Heart Association class, lung disease, recent myocardial infarction, and prior cardiovascular surgery to be associated with need for postoperative dialysis (c statistic=0.83). The risk score accurately differentiated patients' need for postoperative dialysis across a broad risk spectrum and performed well in patients undergoing isolated CABG, off-pump CABG, isolated aortic valve surgery, aortic valve surgery plus CABG, isolated mitral valve surgery, and mitral valve surgery plus CABG (c statistic=0.83, 0.85, 0.81, 0.75, 0.80, and 0.75, respectively).
Our study identifies the major patient risk factors for postoperative dialysis after cardiac surgery. These risk factors have been converted into a simple, accurate bedside risk tool. This tool should facilitate improved clinician-patient discussions about risks of postoperative dialysis.
评估个体患者术后透析风险有助于临床决策和患者咨询。
为开发一种用于估计心脏手术后患者透析概率的简单床旁风险算法，我们评估了449524例接受冠状动脉旁路移植术（CABG）和/或瓣膜手术且登记参加胸外科医师协会国家数据库（2002 - 2004年）中600多家医院研究的患者数据。采用逻辑回归确定术后透析的主要预测因素。然后将模型系数转换为相加风险评分并进行内部验证。该模型还在2005年1月至6月接受心脏手术的86009例患者的第二个样本中进行了验证。心脏手术后6451例患者（1.4%）需要术后透析，单纯CABG手术为1.1%，CABG加二尖瓣手术为5.1%。多变量分析确定术前血清肌酐、年龄、种族、手术类型（CABG加瓣膜手术或仅瓣膜手术与单纯CABG手术相比）、糖尿病、休克、纽约心脏协会分级、肺部疾病、近期心肌梗死以及既往心血管手术与术后透析需求相关（c统计量 = 0.83）。风险评分能准确区分广泛风险范围内患者的术后透析需求，在接受单纯CABG手术、非体外循环CABG手术、单纯主动脉瓣手术、主动脉瓣手术加CABG手术、单纯二尖瓣手术以及二尖瓣手术加CABG手术的患者中表现良好（c统计量分别为0.83、0.85、0.81、0.75、0.80和0.75）。
我们的研究确定了心脏手术后患者术后透析的主要风险因素。这些风险因素已转化为一种简单、准确的床旁风险工具。该工具应有助于改善临床医生与患者关于术后透析风险的讨论。
