Furnary Anthony P, Wu YingXing, Hiratzka Loren F, Grunkemeier Gary L, Page U Scott
Providence Health System, Portland, Ore, USA. Email
Circulation. 2007 Sep 11;116(11 Suppl):I127-33. doi: 10.1161/CIRCULATIONAHA.106.681395.
Aprotinin is frequently used in high-risk cardiac surgery patients to decrease bleeding complications and transfusions of packed red blood cells (PRBC). Transfusions of PRBC are known to directly increase the risk of new onset postoperative renal failure (ARF) in cardiac surgery patients. A recent highly publicized report implicated aprotinin as an independent causal factor for postoperative renal failure, but ignored the potential confounding affect of numerical PRBC data on ARF. We sought to investigate that claim with an analysis that included all perioperative risk factors for renal failure, including PRBC transfusion data.
Prospectively collected patient data from 12 centers contributing to the Merged Cardiac Registry, an international multicenter cardiac surgery database, operated on between January 2000 and February 2006 were retrospectively analyzed. A previously published risk model for ARF incorporating 12 variables was used to calculate a baseline ARF risk score for each patient in whom those variables were available (n=15,174). After adding transfused PRBC data 11,198 patients remained for risk-adjusted assessment of ARF in relation to aprotinin use. Risk-adjusted multivariable analyses were carried out with, and without, consideration of transfused PRBC. Aprotinin was used in 24.6% (2757/11,198). The overall incidence of ARF was 1.6% (180/11,198) and was higher in the aprotinin subset (2.6%, 72/2757 versus 1.3%, 108/8441; P<0.001). The incidence of ARF directly and significantly increased with increasing transfusions of PRBC (P<0.001). Risk-adjusted analysis without transfused PRBC in the model suggests that aprotinin significantly impacts ARF (P=0.008; OR=1.5). However, further risk adjustment with the addition of the highly significant transfused PRBC variable (P<0.0001; OR=1.23/transfused PRBC) to the model attenuates the purported independent affect of aprotinin (P=0.231) on ARF.
The increase in renal failure seen in patients who were administered aprotinin was directly related to increased number of transfusions in that high-risk patient population. Aprotinin use does not independently increase the risk of renal failure in cardiac surgery patients.
抑肽酶常用于高危心脏手术患者，以减少出血并发症和浓缩红细胞（PRBC）输注。已知输注PRBC会直接增加心脏手术患者术后新发肾衰竭（ARF）的风险。最近一份备受关注的报告将抑肽酶列为术后肾衰竭的独立致病因素，但忽略了PRBC数值数据对ARF的潜在混杂影响。我们试图通过一项纳入所有围手术期肾衰竭危险因素（包括PRBC输血数据）的分析来调查这一说法。
对2000年1月至2006年2月期间在国际多中心心脏手术数据库合并心脏登记处12个中心前瞻性收集的患者数据进行回顾性分析。使用先前发表的包含12个变量的ARF风险模型，为每个可获得这些变量的患者（n = 15,174）计算基线ARF风险评分。加入输注PRBC数据后，11,198例患者可用于对与抑肽酶使用相关的ARF进行风险调整评估。在考虑和不考虑输注PRBC的情况下进行风险调整多变量分析。24.6%（2757/11,198）的患者使用了抑肽酶。ARF的总体发生率为1.6%（180/11,198），在抑肽酶亚组中更高（2.6%，72/2757对1.3%，108/8441；P<0.001）。ARF的发生率随着PRBC输注量的增加而直接显著增加（P<0.001）。模型中不考虑输注PRBC的风险调整分析表明，抑肽酶对ARF有显著影响（P = 0.008；OR = 1.5）。然而，在模型中加入高度显著的输注PRBC变量（P<0.0001；OR = 1.23/输注PRBC）进行进一步风险调整后，抑肽酶对ARF的所谓独立影响减弱（P = 0.231）。
接受抑肽酶治疗的患者肾衰竭增加与该高危患者群体中输血次数增加直接相关。在心脏手术患者中，使用抑肽酶并不会独立增加肾衰竭风险。
