Bechtel J F Matthias, Detter Christian, Fischlein Theodor, Krabatsch Thomas, Osswald Brigitte R, Riess Friedrich-Christian, Scholz Fridtjof, Schönburg Markus, Stamm Christof, Sievers Hans-Hinrich, Bartels Claus
Department of Cardiac Surgery, University of Luebeck, Luebeck, Germany.
Ann Thorac Surg. 2008 Jan;85(1):147-53. doi: 10.1016/j.athoracsur.2007.08.048.
The risk of cardiac surgery in dialysis-dependent patients is high, but little is known about the determinants of survival. We initiated a retrospective multicenter study to overcome this limitation.
Nine centers provided data on 522 patients (70% male, aged 61 +/- 11 years) who had chronic dialysis-dependent renal failure. A 14-year period was covered. Most patients had coronary artery bypass grafting, either with (n = 103) or without (n = 326) valve surgery. Multivariable analysis of survival was explored using Cox models.
The proportion of patients with diabetes mellitus increased significantly (from 17%, 1989 to 1993, to 32%, 2000 to 2003; p = 0.021) and was independently associated with 30-day mortality (odds ratio = 3.30, p = 0.001) The mean 30-day mortality was 12% (n = 60), but declined significantly during the study period (from 28%, 1989 to 1993, to 7%, 2000 to 2003; p = 0.003). The 5-year survival probability was 42% (95% confidence interval: 36% to 47%). Patients who had renal transplantation during follow-up (n = 17) had the best survival probability (hazard ratio [HR] = 0.14, p = 0.007). Sinus rhythm (HR = 0.48, p < 0.001) and use of internal thoracic artery grafts (HR = 0.67, p = 0.006) proved beneficial for long-term survival. Predictors of death during long-term follow-up were emergency surgery (HR = 2.25, p = 0.001), diabetes mellitus (HR = 1.46, p = 0.020), number of allogenic transfusions (HR = 1.03/unit, p = 0.015), and age (HR = 1.04/year, p < 0.001).
In dialysis-dependent patients, cardiac surgery has become significantly safer in recent years, but the overall prognosis of the patients remains poor. The observed improvements in the perioperative survival do not necessarily translate into an improved long-term prognosis. Diabetes mellitus is an important independent risk factor for perioperative mortality and death during follow-up.
依赖透析的患者进行心脏手术的风险很高，但关于生存的决定因素知之甚少。我们开展了一项回顾性多中心研究以克服这一局限性。
九个中心提供了522例（70%为男性，年龄61±11岁）慢性依赖透析的肾衰竭患者的数据。涵盖了14年的时间段。大多数患者接受了冠状动脉搭桥术，其中部分患者（n = 103）同时进行了瓣膜手术，部分患者（n = 326）未进行瓣膜手术。使用Cox模型对生存情况进行多变量分析。
糖尿病患者的比例显著增加（从1989年至1993年的17%增至2000年至2003年的32%；p = 0.021），且与30天死亡率独立相关（比值比 = 3.30，p = 0.001）。30天平均死亡率为12%（n = 60），但在研究期间显著下降（从1989年至1993年的28%降至2000年至2003年的7%；p = 0.003）。5年生存概率为42%（95%置信区间：36%至47%）。随访期间接受肾移植的患者（n = 17）生存概率最佳（风险比[HR] = 0.14，p = 0.007）。窦性心律（HR = 0.48，p < 0.001）和使用胸廓内动脉移植物（HR = 0.67，p = 0.006）被证明对长期生存有益。长期随访期间死亡的预测因素为急诊手术（HR = 2.25，p = 0.001）、糖尿病（HR = 1.46，p = 0.020）、异体输血次数（HR = 1.03/单位，p = 0.015）和年龄（HR = 1.04/岁，p < 0.001）。
在依赖透析的患者中，近年来心脏手术已显著更安全，但患者的总体预后仍然很差。围手术期生存的观察到的改善并不一定转化为长期预后的改善。糖尿病是围手术期死亡率和随访期间死亡的重要独立危险因素。
