Jyrala Aarne, Weiss Robert E, Jeffries Robin A, Kay Gregory L
Heart Institute at Good Samaritan Hospital, Department of Cardiothoracic Surgery, Los Angeles, USA.
Interact Cardiovasc Thorac Surg. 2010 May;10(5):777-82. doi: 10.1510/icvts.2009.231068. Epub 2010 Feb 19.
The objective of this study is to evaluate differences in patient presentation and short- and long-term outcomes between patients dichotomized by the level of preoperative s-creatinine (s-crea) without renal failure and to use EuroSCORE (ES) risk stratification for validating differences and for predictive purposes.
A thousand consecutive cardiac surgery patients from January 1999 through May 2000 were analyzed. Patients with off-pump surgery or s-crea >200 micromol/l (>2.2 mg/dl) were excluded leaving 885 patients for analysis. Group 1 (n=703) had s-crea 0.5-1.2 mg/dl and Group 2 (n=182) had elevated s-crea 1.3-2.2 mg/dl but no renal insufficiency.
Group 2 patients were older (P<0.0001), had a higher percentage of males (P=0.008), had lower left ventricular ejection fraction (LVEF) (P=0.001), had higher New York Heart Association (NYHA) classification (P<0.0001), had more diabetics (P=0.001) and had more patients with a history of congestive heart failure (CHF) (P<0.0001). Both additive ES (AES) and logistic ES (LES) variables were higher in Group 2 patients, AES 8.45+/-4.28% vs. 6.05+/-3.80% (P<0.0001) and LES 17.7+/-19.1% vs. 9.57+/-13.3% (P<0.0001). Proportions of emergency operations and use of intra-aortic balloon pulsation (IABP) support did not differ. There were more coronary artery bypass grafting (CABG) with or without concomitant procedures in Group 1 but otherwise the procedures performed were similar. Cardiopulmonary bypass (CPB) times did not differ (P=0.1). Operative mortality was similar (P=0.06) but hospital mortality was higher in Group 2: 19/10.4% vs. 25/3.6% (P<0.0001), odds ratio (OR) 3.16. Total length of stay (LOS) and length of stay in the postoperative intensive care unit (ICU) did not differ. Postoperative renal failure (PORF) (s-crea increase to >2.25 mg/dl or >200 micromol/l) developed in 38/4.5% patients in Group 1 and in 41/22.5% patients in Group 2 (P<0.0001), OR=5.08. Follow-up all-cause mortality was higher in Group 2: 68/37.4% vs. 167/23.8% (P<0.0001), OR=1.91. Both ES definitions predicted hospital mortality, LOS, ICU, PORF and long-term mortality well, while increased s-crea predicted PORF and long-term mortality in both groups.
Mild increase in s-crea is a marker for patients with increased cardiac risk factors and the risk for poor outcomes. Both ES definitions are highly predictive of the outcomes.
本研究的目的是评估术前血清肌酐（s-crea）水平在无肾衰竭情况下进行二分法分组的患者之间，在患者表现以及短期和长期预后方面的差异，并使用欧洲心脏手术风险评估系统（EuroSCORE，ES）风险分层来验证差异并进行预测。
分析了1999年1月至2000年5月期间连续的1000例心脏手术患者。排除非体外循环手术患者或s-crea>200微摩尔/升（>2.2毫克/分升）的患者，留下885例患者进行分析。第1组（n = 703）的s-crea为0.5 - 1.2毫克/分升，第2组（n = 182）的s-crea升高至1.3 - 2.2毫克/分升但无肾功能不全。
第2组患者年龄更大（P<0.0001），男性比例更高（P = 0.008），左心室射血分数（LVEF）更低（P = 0.001），纽约心脏协会（NYHA）分级更高（P<0.0001），糖尿病患者更多（P = 0.001），有充血性心力衰竭（CHF）病史的患者更多（P<0.0001）。第2组患者的相加式ES（AES）和逻辑式ES（LES）变量均更高，AES为8.45±4.28% 对比6.05±3.80%（P<0.0001），LES为17.7±19.1% 对比9.57±13.3%（P<0.0001）。急诊手术比例和主动脉内球囊反搏（IABP）支持的使用情况无差异。第1组进行冠状动脉旁路移植术（CABG）且伴有或不伴有其他手术的比例更高，但其他所进行的手术相似。体外循环（CPB）时间无差异（P = 0.1）。手术死亡率相似（P = 0.06），但第2组的医院死亡率更高：19/10.4% 对比25/3.6%（P<0.0001），比值比（OR）为3.16。总住院时间（LOS）和术后重症监护病房（ICU）住院时间无差异。第1组38/4.5%的患者发生术后肾衰竭（PORF）（s-crea升高至>2.25毫克/分升或>200微摩尔/升），第2组41/22.5%的患者发生（P<0.0001），OR = 5.08。随访期间第2组的全因死亡率更高：68/37.4% 对比167/23.8%（P<0.0001），OR = 1.91。两种ES定义对医院死亡率、LOS、ICU住院时间、PORF和长期死亡率的预测都很好，而s-crea升高对两组的PORF和长期死亡率都有预测作用。
s-crea轻度升高是心脏危险因素增加且预后不良风险增加患者的一个标志物。两种ES定义对预后都有高度预测性。
