胱抑素C：灌注及心肌损伤对小儿心脏手术后早期（<24小时）肾功能的影响

Cystatin C: influence of perfusion and myocardial injury on early (<24 h) renal function after pediatric cardiac surgery.

作者信息

Vassalos Antony, Young David, MacArthur Kenneth, Pollock James, Lyall Fiona, Danton Mark H D

机构信息

Royal Hospital for Sick Children, Yorkhill Division, Glasgow, UK.

出版信息

Paediatr Anaesth. 2011 Dec;21(12):1185-91. doi: 10.1111/j.1460-9592.2011.03654.x. Epub 2011 Aug 11.

DOI:10.1111/j.1460-9592.2011.03654.x

PMID:21831111

Abstract

BACKGROUND

Cardiopulmonary bypass (CPB)-associated renal dysfunction following cardiac surgery is well recognized. In patients with renal disease, cystatin C has emerged as a new biomarker which in contrast to creatinine (Cr) is sensitive to minor changes in glomerular filtration rate (GFR).

AIM

We utilized cystatin C to investigate the association of CPB perfusion parameters with acute renal injury after pediatric cardiac surgery.

METHODS

Twenty children, aged 4-58 months (AVSD, n = 7; VSD, n = 9; and ASD, n = 4), were prospectively studied. Glomerular filtration rate was quantified postoperatively by creatinine clearance (first and second 12-h periods; CrCl(0-12) and CrCl(12-24) ). Serum cystatin C and Cr were measured preoperatively and on days 0-3. Recorded CPB parameters included bypass duration (BP), perfusion pressure (PP), lowest pump flow (Q(min) ), lowest hematocrit, and corresponding lowest oxygen delivery (DO(2 min) ). Myocardial injury was determined by troponin-I.

RESULTS

Postoperatively, GFR remained unchanged (CrCl(0-12) 63.6 ± 37.0 vs CrCl(12-24) 65.1 ± 27.5; P = 0.51) and only correlated with cystatin C (CrCl(0-12) vs cystatin C(Day 0) [r = 0.58, P = 0.018] and Cr(Day 0) [r = 0.09, P = 0.735]). Cr and cystatin C increased postoperatively to peak on days 2 and 3, respectively (Cr(PreOp) 31 ± 6.9 vs Cr(Day 2) 36.9 ± 12.2, P = 0.03; cystatin C(Day 0) 0.83 ± 0.27 vs cystatin C(Day 3) 1.45 ± 0.53, P = 0.02). Increased cystatin C was significantly associated with BP (P = 0.001), mean PP (P = 0.029), Q(min) (P = 0.005), troponin-I (P < 0.001), and DO(2 min) <300 ml·min(-1) ·m(-2) (P = 0.007). Receiver-operator cutoff >1.044 mg·l(-1) for cystatin C exhibited 100% sensitivity and 67% specificity for detecting renal dysfunction, defined as GFR <55 ml·min(-1) ·1.73 m(-2).

CONCLUSIONS

Cystatin C is a sensitive marker of early renal dysfunction following pediatric heart surgery. Variations in bypass parameters, myocardial injury, and ultimately critical oxygen delivery are significantly associated with the degree of renal impairment.

摘要

背景

心脏手术后与体外循环（CPB）相关的肾功能障碍已得到充分认识。在患有肾脏疾病的患者中，胱抑素C已成为一种新的生物标志物，与肌酐（Cr）不同，它对肾小球滤过率（GFR）的微小变化敏感。

目的

我们利用胱抑素C研究小儿心脏手术后CPB灌注参数与急性肾损伤的关系。

方法

前瞻性研究了20名年龄在4 - 58个月的儿童（房间隔缺损，n = 7；室间隔缺损，n = 9；和房间隔缺损，n = 4）。术后通过肌酐清除率（第一个和第二个12小时时间段；CrCl(0 - 12)和CrCl(12 - 24)）对肾小球滤过率进行量化。术前以及术后第0 - 3天测量血清胱抑素C和Cr。记录的CPB参数包括体外循环时间（BP）、灌注压力（PP）、最低泵流量（Q(min)）、最低血细胞比容以及相应的最低氧输送量（DO(2 min)）。通过肌钙蛋白I测定心肌损伤。

结果

术后，GFR保持不变（CrCl(0 - 12) 63.6 ± 37.0 vs CrCl(12 - 24) 65.1 ± 27.5；P = 0.51），且仅与胱抑素C相关（CrCl(0 - 12)与胱抑素C(第0天) [r = 0.58，P = 0.018]和Cr(第0天) [r = 0.09，P = 0.735]）。Cr和胱抑素C术后分别在第2天和第3天达到峰值（Cr(术前) 31 ± 6.9 vs Cr(第2天) 36.9 ± 12.2，P = 0.03；胱抑素C(第0天) 0.83 ± 0.27 vs胱抑素C(第3天) 1.45 ± 0.53，P = 0.02）。胱抑素C升高与BP（P = 0.001）、平均PP（P = 0.029）、Q(min)（P = 0.005）、肌钙蛋白I（P < 0.001）以及DO(2 min) <300 ml·min(-1)·m(-2)（P = 0.007）显著相关。胱抑素C的受试者工作特征曲线截断值>1.044 mg·l(-1)时，对检测定义为GFR <55 ml·min(-1)·1.73 m(-2)的肾功能障碍表现出100%的敏感性和67%的特异性。