Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.
Eur J Cardiothorac Surg. 2013 Mar;43(3):555-9. doi: 10.1093/ejcts/ezs329. Epub 2012 Jun 15.
Renal failure post-cardiac surgery is associated with an increased in hospital morbidity and mortality. We investigated the effect of new onset renal risk, injury or failure [risk, injury, failure, loss and end-stage kidney disease (RIFLE)] post-coronary artery bypass graft (CABG) on long-term survival, in patients with normal preoperative renal function.
The effect of developing postoperative renal risk, injury or failure as defined by the RIFLE criteria on the long-term survival of patients undergoing isolated CABG with a normal renal function was studied. Two separate multivariate analyses were performed based on preoperative serum creatinine or glomerular filtration rate (GFR). Univariate, multivariate, interaction and confounding factor analyses were performed.
A total of 4029 isolated CABG patients were included in the study. 46.5% of patients had chronic kidney disease (CKD) stage 1 (GFR ≥90 ml/min/1.73 m(2)), 50.4% had CKD stage 2 (GFR 60-89 ml/min/1.73 m(2)) and 3.1% had CKD stage 3 (GFR 30-59 ml/min/1.73 m(2)) on admission, despite having a normal serum creatinine. The study group had a median follow-up of 3.6 years (95% CI 0-13.7). Renal risk, injury and failure were associated with a significantly reduced long-term survival (P < 0.001). In patients with normal preoperative serum creatinine, Cox regression analysis revealed that age (P = 0.026), preoperative creatinine (P =0.006) and logistic EuroSCORE (P < 0.0001) were significant factors in addition to the development of postoperative renal risk, injury or failure (P < 0.0001), with regard to determining long-term survival. A confounding factor analysis revealed that discharge creatinine (P = 0.0001) and discharge GFR (P = 0.0006) were significant determinants of long-term survival. In patients with a preoperative GFR >90 ml/min, Cox regression analysis revealed that diabetes (P = 0.004) sex (P = 0.019) and logistic EuroSCORE (P < 0.0001), were also significant factors in addition to the development of postoperative renal risk, injury or failure (P = 0.0001) with regard to determining long-term survival. A significant interaction between diabetes and the development of renal risk, injury or failure exists (P = 0.04). A confounding factor analysis revealed that discharge creatinine was a significant determinant (P = 0.0001) of long-term survival, and discharge GFR was not.
Despite being a biochemically reversible process, the development of renal risk, injury and failure as defined by the RIFLE criteria post-cardiac surgery in patients with a normal preoperative renal function is associated with a significantly worse long-term outcome.
心脏手术后肾功能衰竭与住院期间发病率和死亡率的增加有关。我们研究了冠状动脉旁路移植术（CABG）后新发生的肾风险、损伤或衰竭[风险、损伤、衰竭、丧失和终末期肾病（RIFLE）]对术前肾功能正常患者的长期生存的影响。
根据 RIFLE 标准，研究了术后发生肾风险、损伤或衰竭对接受单纯 CABG 且术前肾功能正常的患者长期生存的影响。根据术前血清肌酐或肾小球滤过率（GFR）进行了两次单独的多变量分析。进行了单变量、多变量、交互和混杂因素分析。
共有 4029 例单纯 CABG 患者纳入本研究。46.5%的患者患有慢性肾脏病（CKD）1 期（GFR≥90ml/min/1.73m2），50.4%的患者患有 CKD 2 期（GFR 60-89ml/min/1.73m2），3.1%的患者患有 CKD 3 期（GFR 30-59ml/min/1.73m2）尽管血清肌酐正常。研究组的中位随访时间为 3.6 年（95%CI 0-13.7）。肾风险、损伤和衰竭与长期生存显著降低相关（P<0.001）。在术前血清肌酐正常的患者中，Cox 回归分析显示，年龄（P=0.026）、术前肌酐（P=0.006）和逻辑 EuroSCORE（P<0.0001）是除术后肾风险、损伤或衰竭（P<0.0001）外，决定长期生存的重要因素。混杂因素分析显示，出院时肌酐（P=0.0001）和出院时 GFR（P=0.0006）是长期生存的重要决定因素。在术前 GFR>90ml/min 的患者中，Cox 回归分析显示，糖尿病（P=0.004）、性别（P=0.019）和逻辑 EuroSCORE（P<0.0001）是除术后肾风险、损伤或衰竭（P=0.0001）外，决定长期生存的重要因素。糖尿病和肾风险、损伤或衰竭的发展之间存在显著的交互作用（P=0.04）。混杂因素分析显示，出院时肌酐是长期生存的重要决定因素（P=0.0001），而出院时 GFR 则不是。
尽管心脏手术后发生的肾风险、损伤和衰竭是一种生化可逆过程，但在术前肾功能正常的患者中，根据 RIFLE 标准发生肾风险、损伤和衰竭与长期预后显著恶化有关。
