Hiraoka Arudo, Chikazawa Genta, Totsugawa Toshinori, Sakaguchi Taichi, Tamura Kentaro, Yoshitaka Hidenori
Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan.
J Card Surg. 2014 Mar;29(2):218-24. doi: 10.1111/jocs.12269. Epub 2013 Dec 13.
The aim of this study is to evaluate acute kidney injury (AKI) after total aortic arch repair (TAR) with moderate hypothermic circulatory arrest (MHCA) and selective antegrade cerebral perfusion (SACP).
A retrospective analysis was performed in 200 patients who underwent TAR with HCA and SACP between 2008 and 2012. The AKI severity was classified into three grades (R=risk, I=injury, F=failure) by RIFLE criteria, and patients who required renal replacement therapy were included in grade F.
Postoperative AKI was observed in 88 patients (44%) including 53 RIFLE-R (27%), 18 RIFLE-I (9%), and 17 RIFLE-F (9%). Significantly higher 30-day mortality was observed in AKI (+) group compared with AKI (-) group (10.2% [9/88] vs. 1.8% [2/112]; p=0.012). The three-year survival rate was 85% in AKI (+) group and 93% in AKI (-) group, and log-rank test revealed better survival in AKI (-) group (p=0.022). Multivariate Cox proportional-hazards regression detected AKI (all grades) and cardiac arrest time as predictors of mid-term mortality (hazard ratio [HR]: 3.2, p=0.041 and HR: 1.02, p=0.006, respectively). Multivariate analysis revealed prolonged operative time (≥ 490 min) as an independent risk factor for AKI (all grades), and emergency, atrial fibrillation, operative time (≥ 490 min), and hypothermia (<24 °C) as risk factors for severe AKI (RIFLE-I and -F).
Postoperative AKI stratified by RIFLE criteria was significantly associated with short- and mid-term outcomes in TAR with MHCA and SACP.
本研究旨在评估在中度低温循环停搏（MHCA）和选择性顺行性脑灌注（SACP）下行全主动脉弓修复术（TAR）后的急性肾损伤（AKI）情况。
对2008年至2012年间接受TAR联合HCA和SACP的200例患者进行回顾性分析。根据RIFLE标准将AKI严重程度分为三个等级（R = 风险，I = 损伤，F = 衰竭），需要肾脏替代治疗的患者归入F级。
88例患者（44%）术后出现AKI，其中53例为RIFLE-R级（27%），18例为RIFLE-I级（9%），17例为RIFLE-F级（9%）。与AKI（-）组相比，AKI（+）组30天死亡率显著更高（10.2% [9/88] 对1.8% [2/112]；p = 0.012）。AKI（+）组三年生存率为85%，AKI（-）组为93%，对数秩检验显示AKI（-）组生存率更好（p = 0.022）。多变量Cox比例风险回归分析发现AKI（所有等级）和心脏停搏时间是中期死亡率的预测因素（风险比[HR]：3.2，p = 0.041和HR：1.02，p = 0.006，分别）。多变量分析显示手术时间延长（≥490分钟）是AKI（所有等级）的独立危险因素，而急诊、心房颤动、手术时间（≥490分钟）和体温过低（<24°C）是严重AKI（RIFLE-I和-F）的危险因素。
在MHCA和SACP下行TAR术后，根据RIFLE标准分层的术后AKI与短期和中期预后显著相关。
