Shavit Linda, Hitti Sharbel, Silberman Shuli, Tauber Rachel, Merin Ofer, Lifschitz Meyer, Slotki Itzchak, Bitran Daniel, Fink Daniel
Adult Nephrology Unit and
Department of Cardiac Surgery, Shaare Zedek Medical Center, Jerusalem, Israel.
Clin J Am Soc Nephrol. 2014 Sep 5;9(9):1536-44. doi: 10.2215/CJN.00110114. Epub 2014 Jul 3.
Preoperative anemia adversely affects outcomes of cardiothoracic surgery. However, in patients with CKD, treating anemia to a target of normal hemoglobin has been associated with increased risk of adverse cardiac and cerebrovascular events. We investigated the association between preoperative hemoglobin and outcomes of cardiac surgery in patients with CKD and assessed whether there was a level of preoperative hemoglobin below which the incidence of adverse surgical outcomes increases.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective observational study included adult patients with CKD stages 3-5 (eGFR<60 ml/min per 1.73 m(2)) undergoing cardiac surgery from February 2000 to January 2010. Patients were classified into four groups stratified by preoperative hemoglobin level: <10, 10-11.9, 12-13.9, and ≥ 14 g/dl. The outcomes were postoperative AKI requiring dialysis, sepsis, cerebrovascular accident, and mortality.
In total, 788 patients with a mean eGFR of 43.5 ± 3.7 ml/min per 1.73 m(2) were evaluated, of whom 22.5% had preoperative hemoglobin within the normal range (men: 14-18 g/dl; women: 12-16 g/dl). Univariate analysis revealed an inverse relationship between the incidence of all adverse postoperative outcomes and hemoglobin level. Using hemoglobin as a continuous variable, multivariate logistic regression analysis showed a proportionally greater frequency of all adverse postoperative outcomes per 1-g/dl decrement of preoperative hemoglobin (mortality: odds ratio, 1.38; 95% confidence interval, 1.23 to 1.57; P<0.001; sepsis: odds ratio, 1.31; 95% confidence interval, 1.14 to 1.49; P<0.001; cerebrovascular accident: odds ratio, 1.31; 95% confidence interval, 1.00 to 1.67; P=0.03; postoperative hemodialysis: odds ratio, 1.38; 95% confidence interval, 1.11 to 1.75; P<0.01). Moreover, preoperative hemoglobin<12 g/dl was an independent risk factor for postoperative mortality (odds ratio, 2.6; 95% confidence interval, 1.1 to 7.3; P=0.04).
Similar to the general population, preoperative anemia is associated with adverse postoperative outcomes in patients with CKD. Whether outcomes could be improved by therapeutically targeting higher preoperative hemoglobin levels before cardiac surgery in patients with underlying CKD remains to be determined.
术前贫血会对心胸外科手术的预后产生不利影响。然而，在慢性肾脏病（CKD）患者中，将贫血治疗至血红蛋白正常目标与不良心脏和脑血管事件风险增加相关。我们研究了CKD患者术前血红蛋白与心脏手术预后之间的关联，并评估术前血红蛋白水平是否存在一个阈值，低于该阈值不良手术预后的发生率会增加。
设计、地点、参与者及测量指标：这项前瞻性观察性研究纳入了2000年2月至2010年1月期间接受心脏手术的3 - 5期CKD成年患者（估算肾小球滤过率[eGFR]<60 ml/（min·1.73 m²））。患者根据术前血红蛋白水平分为四组：<10、10 - 11.9、12 - 13.9和≥14 g/dl。观察指标为术后需要透析的急性肾损伤（AKI）、脓毒症、脑血管意外和死亡率。
总共评估了788例患者，其平均eGFR为43.5±3.7 ml/（min·1.73 m²），其中22.5%的患者术前血红蛋白在正常范围内（男性：14 - 18 g/dl；女性：12 - 16 g/dl）。单因素分析显示所有术后不良结局的发生率与血红蛋白水平呈负相关。将血红蛋白作为连续变量，多因素逻辑回归分析显示，术前血红蛋白每降低1 g/dl，所有术后不良结局的发生频率成比例增加（死亡率：比值比，1.38；95%置信区间，1.23至1.57；P<0.001；脓毒症：比值比，1.31；95%置信区间，1.14至1.49；P<0.001；脑血管意外：比值比，1.31；95%置信区间，1.00至1.67；P = 0.03；术后血液透析：比值比，1.38；95%置信区间，1.11至1.75；P<0.01）。此外，术前血红蛋白<12 g/dl是术后死亡的独立危险因素（比值比，2.6；95%置信区间，1.1至7.3；P = 0.04）。
与普通人群相似，术前贫血与CKD患者术后不良结局相关。对于合并CKD的患者，在心脏手术前通过治疗将术前血红蛋白水平提高是否能改善预后仍有待确定。
