Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
Am J Kidney Dis. 2015 Feb;65(2):283-93. doi: 10.1053/j.ajkd.2014.09.008. Epub 2014 Nov 5.
Robust estimates and sources of variation in risks of clinical outcomes for cardiopulmonary bypass (CPB)-associated acute kidney injury (AKI) are needed to inform clinical practice and policy. We aimed to assess whether the methods for defining acute kidney disease modify the estimated association of AKI with CPB.
Systematic review and meta-analysis.
SETTING & POPULATION: Adults undergoing CPB.
Cohort studies reporting adjusted associations between CPB-associated AKI and early mortality, later mortality, stroke, myocardial infarction, congestive heart failure, all-cause hospitalization, chronic kidney disease, end-stage kidney disease, bleeding complications, or perioperative infection.
CPB-associated AKI and renal replacement therapy.
The primary outcome was early mortality (in-hospital or within 90 days of surgery) in studies reporting adjusted associations and secondary outcomes including total and cardiovascular mortality, major adverse cardiovascular events, rehospitalization, end-stage kidney disease, bleeding, and perioperative infection.
46 studies with 47 unique cohorts comprising 242,388 participants were included. The pooled rate of CPB-associated AKI was 18.2%, and of renal replacement therapy, 2.1%. CPB-associated AKI was associated with early mortality (risk ratio [RR], 4.0; 95% CI, 3.1-5.2; crude mortality with CPB-associated AKI, 4.6%; without CPB-AKI, 1.5%) with considerable heterogeneity between studies (I(2)=87%). The AKI definition did not modify prognostic estimates (P for subgroup analysis = 0.9). When heterogeneity was fully accounted for using credibility ceilings, risks of early mortality were attenuated (RR, 2.2; 95% CI, 1.8-2.8) but remained high. Renal replacement therapy also was associated with early mortality (RR, 5.3; 95% CI, 3.4-8.1). CPB-associated AKI also was associated with long-term mortality (RR, 2.0; 95% CI, 1.7-2.3) and stroke (RR, 2.2; 95% CI, 1.1-4.5). No other outcomes were reported in more than 3 studies.
Unclear attrition from follow-up in most studies and variable adjustment for confounders across studies.
CPB-associated AKI is associated with a more than 2-fold increase in early mortality regardless of AKI definition.
需要稳健的估计和风险来源，以了解心肺旁路（CPB）相关急性肾损伤（AKI）的临床结果，为临床实践和政策提供信息。我们的目的是评估 AKI 定义方法是否会改变 AKI 与 CPB 相关的关联。
系统评价和荟萃分析。
接受 CPB 的成年人。
报告 CPB 相关 AKI 与早期死亡率、晚期死亡率、中风、心肌梗死、充血性心力衰竭、全因住院、慢性肾脏病、终末期肾病、出血并发症或围手术期感染之间调整关联的队列研究。
CPB 相关 AKI 和肾脏替代疗法。
主要结局是报告调整关联的研究中的早期死亡率（住院或手术后 90 天内），次要结局包括总死亡率和心血管死亡率、主要不良心血管事件、再住院、终末期肾病、出血和围手术期感染。
共纳入 46 项研究，涉及 47 个独特队列，共 242388 名参与者。CPB 相关 AKI 的发生率为 18.2%，肾脏替代治疗的发生率为 2.1%。CPB 相关 AKI 与早期死亡率相关（风险比 [RR]，4.0；95%置信区间，3.1-5.2；CPB 相关 AKI 死亡率为 4.6%，无 CPB-AKI 死亡率为 1.5%），研究之间存在显著异质性（I²=87%）。AKI 定义并没有改变预后估计（亚组分析的 P=0.9）。当使用可信度上限充分考虑异质性时，早期死亡率的风险降低（RR，2.2；95%置信区间，1.8-2.8），但仍较高。肾脏替代治疗也与早期死亡率相关（RR，5.3；95%置信区间，3.4-8.1）。CPB 相关 AKI 也与长期死亡率（RR，2.0；95%置信区间，1.7-2.3）和中风（RR，2.2；95%置信区间，1.1-4.5）相关。没有其他结局在超过 3 项研究中报告。
大多数研究中不清楚随访的失访情况，并且研究之间的混杂因素调整也各不相同。
无论 AKI 定义如何，CPB 相关 AKI 与早期死亡率增加超过 2 倍相关。
