Ranucci Marco, Aloisio Tommaso, Carboni Giovanni, Ballotta Andrea, Pistuddi Valeria, Menicanti Lorenzo, Frigiola Alessandro
Departments of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy.
Departments of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy.
Ann Thorac Surg. 2015 Jul;100(1):95-100. doi: 10.1016/j.athoracsur.2015.02.034. Epub 2015 Apr 24.
Severe hemodilution during cardiopulmonary bypass (CPB) is a risk factor for acute kidney injury (AKI) after heart operations. Many improvements to CPB technology have been proposed during the past decade to limit the hemodilution-related AKI risk. The present study is a retrospective analysis of the relationship between hemodilution during CPB and AKI in cardiac operations in the setting of different interventions applied over 14 years.
We retrospectively analyzed 16,790 consecutive patients undergoing heart operations from 2000 to 2013. Various risk factors for AKI were collected and analyzed, together with a number of interventions as possible modifiers of the relationship between a nadir hematocrit (HCT) value during CPB and AKI.
The relationship between the nadir HCT value during CPB and AKI was confirmed in a multivariable analysis, with the relative risk of AKI increasing by 7% per percentage point of decrease of the nadir HCT value during CPB. The relative risk of AKI decreased by 8% per year of observation (p = 0.001) despite a significantly increased risk of AKI (p = 0.001). A sensitivity analysis based on differences before and after different interventions demonstrated a beneficial effect of the application of goal-directed perfusion (aimed at preserving oxygen delivery during CPB), with a reduction in the AKI rate from 5.8% to 3.1% (p = 0.001). A policy restricting angiographic examination on the day of operation was also useful (reduction of AKI rate from 4.8% to 3.7%; p = 0.029).
A bundle of interventions mainly aimed at limiting the renal impact of hemodilution during CPB is effective in reducing the AKI rate.
体外循环（CPB）期间的严重血液稀释是心脏手术后急性肾损伤（AKI）的一个危险因素。在过去十年中，人们提出了许多改进CPB技术的方法，以降低与血液稀释相关的AKI风险。本研究是一项回顾性分析，旨在探讨在14年期间应用不同干预措施的情况下，CPB期间血液稀释与心脏手术中AKI之间的关系。
我们回顾性分析了2000年至2013年期间连续接受心脏手术的16790例患者。收集并分析了AKI的各种危险因素，以及一些作为CPB期间最低血细胞比容（HCT）值与AKI之间关系的可能调节因素的干预措施。
多变量分析证实了CPB期间最低HCT值与AKI之间的关系，CPB期间最低HCT值每降低一个百分点，AKI的相对风险增加7%。尽管AKI风险显著增加（p = 0.001），但AKI的相对风险每年降低8%（p = 0.001）。基于不同干预前后差异的敏感性分析表明，应用目标导向灌注（旨在在CPB期间维持氧输送）具有有益效果，AKI发生率从5.8%降至3.1%（p = 0.001）。一项限制手术当天进行血管造影检查的政策也很有用（AKI发生率从4.8%降至3.7%；p = 0.029）。
一组主要旨在限制CPB期间血液稀释对肾脏影响的干预措施可有效降低AKI发生率。
