Lin Chun-Yu, Tsai Feng-Chun, Chen Yung-Chang, Lee Hsiu-An, Chen Shao-Wei, Liu Kuo-Sheng, Lin Pyng-Jing
From the Department of Cardiothoracic and Vascular Surgery Chang Gung Memorial Hospital (C-YL, F-CT, H-AL, S-WC, K-SL, P-JL), and Department of Nephrology, Chang Gung University College of Medicine, Taoyuan, Taiwan (Y-CC).
Medicine (Baltimore). 2016 Mar;95(9):e2576. doi: 10.1097/MD.0000000000002576.
Preoperative end-stage renal disease carries a high mortality and morbidity risk after aortic valve replacement (AVR), but the effect of renal insufficiency remains to be clarified. Through propensity score analysis, we compared the preoperative demographics, perioperative profiles, and outcomes between patients with and without renal insufficiency. From August 2005 to November 2014, 770 adult patients underwent AVR in a single institution. Patients were classified according to their estimated glomerular infiltration rate (eGFR) as renal insufficiency (eGFR: 30-89 mL/min/1.73 m) or normal (eGFR, ≥90 mL/min/1.73 m). Propensity scoring was performed with a 1:1 ratio, resulting in a matched cohort of 88 patients per group. Demographics, comorbidities, and surgical procedures were well balanced between the 2 groups, except for diabetes mellitus and eGFR. Patients with renal insufficiency had higher in-hospital mortality (19.3% versus 3.4%, P < 0.001), a greater need for postoperative hemodialysis (14.8% versus 3.1%, P = 0.009), and prolonged intubation times (>72 hour; 25% versus 9.1%, P = .008), intensive care unit stays (8.9 ± 9.9 versus 4.9 ± 7.5 days, P = .046), and hospital stays (35.3 ± 31.7 versus 24.1 ± 20.3 days, P = .008), compared with those with normal renal function. Multivariate analysis confirmed that preoperative renal insufficiency was an in-hospital mortality predictor (odds ratio, 2.33; 95% confidence interval, 1.343-4.043; P = .003), as were prolonged cardiopulmonary bypass time, intraaortic balloon pump support, and postoperative hemodialysis. The 1-year survival significantly differed between the 2 groups including (normal 87.5% versus renal insufficiency 67.9%, P < .001) or excluding in-hospital mortality (normal 90.7% versus renal insufficiency 82.1%, P = .05). Patients with preoperative renal insufficiency who underwent AVR had higher in-hospital mortality rates and increased morbidities, especially those associated with hemodynamic instabilities requiring intraaortic balloon pump support or hemodialysis. Earlier surgical intervention for severe aortic valve disease should be considered in patients who show deteriorating renal function during follow-up.
术前终末期肾病在主动脉瓣置换术（AVR）后具有较高的死亡率和发病风险，但肾功能不全的影响仍有待阐明。通过倾向评分分析，我们比较了肾功能不全患者与非肾功能不全患者的术前人口统计学特征、围手术期情况及预后。2005年8月至2014年11月，770例成年患者在单一机构接受了AVR。根据估计的肾小球滤过率（eGFR）将患者分为肾功能不全（eGFR：30 - 89 mL/min/1.73 m²）或正常（eGFR≥90 mL/min/1.73 m²）。以1:1的比例进行倾向评分，每组形成88例患者的匹配队列。除糖尿病和eGFR外，两组间的人口统计学特征、合并症和手术操作情况均衡。肾功能不全患者的住院死亡率更高（19.3%对3.4%，P < 0.001），术后更需要进行血液透析（14.8%对3.1%，P = 0.009），插管时间延长（>72小时；25%对9.1%，P = 0.008），重症监护病房住院时间（8.9 ± 9.9天对4.9 ± 7.5天，P = 0.046）以及住院时间（35.3 ± 31.7天对24.1 ± 20.3天，P = 0.008）。多因素分析证实，术前肾功能不全是住院死亡率的预测因素（比值比，2.33；95%置信区间，1.343 - 4.043；P = 0.003），体外循环时间延长、主动脉内球囊泵支持及术后血液透析也是预测因素。两组的1年生存率有显著差异（包括住院死亡率：正常组87.5%对肾功能不全组67.9%，P < 0.001；排除住院死亡率：正常组90.7%对肾功能不全组82.1%，P = 0.05）。接受AVR的术前肾功能不全患者住院死亡率更高且发病率增加，尤其是那些与需要主动脉内球囊泵支持或血液透析的血流动力学不稳定相关的情况。对于随访期间肾功能恶化的患者，应考虑更早地对严重主动脉瓣疾病进行手术干预。
