Loftus Tyler J, Bihorac Azra, Ozrazgat-Baslanti Tezcan, Jordan Janeen R, Croft Chasen A, Smith Robert Stephen, Efron Philip A, Moore Frederick A, Mohr Alicia M, Brakenridge Scott C
*Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida †Department of Surgery, University of Florida Health, Gainesville, Florida ‡Department of Medicine, University of Florida Health, Gainesville, Florida.
Shock. 2017 Jul;48(1):5-10. doi: 10.1097/SHK.0000000000000825.
Acute kidney injury (AKI) following exploratory laparotomy and temporary abdominal closure (TAC) is poorly understood but clinically significant. We hypothesized that the prevalence of AKI would be highest 96 h following TAC, early hypoxemia would predict AKI, and that AKI would be an independent predictor of mortality.
We performed a retrospective analysis of 251 acute care surgery patients managed with TAC by negative pressure wound therapy (NPWT). Kidney Disease: Improving Global Outcomes AKI stages were assessed on admission, initial TAC, and following TAC at 48 h, 96 h, and 7 d. Multivariate regression was performed to identify risk factors for AKI and inpatient mortality.
Fifty-seven percent of all patients developed AKI within 7 days of laparotomy (stage 1: 14%, 2: 21%, 3: 22%). The prevalence of AKI peaked 48 h following TAC, and stage correlated with inpatient mortality (stage 0: 7%, 1: 13%, 2: 19%, 3: 37%, P < 0.001). Overall mortality was 14%. Factors predictive of stage 2 or 3 AKI at 48 h included age >65 years (OR 2.6 [95% CI 1.4-4.9]), NPWT output >30 mL/h from first TAC to 48 h (2.0 [1.1-3.9]), and three parameters at initial laparotomy: mean arterial pressure <60 mm Hg (2.9 [1.0-8.5]), temperature <36°C (2.1 [1.1-3.8]), and anion gap >21 mEq/L (1.9 [1.0-3.7]). AKI was an independent predictor of inpatient mortality (5.5 [2.5-11.8]).
AKI is common following TAC, reaches greatest prevalence 48 h after initial laparotomy, and is associated with increased mortality. NPWT fluid loss is a risk factor for AKI that is unique to TAC patients.
剖腹探查术和临时腹部关闭术（TAC）后发生的急性肾损伤（AKI）目前了解甚少，但具有临床重要性。我们推测，AKI的患病率在TAC后96小时最高，早期低氧血症可预测AKI，且AKI是死亡率的独立预测因素。
我们对251例接受负压伤口治疗（NPWT）的TAC急性护理手术患者进行了回顾性分析。在入院时、初次TAC时以及TAC后48小时、96小时和7天评估肾脏病：改善全球预后（KDIGO）AKI分期。进行多变量回归以确定AKI和住院患者死亡率的危险因素。
所有患者中有57%在剖腹术后7天内发生AKI（1期：14%，2期：21%，3期：22%）。AKI的患病率在TAC后48小时达到峰值，且分期与住院患者死亡率相关（0期：7%，1期：13%，2期：19%，3期：37%，P<0.001）。总体死亡率为14%。48小时时预测2期或3期AKI的因素包括年龄>65岁（比值比[OR]2.6[95%置信区间（CI）1.4-4.9]）、从初次TAC到48小时NPWT引流量>30 mL/h（2.0[1.1-3.9]）以及初次剖腹探查术时的三个参数：平均动脉压<60 mmHg（2.9[1.0-8.5]）、体温<36°C（2.1[1.1-3.8]）和阴离子间隙>21 mEq/L（1.9[1.0-3.7]）。AKI是住院患者死亡率的独立预测因素（5.5[2.5-11.8]）。
TAC后AKI很常见，在初次剖腹术后48小时患病率最高，且与死亡率增加相关。NPWT液体丢失是TAC患者特有的AKI危险因素。
