Haase-Fielitz Anja, Haase Michael, Bellomo Rinaldo, Calzavacca Paolo, Spura Anke, Baraki Hassina, Kutschka Ingo, Albert Christian
Research and Science Administration of Medical School Brandenburg (MHB), Brandenburg an der Havel, Germany.
Blood Purif. 2017;43(4):298-308. doi: 10.1159/000455061. Epub 2017 Jan 31.
The study aimed to investigate patients' characteristics, fluid and hemodynamic management, and outcomes according to the severity of cardiac surgery-associated acute kidney injury (CSA-AKI).
In a single-center, prospective cohort study, we enrolled 282 adult cardiac surgical patients. In a secondary analysis, we assessed preoperative patients' characteristics, physiological variables, and medication for intra- and postoperative fluid and hemodynamic management and outcomes according to CSA-AKI stages by the Renal risk, Injury, Failure, Loss, End-stage renal disease (RIFLE) classification. Variables of fluid and hemodynamic management were further assessed with regard to the need for postoperative renal replacement therapy (RRT) and in-hospital mortality by the area under the curve for the receiver operating characteristic (AUC-ROC) and multivariate regression analysis.
Patients with worsening RIFLE stage, were significantly older, had lower estimated glomerular filtration rate and higher body mass index, more peripheral vascular and chronic obstructive pulmonary disease, atrial fibrillation, and prolonged duration of cardiopulmonary bypass (all p < 0.01). Patients with more severe AKI stage stayed longer in the intensive care and hospital, had higher in-hospital mortality, and requirement for RRT (all p < 0.001). Also, with worsening RIFLE stage, patients had lower intraoperative mean arterial pressure (MAP); p = 0.047, despite higher doses of norepinephrine (p < 0.001). The intraoperative MAP showed the best discriminatory ability (AUC-ROC: >0.8) for and was independently associated with RRT and in-hospital mortality. Moreover, with increasing AKI severity, patients received significantly more fluid infusion, and required higher dose of furosemide; nonetheless, they had increased postoperative fluid balance.
In this cohort, reduced MAP and increased fluid balance were independently associated with increased mortality and need for RRT after cardiac surgery.
本研究旨在根据心脏手术相关急性肾损伤（CSA-AKI）的严重程度，调查患者的特征、液体和血流动力学管理以及结局。
在一项单中心前瞻性队列研究中，我们纳入了282例成年心脏手术患者。在二次分析中，我们根据肾脏风险、损伤、衰竭、丧失、终末期肾病（RIFLE）分类，评估术前患者的特征、生理变量以及术中和术后液体及血流动力学管理的用药情况及结局。根据接受者操作特征曲线下面积（AUC-ROC）和多变量回归分析，进一步评估液体和血流动力学管理变量与术后肾脏替代治疗（RRT）需求及院内死亡率的关系。
RIFLE分期恶化的患者年龄显著更大，估计肾小球滤过率更低，体重指数更高，外周血管疾病和慢性阻塞性肺疾病、心房颤动更多，体外循环时间更长（所有p<0.01）。AKI分期更严重的患者在重症监护病房和医院的停留时间更长，院内死亡率更高，RRT需求也更高（所有p<0.001）。此外，随着RIFLE分期恶化，患者术中平均动脉压（MAP）更低；p=0.047，尽管去甲肾上腺素剂量更高（p<0.001）。术中MAP对RRT和院内死亡率具有最佳的鉴别能力（AUC-ROC：>0.8），且与之独立相关。此外，随着AKI严重程度增加，患者接受的液体输注显著更多，所需呋塞米剂量更高；尽管如此，他们术后的液体平衡增加。
在本队列中，心脏手术后MAP降低和液体平衡增加与死亡率增加及RRT需求独立相关。
