Saratzis A, Shakespeare J, Jones O, Bown M J, Mahmood A, Imray C H E
NIHR Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK.
Department of Respiratory Physiology and Sleep, University Hospital Coventry and Warwickshire, UK.
Eur J Vasc Endovasc Surg. 2017 May;53(5):717-724. doi: 10.1016/j.ejvs.2017.01.014. Epub 2017 Mar 18.
Acute kidney injury (AKI) is a common complication after endovascular intervention, associated with poor short and long-term outcomes. However, the mechanisms underlying AKI development remain poorly understood. The impact of pre-existing cardiovascular disease and low cardiovascular reserve (CVR) in AKI is unclear; it remains unknown whether AKI is primarily related to pre-existing comorbidity or to procedural parameters. The association between CVR and AKI after EVAR was therefore assessed.
This is a case control study. From a database of 484 patients, 292 undergoing elective endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA) in two tertiary centres were included. Of these, 73 patients who had developed AKI after EVAR were case matched, based on pre-operative estimated glomerular filtration rate (eGFR; within 5 mL/min/1.73 m) and age, with patients who had not developed AKI. Cardiopulmonary exercise testing (CPET) was used to assess CVR using the anaerobic threshold (AT). Development of AKI was defined using the Kidney Disease Improving Outcomes (KDIGO) guidance. Associations between CVR (based on AT levels) and AKI development were then analysed.
Pre-operative AT levels were significantly different between those who did and did not develop AKI (12.1±2.9 SD vs. 14.8±3.0 mL/min/kg, p < .001). In multivariate analysis, a higher level of AT (per 1 mL/min/kg) was associated with a lower odds ratio (OR) of 0.72 (95% CI, 0.63-0.82, p < .001), relative to AKI development. A pre-operative AT level of < 11 mL/min/kg was associated with post-operative AKI development in adjusted analysis, with an OR of 7.8 (95% CI, 3.75-16.51, p < .001). The area under the curve (receiver operating characteristic) for AT as a predictor of post-operative AKI was 0.81 (standard error, 0.06, 95% CI, 0.69-0.93, p < .001).
Poor CVR was strongly associated with the development of AKI. This provides pathophysiological insights into the mechanisms underlying AKI.
急性肾损伤（AKI）是血管内介入治疗后的常见并发症，与短期和长期预后不良相关。然而，AKI发生的机制仍知之甚少。既往存在的心血管疾病和低心血管储备（CVR）对AKI的影响尚不清楚；AKI是主要与既往合并症还是与手术参数相关仍不明确。因此，评估了CVR与腹主动脉瘤腔内修复术（EVAR）后AKI之间的关联。
这是一项病例对照研究。从一个包含484例患者的数据库中，纳入了在两个三级中心接受肾下腹主动脉瘤（AAA）择期血管内动脉瘤修复术（EVAR）的292例患者。其中，73例EVAR术后发生AKI的患者根据术前估计肾小球滤过率（eGFR；相差不超过5 mL/min/1.73 m²）和年龄，与未发生AKI的患者进行病例匹配。采用心肺运动试验（CPET），通过无氧阈值（AT）评估CVR。根据改善全球肾脏病预后组织（KDIGO）指南定义AKI的发生情况。然后分析CVR（基于AT水平）与AKI发生之间的关联。
发生AKI和未发生AKI的患者术前AT水平存在显著差异（12.1±2.9 SD vs. 14.8±3.0 mL/min/kg，p <.001）。在多变量分析中，相对于AKI的发生，较高的AT水平（每增加1 mL/min/kg）与较低的比值比（OR）0.72相关（95% CI，0.63 - 0.82，p <.001）。在调整分析中，术前AT水平< 11 mL/min/kg与术后AKI的发生相关，OR为7.8（95% CI，3.75 - 16.51，p <.001）。AT作为术后AKI预测指标的曲线下面积（受试者工作特征曲线）为0.81（标准误，0.06，95% CI，0.69 - 0.93，p <.001）。
CVR差与AKI的发生密切相关。这为AKI发生的潜在机制提供了病理生理学见解。
