Crawford Todd C, Magruder J Trent, Grimm Joshua C, Lee Shin-Rong, Suarez-Pierre Alejandro, Lehenbauer David, Sciortino Christopher M, Higgins Robert S, Cameron Duke E, Conte John V, Whitman Glenn J
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Ann Thorac Surg. 2017 Sep;104(3):760-766. doi: 10.1016/j.athoracsur.2017.01.019. Epub 2017 Apr 21.
The Society of Thoracic Surgeons (STS) database does not distinguish between a decline in creatinine clearance vs new hemodialysis (HD) when qualifying acute renal failure (ARF) after a cardiac operation. We hypothesized that patients requiring HD experience significantly greater postoperative morbidity and death.
We included all patients who underwent STS index cardiac operations at our institution from 2008 to March 2015 and did not have preexisting renal failure (creatinine >4.0 mg/dL or preoperative HD). We identified patients meeting STS criteria for ARF: threefold rise in serum creatinine, creatinine exceeding 4.0 mg/dL (non-HD ARF) with minimum rise of 0.5 mg/dL, or HD (ARF-HD). After propensity matching non-HD ARF and ARF-HD groups across 14 variables (including baseline glomerular filtration rate), we compared incidences of our primary outcome, death, and secondary outcomes, intensive care unit (ICU) and hospital length of stay (LOS), and discharge to a location other than home.
Among 4,154 study patients, we identified 113 (2.7%) that experienced new-onset non-HD ARF (n = 57) or ARF-HD (n = 56) postoperatively. Propensity matching resulted in 51 well-matched pairs who experienced non-HD ARF or ARF-HD (all p > 0.10). Patients requiring HD suffered significantly greater operative mortality (67% vs 22%, p < 0.01), longer ICU LOS (326 vs 176 hours, p < 0.01), and greater postoperative hospital LOS (34 vs 17 days, p < 0.01). ARF-HD patients also demonstrated a trend toward higher rates of discharge to a location other than home (71% vs 45%, p = 0.08).
After cardiac operations, patients who experienced ARF-HD experienced triple the mortality and double the ICU and postoperative hospital LOS compared with patients who experienced non-HD ARF.
在判定心脏手术后的急性肾衰竭（ARF）时，胸外科医师协会（STS）数据库未区分肌酐清除率下降与新开始血液透析（HD）的情况。我们推测需要进行血液透析的患者术后发病率和死亡率显著更高。
我们纳入了2008年至2015年3月在我们机构接受STS心脏指数手术且术前不存在肾衰竭（肌酐>4.0mg/dL或术前血液透析）的所有患者。我们确定了符合STS急性肾衰竭标准的患者：血清肌酐升高三倍、肌酐超过4.0mg/dL（非血液透析急性肾衰竭）且最低升高0.5mg/dL，或血液透析（急性肾衰竭-血液透析）。在对非血液透析急性肾衰竭和急性肾衰竭-血液透析组进行14个变量（包括基线肾小球滤过率）的倾向匹配后，我们比较了主要结局（死亡）和次要结局（重症监护病房（ICU）和住院时间（LOS））的发生率，以及出院去向不是家中的情况。
在4154例研究患者中，我们确定了113例（2.7%）术后出现新发非血液透析急性肾衰竭（n = 57）或急性肾衰竭-血液透析（n = 56）。倾向匹配产生了51对匹配良好的经历非血液透析急性肾衰竭或急性肾衰竭-血液透析的患者（所有p>0.10）。需要血液透析的患者手术死亡率显著更高（67%对22%，p<0.01），ICU住院时间更长（326小时对176小时，p<0.01），术后住院时间更长（34天对17天，p<0.01）。急性肾衰竭-血液透析患者出院去向不是家中的比例也有更高的趋势（71%对45%，p = 0.08）。
心脏手术后，经历急性肾衰竭-血液透析的患者与经历非血液透析急性肾衰竭的患者相比，死亡率增加两倍，ICU和术后住院时间增加一倍。
