Patterson Taylor, Hehir David A, Buelow Matthew, Simpson Pippa M, Mitchell Michael E, Zhang Liyun, Eslami Mehdi, Murkowski Kathleen, Scott John P
1 Medical College of Wisconsin, Milwaukee, WI, USA.
2 AI Dupont Hospital for Children, Nemours Cardiac Center, Wilmington, DE, USA.
World J Pediatr Congenit Heart Surg. 2017 May;8(3):367-375. doi: 10.1177/2150135117701376.
Acute kidney injury (AKI) is common following cardiopulmonary bypass. Fontan completion may result in systemic venous hypertension and low cardiac output, reducing renal perfusion pressure (RPP) and further increasing the risk of AKI. We investigated the incidence and risk factors for post-Fontan AKI.
Single-center retrospective study of children undergoing Fontan completion from 2005 to 2012. Demographic and hemodynamic variables were assessed for association with AKI. Subgroup analysis was performed on patients with high-grade AKI (creatinine increase of ≥2.0 × baseline). Vital sign data were collected hourly for the first postoperative day.
A total of 186 patients underwent Fontan at 3.1 (2.5-3.8) years of age and 13.5 kg (12.2-15.1). Acute kidney injury occurred in 97 (52%) patients, with high-grade AKI in 52 (28%). Univariate analysis identified reduced RPP in patients with AKI compared to those without AKI, 50 (45-56) mm Hg versus 58 (54-61) mm Hg ( P < .0001), due to lower mean arterial blood pressure, 63 (60-69) versus 70 (66-73) mm Hg ( P < .0001), and higher central venous pressure, 14 (12-16) versus 13 (11-14) mm Hg, ( p < .0001). Multivariable logistic regression and classification tree analyses further identified elements of RPP as significant predictors of AKI, especially high-grade AKI. Postoperative intubation was linked to AKI development. Patients with AKI had decreased postoperative urine output with increased colloid requirements, duration of chest tube insertion, and hospital length of stay.
Acute kidney injury occurs frequently following the Fontan procedure. Associated factors include reduced RPP, high colloid requirements, and postoperative intubation. Targeted hemodynamic interventions may serve to reduce the incidence of post-Fontan AKI.
急性肾损伤（AKI）在体外循环后很常见。Fontan手术完成后可能导致体循环静脉高压和心输出量降低，从而降低肾灌注压（RPP），进一步增加AKI的风险。我们调查了Fontan术后AKI的发生率及危险因素。
对2005年至2012年接受Fontan手术的儿童进行单中心回顾性研究。评估人口统计学和血流动力学变量与AKI的相关性。对重度AKI（肌酐升高≥2.0倍基线值）患者进行亚组分析。术后第一天每小时收集生命体征数据。
共有186例患者在3.1（2.5 - 3.8）岁、体重13.5 kg（12.2 - 15.1）时接受了Fontan手术。97例（52%）患者发生急性肾损伤，其中52例（28%）为重度AKI。单因素分析发现，与未发生AKI的患者相比，发生AKI的患者RPP降低，分别为50（45 - 56）mmHg和58（54 - 61）mmHg（P <.0001），这是由于平均动脉血压较低，分别为63（60 - 69）mmHg和70（66 - 73）mmHg（P <.0001），以及中心静脉压较高，分别为14（12 - 16）mmHg和13（11 - 14）mmHg（P <.0001）。多变量逻辑回归和分类树分析进一步确定RPP因素是AKI的重要预测因素，尤其是重度AKI。术后插管与AKI的发生有关。发生AKI的患者术后尿量减少，胶体需求量增加，胸管留置时间延长，住院时间延长。
Fontan手术后急性肾损伤频繁发生。相关因素包括RPP降低、胶体需求量高和术后插管。有针对性的血流动力学干预可能有助于降低Fontan术后AKI的发生率。
