Rao Shobhana Nayak, Shenoy M Pradeep, Gopalakrishnan Mundayat, Kiran B Amith
Deptartment of Nephrology, K.S.Hegde Medical Academy, Derlakatte, Mangalore, Karnataka, India.
Department of Cardiothoracic Surgery, K.S.Hegde Medical Academy, Derlakatte, Mangalore, Karnataka, India.
Indian Heart J. 2018 Jul-Aug;70(4):533-537. doi: 10.1016/j.ihj.2017.11.022. Epub 2017 Nov 29.
Acute kidney injury (AKI) after cardiac surgery is a frequent post-operative complication associated with an increased risk of mortality, morbidity and hospital costs. Preoperative risk scores such as the Cleveland Clinic Scoring Tool (CCST) have been validated in Western population group to identify patients at higher risk of AKI and may facilitate preventive strategies. However, the scoring tool has not been validated systematically in a South Asian cohort. We aimed to evaluate the applicability of the CCST in prediction of AKI after open cardiac surgery in a South-Indian tertiary care center.
A retrospective study of all patients who underwent elective open cardiac surgery over a 4year period from Jan 2012 to Dec 2015 at a single centre were included and relevant details extracted from a comprehensive chart review. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Patients were risk stratified as per the CCST to assess for prediction of AKI into low risk (0-2), intermediate risk (3-5) and high risk (>6) groups.
A total of 276 patients underwent open cardiac surgery with mean age of 51.5±13.06 yrs. This included 177 (64.1%) males and 99 females (35.8%). Overall incidence of AKI was 6.88%. Mean age, gender, BMI, preoperative serum creatinine, diabetes mellitus, chronic obstructive pulmonary disease, cardiopulmonary bypass time was similar in patients who developed AKI vs those who did not have AKI postoperatively. The mean CCST scores were 1.6 in those without AKI, 1.5 in stage 1, 3.0 in stage 2 and 3.4 in stage 3 AKI. Higher risk scores predicted greater risk of AKI. A total of 106 patients (38.4%) were on ACE/ARB, 119 patients (43.1%) received beta-blockers, 110 (39.8%) received diuretics while 144(52.1%) had received preoperative statins. Comparison of drug use between the two groups revealed that preoperative use of ACEI/ARB was associated with highest risk of AKI (p=0.006). Mortality rate was also high at 15.7% in those with AKI compared to 3.1% in non-AKI group (p=0.04).
The modified CCST was valid in risk identification of patients with severe stage of AKI but did not have strong discrimination for early AKI stages. Preoperative statin use did not protect against AKI in our study, however preoperative ARB/ACEI use was significantly associated with occurrence of postoperative AKI.
心脏手术后急性肾损伤（AKI）是一种常见的术后并发症，与死亡率、发病率和住院费用增加相关。术前风险评分，如克利夫兰诊所评分工具（CCST），已在西方人群中得到验证，以识别AKI风险较高的患者，并可能有助于采取预防策略。然而，该评分工具尚未在南亚队列中进行系统验证。我们旨在评估CCST在印度南部一家三级护理中心预测心脏直视手术后AKI的适用性。
对2012年1月至2015年12月在单一中心接受择期心脏直视手术的所有患者进行回顾性研究，从全面的病历审查中提取相关细节。主要结局是根据改善全球肾脏病预后组织（KDIGO）标准定义的AKI。根据CCST对患者进行风险分层，以评估AKI的预测情况，分为低风险（0 - 2）、中度风险（3 - 5）和高风险（>6）组。
共有276例患者接受了心脏直视手术，平均年龄为51.5±13.06岁。其中男性177例（64.1%），女性99例（35.8%）。AKI的总体发生率为6.88%。发生AKI的患者与术后未发生AKI的患者在平均年龄、性别、体重指数、术前血清肌酐、糖尿病、慢性阻塞性肺疾病、体外循环时间方面相似。未发生AKI的患者平均CCST评分为1.6，1期为1.5，2期为3.0，3期AKI为3.4。风险评分越高，AKI风险越大。共有106例患者（38.4%）使用了ACE/ARB，119例患者（43.1%）接受了β受体阻滞剂，110例（39.8%）接受了利尿剂，而144例（52.1%）接受了术前他汀类药物。两组药物使用情况比较显示，术前使用ACEI/ARB与AKI风险最高相关（p = 0.006）。AKI患者的死亡率也很高，为15.7%，而非AKI组为3.1%（p = 0.04）。
改良后的CCST在识别严重AKI阶段患者的风险方面有效，但对早期AKI阶段的鉴别能力不强。在我们的研究中，术前使用他汀类药物并不能预防AKI，然而术前使用ARB/ACEI与术后AKI的发生显著相关。
