Lin Yu-Feng, Huang Tao-Min, Lin Shuei-Liong, Wu Vin-Cent, Wu Kwan-Dun
Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan,
Clin Epidemiol. 2018 Oct 26;10:1583-1598. doi: 10.2147/CLEP.S169302. eCollection 2018.
Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied.
We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected.
AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79-3.31), 30-day (aHR=3.65, 95% CI 3.37-3.94), and long-term (aHR=3.22, 95% CI 3.01-3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75-0.97), 30-day (aHR=0.79, 95% CI 0.70-0.89), and long-term (aHR=0.80, 95% CI 0.72-0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18-2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96-2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients.
AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred.
及时评估围手术期并发症对于手术患者的综合护理至关重要。需要透析的急性肾损伤（AKI-D）与高死亡率相关，但对于患者的长期预后如何演变知之甚少。AKI-D与术后结局的关联尚未得到充分研究。
我们对来自国民健康保险研究数据库的患者进行了调查，并通过多中心肾脏疾病临床试验联盟队列进行了验证。对所有18岁及以上接受四种主要手术（心胸、食管、肠道和肝脏）的AKI-D患者进行了回顾性研究（N = 106,573）。收集了患者的人口统计学资料、手术类型、入院前的合并症以及术后结局，包括住院期间、30天和长期死亡率以及透析依赖情况。
AKI-D是大手术后30天和长期死亡率的首要危险因素。在1664例AKI-D患者和6656例匹配对照中，住院期间发生AKI-D与住院期间（调整后风险比[aHR]=3.04，95%CI 2.79-3.31）、30天（aHR=3.65，95%CI 3.37-3.94）和长期（aHR=3.22，95%CI 3.01-3.44）死亡率相关。与非心胸手术的AKI-D患者相比，接受心胸手术（CTS）的患者住院期间（aHR=0.85，95%CI 0.75-0.97）、30天（aHR=0.79，95%CI 0.70-0.89）和长期（aHR=0.80，95%CI 0.72-0.90）死亡率较低。CTS患者30天透析依赖风险较高（亚风险比[sHR]=1.67，95%CI 1.18-2.38），但以死亡率作为竞争风险时，AKI-D后长期透析依赖风险相似（sHR=1.38，95%CI 0.96-2.00）。与CTS患者相比，非CTS患者败血症、氮质血症、低白蛋白血症和代谢性酸中毒的合并症更多。
AKI对术后结局具有至关重要的影响，这种影响远远超出出院范围。围手术期评估的目标应包括确保不同手术中肾功能的恢复，并在术后AKI发生后优化随访以减轻并发症。
