Eagles Matthew E, Powell Maria F, Ayling Oliver G S, Tso Michael K, Macdonald R Loch
1Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary.
2Department of Internal Medicine, University of Calgary, Alberta.
J Neurosurg. 2019 Jul 12;133(3):765-772. doi: 10.3171/2019.4.JNS19103. Print 2020 Sep 1.
Acute kidney injury (AKI) is associated with death in critically ill patients, but this complication has not been well characterized after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of this study was to determine the incidence of AKI after aSAH and to identify risk factors for renal dysfunction. Secondary objectives were to examine what effect AKI has on patient mortality and functional outcome at 12 weeks post-aSAH.
The authors performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data set (clinical trial registration no.: NCT00111085, https://clinicaltrials.gov). The primary outcome of interest was the development of AKI, which was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Secondary outcomes of interest were death and a modified Rankin Scale score greater than 2 at 12 weeks post-aSAH. Propensity score matching was used to assess for a significant treatment effect related to clazosentan administration and AKI. Univariate analysis, locally weighted scatterplot smoothing (LOWESS) curves, and stepwise logistic regression models were used to evaluate for associations between baseline or disease-related characteristics and study outcomes.
One hundred fifty-six (38%) of the 413 patients enrolled in the CONSCIOUS-1 trial developed AKI during their ICU stay. A history of hypertension (p < 0.001) and the number of nephrotoxic medications administered (p = 0.029) were independent predictors of AKI on multivariate analysis. AKI was an independent predictor of death (p = 0.028) but not a poor functional outcome (p = 0.21) on multivariate testing. Unresolved renal dysfunction was the strongest independent predictor of death in this cohort (p < 0.001).
AKI is a common complication following aSAH. Patients with premorbid hypertension and those treated with nephrotoxic medications may be at greater risk for renal dysfunction. AKI appears to confer an increased probability of death after aSAH.
急性肾损伤（AKI）与危重症患者的死亡相关，但这种并发症在动脉瘤性蛛网膜下腔出血（aSAH）后尚未得到充分描述。本研究的目的是确定aSAH后AKI的发生率，并识别肾功能障碍的危险因素。次要目的是研究AKI对aSAH后12周患者死亡率和功能结局的影响。
作者对“氯沙坦克服蛛网膜下腔出血后发生的神经缺血和梗死（CONSCIOUS-1）”试验数据集进行了事后分析（临床试验注册号：NCT00111085，https://clinicaltrials.gov）。感兴趣的主要结局是AKI的发生，根据《改善全球肾脏病预后（KDIGO）指南》进行定义。感兴趣的次要结局是aSAH后12周的死亡和改良Rankin量表评分大于2。倾向评分匹配用于评估与氯沙坦给药和AKI相关的显著治疗效果。单因素分析、局部加权散点图平滑（LOWESS）曲线和逐步逻辑回归模型用于评估基线或疾病相关特征与研究结局之间的关联。
CONSCIOUS-1试验纳入的413例患者中有156例（38%）在重症监护病房（ICU）住院期间发生了AKI。多因素分析显示，高血压病史（p < 0.001）和使用肾毒性药物的数量（p = 0.029）是AKI的独立预测因素。多因素检验显示，AKI是死亡的独立预测因素（p = 0.028），但不是功能结局不良的预测因素（p = 0.21）。未解决的肾功能障碍是该队列中死亡的最强独立预测因素（p < 0.001）。
AKI是aSAH后的常见并发症。病前有高血压的患者和接受肾毒性药物治疗的患者可能发生肾功能障碍风险更高。AKI似乎会增加aSAH后死亡的可能性。
