心脏手术中术中静脉淤血与急性肾损伤：一项观察性队列研究。
Intraoperative venous congestion and acute kidney injury in cardiac surgery: an observational cohort study.
机构信息
Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
出版信息
Br J Anaesth. 2021 Mar;126(3):599-607. doi: 10.1016/j.bja.2020.12.028. Epub 2021 Feb 4.
BACKGROUND
Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery.
METHODS
In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ([TIMP-2]⋅[IGFBP7]), a marker of renal stress. We measured associations between venous congestion, AKI and [TIMP-2]⋅[IGFBP7], adjusted for potential confounders. Values are reported as median (25th-75th percentile).
RESULTS
Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81-567) for CVP >12 mm Hg, 66 mm Hg min (12-221) for CVP >16 mm Hg, and 11 mm Hg min (1-54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio=1.06; 95% confidence interval [CI], 1.02-1.10; P=0.008; odds ratio=1.12; 95% CI, 1.02-1.23; P=0.013; and odds ratio=1.30; 95% CI, 1.06-1.59; P=0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased [TIMP-2]⋅[IGFBP7] measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative [TIMP-2]⋅[IGFBP7].
CONCLUSION
Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.
背景
增加血管内容量与急性肾损伤（AKI）的保护有关，但在充血性心力衰竭患者中，静脉充血与 AKI 增加有关。我们检验了术中静脉充血与心脏手术后 AKI 相关的假说。
方法
在参与他汀类药物预防 AKI 心脏手术试验的患者中，通过中心静脉压（CVP）>12、16 或 20mmHg 的时间-曲线下面积（AUC）来量化静脉充血（mm Hg min）。使用肾脏病预后质量倡议（KDIGO）标准和组织金属蛋白酶抑制剂-2 和胰岛素样生长因子结合蛋白 7（[TIMP-2]⋅[IGFBP7]）的尿浓度定义 AKI，这是一种肾应激标志物。我们调整了潜在混杂因素后，测量了静脉充血、AKI 和 [TIMP-2]⋅[IGFBP7] 之间的相关性。数值以中位数（25-75 分位数）报告。
结果
根据 KDIGO 标准，425 例患者中有 104 例（24.5%）发生 AKI。CVP>12mmHg 的 AUC 为 273mmHg min（81-567），CVP>16mmHg 的 AUC 为 66mmHg min（12-221），CVP>20mmHg 的 AUC 为 11mmHg min（1-54）。每个阈值的中位数静脉充血 AUC 增加 60mmHg min 与 AKI 增加独立相关（比值比=1.06；95%置信区间[CI]，1.02-1.10；P=0.008；比值比=1.12；95%CI，1.02-1.23；P=0.013；比值比=1.30；95%CI，1.06-1.59；P=0.012，CVP>12、>16 和>20mmHg 分别）。体外循环前的静脉充血也与体外循环期间和手术后测量的 [TIMP-2]⋅[IGFBP7] 增加相关，但体外循环后的静脉充血和整个手术期间的静脉充血均与术后 [TIMP-2]⋅[IGFBP7] 无关。
结论
心脏手术后术中静脉充血与 AKI 增加独立相关。
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