Petchmak Peerawitch, Wongmahisorn Yuthapong, Trongtrakul Konlawij
Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
Department of Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
PeerJ. 2021 May 3;9:e11324. doi: 10.7717/peerj.11324. eCollection 2021.
End-stage kidney disease (ESKD) is a major worldwide health problem. Patients with ESKD are thought to have a significant risk for development of complications following an operation. However, the study of ESKD and its outcomes following major operations remains rare, particularly in critical illness. Therefore, this study aimed to demonstrate how the outcomes of ESKD patients were affected when they underwent a major operation and were admitted to the intensive care unit (ICU), compared with non-ESKD patients.
A retrospective matched case cohort study was conducted in 122 critically ill surgical patients who underwent a major operation and were admitted to the ICU, during 2013 and 2016. Sixty-one ESKD patients who required long-term dialysis were enrolled and compared with 61 matched non-ESKD patients. The matching criteria were the same age interval (±5 years), gender, and type of operation. The ICU mortality was compared to the primary outcome of the study.
Patients' baseline characteristics between ESKD and non-ESKD were similar to a priori matching criteria and other demographics, except for pre-existing diabetes mellitus and hypertension, which were found significantly more in ESKD ( = 0.03 and 0.04, respectively). For operations, ESKD showed a higher grade of the American Society of Anesthesiologist (ASA) physical status ( < 0.001), but there were no differences for emergency surgery ( = 0.71) and duration of operation ( = 0.34). At ICU admission, the severity of illness measured by the Sequential Organ Failure Assessment (SOFA) score was greater in ESKD (8.9 ± 2.6 vs 5.6 ± 2.5; < 0.001). However, after eliminating renal domain, SOFA non-renal score was equivalent (5.7 ± 2.2 vs 5.2 ± 2.3, = 0.16). The ICU mortality was significantly higher in critically-ill surgical patients with ESKD than non-ESKD (23% vs 5%, =0.007), along with hospital mortality rates (34% vs 10%, = 0.002). The multivariable logistic regression analyses adjusted for age and SOFA non-renal score demonstrated that ESKD had a significant association with ICU and hospital mortality (adjOR = 5.59; 95%CI [1.49-20.88], = 0.01 and adjOR = 4.55; 95%CI[1.67-12.44], = 0.003, respectively).
Patients who underwent a major operation and needed intensive care admission with pre-existing ESKD requiring long-term dialysis were associated with greater mortality than patients without ESKD. More careful assessment before, during, and after major surgical procedures should be performed in this group of patients to improve post-operative outcomes.
终末期肾病（ESKD）是一个全球性的主要健康问题。ESKD患者被认为在手术后发生并发症的风险很高。然而，关于ESKD及其在大手术后的结局的研究仍然很少，尤其是在危重病方面。因此，本研究旨在比较ESKD患者与非ESKD患者在接受大手术并入住重症监护病房（ICU）时，其结局受到了怎样的影响。
对2013年至2016年期间122例接受大手术并入住ICU的危重病手术患者进行了一项回顾性匹配病例队列研究。纳入61例需要长期透析的ESKD患者，并与61例匹配的非ESKD患者进行比较。匹配标准为相同的年龄区间（±5岁）、性别和手术类型。将ICU死亡率作为研究的主要结局进行比较。
ESKD组和非ESKD组患者的基线特征与预先设定的匹配标准及其他人口统计学特征相似，但ESKD组中既往糖尿病和高血压的发生率显著更高（分别为P = 0.03和0.04）。在手术方面，ESKD组的美国麻醉医师协会（ASA）身体状况分级更高（P < 0.001），但急诊手术情况（P = 0.71）和手术持续时间（P = 0.34）无差异。入住ICU时，用序贯器官衰竭评估（SOFA）评分衡量的疾病严重程度在ESKD组更高（8.9±2.6 vs 5.6±2.5；P < 0.001）。然而，剔除肾脏领域后，SOFA非肾脏评分相当（5.7±2.2 vs 5.2±2.3，P = 0.16）。ESKD的危重病手术患者的ICU死亡率显著高于非ESKD患者（23% vs 5%，P = 0.007），医院死亡率也是如此（34% vs 10%，P = 0.002）。对年龄和SOFA非肾脏评分进行调整的多变量逻辑回归分析表明，ESKD与ICU死亡率和医院死亡率显著相关（调整后的比值比[adjOR] = 5.59；95%置信区间[CI][1.49 - 20.88]，P = 0.01；adjOR = 4.55；95%CI[1.67 - 12.44]，P = 0.003）。
与无ESKD的患者相比，接受大手术且因预先存在的ESKD需要长期透析而需要入住重症监护的患者死亡率更高。对于这组患者，在大手术前、手术中和手术后应进行更仔细的评估，以改善术后结局。
