Chen Lihai, Hong Liang, Ma Aixia, Chen Yanfei, Xiao Yue, Jiang Feng, Huang Ruijian, Zhang Cui, Bu Xinyi, Ge Yali, Zhou Jifang
Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical university, Jiangsu, China.
Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, China.
Br J Anaesth. 2022 May;128(5):785-795. doi: 10.1016/j.bja.2022.01.032. Epub 2022 Mar 4.
The pathophysiological mechanisms by which venous congestion and hypotension lead to acute adverse kidney events after cardiac surgery with cardiopulmonary bypass have not been elucidated. We tested the hypothesis that intraoperative hypotension and venous congestion are associated with acute kidney injury and acute kidney disease.
Primary exposures were venous congestion and intraoperative hypotension defined by central venous pressure ≥12, 16, or 20 mm Hg or mean arterial pressure ≤55, 65, or 75 mm Hg. The primary outcomes were acute kidney injury and acute kidney disease. Multivariable logistic regression and Cox proportional hazard models were used, adjusted for relevant confounding factors and multiple comparisons.
Of 5127 eligible subjects, 1070 (20.9%) and 327 (7.2%) developed acute kidney injury and acute kidney disease, respectively. The occurrence of acute kidney injury was statistically associated with both venous congestion and intraoperative hypotension. The cumulative incidence rate for new onset acute kidney disease was 1.34 (95% confidence interval [CI], 1.21-1.60) per 100 person-days. Acute kidney disease was significantly associated with each 10 min epoch of central venous pressure ≥12 mm Hg (hazard ratio [HR]=1.03; 99% CI, 1.01-1.06; P<0.001), ≥16 mm Hg (HR=1.04; 99% CI, 1.01-1.07; P<0.001), and ≥20 mm Hg (HR=1.07; 99% CI, 1.02-1.13; P<0.001). Venous congestion was associated with an 8-17% increased risk for de novo renal replacement therapy. In contrast, intraoperative hypotension was not associated with development of acute kidney disease.
Although both venous congestion and intraoperative hypotension are associated with acute kidney injury, only venous congestion correlates with acute kidney disease among patients undergoing cardiac surgery requiring cardiopulmonary bypass. The reported associations are suggestive of a pathophysiological role of venous congestion in acute kidney disease.
体外循环心脏手术后，静脉淤血和低血压导致急性不良肾脏事件的病理生理机制尚未阐明。我们检验了术中低血压和静脉淤血与急性肾损伤和急性肾病相关的假设。
主要暴露因素为静脉淤血和术中低血压，分别定义为中心静脉压≥12、16或20 mmHg，或平均动脉压≤55、65或75 mmHg。主要结局为急性肾损伤和急性肾病。使用多变量逻辑回归和Cox比例风险模型，并对相关混杂因素和多重比较进行校正。
在5127名符合条件的受试者中，分别有1070名（20.9%）和327名（7.2%）发生了急性肾损伤和急性肾病。急性肾损伤的发生与静脉淤血和术中低血压均存在统计学关联。新发急性肾病的累积发病率为每100人日1.34（95%置信区间[CI]，1.21 - 1.60）。急性肾病与中心静脉压≥12 mmHg的每10分钟时段显著相关（风险比[HR]=1.03；99% CI，1.01 - 1.06；P<0.001），≥16 mmHg（HR=1.04；99% CI，1.01 - 1.07；P<0.001），以及≥20 mmHg（HR=1.07；99% CI，1.02 - 1.13；P<0.001）。静脉淤血与新发肾脏替代治疗风险增加8 - 17%相关。相比之下，术中低血压与急性肾病的发生无关。
虽然静脉淤血和术中低血压均与急性肾损伤相关，但在需要体外循环的心脏手术患者中，只有静脉淤血与急性肾病相关。所报道的关联提示静脉淤血在急性肾病中具有病理生理作用。
