Ruan Xia, Li Mohan, Pei Lijian, Lan Ling, Chen Weiyun, Zhang Yuelun, Yu Xuerong, Yu Chunhua, Yi Jie, Zhang Xiuhua, Huang Yuguang
Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Perioper Med (Lond). 2023 May 16;12(1):17. doi: 10.1186/s13741-023-00306-2.
Perioperative acute kidney injury (AKI) has been one of the leading causes of morbidity and mortality for surgical patients. Pheochromocytoma is a rare, catecholamine-secreting neuroendocrine neoplasm characterized by typical long-term hypertension that needs surgical resection. Our objective was to determine whether intraoperative mean arterial pressures (MAPs) less than 65 mmHg are associated with postoperative AKI after elective adrenalectomy in patients with pheochromocytoma.
We performed a retrospective review of patients undergoing adrenalectomy for pheochromocytoma between 1991 and 2019 at Peking Union Medical College Hospital, Beijing, China. Two intraoperative phases, before and after tumor resection, were recognized based on distinctly different hemodynamic characteristics. The authors evaluated the association between AKI and each blood pressure exposure in these two phases. The association between the time spent under different absolute and relative MAP thresholds and AKI was then evaluated adjusting for potential confounding variables.
We enrolled 560 cases with 48 patients who developed AKI postoperatively. The baseline and intraoperative characteristics were similar in both groups. Though time-weighted average MAP was not associated with postoperative AKI during the whole operation (OR 1.38; 95% CI, 0.95-2.00; P = 0.087) and before tumor resection phase (OR 0.83; 95% CI, 0.65-1.05; P = 0.12), both time-weighted MAP and time-weighted percentage changes from baseline were strongly associated with postoperative AKI after tumor resection, with OR 3.50, 95% CI (2.25, 5.46) and 2.03, 95% CI (1.56, 2.66) in the univariable logistic analysis respectively, and with OR 2.36, 95% CI (1.46, 3.80) and 1.63, 95% CI (1.23, 2.17) after adjusting sex, surgical type (open vs. laparoscopic) and estimated blood loss in the multiple logistic analysis. At any thresholds of MAP less than 85, 80, 75, 70, and 65 mmHg, prolonged exposure was associated with increased odds of AKI.
We found a significant association between hypotension and postoperative AKI in patients with pheochromocytoma undergoing adrenalectomy in the period after tumor resection. Optimizing hemodynamics, especially blood pressure after the adrenal vessel ligation and tumor is resected, is crucial for the prevention of postoperative AKI in patient with pheochromocytoma, which could be different from general populations.
围手术期急性肾损伤（AKI）一直是外科患者发病和死亡的主要原因之一。嗜铬细胞瘤是一种罕见的、分泌儿茶酚胺的神经内分泌肿瘤，其特征为典型的长期高血压，需要手术切除。我们的目的是确定择期肾上腺切除术治疗嗜铬细胞瘤患者时，术中平均动脉压（MAP）低于65 mmHg是否与术后AKI相关。
我们对1991年至2019年在中国北京协和医院接受嗜铬细胞瘤肾上腺切除术的患者进行了回顾性研究。根据明显不同的血流动力学特征，识别出两个术中阶段，即肿瘤切除前和切除后。作者评估了这两个阶段中AKI与每次血压暴露之间的关联。然后在调整潜在混杂变量的情况下，评估了在不同绝对和相对MAP阈值下的暴露时间与AKI之间的关联。
我们纳入了560例患者，其中48例术后发生AKI。两组的基线和术中特征相似。尽管全手术过程中的时间加权平均MAP与术后AKI无关（OR 1.38；95%CI，0.95 - 2.00；P = 0.087），肿瘤切除前阶段也无关（OR 0.83；95%CI，0.65 - 1.05；P = 0.12），但时间加权MAP和相对于基线的时间加权百分比变化在肿瘤切除后均与术后AKI密切相关，单因素逻辑回归分析中OR分别为3.50，95%CI（2.25，5.46）和2.03，95%CI（1.56，2.66），多因素逻辑回归分析在调整性别、手术类型（开放手术与腹腔镜手术）和估计失血量后，OR分别为2.36，95%CI（1.46，3.80）和1.63，95%CI（1.23，2.17）。在MAP低于85、80、75、70和65 mmHg的任何阈值下，长时间暴露均与AKI的发生几率增加相关。
我们发现，嗜铬细胞瘤患者肾上腺切除术后肿瘤切除阶段的低血压与术后AKI之间存在显著关联。优化血流动力学，尤其是在肾上腺血管结扎和肿瘤切除后的血压，对于预防嗜铬细胞瘤患者术后AKI至关重要，这可能与一般人群不同。
