Demirjian Sevag, Bakaeen Faisal, Tang W H Wilson, Donaldson Chase, Taliercio Jon, Huml Anne, Gadegbeku Crystal A, Gillinov A Marc, Insler Steven
Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH.
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH.
Crit Care Explor. 2024 Mar 22;6(4):e1063. doi: 10.1097/CCE.0000000000001063. eCollection 2024 Apr.
Examine the: 1) relative role of hemodynamic determinants of acute kidney injury (AKI) obtained in the immediate postcardiac surgery setting compared with established risk factors, 2) their predictive value, and 3) extent mediation via central venous pressure (CVP) and mean arterial pressure (MAP).
Retrospective observational study. The main outcome of the study was moderate to severe AKI, per kidney disease: improving global outcomes, within 14 days of surgery.
U.S. academic medical center.
Adult patients undergoing cardiac surgery between January 2000 and December 2019 ( = 40,426) in a single U.S.-based medical center. Pulmonary artery catheter measurements were performed at a median of 102 minutes (11, 132) following cardiopulmonary bypass discontinuation.
None.
The median age of the cohort was 67 years (58, 75), and 33% were female; 70% had chronic hypertension, 29% had congestive heart failure, and 3% had chronic kidney disease. In a multivariable model, which included comorbidities and traditional intraoperative risk factors, CVP ( < 0.0001), heart rate ( < 0.0001), cardiac index ( < 0.0001), and MAP ( < 0.0001), were strong predictors of AKI, and superseded factors such as surgery type and cardiopulmonary bypass duration. The cardiac index had a significant interaction with heart rate ( = 0.026); a faster heart rate had a differentiating effect on the relationship of cardiac index with AKI, where a higher heart rate heightened the risk of AKI primarily in patients with low cardiac output. There was also significant interaction observed between CVP and MAP ( = 0.009); where the combination of elevated CVP and low MAP had a synergistic effect on AKI incidence.
Hemodynamic factors measured within a few hours of surgery showed a strong association with AKI. Furthermore, determinants of kidney perfusion, namely CVP and arterial pressure are interdependent; as are constituents of stroke volume, that is, cardiac output and heart rate.
研究：1）心脏手术后即刻获得的急性肾损伤（AKI）血流动力学决定因素与既定危险因素相比的相对作用；2）它们的预测价值；3）通过中心静脉压（CVP）和平均动脉压（MAP）的中介程度。
回顾性观察研究。研究的主要结局是根据改善全球肾脏病预后组织（KDIGO）标准，术后14天内发生的中度至重度AKI。
美国学术医疗中心。
2000年1月至2019年12月期间在美国一家医疗中心接受心脏手术的成年患者（n = 40426）。在体外循环停止后的中位数时间为102分钟（11，132）时进行肺动脉导管测量。
无。
该队列的中位年龄为67岁（58，75），33%为女性；70%患有慢性高血压，29%患有充血性心力衰竭，3%患有慢性肾脏病。在一个包含合并症和传统术中危险因素的多变量模型中，CVP（P < 0.0001）、心率（P < 0.0001）、心脏指数（P < 0.0001）和MAP（P < 0.0001）是AKI的强预测因素，并取代了手术类型和体外循环持续时间等因素。心脏指数与心率有显著交互作用（P = 0.026）；心率加快对心脏指数与AKI的关系有区分作用，在低心输出量患者中，较高的心率主要增加了AKI的风险。CVP和MAP之间也观察到显著交互作用（P = 0.009）；CVP升高和MAP降低的组合对AKI发生率有协同作用。
术后数小时内测量的血流动力学因素与AKI密切相关。此外，肾脏灌注的决定因素，即CVP和动脉压是相互依赖的；心输出量的组成部分，即心脏指数和心率也是如此。
