Chaikof E L, Smith R B, Salam A A, Dodson T F, Lumsden A B, Kosinski A S, Coyle K A, Allen R C
Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA.
J Vasc Surg. 1994 Jan;19(1):135-46; discussion 146-8. doi: 10.1016/s0741-5214(94)70128-8.
The durability of renal preservation after surgical intervention has not been well defined, particularly in patients with associated aortic disease. A review of all patients at the Emory University Hospital with renal insufficiency (creatinine level > or = 1.8) and concomitant atherosclerotic aortic and renovascular disease was undertaken.
Fifty patients underwent both renal revascularization (71 kidneys) and the repair of aneurysmal or symptomatic aortic occlusive disease between 1982 and 1992. Hypertension was present in 96% of patients and diabetes was present in 10%. The preoperative estimated glomerular filtration rate (EGFR) was 25.18 +/- 8.29 ml/min (creatinine level 3.1 +/- 1.5 mg/dl). Operative management included bilateral renal artery repair (n = 21), unilateral repair alone (n = 17), and unilateral repair with contralateral nephrectomy (n = 12). The relative percent change in the postoperative EGFR (> or = 7 days after operation) increased by at least 20% in 42% of the patients, had decreased by 20% or more in only 4%, and was otherwise categorized as unchanged in the remaining 54% of the study group.
The 30-day operative mortality rate was 2.0% (1 of 50). Forty-five of the surviving 49 patients (91.8%) were available for follow-up (median 49 months). During this period nine patients (18.4%) eventually required dialysis, four within 6 months of operation, and 19 patients died. Neither subgroup experienced a retrieval of renal function after operation. Five-year survival rate was 61%, and a trend was noted between the risk of death and the relative change in EGFR after operation (p = 0.13). The likelihood of eventually requiring long-term dialysis was highest among those patients with low preoperative functional renal reserve as measured by preoperative creatinine level of 3 mg/dl or greater (p < 0.0001), or preoperative EGFR less than 20 ml/min (p = 0.0001). Blood pressure was cured or improved in 50% at late follow-up.
Early improvement of renal function may be observed in nearly one half of patients subjected to combined aortic and renal revascularization. Nonetheless, renal preservation may not be sustainable in patients with compromised preoperative function. Intervention before marked functional decline remains the best option for minimizing the risk of eventual dialysis.
手术干预后肾脏保存的耐久性尚未明确界定，尤其是在伴有主动脉疾病的患者中。我们对埃默里大学医院所有肾功能不全（肌酐水平≥1.8）且伴有动脉粥样硬化性主动脉和肾血管疾病的患者进行了回顾性研究。
1982年至1992年间，50例患者同时接受了肾血管重建术（71个肾脏）以及动脉瘤或有症状的主动脉闭塞性疾病修复术。96%的患者患有高血压，10%的患者患有糖尿病。术前估计肾小球滤过率（EGFR）为25.18±8.29 ml/分钟（肌酐水平3.1±1.5 mg/dl）。手术管理包括双侧肾动脉修复（n = 21）、单纯单侧修复（n = 17）以及单侧修复加对侧肾切除术（n = 12）。术后EGFR（术后≥7天）相对百分比变化至少增加20%的患者占42%，降低20%或更多的仅占4%，其余54%的研究组患者变化归类为无变化。
30天手术死亡率为2.0%（50例中的1例）。49例存活患者中有45例（91.8%）可供随访（中位随访时间49个月）。在此期间，9例患者（18.4%）最终需要透析，4例在术后6个月内需要透析，19例患者死亡。两个亚组术后均未出现肾功能恢复。5年生存率为61%，并且观察到术后死亡风险与EGFR相对变化之间存在趋势（p = 0.13）。术前肌酐水平≥3 mg/dl或术前EGFR＜20 ml/分钟所测量的术前功能性肾储备低的患者中，最终需要长期透析的可能性最高（p＜0.0001），或术前EGFR＜20 ml/分钟（p = 0.0001）。在后期随访中，50%的患者血压得到治愈或改善。
在接受主动脉和肾血管联合重建术的患者中，近一半患者可能会观察到肾功能早期改善。尽管如此，术前功能受损的患者肾脏保存可能无法持续。在明显功能下降之前进行干预仍然是将最终透析风险降至最低的最佳选择。
