肝移植术后急性肾损伤的发生率及危险因素

doi:10.3969/j.issn.1006-7795.2018.01.004

摘要/Abstract

摘要： 目的回顾性分析肝移植患者术后发生急性肾损伤（acute kidney injury，AKI）的临床特征及危险因素。方法收集2013年6月1日至2016年10月31日入住首都医科大学附属北京友谊医院重症医学科的成年肝移植患者，除外肝肾联合移植、肾移植术后、二次肝移植、终末期肾病依赖透析患者、术前诊断AKI的患者。将所有入组的患者依据改善全球肾脏病预后组织（Kidney Disease：Improving Global Outcomes，KDIGO）标准分为急性肾损伤组和非急性肾损伤组。纳入分析的因素包括人口学特征，既往病史包括高血压、糖尿病病史，肝病分型，终末期肝病模型（model for end-stage liver disease，MELD）评分。术前化学检验指标：肌酐、白蛋白、总胆红素、丙氨酸氨基转移酶（alanine transaminase，ALT）、门冬氨酸氨基转移酶（aspartate transaminase，AST）。术中记录：手术时间、冷/热缺血时间、液体平衡。术后资料：重症监护病房（intensive care unit，ICU）住院天数，总住院天数和28 d病死率。用单因素方差分析找出两组间有差别的变量，再用Logistic回归分析筛选出发生急性肾损伤的危险因素，受试者工作特征（receiver operating characteristic，ROC）曲线建立预测模型。结果在纳入的279例肝移植术后患者中，成年人（年龄 ≥ 18岁）124例，急性肾损伤68例，发生率为54.8%，在发生急性肾损伤患者中，根据KDIGO分期，Ⅰ期患者45例，所占比例为66.2%；Ⅱ期患者9例，所占比例为13.2%，Ⅲ期患者14例，所占比例为20.6%。Logistic回归模型分析显示成年人肝移植术后发生AKI的独立高危因素包括术中低血压时间比值比（odd ratio，OR）=1.020、术中失血量（OR=1.036）和术中液体正平衡（OR=1.015），ROC曲线中其界值分别为27.5 min、32.5 mL/kg、31.2 mL/kg，曲线下面积分别为0.662（P=0.002，95% CI：0.567~0.757）、0.637（P=0.009，95%CI： 0.540~0.734）和0.624（P=0.017，95% CI：0.526~0.723）。结论肝移植患者术后AKI发生率为54.8%，危险因素为术中低血压时间、术中失血量和术中液体正平衡，AKI组住院时间较非AKI组住院时间延长。

关键词: 急性肾损伤, 肝移植, 危险因素

Abstract: Objective To investigate clinical characteristics and risk factors of acute kidney injury (AKI) in patients following liver transplantation. The clinical outcomes of patients with AKI were also studied.Methods This was a retrospective observational study with data collected from intensive care unit (ICU) at Beijing Friendship Hospital, Capital Medical University. All the adult patients following liver transplantation admitted to ICU from June 1, 2013 to October 31, 2016 were included. Patients under kidney transplantation at the same time or ever for kidney transplantation or underwent retransplantation or with end stage renal dysfunction relying on renal replacement therapy or diagnosed as AKI before transplantation were excluded. AKI was diagnosed and classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Information recorded from patients' charts included demographic characteristics, previous history of hypertension, diabetes mellitus, previous liver disease, and model for end-stage liver disease (MELD) score. Preoperative laboratory values were also recorded:creatinine, albumin, total bilirubin(Tbil),alanine transaminase (ALT) and aspartate transaminase (AST). From the intraoperative period, we recorded the following data:duration of surgery, cold/warm ischemia time, fluid balance. Postoperative factors included:days in ICU, overall in-hospital stay and 28 days mortality rates. Univariate analysis was used to identify the difference between the two groups, and then logistic regression analysis was used to estimate the risk factors of acute kidney injury, and receiver operating characteristic(ROC) curve was used to form prediction model.Results Among the 279 patients after liver transplantation, 124 patients were adult(≥ 18 years),with 68 (54.8%) developed AKI according to KDIGO category:66.2% belonged to the stage 1, 13.2%(n=9) to the stage 2, and 20.6% (n=14) to the stage 3. Multivariate logistic regression analysis revealed that the development of AKI was associated with intraoperative hypotension duration(odd ratio,OR=1.020), excessive loss of blood(OR=1.036) and fluid balance during surgery(OR=1.015). The cut off value was 27.5 min, 32.5 mL/kg, and 31.2 mL/kg. Area under curve(AUC) was 0.662 (P=0.002, 95% CI:0.567-0.757), 0.637 (P=0.009, 95% CI:0.540-0.734), 0.624 (P=0.017, 95% CI:0.526-0.723).Conclusion The incidence rate of AKI was 54.8%. The risk factors were intraoperative hypotension duration and excessive loss of blood and fluid balance during operation. AKI is independently associated with longer duration of hospitalization.

Key words: acute kidney injury (AKI), liver transplantation, risk factors

中图分类号:

R617

岳竹, 李昂, 刘培, 白静, 庄海舟, 段美丽. 肝移植术后急性肾损伤的发生率及危险因素[J]. 首都医科大学学报, 2018, 39(1): 14-20.

Yue Zhu, Li Ang, Liu Pei, Bai Jing, Zhuang Haizhou, Duan Meili. Acute kidney injury after liver transplantation: incidence and risk factors[J]. Journal of Capital Medical University, 2018, 39(1): 14-20.

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