尿微量白蛋白/ 尿肌酐比值预测体外循环心脏 手术后急性肾损伤及预后的价值分析

Predictive value of uACR for AKI after cardiac surgery with cardiopulmonary bypass

摘要:

目的 探讨尿微量白蛋白/ 尿肌酐比值（uACR）预测体外循环心脏手术后发生急性肾损伤 （AKI）及短期治疗结局的临床价值。方法 选取2018 年2 月—2019 年5 月在上海市第一人民医院治疗的心 脏停跳条件下全身麻醉行体外循环心脏手术的82 例患者。根据术后7 d 内是否发生AKI，分为AKI 组30 例 和非AKI 组52 例。比较两组患者入重症监护病房（ICU）当日uACR、血清肌酐（Scr）、急性生理学与慢 性健康状况评估Ⅱ（APACHE Ⅱ）评分和估算的肾小球滤过率（eGFR）。受试者工作特征（ROC）曲线确 定uACR 预测AKI、重症AKI 及术后28 d 死亡的效能。多因素Cox 回归模型分析体外循环心脏手术患者 发生AKI 的危险因素。结果 AKI 组入ICU 时APACHE Ⅱ评分、Scr 及uACR 高于非AKI 组（P <0.05）， 而eGFR 值低于非AKI 组（P <0.05）。经多因素Cox 回归分析，年龄[Rl ^ R=1.078（95% CI ：1.002，1.315）]、 高血压[Rl ^ R=2.184（95% CI ：1.294，5.165）]、糖尿病[Rl ^ R=1.297（95% CI ：1.046，1.485）]、体外循环时 间[Rl ^ R=3.882（95% CI ：2.127，5.089）]、主动脉阻断时间[Rl ^ R=1.406（95% CI ：1.079，2.178）] 及入ICU 时uACR[Rl ^ R=1.914（95% CI ：1.453，3.162）] 是体外循环心脏手术患者术后发生AKI 的独立危险因素 （P <0.05）。经ROC 曲线分析，入ICU 时uACR 预测AKI、重症AKI、术后28 d 内死亡的ROC 曲线下的 面积分别为0.784（95% CI ：0.691，0.835）、0.550（95% CI ：0.507，0.615）及0.716（95% CI ：0.680，0.782）。 结论 uACR 在一定程度上可以反映肾脏早期损伤程度，有望成为体外循环心脏手术后发生AKI 的早期预警 和预后判断指标。

关键词:心脏病;肾疾病;外科手术;体外循环;预后

Abstract:

Objective To investigate the predictive value of urinary albumin/creatinine ratio (uACR) for the occurrence and prognosis of acute kidney injury (AKI) after cardiac surgery with cardiopulmonary bypass (CPB). Methods 82 patients undergoing cardiac surgery with CPB in our hospital were selected from February 2018 to May 2019 and divided into AKI group (n = 30 patients, 36.59%) and non-AKI group (n = 52 patients, 63.41%) according to serum creatinine (SCr) changes. The uACR ratio, SCr, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score and estimated glomerular filtration rate (eGFR) at ICU admission were detected and compared between AKI group and non-AKI group. Multivariate Cox regression model and receiver operating characteristic (ROC) curve were used to analyze the risk factors of AKI and predictive value of uACR for AKI after the surgery. Results Compared with non-AKI group, the uACR, SCr, APACHE Ⅱ scores in 30 AKI patients were higher (P < 0.05) while eGFR value was lower (P < 0.05). The results of multivariate Cox regression analysis showed that age [Rl ^ R = 1.078 (95% CI: 1.002, 1.315)], hypertension [Rl ^ R = 2.184 (95% CI: 1.294, 5.165)], diabetes mellitus [Rl ^ R = 1.297 (95% CI: 1.046, 1.485)], CPB [Rl ^ R = 3.882 (95% CI: 2.127, 5.089)], aortic cross-clamp time [Rl ^ R = 1.406 (95% CI: 1.079, 2.178)] and uACR at ICU admission [Rl ^ R = 1.914 (95% CI: 1.453, 3.162)] would be the risk factors of AKI (P < 0.05). The area under ROC curve of uACR predictive for AKI, severe AKI and death within 28 days after the surgery were respectively 0.784 (95% CI: 0.691, 0.835), 0.550 (95% CI: 0.507, 0.615), 0.716 (95% CI: 0.680, 0.782). Conclusions Our data suggested that uACR might reflect the severity of early AKI after cardiac surgery with CPB, which would be the sensitive predictor of the occurrence and prognosis of AKI patients with cardiac surgery with CPB.

Key words:cardiac surgery with cardiopulmonary bypass; acute kidney injury; urinary albumin/creatinine ratio; prognosis