关于先天性心脏病小儿术后急性肾损伤的回顾性分析

发布时间：2018-05-26 04:27

本文选题：先天性心脏病 + 儿童　；参考：《第三军医大学》2017年硕士论文

【摘要】：据统计,先天性心脏病(以下简称先心病)发病率达到了9‰,手术治疗是先心病的主要治疗方式,而术后急性肾损伤(acute kidney injury,AKI)是先心病术后的一个严重并发症,其发病率为5~33%。目前术后AKI的治疗效果不确切,因此术后AKI的早期预防、及时诊断对降低AKI发生率和严重程度,以及降低术后通气时间、ICU时长、住院天数、在院死亡率具有重要意义。目前先心病术后AKI的研究得到越来越多人的重视,但是先心病患者是个年龄跨度很大的群体,其中小儿由于肾功能尚未发育完善,与成人相比,疾病特征存在显著差异,术后AKI风险较成人更高,但目前这方面的研究很少,因此我们将4岁的患儿作为研究对象,探讨先心病患儿术后急性肾损伤的疾病特点。一、先天性心脏病小儿术后急性肾损伤之临床危险因素对高风险患儿进行甄别是实现先心病术后AKI早期预防、早期诊断的必要条件,因此探讨术后发生AKI的危险因素以期帮助临床医师及时发现高风险患儿,对于降低术后AKI发生率、改善患者预后非常重要。目前国内外已经有一些研究探讨了先心术后AKI的危险因素,但结果不尽一致,除了纳入研究对象的就诊机构以及研究本身纳入的分析因素不一样外,纳入对象的年龄段不同可能是一个主要原因。年龄越小,患儿肾功能越不成熟,先心术后发生AKI的几率越大,因此本研究我们将4岁患儿作为研究对象,探讨术后AKI发生的危险因素。目的:分析4岁先心病患儿术后发生AKI的危险因素。方法:收集2015年4月至2016年4月于新桥医院行先心病手术治疗4岁患儿的相关资料,以改良儿童肾脏疾病风险分级(pediatric risk injury failure loss and end stage kidney diseases,pRIFLE)作为AKI的诊断标准,统计患儿行先心病手术后AKI的发生率,比较术后发生AKI的患儿与未发生AKI(N-AKI)患儿之间的差异,利用多因素Logistic回归筛选先心病患儿术后发生AKI的临床危险因素。结果:本研究共纳入298例患儿,其中107例(35.91%)患儿术后发生AKI,分别是危险期82例(27.52%),损伤期16例(5.37%),衰竭期9例(3.02%)。与N-AKI组相比,在术前情况上,AKI组患儿的平均身高、年龄、体质量更低,术前合并紫绀和其他重要疾病的比率更高,而术前血清肌酐(serum creatinine,Scr)含量更低;在手术情况上,AKI组患儿的术前ASA分级更高,手术时间、主动脉钳闭时间(aortic clamping time,ACT)、体外循环(cardiopulmonary bypass,CPB)时间更长;在术后情况上,AKI组患儿的术后平均尿素(Urea)、Scr、尿酸(uric acid,Ua)、视黄醇结合蛋白值(retinal conjugated protein,RBP)、胱抑素(cystatin-C,CystC)更高,肌酐清除率(estimated creatinine clearance,eCCl)更低;在预后上,AKI组患儿的平均住院时长、死亡率更高。将组间差异显著的指标纳入回归分析,结果发现其中年龄1岁、术前合并紫绀、术前Scr低、手术时间较长是4岁患儿行先心手术后发生AKI的独立危险因素。结论:年龄1岁、术前合并紫绀、术前Scr低的患儿术后发生AKI的风险较高,同时手术时间延长也会显著增加先心病患儿术后AKI的发生风险。二、先天性心脏病小儿术后急性肾损伤之体液平衡对诊断、住院天数的影响Scr含量测定受到年龄、肌肉含量与质量、蛋白分解代谢、肾功能、心输出量、体液容量等因素的影响,而受到手术治疗、体液治疗的影响,先心病患儿体液容量从术间到术后ICU期间可产生较大波动,体液容量波动可造成测定的Scr也产生波动,那么体液平衡是否可能通过影响Scr水平而改变术后AKI的诊断结果,甚至影响患儿的预后?为此,我们以简单公式校正Scr,探讨体液平衡校正Scr对AKI诊断结果的影响,同时以住院天数作为预后指标,研究体液平衡是否会通过改变先心病患儿术后AKI的诊断结果对住院天数造成影响。目的:研究体液平衡对先心病患儿术后AKI诊断、住院天数的影响。方法:收集2015年4月~2016年4月于新桥医院行先心病手术治疗的4岁患儿资料,以pRIFLE分级作为AKI的诊断标准,探讨使用体液平衡校正Scr前后AKI发生率的差异;利用多元逐步线性回归排除年龄、NYHA分级、合并疾病、RACHS-1分级等因素的干扰,比较体液平衡校正后新增的AKI或N-AKI组患儿与其他患儿住院天数的差异,研究体液平衡是否会通过影响AKI诊断影响患儿预后。结果:本研究共纳入286例患儿,与校正Scr前相比,169体液正平衡患儿Scr校正后AKI发生率更高,117例体液负平衡患儿Scr校正后AKI发生率更低,但总体而言,AKI发生率不受体液平衡校正Scr的影响;同时多元逐步线性回归分析也显示体液平衡校正后新增的AKI或N-AKI组患儿与其他患儿住院天数没有差异。结论:与校正Scr前相比,校正Scr后pRIFLE标准诊断的AKI发生率更高,体液正平衡掩盖AKI的发生;体液负平衡校正Scr后诊断的AKI发生率更低;体液平衡不会通过影响AKI诊断结果影响患儿住院天数。
[Abstract]:According to statistics, the incidence of congenital heart disease (hereinafter referred to as congenital heart disease) reached 9 per thousand, surgical treatment is the main treatment of congenital heart disease, and postoperative acute renal injury (acute kidney injury, AKI) is a serious complication after congenital heart disease, the incidence of the incidence of AKI after 5~33%. preoperation is not accurate, so the early stage of postoperative AKI Prevention, timely diagnosis to reduce the incidence of AKI and severity, and reduce postoperative ventilation time, ICU length, the number of days in hospital, the hospital mortality is of great significance. At present, the study of AKI after congenital heart disease has been paid more and more attention, but the patients with congenital heart disease are a large age group, among which children have not been able to have renal function. There are significant differences in disease characteristics compared with adults, and the risk of postoperative AKI is higher than that of adults, but at present there are few studies in this area. Therefore, 4 year old children are used as research subjects to explore the characteristics of acute renal injury in children with congenital heart disease. First, the clinical risk factors of acute renal injury after congenital heart disease. Screening for high-risk children is a necessary condition for early prevention and early diagnosis of AKI after congenital heart disease. Therefore, it is very important to explore the risk factors of AKI after operation to help clinicians to find high-risk children in time. It is very important to reduce the incidence of postoperative AKI and improve the prognosis of patients. The risk factors of AKI after the first heart operation are not the same, but the age segment of the subjects may be a major cause in addition to the medical institutions and the analysis factors involved in the study. The younger the age, the less mature the renal function is, the greater the probability of AKI after the first heart operation, so this study is my study. We studied the risk factors of postoperative AKI in children with 4 years of age. Objective: to analyze the risk factors of AKI in children with congenital heart disease after 4 years of age. Methods: to collect related data of 4 year old children in new bridge hospital from April 2015 to April 2016, in order to improve the risk classification of children's kidney disease (pediatric risk injury) Failure loss and end stage kidney diseases, pRIFLE), as a diagnostic criterion for AKI, to count the incidence of AKI in children with congenital heart disease, compare the difference between children with AKI after operation and those without AKI. 298 children were included in 298 cases, of which 107 cases (35.91%) had 82 cases (27.52%), 16 cases (5.37%) and 9 (3.02%) in the period of failure. Compared with group N-AKI, the average height, age, and body mass of group AKI were lower, and the rate of cyanosis and other important diseases was higher before operation, and the pre operation blood was higher than that of group AKI. The content of serum creatinine (Scr) was lower, and in the operation, the preoperative ASA classification was higher in the group AKI, the operation time, the time of the aortic clamping (aortic clamping time, ACT), and the extracorporeal circulation (cardiopulmonary bypass, CPB) longer. The value of retinol binding protein (retinal conjugated protein, RBP), cystatin (cystatin-C, CystC) was higher, the creatinine clearance rate (estimated creatinine clearance, eCCl) was lower; in the prognosis, the average length of hospitalization and higher mortality in the AKI group were higher. The results of the difference between groups were included in the regression analysis. The results were found to be 1 years old and preoperatively. Cyanosis, with low preoperative Scr and longer operation time, is an independent risk factor for AKI after 4 years of pre operation. Conclusion: age 1 years old, cyanosis before operation, high risk of AKI in children with low Scr before operation, and the prolonged operation time will significantly increase the risk of AKI in children with Preoperation. Two, congenital heart disease. Influence of Scr content on age, muscle content and quality, protein catabolism, renal function, cardiac output, body fluid volume and so on, and affected by surgical treatment and fluid therapy, the fluid volume of children with congenital heart disease can be measured from the operation to the postoperative ICU period. If the fluctuation of the body fluid volume can cause the fluctuation of the measured Scr, is it possible for the body fluid balance to change the diagnostic results of the postoperative AKI by affecting the Scr level and even affect the prognosis of the children? For this reason, we use a simple formula to correct the Scr and explore the influence of the body fluid balance correction Scr on the results of the AKI diagnosis, and at the same time in the hospital days As a prognostic indicator, study whether body fluid balance will affect the number of days of hospitalization by changing the diagnostic results of AKI in children with congenital heart disease. Objective: To study the effect of body fluid balance on postoperative AKI diagnosis and the number of days in hospital for children with congenital heart disease. Methods: to collect 4 year old children who were treated with congenital heart disease in Xinqiao Hospital in April, April 2015. Data, using pRIFLE classification as a diagnostic criterion for AKI, the difference in the incidence of AKI before and after the use of body fluid balance to correct Scr was investigated. The interference of factors such as age, NYHA classification, disease and RACHS-1 classification were excluded by multiple stepwise linear regression, and the difference of the number of days of hospitalization between children with AKI or N-AKI group and other children was compared after the correction of body fluid balance. Whether or not the body fluid balance could affect the prognosis of children by affecting the AKI diagnosis. Results: 286 children were included in this study. Compared with the corrected Scr, the incidence of AKI was higher after the correction of Scr in children with positive balance of body fluid, and the incidence of AKI was lower in 117 cases with negative balance of body fluid after Scr correction, but overall, the AKI incidence rate of non receptor fluid balance corrected Scr. The multiple stepwise linear regression analysis also showed that the number of children in the new AKI or N-AKI group after correction of body fluid balance was not different from that of other children. Conclusion: compared with the correction of Scr before the correction of Scr, the incidence of AKI was higher after the correction of Scr, the positive balance of the body fluid concealed the occurrence of AKI, and the negative balance of body fluid corrected the AKI hair after Scr. Lower birth rate; humoral balance does not affect the length of hospital stay in children by affecting AKI diagnostic results.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.5

【参考文献】