心脏手术后急性肾损伤的风险因素：临床预防以及对中长期预后的影响

发布时间：2018-03-26 06:29

本文选题：一站式杂交手术　切入点：心脏术后急性肾损伤　出处：《北京协和医学院》2015年博士论文

【摘要】：第一部分：一站式冠状动脉再血管化手术与非体外循环下冠状动脉移植术对术后肾功能及术后出血量的比较研究研究目的一站式冠状动脉杂交手术给冠心病多支病变患者提供了微创、安全、方便的治疗方法。左侧乳内动脉至前降支的搭桥保障了左室壁的血管供应,乳内动脉作为桥血管的优势在于长久性和血管的通畅性。其次内科介入支架植入术减少外科血管吻合口,创伤小,患者更加容易接受。但是一站式杂交手术患者术中要接受大量造影剂,再加上围术期特殊的抗血小板凝集药物的应用,一站式杂交手术患者术后急性肾损伤以及出血量成为临床医生的担忧。本研究的目的就是通过对比一站式杂交手术患者以及同期非体外循环下冠状动脉移植术患者的术后出血量以及肌酐值,探索一站式杂交手术在术后出血量以及肾损伤方面的安全性。为临床工作中患者选择提供依据。研究方法本研究回顾性的收集了2007年6月至2011年1月期间阜外医院实施的一站式冠状动脉杂交手术患者共141例。通过倾向性评分收集同期手术的非体外循环下冠状动脉移植术患者共141例。通过病史采集,收集术前可能影响预后的临床变量,记录术后肌酐值变化,术后出血量以及一般临床预后变量。最后通过统计学方法对两组数据进行分析统计。结果与非体外循环下冠状动脉移植术相比,一站式杂交手术患者术后12小时出血量以及总出血量明显低于对照组,P值分别为0.04和P0.001。同时,一站式杂交组患者术后血液输注率明显低于非体外循环下冠状动脉移植术患者(P=0.001)。一站式杂交手术患者术后急性肾损伤的发生率略高于非体外循环下冠状动脉移植术患者,但是没有达到统计学差异(25.2% vs 17.6%,p=0.13)。术后转归方面,一站式杂交组患者术后血流动力学更加稳定,血管活性药物的使用更少,呼吸系统并发症更少,机械通气时间以及ICU住院时长都显著低于对照组。结论与非体外循环下不停跳冠状动脉移植术相比,一站式杂交手术有明显的优势,主要体现在术后出血量更少,输血率更低,而且并不明显增加术后肾损伤的几率。一站式杂交手术是安全、可靠的冠状动脉再血管化治疗方式。第二部分：血小板计数,急性肾损伤以及冠状动脉移植术后中长期死亡率的研究研究背景体外循环下,血小板激活以及聚集可能是术后终末器官缺血性并发症的主要原因。血小板在术后急性中风以及心肌梗塞中的作用已经被研究证实过,但是血小板与心脏术后急性肾损伤的关系的研究并不明确。研究目的本研究主要目的在于探索非免疫性血小板减少症与冠状动脉移植术术后急性肾损伤以及术后中长期死亡率之间的关系研究方法我们回顾性收集了4201例冠状动脉移植术病人资料。同时记录患者术后10日内每日血小板的最低值作为连续性变量,分析血小板低值(连续性变量)与术后急性肾损伤以及死亡率之间的关系。再者,我们将术后血小板计数处于整体患者血小板计数10%的患者作为观察组,即血小板计数10%低限组,并将此作为二分类变量进行统计。最后进行单因素和多因素分析,探索术后血小板计数(连续性变量以及二分类变量)与术后急性肾损伤以及死亡率之间的联系。研究结果术后血小板低值的平均值为121x109/L.术后急性肾损伤(KDIGO标准)发生率为50%,其中1.6% (34例)患者为AKIⅡ级,2%(42例)为AKIⅢ级。术后血小板计数每升高30x109/L,其术后急性肾损伤的风险下降约7%(OR,0.93；95%CI,0.89-0.98；P=0.003),更重要的是,术后30天死亡率下降约46%(OR，，0.54；95% CI,0.41-0.69；P0.0001)。术后血小板计数处于整体患者人群最低10%的患者,其术后进展到更加级别的急性肾损伤的几率增加3.5倍,血小板计数10%低限组的患者其术后30天以及长期死亡率明显高于剩余的患者。OR值分别为术后30天OR 4.34；95%CI,2.46-7.58；p0.0001,统计调整后术后长期死亡率OR值为1.33；95%CI,1.12 to 1.59;P=0.001。结论我们的研究发现术后血小板计数与术后急性肾损伤以及死亡率有显著性相关。第三部分：负荷剂量阿托伐他汀对冠状动脉旁路移植术后肾脏保护作用及炎性反应调节作用的研究-前瞻性随机双盲研究研究背景阿托伐他汀不仅有明确的降脂作用,近年来他汀类药物的抗炎、抗氧化应激、增加内皮细胞功能等降脂外作用成为很多临床疾病的有效预防和治疗替代方法。他汀类药物在冠心病介入治疗患者中显示有明显的抗炎、保护术后肾功能作用。甚至单次负荷剂量术前给药都显示了令人满意的肾脏保护作用。但是在外科围术期应用中,大多数回顾性研究的结果不一致,目前缺少前瞻性负荷剂量他汀类治疗的临床证据。研究目的本研究希望通过前瞻性随机双盲设计对负荷剂量他汀药物在冠状动脉移植术中的应用,探索他汀类药物对体外循环手术患者的潜在肾脏保护作用以及炎症调节作用。研究方法经阜外医院伦理委员会审核后,本研究纳入患者96例,其中92例患者完成随访(阿托伐他汀组47例,安慰剂组45例)。患者入选后,根据随即数字表,随机分为阿托伐他汀组和安慰剂组。阿托伐他汀组术前12小时给予阿托伐他汀80mmg,术前2小时加服阿托伐他汀40mmg,安慰剂组患者服用同等剂量安慰剂。在术中以及术后抽取血液样本并记录相关临床变量并统计分析。研究结果研究结果显示两组患者术前基线资料基本平齐,阿托伐他汀组术后NGAL值显著低于安慰剂组,但术后两组之间肌酐值没有显著差异。在本研究中阿托伐他汀有抑制Th1细胞相关因子倾向,而两组之间Th2细胞相关因子含量无明显差异。术后临床转归比较中,两组之间急性肾损伤的发生率无明显差异。术后房颤、呼吸系统并发症、输血率、机械通气时间和ICU住院时间等均无明显差异。但阿托伐他汀组患者术后中风发生率低于安慰剂组,但未达统计学显著差异。研究结论本研究结果显示,体外循环下冠状动脉移植术患者术前负荷剂量阿托伐他汀是有效、安全的。阿托伐他汀有保护心脏手术后肾功能的作用,同时对于体外循环下的免疫调节作用可能是降低术后并发症的原因之一。
[Abstract]:The first part: the safety of one-stop coronary revascularization procedures with off-pump coronary artery bypass grafting on the amount of bleeding and postoperative renal function after surgery and the comparative study of the research objective of one-stop hybrid coronary artery surgery for multivessel coronary heart disease patients with minimally invasive, easy treatment method. The left internal mammary bypass artery to the anterior descending branch of the left ventricular wall to protect the blood supply, the internal mammary artery as vascular bridge has the advantage of long term patency and vascular interventional stent implantation. Secondly reduce surgical trauma, vascular anastomosis, were easier to accept. But the one-stop hybrid surgery to accept a large number of contrast agent, plus the application of antiplatelet drug special peri operation period, acute kidney injury of one-stop hybrid surgery patients with postoperative bleeding and becoming the concern. The purpose of this study is to By comparing the one-stop hybrid surgery patients and the same amount of bleeding and creatinine values under extracorporeal circulation in patients with coronary artery transplantation after operation, explore the one-stop hybrid operating safety and the amount of bleeding in the postoperative renal damage. Provide the basis for the selection of patients in clinical practice. This study retrospectively collected from June 2007 to January 2011 in Fuwai Hospital during the implementation of one-stop hybrid coronary artery surgery in 141 cases. The propensity score of off-pump surgery collected patients undergoing coronary artery bypass grafting in 141 cases. Through history collection, collection of preoperative clinical variables may influence prognosis, postoperative creatinine changes, surgery after bleeding and general clinical prognostic variables. Finally, through the statistical analysis of the statistical method to the data of the two groups were compared. Results with off-pump coronary artery bypass grafting, Significantly lower than the control group and the total amount of bleeding amount of bleeding in 12 hours of one-stop hybrid surgery patients, P = 0.04 and P0.001. at the same time, a one-stop hybrid group of patients after blood infusion rate was significantly lower than that of off-pump coronary artery bypass grafting patients (P=0.001). The one-stop hybrid surgery after the occurrence of acute kidney injury rate is slightly higher than that of off-pump coronary artery bypass grafting patients, but did not reach statistical significance (25.2% vs 17.6%, p=0.13). The outcome after operation, one stop hybrid group were more stable hemodynamics, blood vessel active drug use fewer respiratory complications, less mechanical ventilation time and ICU stay were significantly lower than the control group. Conclusion with off-pump off-pump coronary artery transplantation compared to the one-stop hybrid procedure has obvious advantages, mainly reflected in the amount of postoperative bleeding more Less, lower transfusion rates, but does not significantly increase the probability of renal injury after operation. One stop hybrid operation is safe and reliable for coronary artery revascularization. The second part: the platelet count, and acute kidney injury after coronary artery bypass grafting in long-term mortality research background of extracorporeal circulation, platelet activation and may be gathered after end organ ischemic complications have been studied. The main reason of platelets demonstrated in acute stroke and myocardial infarction after operation, but the research on the relationship between platelet and acute kidney injury after cardiac surgery is not clear. The purpose of the study the main purpose of this study is to research the relation between long-term mortality between exploration non immune thrombocytopenia and coronary artery transplantation after acute kidney injury and postoperative we retrospectively collected 4201 cases of coronary artery graft Implantation of patient data were recorded at the same time. After 10 days the daily minimum value of platelets as a continuous variable, analysis of platelet low value (continuous variables) and the relationship between postoperative acute kidney injury and mortality. Furthermore, we will postoperative platelet count in patients with overall platelet counts of 10% patients as observation group that is, low platelet counts of 10% groups, and will carry out the statistics as two classification variables. Finally, single factor and multi factor analysis, explore the postoperative platelet count (continuous variables and two variables) and postoperative acute kidney injury and mortality. The average results of postoperative platelet low value for acute kidney injury after 121x109/L. (KDIGO) incidence rate was 50%, of which 1.6% (34 cases) of patients with AKI grade II, 2% (42 cases) for the AKI grade. Postoperative platelet count per 30x109/L increase in acute kidney after operation The risk of injury decreased by about 7% (OR, 0.93; 95%CI, 0.89-0.98; P=0.003), more importantly, a decrease of about 46% 30 day postoperative mortality (OR, 0.54; 95% CI, 0.41-0.69; P0.0001). Postoperative platelet count in patients with the lowest overall population in 10% of patients, the postoperative risk of progression to acute renal injury level increased 3.5 times more, low platelet counts of 10% group of patients within 30 days of surgery and long-term mortality was significantly higher than that of the rest of the patients with.OR respectively after 30 days OR 4.34; 95%CI, 2.46-7.58; P0.0001, the adjusted statistical postoperative long-term mortality OR value is 1.33; 95%CI, 1.12 to 1.59; our study conclusion P=0.001. found postoperative platelet count and postoperative acute kidney injury and mortality were significantly related. The third part: the loading dose of atorvastatin on renal protection and regulation of inflammatory response after coronary artery bypass grafting The study of prospective randomized double-blind study background of atorvastatin not only have lipid-lowering effect clear, in recent years, statins, anti-inflammatory, anti oxidative stress, increase endothelial cells function in the pleiotropic effects become effective in the prevention and treatment of many alternative approaches to clinical disease. Statin intervention patients showed obvious anti-inflammatory in coronary heart disease, renal function protection after operation. Even a single loading dose of preoperative administration showed renal protective effect satisfactory. But in surgery, most retrospective studies are not consistent at the lack of prospective clinical evidence of loading dose of statin therapy. The purpose of this study hope the prospective randomized double-blind design of loading dose of statins in coronary artery bypass grafting in the exploration of statins in patients with cardiopulmonary bypass Potential regulation protect renal function and inflammation. Research methods by the ethics committee of Fuwai Hospital after the examination, this study included 96 patients, including 92 patients completed follow-up (atorvastatin group 47 cases, 45 patients in the placebo group). Patients were enrolled, according to the random number table, randomly divided into atorvastatin group and placebo group atorvastatin group were given atorvastatin 12 hours before 80mmg, 2 hours prior to surgery plus atorvastatin 40mmg, placebo group were given the same dose of placebo. The intraoperative and postoperative blood samples and record the relevant clinical variables and statistical analysis. Results: the results showed that two groups of patients with baseline information the basic level of atorvastatin group after NGAL was significantly lower than that of the placebo group, but the postoperative creatinine values between the two groups were no significant difference. In this study, atorvastatin can inhibit Th1 cells by Guan Yin Sub tendency, but there was no significant difference between the two groups of Th2 cell related cytokines content. The postoperative clinical outcome in comparison between the two groups, the incidence of acute kidney injury. No significant differences in postoperative atrial fibrillation, respiratory complications, blood transfusion rate, duration of mechanical ventilation and ICU stay were no significant difference of stroke. But the effect of atorvastatin in patients with statin group was lower than that of the placebo group, but there was no significant difference. Conclusion the results of this study show that under cardiopulmonary bypass in patients undergoing coronary artery transplantation preoperative loading dose of atorvastatin is effective and safe. A supporting lovastatin protect renal function after cardiac surgery, at the same time under extracorporeal circulation for the immune regulatory effect is one of the reduction of postoperative complications.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R654.2;R692

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