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肺移植后的急性肾脏损伤会增加死亡率

[日期:2012-07-08] 来源:  作者: [字体: ]

需要肾脏替代治疗(RRT)的急性肾损伤会增加心脏手术后的死亡率。但关于肺移植术后肾脏替代治疗的影响研究还很有限。来自约翰霍普金斯大学的Timothy J. George等人评估了肺移植术后RRT相关的危险因素与临床结果。

他们回顾性地分析了来自美国网络器官共享数据库(united network for organ sharing database,UNOS)的所有肺移植受体患者的情况。他们对术前患者的肾功能依据肾小球滤过率(GFR)进行分层,GFR通过MDRD公式计算得到(分层标准: 90, 60 - 90, 及 <60 mL ? min–1? 1.73m–2)。原始结果是评估一月、一年、五年生存率及对肺移植后RRT(LTx RRT)的依赖程度。并用风险调整的多变量Cox比例风险回归来预测死亡率,用多变量逻辑回归模型来评估RRT带来的风险。

结果发现,从2001年至2011年共有12108名患者接受了肺移植。其中有655名患者(5.51%)需要RRT。与不需RRT的肺移植患者相比,需要肺移植术后RRT的患者的30天生存率有所下降,(96.7% Vs 76.0%, p < 0.001),1 年生存率 (85.5% Vs35.8%, p < 0.001), 及5年生存率 (56.4% Vs20.0%, p < 0.001)亦有下降。这些差异在多变量分析中依然存在:(30天生存率比:[HR] 7.98 [6.16 - 10.33], p < 0.001), 1 年生存率(HR 7.93 [6.84 -9.19], p < 0.001), 及 5 年生存率 (HR 5.39 [4.75 -6.11], p < 0.001)。术前肾小球滤过率(GFR)是术后是否需要RRT的重要预测因子:GFR 为 60 -90 (比值比OR: 1.42 [1.16 - 1.75], p = 0.001) ;FR ≤ 60 (比值比OR为2.68 [2.07 to 3.46], p < 0.001]。高中心血容量一个保护因素。

因此,他们得出结论:在这个目前最大规模评估肺移植后的急性肾损伤的研究中,需要行RRT的发生率是5.51%,肺移植术后RRT非常显著地增加了短期与长期的死亡率。多种因素,特别是术前肾功能,可以作为肺移植术后RRT的预测因子,亦可作为肺移植术前评估术后发生急性肾损伤风险大小的依据。

Ann Thorac Surg 2012;94:185-192. doi:10.1016/j.athoracsur.2011.11.032

2012 The Society of Thoracic Surgeons

Acute Kidney Injury Increases Mortality After Lung Transplantation

Timothy J. George, MDa, George J. Arnaoutakis, MDa, Claude A. Beaty, MDa, Matthew R. Pipeling, MDb, Christian A. Merlo, MD, MPHb, John V. Conte, MDa, Ashish S. Shah, MDa,*

a Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

b Division of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland

Background: Acute kidney injury requiring renal replacement therapy (RRT) is associated with increased mortality after cardiac surgery. Studies examining the impact of RRT after lung transplantation (LTx) are limited. We evaluated risk factors and outcomes associated with RRT after LTx.

Methods: We retrospectively reviewed all LTx recipients in the United Network for Organ Sharing database. Preoperative renal function was stratified by glomerular filtration rate (GFR) as determined by the Modification of Diet in Renal Disease formula (strata: 90, 60 to 90, and <60 mL ? min–1? 1.73m–2). Primary outcomes were 30-day, 1-year, and 5-year survival and need for post-LTx RRT. Risk adjusted multivariable Cox proportional hazards regression examined mortality. A multivariable logistic regression model evaluated risk factors for RRT.

Results: From 2001 to 2011, 12,108 patients underwent LTx. After LTx, 655 patients (5.51%) required RRT. Patients requiring post-LTx RRT had decreased survival at 30 days (96.7% versus 76.0%, p < 0.001), 1 year (85.5% versus 35.8%, p < 0.001), and 5 years (56.4% versus 20.0%, p < 0.001). These differences persisted on multivariable analysis at 30 days (hazard ratio [HR] 7.98 [6.16 to 10.33], p < 0.001), 1 year (HR 7.93 [6.84 to 9.19], p < 0.001), and 5 years (HR 5.39 [4.75 to 6.11], p < 0.001). Preoperative kidney function was an important predictor of post-LTx RRT for a GFR of 60 to 90 (odds ratio 1.42 [1.16 to 1.75], p = 0.001) and a GFR less than 60 (odds ratio 2.68 [2.07 to 3.46], p < 0.001]. High center volume was protective.

Conclusions: In the largest study to evaluate acute kidney injury after LTx, the incidence of RRT is 5.51%. The need for post-LTx RRT dramatically increases both short- and long-term mortality. Several variables, including preoperative renal function, are predictors of post-LTx RRT and could be used to identify transplant candidates at risk for acute kidney injury.

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