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中心静脉压峰值与体外循环心脏术后急性肾损伤的相关性

张宏民 陈秀凯 王小亭 刘大为 柴文昭

张宏民, 陈秀凯, 王小亭, 刘大为, 柴文昭. 中心静脉压峰值与体外循环心脏术后急性肾损伤的相关性[J]. 协和医学杂志, 2022, 13(6): 1005-1011. doi: 10.12290/xhyxzz.2022-0448
引用本文: 张宏民, 陈秀凯, 王小亭, 刘大为, 柴文昭. 中心静脉压峰值与体外循环心脏术后急性肾损伤的相关性[J]. 协和医学杂志, 2022, 13(6): 1005-1011. doi: 10.12290/xhyxzz.2022-0448
ZHANG Hongmin, CHEN Xiukai, WANG Xiaoting, LIU Dawei, CHAI Wenzhao. Peak Value of Central Venous Pressure and Acute Kidney Injury in Cardiac Patients After Cardiopulmonary Bypass Surgery[J]. Medical Journal of Peking Union Medical College Hospital, 2022, 13(6): 1005-1011. doi: 10.12290/xhyxzz.2022-0448
Citation: ZHANG Hongmin, CHEN Xiukai, WANG Xiaoting, LIU Dawei, CHAI Wenzhao. Peak Value of Central Venous Pressure and Acute Kidney Injury in Cardiac Patients After Cardiopulmonary Bypass Surgery[J]. Medical Journal of Peking Union Medical College Hospital, 2022, 13(6): 1005-1011. doi: 10.12290/xhyxzz.2022-0448

中心静脉压峰值与体外循环心脏术后急性肾损伤的相关性

doi: 10.12290/xhyxzz.2022-0448
基金项目: 

中国医学科学院医学与健康科技创新工程 2020-I2M-C & T-B-045

详细信息
    通讯作者:

    柴文昭, E-mail: chaiwenzhao@126.com

  • 中图分类号: R605.97

Peak Value of Central Venous Pressure and Acute Kidney Injury in Cardiac Patients After Cardiopulmonary Bypass Surgery

Funds: 

CAMS Innovation Fund for Medical Sciences 2020-I2M-C & T-B-045

More Information
  • 摘要:   目的  探究体外循环心脏手术(cardiopulmonary bypass surgery, CBS)后中心静脉压峰值(peak value of central venous pressure, CVPp)与急性肾损伤(acute kidney injury, AKI)的关系。  方法  回顾性收集2016年5月1日至2018年5月1日北京协和医院重症医学科所有CBS患者的临床资料。记录转入ICU后即刻中心静脉压(central venous pressure, CVP)(CVP 0h)、6 h时CVP(CVP 6h), 转入ICU 48 h内CVPp(CVPp 48h), 以及转入ICU 48 h后AKI发生率及院内死亡率。采用受试者操作特征(receiver operating characteristic, ROC)曲线评估CVP相关指标预测CBS术后发生AKI的临床价值并确定最佳临界值; 采用单因素与多因素Logistic回归分析CBS术后发生AKI、院内死亡的危险因素。  结果  共入选符合纳入和排除标准的CBS患者485例, AKI发生率为25.2%(122/485), 院内死亡率为2.5%(12/485)。ROC曲线分析显示, CVPp 48h预测CBS术后发生AKI的曲线下面积(area under the curve, AUC)为0.634(95% CI: 0.577~0.692, P<0.001), 最佳临界值为14 mm Hg, 灵敏度为49.6%, 特异度为63.5%。多因素Logistic回归分析显示, 高血压(OR=2.505, 95% CI: 1.581~3.969, P<0.001)、肺动脉高压(OR=2.552, 95% CI: 1.573~4.412, P<0.001)、主动脉阻断时间延长(OR=1.009, 95% CI: 1.004~1.014, P=0.001)、CVPp 48h≥14 mm Hg(OR=1.613, 95% CI: 1.030~2.526, P=0.037)是CBS术后发生AKI的独立危险因素; CVPp 48h≥14 mm Hg是院内死亡的独立危险因素(OR=8.044, 95% CI: 1.579~40.979, P=0.012)。  结论  CVPp 48h升高可能增加CBS术后AKI发生风险, 对其动态监测有助于AKI的预防和早期识别。
    作者贡献:张宏民负责研究设计并撰写论文初稿;陈秀凯、王小亭、刘大为提出修改意见;柴文昭负责论文修订。
    利益冲突:所有作者均声明不存在利益冲突
  • 图  1  CVP相关指标预测CBS术后AKI的受试者操作曲线图

    CBS、CVP、CVPp、AKI:同表 1

    表  1  485例CBS术后患者临床资料

    指标 数值
    年龄[M(P25, P75),岁] 55(45, 65)
    男性[n(%)] 310(63.9)
    APACHE Ⅱ评分(x±s, 分) 16.9±6.8
    SOFA评分(x±s, 分) 9.5±4.1
    高血压[n(%)] 220(45.4)
    糖尿病[n(%)] 96(19.8)
    肺动脉高压[n(%)] 128(26.4)
    慢性肾脏病[n(%)] 37(7.6)
    手术类型[n(%)]
      主动脉手术 36(7.4)
      冠状动脉搭桥术 135(27.8)
      先天性心脏病矫正术* 19(3.9)
      心脏肿瘤切除术 39(8.0)
      瓣膜手术 241(49.7)
      冠状动脉搭桥+瓣膜手术 15(3.1)
    NYHA分级[n(%)]
      Ⅰ 171(35.3)
      Ⅱ 228(47.0)
      Ⅲ 63(13.0)
      Ⅳ 23(4.7)
    体外循环时间[M(P25, P75),min] 134(105, 170)
    主动脉阻断时间[M(P25, P75),min] 92(66, 118)
    CVP[M(P25, P75),mm Hg]
      CVP 0h 9(8, 11)
      CVP 6h 9(8, 11)
      CVPp 48h 13(12, 14)
    预后
      ICU住院时间[M(P25, P75),d] 5(3, 6)
      机械通气时间[M(P25, P75),h] 44(29, 63)
      入ICU 48 h后AKI[n(%)] 122(25.2)
      院内死亡[n(%)] 12(2.5)
    *包括房间隔缺损、室间隔缺损
    CBS:体外循环心脏手术;APACHE Ⅱ:急性生理学及慢性健康状况Ⅱ;SOFA:序贯器官衰竭评分;NYHA:纽约心脏协会;CVP:中心静脉压;CVPp:CVP峰值;AKI:急性肾损伤
    下载: 导出CSV

    表  2  CBS术后发生AKI危险因素的Logistic回归分析

    指标 β SE Wald OR(95% CI) P
    单因素分析
      年龄 0.005 0.004 1.441 1.005(0.997~1.012) 0.230
      糖尿病 -0.084 0.285 0.099 0.920(0.546~1.549) 0.753
      高血压 0.708 0.213 11.019 2.030(1.336~3.083) 0.001
      肺动脉高压 0.640 0.226 7.999 1.896(1.217~2.954) 0.005
      NYHA Ⅲ~Ⅳ级 0.419 0.262 2.570 1.521(0.911~2.539) 0.109
      体外循环时间 0.002 0.001 1.736 1.002(0.999~1.005) 0.188
      主动脉阻断时间 0.008 0. 002 11.597 1.008(1.004~1.013) 0.001
      CVPp 48h≥14 mm Hg 0.480 0.212 5.107 1.616(1.066~2.450) 0.024
    多因素分析
      高血压 0.918 0.235 15.307 2.505(1.581~3.969) <0.001
      肺动脉高压 0.937 0.247 14.390 2.552(1.573~4.142) <0.001
      主动脉阻断时间 0.009 0.003 12.370 1.009(1.004~1.014) 0.001
      CVPp 48h≥14 mm Hg 0.478 0.229 4.368 1.613(1.030~2.526) 0.037
    CBS、NYHA、CVP、CVPp、AKI:同表 1
    下载: 导出CSV

    表  3  CBS术后院内死亡危险因素的Logistic回归分析

    指标 β SE Wald OR(95% CI) P
    单因素分析
      年龄 -0.001 0.011 0.005 0.999(0.978~1.021) 0.943
      糖尿病 -1.017 1.051 0.937 0.362(0.046~2.836) 0.333
      高血压 -0.158 0.593 0.071 0.854(0.267~2.729) 0.790
      肺动脉高压 -0.075 0.675 0.012 0.928(0.247~3.483) 0.912
      NYHA Ⅲ~Ⅳ级 -0.851 1.051 0.654 0.427(0.054~3.354) 0.419
      体外循环时间 0.002 0.001 3.238 1.002(1.000~1.004) 0.072
      主动脉阻断时间 0.016 0.005 8.499 1.016(1.005~1.027) 0.004
      CVPp 48h≥14 mm Hg 2.144 0.780 7.547 8.534(1.849~39.401) 0.006
    多因素分析
      体外循环时间 0.001 0.001 1.323 1.001(0.999~1.004) 0.250
      主动脉阻断时间 0.011 0.006 3.609 1.011(1.000~1.023) 0.057
      CVPp 48h≥14 mm Hg 2.085 0.831 6.300 8.044(1.579~40.979) 0.012
    CBS、NYHA、CVP、CVPp、AKI:同表 1
    下载: 导出CSV
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出版历程
  • 收稿日期:  2022-08-15
  • 录用日期:  2022-10-10
  • 刊出日期:  2022-11-30

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