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Peak Value of Central Venous Pressure and Acute Kidney Injury in Cardiac Patients After Cardiopulmonary Bypass Surgery
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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。 Abstract:Objective To explore the relationship between the post-operative peak value of central venous pressure (CVPp) and the incidence of acute kidney injury (AKI) in patients who had undergone cardiopulmonary bypass surgery (CBS). Methods Clinical data were retrospectively collected from 1 May 2016 to 1 May 2018 from all patients undergoing CBS in the Department of Intensive Care Medicine, Peking Union Medical College Hospital. The CVP values immediately after transfer to ICU (CVP 0h) and at 6 h(CVP 6h), and CVPp within 48 h(CVPp 48h) of transfer to ICU, the incidence of AKI after 48 h of transfer to ICU and in-hospital mortality were recorded. The receiver operating characteristic (ROC) curve was used to evaluate the clinical value of CVP-related indicators in predicting AKI after CBS and determine the optimal threshold. The risk factors for AKI and in-hospital mortality after CBS were analysed using single factor and multifactorial Logistic regression. Results A total of 485 patients after CBS who met the inclusion and exclusion criteria were enrolled, with an incidence of AKI after 48 h of transfer to ICU of 25.2% (122/485) and an in-hospital mortality rate of 2.5% (12/485). The ROC curve analysis showed that the area under the curve (AUC) for CVPp 48h to predict AKI after CBS was 0.634 (95% CI: 0.577-0.692, P < 0.001), with an optimal threshold value of 14 mm Hg, sensitivity of 49.6% and specificity of 63.5%. Multifactorial logistic regression analysis showed that hypertension(OR=2.505, 95% CI: 1.581-3.969, P < 0.001), pulmonary hyperten-sion(OR=2.552, 95% CI: 1.573-4.412, P < 0.001), prolonged aortic block time(OR=1.009, 95% CI: 1.004-1.014, P=0.001), and CVPp 48h≥14 mm Hg(OR=1.613, 95% CI: 1.030-2.526, P=0.037) were independent risk factors for AKI after CBS; CVPp 48h≥14 mm Hg was an independent risk factor for in-hospital death(OR=8.044, 95% CI: 1.579-40.979, P=0.012). Conclusions CVPp 48h is associated with AKI in patients who have undergone CBS. The monitoring and management of CVP might be a way to improve the prognosis of these patients. -
Key words:
- central venous pressure /
- cardiac surgery /
- acute kidney injury /
- cardiopulmonary bypass
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 -
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
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表 2 CBS术后发生AKI危险因素的Logistic回归分析
指标 β值 SE值 Wald值 OR(95% CI) P值 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
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表 3 CBS术后院内死亡危险因素的Logistic回归分析
指标 β值 SE值 Wald值 OR(95% CI) P值 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
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[1] Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study[J]. JAMA, 2005, 29: 813-818. [2] Lassnigg A, Schmidlin D, Mouhieddine M, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study[J]. J Am Soc Nephrol, 2004, 15: 1597-1605. doi: 10.1097/01.ASN.0000130340.93930.DD [3] Loef BG, Epema AH, Smilde TD, et al. Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival[J]. J Am Soc Nephrol, 2005, 16: 195-200. doi: 10.1681/ASN.2003100875 [4] Burns KE, Chu MW, Novick RJ, et al. Perioperative N-acetylcysteine to prevent renal dysfunction in high-risk patients undergoing cabg surgery: a randomized controlled trial[J]. JAMA, 2005, 294: 342-350. doi: 10.1001/jama.294.3.342 [5] Magder S. Understanding central venous pressure: not a preload index?[J]. Curr Opin Crit Care, 2015, 21: 369-375. doi: 10.1097/MCC.0000000000000238 [6] De Backer D, Vincent JL. Should we measure the central venous pressure to guide fluid management? Ten answers to 10 questions[J]. Crit Care, 2018, 22: 43. doi: 10.1186/s13054-018-1959-3 [7] Honore PM, Jacobs R, Hendrickx I, et al. Prevention and treatment of sepsis-induced acute kidney injury: an update[J]. Ann Intensive Care, 2015, 5: 51. doi: 10.1186/s13613-015-0095-3 [8] Chen X, Wang X, Honore PM, et al. Renal failure in critically ill patients, beware of applying (central venous) pressure on the kidney[J]. Ann Intensive Care, 2018, 8: 91. doi: 10.1186/s13613-018-0439-x [9] Spiegel R, Teeter W, Sullivan S, et al. The use of venous Doppler to predict adverse kidney events in a general ICU cohort[J]. Crit Care, 2020, 24: 615. doi: 10.1186/s13054-020-03330-6 [10] Williams JB, Peterson ED, Wojdyla D, et al. Central venous pressure after coronary artery bypass surgery: does it predict postoperative mortality or renal failure?[J]. J Crit Care, 2014, 29: 1006-1010. doi: 10.1016/j.jcrc.2014.05.027 [11] Gambardella I, Gaudino M, Ronco C, et al. Congestive kidney failure in cardiac surgery: the relationship between central venous pressure and acute kidney injury[J]. Interact Cardiovasc Thorac Surg, 2016, 23: 800-805. doi: 10.1093/icvts/ivw229 [12] Yang Y, Ma J, Zhao L. High central venous pressure is associated with acute kidney injury and mortality in patients underwent cardiopulmonary bypass surgery[J]. J Crit Care, 2018, 48: 211-215. doi: 10.1016/j.jcrc.2018.08.034 [13] Wang XT, Chen H, Liu DW, et al. The correlation between CVP-derived parameters and the prognosis of critically ill patients[J]. J Crit Care, 2017, 40: 257-264. doi: 10.1016/j.jcrc.2017.03.011 [14] Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)[J]. Crit Care, 2013, 17: 204. doi: 10.1186/cc11454 [15] Prowle JR, Forni LG, Bell M, et al. Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative[J]. Nat Rev Nephrol, 2021, 17: 605-618. doi: 10.1038/s41581-021-00418-2 [16] Palomba H, de Castro I, Neto AL, et al. Acute kidney injury prediction following elective cardiac surgery: AKICS Score[J]. Kidney Int, 2007, 72: 624-631. doi: 10.1038/sj.ki.5002419 [17] Choi SJ, Ha EJ, Jhang WK, et al. Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients[J]. BMC Pediatr, 2018, 18: 58. doi: 10.1186/s12887-018-1059-1 [18] Wang XT, Yao B, Liu DW, et al. Central Venous Pressure Dropped Early is Associated with Organ Function and Prognosis in Septic Shock Patients: A Retrospective Observa-tional Study[J]. Shock, 2015, 44: 426-430. doi: 10.1097/SHK.0000000000000445 [19] Guyton AC. Determination of cardiac output by equating venous return curves with cardiac response curves[J]. Physiol Rev, 1955, 3: 123-129. [20] Berlin DA, Bakker J. Starling curves and central venous pressure[J]. Crit Care, 2015, 19: 55. doi: 10.1186/s13054-015-0776-1 [21] Boyd JH, Forbes J, Nakada TA, et al. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality[J]. Crit Care Med, 2011, 39: 259-265. doi: 10.1097/CCM.0b013e3181feeb15 [22] Denault AY, Couture P, Beaulieu Y, et al. Right Ventricu-lar Depression After Cardiopulmonary Bypass for Valvular Surgery[J]. J Cardiothorac Vasc Anesth, 2015, 29: 836-844. doi: 10.1053/j.jvca.2015.01.011 [23] Vonk-Noordegraaf A, Haddad F, Chin KM, et al. Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology[J]. J Am Coll Cardiol, 2013, 62: D22-D33. doi: 10.1016/j.jacc.2013.10.027 [24] Hrymak C, Strumpher J, Jacobsohn E. Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management[J]. Can J Cardiol, 2017, 33: 61-71. doi: 10.1016/j.cjca.2016.10.030 [25] Zhang H, Wang X, Chen X, et al. Tricuspid annular plane systolic excursion and central venous pressure in mechani-cally ventilated critically ill patients[J]. Cardiovasc Ultrasound, 2018, 16: 11. doi: 10.1186/s12947-018-0130-2 [26] Vellinga NA, Ince C, Boerma EC. Elevated central venous pressure is associated with impairment of microcirculatory blood flow in sepsis: a hypothesis generating post hoc analysis[J]. BMC Anesthesiol, 2013, 13: 17. doi: 10.1186/1471-2253-13-17 [27] Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure[J]. J Am Coll Cardiol, 2009, 53: 589-596. doi: 10.1016/j.jacc.2008.05.068 [28] Royster RL. Myocardial dysfunction following cardiopulmonary bypass: recovery patterns, predictors of inotropic need, theoretical concepts of inotropic administration[J]. J Cardiothorac Vasc Anesth, 1993, 7: 19-25. doi: 10.1016/1053-0770(93)90093-Z -
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