合并急性肾损伤的感染性心内膜炎的临床特点和预后分析

doi:10.19723/j.issn.1671-167X.2019.04.025

摘要/Abstract

摘要：

目的:探讨合并急性肾损伤(acute kidney injury,AKI)的感染性心内膜炎(infective endocarditis,IE)患者的临床特点,分析此类患者的围术期及预后情况。方法:回顾性分析2002年1月至2018年6月在北京大学第一医院心脏外科就诊的IE患者100例。根据患者术前情况及AKIN标准,分为AKI组和非AKI组,比较两组临床资料和术后并发症的差异,随访对比两组预后情况。结果:AKI组21例和非AKI组79例,总体平均年龄(43.7±15.7)岁,男女比例3 :1,IE患者中AKI的发生率为21%。两组间年龄、性别构成差异无统计学意义。与非AKI组相比,AKI组患者皮疹及下肢水肿的比例更高(P=0.017和P=0.001),尿潜血及尿蛋白阳性率更高(P<0.001),血红蛋白及血清白蛋白水平更低(P<0.001),临床心功能更差(P=0.033)。两组病原菌检出率及病原菌种类差异无统计学意义。除9例患者拒绝手术外,其余91例患者均接受了体外循环下心内直视手术,包括AKI组19例和非AKI组72例。AKI组患者围术期红细胞用量更多(P=0.010),术后呼吸机使用时间及监护室停留时间更长(P=0.028和P=0.003)。以两组患者术前末次肌酐为基准,AKI组新发术后肾功能不全比例更高(P=0.004)。两组患者院内死亡率差异无统计学意义(P=0.463),随访期间两组生存率差异未见统计学意义(P=0.581)。结论:与非AKI组相比,合并AKI的IE患者围术期并发症发生率更高,但两组患者院内死亡率及预后无明显差异。

关键词: 急性肾损伤, 心内膜炎, 细菌性, 心脏外科手术

Abstract:

Objective: To investigate the clinical features and treatment of infective endocarditis (IE) patients with acute kidney injury (AKI), and to compare the adverse complications and outcome with IE patients without AKI.Methods: Clinical data of 100 IE cases in Peking University First Hospital from January 2002 to June 2018 were retrospectively reviewed. The patients were divided into AKI group (n=21) and non-AKI group (n=79) based on the AKI network (AKIN) definition. The clinical data and prognosis were compared between the two groups.Results: The incidence of AKI was 21%. The average age was (43.7±15.7) years, and the ratio of male to female was 3 :1. There was no significant diffe-rence in age and gender between the two groups. Compared with non-AKI group, the AKI group had more rash and lower limbs edema (P=0.017 and P=0.001), higher urine blood and protein positive rate (both P<0.001). Lower hemoglobin and serum albumin level (both P<0.001), worse clinical cardiac function (NYHA Ⅲ-Ⅳ, P=0.033) were found in AKI group compared with non-AKI group. There was no significant difference in microbiologic positive rate and pathogenic bacteria sorts between the two groups. Nine patients refused surgery, and the other 91 cases underwent cardiac surgery with cardiopulmonary bypass under general anesthesia, including 19 cases of AKI group and 72 cases of non-AKI group. The ventilation time and intensive care unit (ICU) stay time were longer in AKI group than in non-AKI group (P=0.028 and P=0.003). AKI group needed more red blood cell transfusion (P=0.010). Using the last serum creatinine before surgery as basic level, there was more new-onset AKI cases in AKI group than in non-AKI group. During the median follow-up time 42 months, there was no significant difference in perioperative and follow-up mortality between the two groups (P=0.463 and P=0.581).Conclusion: More perioperation complications occurred in IE patients with AKI, but no significant difference in in-hospital and follow-up mortality between the AKI and non-AKI groups was observed.

Key words: Acute kidney injury, Endocarditis, bacterial, Cardiac surgical procedures

中图分类号:

R542.42

张思宇,李西慧,肖锋. 合并急性肾损伤的感染性心内膜炎的临床特点和预后分析[J]. 北京大学学报（医学版）, 2019, 51(4): 737-741.

Si-yu ZHANG,Xi-hui LI,Feng XIAO. Clinical features and prognosis of infective endocarditis patients with acute kidney injury[J]. Journal of Peking University(Health Sciences), 2019, 51(4): 737-741.

图/表 5

表1

表2

表3

表4

AKI组和非AKI组术后临床资料比较"

Items	AKI group (n=19)	Non-AKI group (n=72)	P
Surgery, n (%)
Valve replacement	17 (89.5)	65 (90.3)	0.917
CHD repair	4 (21.1)	7 (9.7)	0.178
CABG	1 (5.3)	4 (5.6)	0.960
Operative condition, $x ?$ ±s
CPB duration/min	128.3±58.9	115.9±48.2	0.344
Aortic clamping duration/min	92.6±54.6	81.7±36.5	0.419
RBC transfusion/IU	7.7±3.7	5.0±3.9	0.010
Drainage after surgery/mL	1 048.9±655.8	758.9±565.3	0.058
Complications, n (%)
Prolonged ventilation time	6 (31.6)	8 (11.1)	0.028
Prolonged ICU stay time	12 (63.2)	19 (26.4)	0.003
Low cardiac output	2 (10.5)	2 (2.8)	0.143
New onset of AF	4 (21.1)	6 (8.3)	0.115
New onset of stroke	1 (5.3)	4 (5.6)	0.960
Acute kidney injury	13 (68.4)	23 (31.9)	0.004
In-hospital death	0	2 (2.8)	0.463

表4

图1

参考文献 20

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Items	AKI group (n=21)	Non-AKI group (n=79)	P
Age/years	45.9±14.5	43.3±16.3	0.511
Male	13 (61.9)	62 (78.5)	0.119
Hypertension	7 (33.3)	25 (31.6)	0.883
Diabetes	4 (19.0)	7 (8.9)	0.185
Fever	19 (90.5)	71 (89.9)	0.935
Lower limbs edema	11 (52.4)	13 (16.5)	0.001
Rash	6 (28.6)	7 (8.9)	0.017
Arthralgia	2 (9.5)	8 (10.1)	0.935
Short of breath	11 (52.4)	32 (40.5)	0.329
Stroke	1 (4.8)	16 (20.3)	0.093
Hemoglobin/(g/L)	96.1±15.0	116.0±20.7	<0.001
Peak SCr preoperation/ (μmol/L)	313.0±187.5	87.8±19.2	<0.001
Alb/(g/L)	32.4±6.2	37.6±5.7	<0.001
CRP/(mg/L)	54.5±42.1	64.7±56.5	0.442
Urine blood positive	14 (66.7)	20 (25.3)	<0.001
Urine protein positive	20 (95.2)	29 (36.7)	<0.001
LVEF/%	63.7±11.9	66.5±9.3	0.249
NYHAⅢ-Ⅳ	9 (42.9)	16 (20.3)	0.033

Items	AKI group (n=21)	Non-AKI group (n=79)	P
Blood culture positive,n (%)	9 (42.9)	45 (57.0)	0.249
Pathogenic bacteria, n (%)
Streptococci	3 (14.3)	28 (35.4)	0.062
Staphylococcus	3 (14.3)	8 (10.1)	0.588
Enterococcus	1 (4.8)	4 (5.1)	0.955
G- bacillus	2 (9.5)	5 (6.3)	0.610

Vegetation location	AKI group (n=21)	Non-AKI group (n=79)	P
Aorta valve	14 (66.7)	38 (48.1))	0.130
Mitral valve	8 (38.1)	45 (57.0)	0.124
Other	3 (14.3)	6 (7.6)	0.341