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北京大学学报（医学版） ›› 2021, Vol. 53 ›› Issue (1): 188-194. doi: 10.19723/j.issn.1671-167X.2021.01.028

• 论著 • 上一篇    下一篇

肺叶切除术中少尿与术后急性肾损伤的关系

孟昭婷,穆东亮()   

  1. 北京大学第一医院麻醉科,北京 100034
  • 收稿日期:2020-04-13 出版日期:2021-02-18 发布日期:2021-02-07
  • 通讯作者: 穆东亮 E-mail:mudongliang@icloud.com
  • 基金资助:
    国家重点研发计划项目(2018YFC2001800)

Impact of oliguria during lung surgery on postoperative acute kidney injury

MENG Zhao-ting,MU Dong-liang()   

  1. Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
  • Received:2020-04-13 Online:2021-02-18 Published:2021-02-07
  • Contact: Dong-liang MU E-mail:mudongliang@icloud.com
  • Supported by:
    National Key Pesearch and Development Program of China(2018YFC2001800)

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摘要：

目的: 探索术中尿量对术后急性肾损伤(acute kidney injury, AKI)的影响,以及术后AKI发生的独立危险因素。方法: 选择2017年7月至2019年6月于北京大学第一医院在全身麻醉下接受择期肺叶切除术的患者作为研究对象进行回顾性队列研究。将入组患者按照是否发生术后AKI分为AKI组和对照组。首先对围术期各变量进行单因素分析,探讨其与术后AKI的关系;其次,采用受试者工作特征曲线(receiver operating characteristic curve,ROC curve)分析术中尿量对术后AKI的预测价值,并以约登(Youden)指数为最大值时的上下4个界值[以0.1 mL/(kg·h)为间隔]为少尿界值,采用单因素分析探索各界值定义下的少尿与AKI发生风险的关系,并取OR值最大者为少尿界值;最后,将单因素分析中P<0.10的围术期各变量共同代入多因素Logistic回归模型,分析术后AKI的独立危险因素。结果: 共1 393名患者最终纳入研究,术后AKI发生率为2.2%。ROC曲线显示术中单位尿量用于预测术后AKI的曲线下面积为0.636(P=0.009), 约登指数为最大值时(约登指数0.234,敏感度48.4%,特异度75.0%)的少尿界值为0.785 mL/(kg·h)。进一步取0.7、0.8、0.9、1.0 mL/(kg·h)以及传统界值0.5 mL/(kg·h)为少尿界值分析少尿对术后AKI的影响。单因素分析显示,以小于0.8 mL/(kg·h)为少尿界值时,少尿患者发生AKI的风险增加最为显著(OR=2.774, 95%CI 1.357~5.671, P=0.004)。多因素回归分析显示术中尿量<0.8 mL/(kg·h)(OR=2.698,95%CI 1.260~5.778, P=0.011)是术后AKI发生的独立危险因素,另两个独立危险因素为术前血红蛋白≤120.0 g/L(OR=3.605, 95%CI 1.545~8.412, P=0.003)以及术前估计肾小球滤过率<30 mL/(min·1.73 m2)(OR=11.009, 95%CI 1.813~66.843, P=0.009)。 结论: 对于肺叶切除术,术中少尿是术后AKI发生的独立危险因素,且尿量<0.8 mL/(kg·h)是可能的筛选标准。

关键词: 肺外科手术, 少尿症, 急性肾损伤, 排尿量, 危险因素

Abstract:

Objective: To explore the influence of intraoperative urine volume on postoperative acute kidney injury (AKI) and the independent risk factors of AKI.Methods: This was a retrospective cohort study recruiting patients who received selective pulmonary resection under general anesthesia in Peking University First Hospital from July, 2017 to June, 2019. The patients were divided into the AKI group and the control group according to whether they developed postoperative AKI or not. Firstly, univariate analysis was used to analyze the relationship between perioperative variables and postoperative AKI. Secondly, receiver operating characteristic (ROC) curve was used to explore the predictive value of intraoperative urine output for postoperative AKI. The nearest four cutoff values [with the interval of 0.1 mL/(kg·h)] at maximum Youden index were used as cutoff values of oliguria. Then univariate analysis was used to explore the relationship between oliguria defined by these four cutoff values and the risk of AKI. And the cutoff value with maximum OR was chosen as the threshold of oliguria in this study. Lastly, the variables with P<0.10 in the univariate analysis were selected for inclusion in a multivariate Logistic model to analyze the independent predictors of postoperative AKI.Results: A total of 1 393 patients were enrolled in the study. The incidence of postoperative AKI was 2.2%. ROC curve analysis showed that the area under curve (AUC) of intraoperative urine volume used for predicting postoperative AKI was 0.636 (P=0.009), and the cutoff value of oliguria was 0.785 mL/(kg·h) when Youden index was maximum (Youden index =0.234, sensitivity =48.4%, specificity =75.0%). Furthermore, 0.7, 0.8, 0.9, 1.0 mL/(kg·h) and the traditional cutoff value of 0.5 mL/(kg·h) were used to analyze the influence of oliguria on postoperative AKI. Univariate analysis showed that, when 0.8 mL/(kg·h) was selected as the threshold of oliguria, the patients with oliguria had the most significantly increased risk of AKI (AKI group 48.4% vs. control group 25.3%, OR=2.774, 95%CI 1.357-5.671, P=0.004). Multivariate regression analysis showed that intraoperative urine output <0.8 mL/(kg·h) was one of the independent risk factors of postoperative AKI (OR=2.698,95%CI 1.260-5.778, P=0.011). The other two were preoperative hemoglobin ≤120.0 g/L (OR=3.605, 95%CI 1.545-8.412, P=0.003) and preoperative estimated glomerular filtration rate <30 mL/(min·1.73 m2) (OR=11.009, 95%CI 1.813-66.843, P=0.009). Conclusion: Oliguria is an independent risk fact or of postoperative AKI after pulmonary resection, and urine volume <0.8 mL/(kg·h) is a possible screening criterium.

Key words: Pulmonary surgical procedures, Oliguria, Acute kidney injury, Urine output, Risk factors

中图分类号: 

  • R614

图1

病例入组流程图"

表1

两组患者术前基本资料"

Items All patients (n=1 393) Control group (n=1 362) AKI group (n=31) P
Male, n(%) 700 (50.3) 684 (50.2) 16 (51.6) 0.878
Age/years, x-±s 59.8±10.6 59.8±10.6 58.8±10.7 0.616
BMI/(kg/m2), x-±s 24.5±3.4 24.5±3.4 25.2±3.2 0.247
Pulmonary malignant tumor, n(%) 1 213 (87.1) 1 184 (86.9) 29 (93.5) 0.214
Preoperative comorbidity, n(%)
Stroke 129 (9.3) 127 (9.3) 2 (6.5) 0.441
Hypertension 548 (39.3) 534 (39.2) 14 (45.2) 0.502
Coronary heart disease 159 (11.4) 155 (11.4) 4 (12.9) 0.480
Diabetes mellitus 247 (17.7) 237 (17.4) 10 (32.3) 0.032
History of nephrectomya 12 (0.9) 11 (0.8) 1 (3.2) 0.237
History of medication, n(%)
Aspirin 123 (8.8) 121 (8.9) 2 (6.5) 0.474
ACEI 45 (3.2) 44 (3.2) 1 (3.2) 0.735
ARB 191 (13.7) 184 (13.5) 7 (22.6) 0.120
Diuretics 47 (3.4) 46 (3.4) 1 (3.2) 0.719
Preoperative laboratory examination
Hb/(g/L), x-±s 135.5±14.0 135.7±13.9 126.7±16.4 <0.001
Hb≤120 g/L, n(%) 183 (13.1) 171 (12.6) 12 (38.7) <0.001
Alb/(g/L), M (IQR) 40.0 (38.0-42.6) 40.0 (38.0-42.6) 39.3 (36.9-41.3) 0.060
eGFR<30 mL/(min·1.73 m2), n(%) 7 (0.5) 4 (0.3) 3 (9.7) <0.001
Dehydration indexb>20, n(%) 541 (38.8) 527 (38.7) 14 (45.2) 0.465
Other examinations, n(%)
SBPc>140 mmHg 392 (28.1) 382 (28.0) 10 (32.3) 0.606
DBPc>90 mmHg 81 (5.8) 80 (5.9) 1 (3.2) 0.452
ASA physical status Ⅲ-Ⅳ, n(%) 196 (14.1) 186 (13.7) 10 (32.3) 0.007

表2

两组患者围术期相关资料"

Items All patients (n=1 393) Control group (n=1362) AKI group (n=31) P
Lung surgery type, n(%) 0.392
Partial lobectomy 347 (24.9) 340 (25.0) 7 (22.6)
Lobectomy or bilobectomy 1 016 (72.9) 994 (73.0) 22 (71.0)
Pneumonectomy 30 (2.2) 28 (2.1) 2 (6.5)
Total intravenous anesthesia, n(%) 299 (21.5) 295 (21.7) 4 (12.9) 0.240
Nerve block, n(%) 0.883
None 317 (22.8) 311 (22.8) 6 (19.4)
Paravertebral block 1 000 (71.8) 977 (71.7) 23 (74.2)
Epidural block 76 (5.5) 74 (5.4) 2 (6.5)
Intraoperative medication, n(%)
Dexmedetomidine 729 (52.3) 712 (52.3) 17 (54.8) 0.778
Ephedrine 593 (42.6) 580 (42.6) 13 (41.9) 0.942
Norepinephrine 298 (21.4) 291 (21.4) 7 (22.6) 0.870
Intraoperative fluid balance
Calculated infusiona/[mL/(kg·h)], M(IQR) 4.9 (3.8-6.2) 4.9 (3.9-6.2) 4.0 (3.3-5.2) 0.083
Artificial colloid, n(%) 288 (20.7) 281 (20.6) 7 (22.6) 0.791
Allogeneic erythrocytes, n(%) 33 (2.4) 32 (2.3) 1 (3.2) 0.528
Allogenic plasma, n(%) 30 (2.2) 29 (2.1) 1 (3.2) 0.495
Blood loss/mL, M(IQR) 50 (0-100) 50 (0-100) 50 (0-200) 0.854
Calculated urine outputb/[mL/(kg·h)], M(IQR) 1.2 (0.8-1.9) 1.2 (0.8-1.9) 0.9 (0.6-1.4) 0.009
Intraoperative monitoring, n(%)
Low SBPc 1 250 (89.7) 1 223 (89.8) 27 (87.1) 0.551
Low SBPc lasting more than 30 min 953 (68.4) 931 (68.4) 22 (71.0) 0.757
SpO2<90% 234 (16.8) 228 (16.7) 6 (19.4) 0.700
SpO2<90% lasting more than 10 min 106 (7.6) 103 (7.6) 3 (9.7) 0.424
Anesthesia duration/min, x-±s 292.4±90.5 292.1±90.4 305.4±96.3 0.420
Surgery duration/min, x-±s 197.9±84.6 197.8±84.5 205.3±88.2 0.626

图2

术中单位尿量用于预测术后AKI的ROC曲线"

表3

术中尿量对术后AKI的预测价值"

Items All patients (n=1 393) Control group (n=1 362) AKI group (n=31) OR(95%CI) P
Calculated urine outputa, n(%)
<0.5 mL/(kg·h) 126 (9.0) 122 (9.0) 4 (12.9) 1.506 (0.518-4.374) 0.306
<0.7 mL/(kg·h) 261 (18.7) 250 (18.4) 11 (35.5) 2.446 (1.157-5.171) 0.016
<0.8 mL/(kg·h) 359 (25.8) 344 (25.3) 15 (48.4) 2.774 (1.357-5.671) 0.004
<0.9 mL/(kg·h) 444 (31.9) 428 (31.4) 16 (51.6) 2.328 (1.140-4.752) 0.017
<1.0 mL/(kg·h) 520 (37.3) 503 (36.9) 17 (54.8) 2.074 (1.014-4.243) 0.042

表4

术后AKI的独立危险因素"

Items Univariate analysis Multivariate analysis
Estimated difference (95%CI) P OR(95%CI) P
Diabetes mellitus OR=2.260 (1.051-4.862) 0.037 - 0.353
Preoperative Hb≤120.0 g/L OR=4.399 (2.098-9.222) <0.001 3.605 (1.545-8.412) 0.003
Preoperative Alb/(g/L) Median difference=1.100 (0.000-2.400)b 0.060 - 0.525
eGFR<30 mL/(min·1.73 m2) OR=36.375 (7.775-170.186) <0.001 11.009 (1.813-66.843) 0.009
ASA physical status Ⅲ-Ⅳ OR=3.011 (1.396-6.494) 0.005 - 0.327
Calculated infusiona/[mL/(kg·h)] Median difference=0.530 (-0.070-1.140)b 0.083 - 0.315
Intraoperative urine output<0.8 mL/(kg·h) OR=2.774 (1.357-5.671) 0.004 2.698 (1.260-5.778) 0.011
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