Email Alert | RSS

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)

RICH HTML

 8   

PDF (PC)

130

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
[1] Nadim MK, Forni LG, Bihorac A, et al. Cardiac and vascular surgery-associated acute kidney injury: the 20th International Consensus Conference of the ADQI (acute disease quality initiative) group[J]. J Am Heart Assoc, 2018,7(11):e8834.
[2] Sanaiha Y, Kavianpour B, Dobaria V, et al. Acute kidney injury is independently associated with mortality and resource use after emergency general surgery operations[J]. Surgery, 2020,167(2):328-334.
doi: 10.1016/j.surg.2019.07.035 pmid: 31668777
[3] Vaara ST, Bellomo R. Postoperative renal dysfunction after noncardiac surgery[J]. Curr Opin Crit Care, 2017,23(5):440-446.
doi: 10.1097/MCC.0000000000000439 pmid: 28820797
[4] Grams ME, Sang Y, Coresh J, et al. Acute kidney injury after major surgery: a retrospective analysis of veterans health administration data[J]. Am J Kidney Dis, 2016,67(6):872-880.
doi: 10.1053/j.ajkd.2015.07.022 pmid: 26337133
[5] Cardinale D, Cosentino N, Moltrasio M, et al. Acute kidney injury after lung cancer surgery: Incidence and clinical relevance, predictors, and role of N-terminal pro B-type natriuretic peptide[J]. Lung Cancer, 2018,123(9):155-159.
[6] Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup[J]. Crit Care, 2016,20(1):299-311.
doi: 10.1186/s13054-016-1478-z pmid: 27670788
[7] Weiss R, Meersch M, Pavenstädt HJ, et al. Acute kidney injury: a frequently underestimated problem in perioperative medicine[J]. Dtsch Arztebl Int, 2019,116(49):833-842.
doi: 10.3238/arztebl.2019.0833 pmid: 31888797
[8] Zarbock A, Koyner JL, Hoste EAJ, et al. Update on perioperative acute kidney injury[J]. Anesth Analg, 2018,127(5):1236-1245.
doi: 10.1213/ANE.0000000000003741 pmid: 30138176
[9] du Toit L, Biccard BM. The relationship between intraoperative oliguria and acute kidney injury[J]. Br J Anaesth, 2019,122(6):707-710.
doi: 10.1016/j.bja.2019.03.008 pmid: 30961912
[10] Hori D, Katz1 NM, Fine DM, et al. Defining oliguria during cardiopulmonary bypass and its relationship with cardiac surgery-associated acute kidney injury[J]. Br J Anaesth, 2016,117(6):733-740.
pmid: 27956671
[11] Mizota T, Yamamoto Y, Hamada M, et al. Intraoperative oliguria predicts acute kidney injury after major abdominal surgery[J]. Br J Anaesth, 2017,119(6):1127-1134.
doi: 10.1093/bja/aex255 pmid: 29136086
[12] Kim HJ, Cha SI, Kim CH, et al. Risk factors of postoperative acute lung injury following lobectomy for nonsmall cell lung cancer[J]. Medicine, 2019,98(13):e15078.
doi: 10.1097/MD.0000000000015078 pmid: 30921242
[13] O’Connor ME, Kirwan CJ, Pearse RM, et al. Incidence and associations of acute kidney injury after major abdominal surgery[J]. Intensive Care Med, 2016,42(4):521-530.
doi: 10.1007/s00134-015-4157-7 pmid: 26602784
[14] Levey AS, Coresh J, Greene T, et al. Expressing the modification of diet in renal disease study equation for estimating glomerular filtration rate with standardized serum creatinine values[J]. Clin Chem, 2007,53(4):766-772.
doi: 10.1373/clinchem.2006.077180 pmid: 17332152
[15] Quan S, Pannu N, Wilson T, et al. Prognostic implications of adding urine output to serum creatinine measurements for staging of acute kidney injury after majorsurgery: a cohort study[J]. Nephrol Dial Transplant, 2016,31(12):2049-2056.
doi: 10.1093/ndt/gfw374 pmid: 27941063
[16] Kellum JA, Sileanu FE, Murugan R, et al. Classifying AKI by urine output versus serum creatinine level[J]. J Am Soc Nephrol, 2015,26(9):2231-2238.
doi: 10.1681/ASN.2014070724 pmid: 25568178
[17] Eknoyan G. Rufus of ephesus and his “diseases of the kidneys”[J]. Nephron, 2002,91(3):383-390.
doi: 10.1159/000064277 pmid: 12119467
[18] Macedo E, Malhotra R, Bouchard J, et al. Oliguria is an early predictor of higher mortality in critically ill patients[J]. Kidney Int, 2011,80(7):760-770.
doi: 10.1038/ki.2011.150 pmid: 21716258
[19] Inácio R, Gameiro J, Amaro S, et al. Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis [J/OL]. J Bras Nefrol[2019-12-01]. https://doi.org/10.1590/2175-8239-jbn-2019-0244.
[20] Rung GW, Marshall WK. Nerve blocks in the critical care environment[J]. Crit Care Clin, 1990,6(2):343-367.
pmid: 2188709
[21] Matot I, Dery E, Bulgov Y, et al. Fluid management during video-assisted thoracoscopic surgery for lung resection: a ran-domized, controlled trial of effects on urinary output and postoperative renal function[J]. J Thorac Cardiovasc Surg, 2013,146(2):461-466.
doi: 10.1016/j.jtcvs.2013.02.015 pmid: 23558303
[22] Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus liberal fluid therapy for major abdominal surgery[J]. N Engl J Med, 2018,378(24):2263-2274.
doi: 10.1056/NEJMoa1801601 pmid: 29742967
[1] 苏俊琪,宋扬,谢尚. 口腔鳞状细胞癌患者修复重建术后感染的病原学特征及感染风险预测模型的构建[J]. 北京大学学报（医学版）, 2022, 54(1): 68-76.
[2] 许昊,张国栋,范桄溥,陈彧. 冠状动脉旁路移植术后新发心房颤动的血浆预测因子:倾向性评分匹配研究[J]. 北京大学学报（医学版）, 2021, 53(6): 1139-1143.
[3] 牛占岳,薛艳,张静,张贺军,丁士刚. 胃腺瘤性息肉的内镜和病理特点及癌变的危险因素分析[J]. 北京大学学报（医学版）, 2021, 53(6): 1122-1127.
[4] 朱敬先,鲁胜楠,蒋艳芳,姜玲,王健全. 老年肩袖损伤手术患者术前肺功能的影响因素[J]. 北京大学学报（医学版）, 2021, 53(5): 902-906.
[5] 王佳文,刘敬超,孟令峰,张威,刘晓东,张耀光. 间质性膀胱炎/膀胱疼痛综合征患者生活质量及相关因素分析[J]. 北京大学学报（医学版）, 2021, 53(4): 653-658.
[6] 孙争辉,黄晓娟,董靖晗,刘茁,颜野,刘承,马潞林. 临床T1期肾细胞癌肾窦侵犯的危险因素[J]. 北京大学学报（医学版）, 2021, 53(4): 659-664.
[7] 周柏林,李危石,孙垂国,齐强,陈仲强,曾岩. 脊柱手术后深部切口感染患者多次清创的危险因素[J]. 北京大学学报（医学版）, 2021, 53(2): 286-292.
[8] 夏芳芳,鲁芙爱,吕慧敏,杨国安,刘媛. 系统性红斑狼疮伴间质性肺炎的临床特点及相关因素分析[J]. 北京大学学报（医学版）, 2021, 53(2): 266-272.
[9] 刘晓强,杨洋,周建锋,刘建彰,谭建国. 640例单牙种植术对血压和心率影响的队列研究[J]. 北京大学学报（医学版）, 2021, 53(2): 390-395.
[10] 侯国进,周方,田耘,姬洪全,张志山,郭琰,吕扬,杨钟玮,张雅文. 后路短节段跨伤椎椎弓根螺钉固定治疗胸腰段爆裂骨折术后再发后凸的危险因素[J]. 北京大学学报（医学版）, 2021, 53(1): 167-174.
[11] 王迎春,黄永辉,常虹,姚炜,闫秀娥,李柯,张耀鹏,郑炜. 十二指肠乳头息肉良、恶性病变比较及活检准确性[J]. 北京大学学报（医学版）, 2021, 53(1): 204-209.
[12] 唐果,龙丽,韩雅欣,彭清,刘佳君,尚华. 类风湿关节炎合并结核感染的临床特点及相关因素[J]. 北京大学学报（医学版）, 2020, 52(6): 1029-1033.
[13] 陈家丽,金月波,王一帆,张晓盈,李静,姚海红,何菁,李春. 老年发病类风湿关节炎的临床特征及其心血管疾病危险因素分析:一项大样本横断面临床研究[J]. 北京大学学报（医学版）, 2020, 52(6): 1040-1047.
[14] 王一帆,范稹,成姚斌,金月波,霍阳,何菁. 原发性干燥综合征患者睡眠障碍的相关影响因素[J]. 北京大学学报（医学版）, 2020, 52(6): 1063-1068.
[15] 杨航,杨林承,张瑞涛,凌云鹏,葛庆岗. 合并高血压、冠心病、糖尿病的新型冠状病毒肺炎患者发生病死的危险因素分析[J]. 北京大学学报（医学版）, 2020, 52(3): 420-424.
Viewed
Full text


Abstract

Cited
  Shared   
  Discussed   
[1] 张三. 中文标题测试[J]. 北京大学学报（医学版）, 2010, 42(1): 1 -10 .
[2] 赵磊, 王天龙 . 右心室舒张末期容量监测用于肝移植术中容量管理的临床研究[J]. 北京大学学报（医学版）, 2009, 41(2): 188 -191 .
[3] 万有, , 韩济生, John E. Pintar. 孤啡肽基因敲除小鼠电针镇痛作用增强[J]. 北京大学学报（医学版）, 2009, 41(3): 376 -379 .
[4] 张燕, 韩志慧, 钟延丰, 王盛兰, 李玲玲, 郑丹枫. 骨骼肌活组织检查病理诊断技术的改进及应用[J]. 北京大学学报（医学版）, 2009, 41(4): 459 -462 .
[5] 赵奇, 薛世华, 刘志勇, 吴凌云. 同向施压测定自酸蚀与全酸蚀粘接系统粘接强度[J]. 北京大学学报（医学版）, 2010, 42(1): 82 -84 .
[6] 林红, 王玉凤, 吴野平. 学校生活技能教育对小学三年级学生行为问题影响的对照研究[J]. 北京大学学报（医学版）, 2007, 39(3): 319 -322 .
[7] 丰雷, 程嘉, 王玉凤. 注意缺陷多动障碍儿童的运动协调功能[J]. 北京大学学报（医学版）, 2007, 39(3): 333 -336 .
[8] 李岳玲, 钱秋瑾, 王玉凤. 儿童注意缺陷多动障碍成人期预后及其预测因素[J]. 北京大学学报（医学版）, 2007, 39(3): 337 -340 .
[9] . 书讯[J]. 北京大学学报（医学版）, 2007, 39(3): 225 -328 .
[10] 牟向东, 王广发, 刁小莉, 阙呈立. 肺黏膜相关淋巴组织型边缘区B细胞淋巴瘤一例[J]. 北京大学学报（医学版）, 2007, 39(4): 346 -350 .
ISSN 1671-167X
CN 11-4691/R
主管单位：中华人民共和国教育部
主办单位：北京大学
地址： 北京市海淀区学院路38号 北京大学医学部 《北京大学学报（医学版）》
邮编：100191
电话：010-82801551
Email： xbbjb2@bjmu.edu.cn

《北京大学学报（医学版）》
微信公众号
版权所有 © 2018 《北京大学学报（医学版）》编辑部