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Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (1): 188-194. doi: 10.19723/j.issn.1671-167X.2021.01.028

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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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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

CLC Number: 

  • R614

Figure 1

Flowchart of study AKI, acute kidney disease. a, the estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration creatinine equation[14]. End-stage renal disease was defined as eGFR<15 mL/(min·1.73 m2) or receiving hemodialysis. b, furosemide or mannitol."

Table 1

Preoperative baseline data of the two groups"

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

Table 2

Perioperative data of the two groups"

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

Figure 2

The ROC of intraoperative calculated urine output for prediction of postoperative AKI AUC, area under curve; ROC, receiver operating characteristic curve; AKI, acute kidney injury."

Table 3

Predictive value of intraoperative urine volume for postoperative AKI"

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

Table 4

Independent risk factors of postoperative AKI"

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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