Analysis of risk factors of early acute kidney injury after liver transplantation from DCD donor liver
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摘要:
目的 分析心脏死亡器官捐献（DCD）供肝肝移植术后早期急性肾损伤（AKI）的相关危险因素。 方法 回顾性分析184例DCD供肝肝移植供、受体资料。根据术后早期是否发生AKI分为AKI组和非AKI组，并且对AKI组行AKI分期。比较两组一般资料和术前、术中、术后相关指标的差异。用Kaplan-Meier曲线分析非AKI组和AKI组不同分期累积存活率等预后情况。 结果 本研究纳入病例184例，术后早期发生AKI 68例（37.0%），其中AKI 1期31例，AKI 2期26例，AKI 3期11例，且发生多在术后3 d内。单因素分析结果显示术前白蛋白 < 35 g/L、术前血清钠≤ 137 mmol/L、手术时间>7.5 h、术中出血量>3 000 mL、术中红细胞输注量>15 U、术中尿量≤ 100 mL/h这6项指标为肝移植术后早期发生AKI的危险因素（均为P < 0.05）。Logistic多变量回归分析结果表明术中红细胞输注量>15 U是肝移植术后早期发生AKI的独立危险因素[比值比（OR）1.061，95%可信区间（CI）1.008~1.118，P=0.024]。Kaplan-Meier生存曲线结果表明随着AKI程度不断加重，其累积存活率逐渐降低，差异有统计学意义（均为P < 0.05）。 结论 肝移植患者术后早期AKI的发生率较高，且严重程度与受体的短期和长期预后密切相关，术中大量输注红细胞是AKI发生的独立危险因素。 -
关键词:
- 肝移植 /
- 心脏死亡器官捐献（DCD） /
- 急性肾损伤（AKI） /
- 危险因素 /
- 红细胞 /
- 持续性肾脏替代治疗 /
- 出血量
Abstract:Objective To analyze the risk factors of early acute kidney injury (AKI) after liver transplantation from donation after cardiac death(DCD) donor liver. Methods Clinical data of 184 donors and recipients undergoing liver transplantation from DCD donor liver were retrospectively analyzed. According to the incidence of early AKI, all participants were divided into the AKI and non-AKI groups. The patients in the AKI group were subject to AKI staging. Baseline data, preoperative, intraoperative and postoperative related parameters were statistically compared between two groups. The cumulative survival rate and clinical prognosis of patients in non-AKI group and AKI group with different staging were statistically analyzed by Kaplan-Meier curve analysis. Results Among 184 patients, 68 cases (37.0%) presented with early AKI after liver transplantation including 31 stage 1 AKI, 26 stage 2 AKI and 11 stage 3 AKI, mainly occurring within postoperative 3 d. Univariate analysis revealed that preoperative levels of albumin < 35 g/L, preoperative levels of serum sodium ≤137 mmol/L, operation time>7.5 h, intraoperative hemorrhage volume>3 000 mL, intraoperative red cell infusion volume>15 U and intraoperative urine amount ≤100 mL/h were the risk factors of early AKI after liver transplantation (all P < 0.05). Multi-variate Logistic regression analysis demonstrated that intraoperative red cell infusion > 15 U was an independent risk factor of early AKI after liver transplantation [odds ratio(OR) 1.061, 95% confidence interval(CI) 1.008-1.118, P=0.024]. Result of Kaplan-Meier survival curve suggested that the cumulative survival rate was gradually reduced along with the aggravation of AKI with statistical significance (all P < 0.05). Conclusions The incidence of early AKI following liver transplantation is relatively high. The severity of early AKI is intimately correlated with the short-and long-term prognosis of the recipients. A large quantity of intraoperative red blood cell infusion is an independent risk factor of AKI. -
图 1 AKI不同分期患者与非AKI患者KaplanMeier生存曲线
Figure 1. Kaplan-Meier survival curves of AKI patients in different stage and non-AKI patients
表 1 AKI组与非AKI组一般资料和围手术期指标的比较
Table 1. Comparison of general information and perioperative indexes between AKI group and non-AKI group
指标 AKI组（n=68） 非AKI组（n=116） P值 供体因素 年龄（x±s，岁） 40.4±1.80 41.4±1.3 0.646 性别（n男/n女） 59/9 94/22 0.316 受体因素 一般资料 年龄（x±s，岁） 46.8±1.3 45.1±1.0 0.303 性别（n男/n女） 54/14 95/21 0.678 BMI（x±s，kg/m2） 22.50±0.43 21.86±0.25 0.205 糖尿病史[n(%)] 4(6) 2(2) 0.270 高血压史[n(%)] 2(3) 2(2) 0.982 上腹部手术史[n(%)] 29(43) 39(34) 0.221 原发病[n(%)] 0.693 乙肝后肝硬化 35(51) 62(53) 丙肝后肝硬化 08(12) 8(7) 胆源性肝硬化 2(3) 7(6) 酒精性肝硬化 1(1) 4(3) 原发性肝癌 013(19) 18(16) 其他 009(13) 17(15) 术前指标 ALT（x±s，U/L） 114±33 089±21 0.480 AST（x±s，U/L） 187±59 122±31 0.321 TB（x±s，μmol/L） 122±19 114±13 0.833 DB（x±s，μmol/L） 072±13 46±7 0.085 白蛋白（x±s，g/L） 32.5±0.6 34.4±0.5 0.031 血红蛋白（x±s，g/L） 100.7±2.50 109.0±2.70 0.032 Scr（x±s，μmol/L） 59.2±2.6 74.9±5.0 0.004 血清钠（x±s，mmol/L） 136.7±0.70 138.5±0.50 0.034 eGFR[x±s，mL/（min·1.73m2）] 89.3±2.6 90.6±2.9 0.178 PT（x±s，s） 19.7±0.6 18.7±0.4 0.167 Child-Pugh评分（x±s，分） 10.43±0.25 10.02±0.18 0.181 MELD评分（x±s，分） 18.6±1.0 18.2±0.8 0.851 MELD-Na评分（x±s，分） 20.6±1.3 20.2±1.4 0.863 术中指标 手术时间（x±s，h） 06.86±0.15 06.44±0.10 0.024 出血量（x±s，mL） 2 882±305 2 035±160 0.015 下腔静脉阻断时间（x±s，min） 054.4±1.60 51.9±1.0 0.163 冷缺血时间（x±s，h） 005.31±0.210 05.09±0.13 0.352 热缺血时间（x±s，min） 009.84±0.430 09.29±0.20 0.252 红细胞输注量[M(R)，U] 10(6~18) 8(4~13) 0.015 血浆输注量[M(R)，mL] 1 600(1 050~2 400) 1 600(1 000~2 150) 0.481 胶体输注量（x±s，mL） 1 001±730 983±48 0.824 尿量（x±s，mL/h） 00218±1110 0275±131 0.003 使用血管活性药物[n(%)] 22(32) 39(34) 0.860 低血压状态[n(%)] 34(50) 55(47) 0.735 术后指标 ICU停留时间（x±s，h） 0182±104 144±58 0.006 住院时间（x±s，d） 022±10 021±10 0.587 乙肝为乙型病毒型肝炎; 丙肝为丙型病毒型肝炎 
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表 2 肝移植术后早期AKI危险因素的单因素分析
Table 2. Univariate analysis of the risk factors of early AKI after liver transplantation
变量 OR值 95%CI P值 术前白蛋白 < 35 g/L 1.949 1.037~3.663 0.038 术前血清钠≤137 mmol/L 1.860 1.015~3.407 0.045 手术时间 > 7.5 h 2.258 1.079~4.726 0.031 术中出血量 > 3 000 mL 2.264 1.156~5.293 0.034 术中红细胞输注量 > 15 U 2.145 1.060~4.340 0.034 术中尿量≤100 mL/h 2.748 1.145~6.594 0.024
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[1] 中华医学会器官移植学分会. 中国心脏死亡器官捐献工作指南(第2版)[J]. 中华器官移植杂志, 2011, 32(12): 756-758. DOI: 10.3760/cma.j.issn.0254-1785.2011.12.014.Branch of Organ Transplantation of Chinese Medical Association. Guideline on donation after cardiac death in China(2nd edition)[J]. Chin J Organ Transplant, 2011, 32(12): 756-758. DOI: 10.3760/cma.j.issn.0254-1785.2011.12.014. [2] 中国医师协会器官移植分会, 中华医学会外科学分会器官移植学组, 中国肝移植注册中心科学委员会, 等. 中国移植器官保护专家共识[J]. 中华肝胆外科杂志, 2016, 22(9): 577-586. DOI: 10.3760/cma.j.issn.1007-8118.2016.09.001.Branch of Organ Transplant Physicians of Chinese Medical Doctor Association, Section of Organ Transplantation of Surgery Branch of Chinese Medical Association, Scientific Committee of China Liver Transplant Registry (CLTR) Center, et al. Chinese expert consensus on organ protection in transplantation[J]. Chin J Hepatobiliary Surg, 2016, 22(9): 577-586. DOI: 10.3760/cma.j.issn.1007-8118.2016.09.001. [3] LEITHEAD JA, TARICIOTTI L, GUNSON B, et al. Donation after cardiac death liver transplant recipients have an increased frequency of acute kidney injury[J]. Am J Transplant, 2012, 12(4): 965-975. DOI: 10.1111/j.1600-6143.2011.03894.x. [4] BARRI YM, SANCHEZ EQ, JENNINGS LW, et al. Acute kidney injury following liver transplantation: definition and outcome[J]. Liver Transpl, 2009, 15(5): 475-483. DOI: 10.1002/lt.21682. [5] LEWIS J, PELTIER J, NELSON H, et al. Development of the University of Wisconsin donation after cardiac death evaluation tool[J]. Prog Transplant, 2003, 13(4): 265-273. DOI: 10.7182/prtr.13.4.w48g8051530058q3. [6] KELLUM JA, LAMERIRE N, KDIGD AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)[J]. Crit Care, 2013, 17(1): 204. DOI: 10.1186/cc11454. [7] XU X, LING Q, WEI Q, et al. An effective model for predicting acute kidney injury after liver transplantation[J]. Hepatobiliary Pancreat Dis Int, 2010, 9(3): 259-263. https://www.researchgate.net/publication/44651530_An_effective_model_for_predicting_acute_kidney_injury_after_liver_transplantation [8] 王建星, 刘亚玲, 狄长安, 等.持续肾替代治疗在肝移植术后急性肾损伤的应用[J].中华肝胆外科杂志, 2015, 21(1): 39-43. DOI: 10.3760/cma.j.issn.1007-8118.2015.01.011.WANG JX, LIU YL, DI CA, et al. Continuous renal replacement therapy for patients with renal failure after liver transplantation[J]. Chin J Hepatobiliary Surg, 2015, 21(1): 39-43. DOI: 10.3760/cma.j.issn.1007-8118.2015.01.011. [9] 朱铭力, 郦忆, 钱家麒, 等.肝移植术后急性肾损伤的发生情况及其与预后的关系[J].中华肾脏病杂志, 2009, 25(2): 86-92. DOI: 10.3760/cma.j.issn.1001-7097. 2009.02.003.ZHU ML, LI Y, QIAN JQ, et al. Incidence of acute kidney injury and its association with prognosis after liver transplantation[J]. Chin J Nephrol, 2009, 25(2): 86-92.DOI: 10.3760/cma.j.issn.1001-7097.2009.02.003. [10] TIAN F, WANG ZB, MENG DM, et al. Preliminary study on the role of virtual touch tissue quantification combined with a urinary β2-microglobulin test on the early diagnosis of gouty kidney damage[J]. Ultrasound Med Biol, 2014, 40(7): 1394-1399. DOI: 10.1016/j.ultrasmedbio.2014.01.013. [11] 中华医学会外科学分会器官移植学组. 肝移植受者肾功能损伤诊疗指南[J/CD]. 中华移植杂志(电子版), 2011, 5(3): 60-62. DOI: 10.3877/cma.j.issn.1647-3903.2011.03.017.Section of Organ Transplantation of Surgery Branch of Chinese Medical Association. Guideline for the diagnosis and treatment of renal function injury in liver transplant recipients[J/CD]. Chin J Transplant(Electr Vers), 2011, 5(3): 60-62. DOI: 10.3877/cma.j.issn.1647-3903.2011.03.017.issn.1647-3903.2011.03.017. [12] ERDOST HA, OZKARDESLER S, AKAN M, et al. Comparison of the RIFLE, AKIN, and KDIGO diagnostic classifications for acute renal injury in patients undergoing liver transplantation[J]. Transplant Proc, 2016, 48(6): 2112-2118. DOI: 10.1016/j.transproceed.2016.03.044. [13] KARROWNI W, VORA AN, DAI D, et al. Blood transfusion and the risk of acute kidney injury among patients with acute coronary syndrome undergoing percutaneous coronary intervention[J]. Circ Cardiovasc Interv, 2016, 9(9):e003279. DOI: 10.1161/CIRCINTERVENTIONS. 115.003279. [14] NEUBERGER JM, MAMELOK RD, NEUHAUS P, et al. Delayed introduction of reduced-dose tacrolimus, and renal function in liver transplantation: the 'ReSpECT' study[J]. Am J Transplant, 2009, 9(2): 327-336. DOI: 10.1111/j.1600-6143.2008.02493.x. [15] VARO E, LÓPEZ A, RIVERO C. Initial immunosuppression in liver transplant recipients with impaired renal function[J]. Transplant Proc, 2005, 37(9): 3909-3912. DOI: 10.1016/j.transproceed.2005.09.115. [16] 周景霞, 尤丕聪, 刘春涛, 等.探讨急性肾损伤分期的KDIGO标准在选择连续性血液净化治疗介入时机中的指导意义[J].中华危重病急救医学, 2013, 25(7): 420-423. DOI: 10.3760/cma.j.issn.2095-4352. 2013.07.013.ZHOU JX, YOU PC, LIU CT, et al. Role of acute kidney injury staging by KDIGO criteria in choosing the opportune time of continuous blood purification[J]. Chin Crit Care Med, 2013, 25(7): 420-423.DOI: 10.3760/cma.j.issn.2095-4352.2013.07.013. [17] 陈敏华, 呼邦传, 李茜, 等.基于KDIGO分级的早期连续性肾脏替代治疗对重症急性肾损伤患者预后的影响[J].中华危重病急救医学, 2016, 28(3): 246-251. DOI: 10.3760/cma.j.issn.2095-4352.2016.03.011.CHEN MH, HU BC, LI Q, et al. Effect of early initiation of continuous renal replacement therapy based on the KDIGO classification on the prognosis of critically ill patients with acute kidney injury[J].Chin Crit Care Med, 2016, 28(3): 246-251. DOI: 10.3760/cma.j.issn.2095-4352.2016.03.011. -
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