Açık kalp cerrahisi sonrası gelişen akut böbrek hasarının insidansı, preoperatif, intraoperatif ve postoperatif belirleyicileri
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Tarih
2020
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Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Ege Üniversitesi Tıp Fakültesi Etik Kurulu onayının alınmasını takiben, Kalp ve Damar Cerrahisi Anabilim Dalı'nda 01.01.2017 - 31.12.2017 tarihlerinde genel anestezi altında elektif açık kalp cerrahisi (koroner arter baypas greftleme ve kalp kapak cerrahisi) uygulanan erişkin hastalar çalışmaya dahil edilerek, dosyaları retrospektif olarak tarandı. Kardiyopulmoner baypas kullanılmadan off-pump cerrahi teknik ile opere edilen, majör organ yetmezliği olan (ciddi karaciğer yetmezliği veya böbrek yetmezliği / hemodiyalize bağımlı olan hastalar), acil cerrahi veya "redo" cerrahi geçiren, aort gibi büyük damarlarına cerrahi girişim uygulanan, kalp yetmezliğine yönelik cerrahi girişim uygulanan ve 18 yaşın altındaki hastalar çalışmamıza dahil edilmedi. Çalışmamızda, retrospektif olarak dosyası taranan her hasta KDIGO skorlama sistemine göre perioperatif dönemde olası akut böbrek hasarı açısından değerlendirilerek, böbrek hasarı kriterlerine uyması durumunda evrelendirildi ve renal replasman tedavisi ya da hemodiyaliz gereksinimi olup olmadığı kaydedildi. Hastalar, KDİGO değeri 0 olup, akut böbrek hasarı gelişmeyenler (GRUP 1) ve KDİGO değeri 1,2 veya 3 olup, akut böbrek hasarı gelişenler (GRUP 2) olarak gruplandırıldı. Akut böbrek hasarı ile ilişkili olabilecek ve aşağıda yer alan preoperatif, intraoperatif ve postoperatif belirleyiciler veya risk faktörleri her iki grupta araştırıldı. Hastaların dosyaları retrospektif olarak taranarak, perioperatif döneme ait olası sistemik komplikasyonlar, araştırıldı ve kaydedildi. İstatistiksel hesaplamalarda SPSS 21.0 (Windows için SPSS. IL, ABD) programından yararlanıldı. Veriler median ve yüzde (%) şeklinde ifade edildi. İstatistiksel analizlerde gruplar arası karşılaştırmalarda kategorik değişkenler için Ki-kare ve Fisher Exact testi, niceliksel değişkenler için bağımsız örnekli t testi ve Mann-Whitney U testi uygulandı. Normal dağılımı saptamak için Kolmogorov-Smirnov testi uygulanacaktır. P < 0.05 istatistiksel olarak anlamlı kabul edildi. Çalışmamıza dahil edilen hastalarda KDIGO skorlama sistemine göre akut böbrek hasarının 75 hastada geliştiği bulundu. Akut böbrek hasarı gelişen 75 hasta içerisinde Evre 1 kriterlerine uyan hasta sayısı 34 (%45.3), Evre 2 kriterlerine uyan hasta sayısı 23 (%30.7) ve Evre 3 kriterlerine uyan hasta sayısı 18 (%24) olarak bulundu. Akut böbrek hasarı gelişen hastalar içerisinde 26 hastada (%34.6) hemodiyaliz gereksinimi ve 8 hastada (%10,6) renal replasman tedavisi gereksinimi olduğu bulundu. Çalışmamızda, hasta yaşı açısından gruplar arasında anlamlı fark saptandı; GRUP 1'in yaş median değeri 62 yıl ve GRUP 2'nin yaş median değeri 67 yıl olarak bulundu (P<0.001). EuroSCORE değeri açısından hasta grupları arasında anlamlı fark saptandı; Euroscore değeri arttıkça akut böbrek hasarı insidansının arttığı görüldü (P<0.001). Hipertansiyon (P=0.023) ve Diabetes Mellitus (P<0.001) insidansları açısından hasta gupları arasında anlamlı farklar saptandı. Preoperatif üre, kreatinin ve GFR değerlerinin her biri açısından hasta grupları arasında anlamlı farklar saptandı (P<0.001). Preoperatif hemoglobin değeri açısından hasta grupları arasında anlamlı farklar saptandı; preoperatif median hemoglobin değeri GRUP 1'de 13.8 g/dL, GRUP 2'de 12.4 g/dL olarak bulundu (P=0.002). Çalışmamızda, cerrahi tipi açısından hasta grupları arasında anlamlı fark saptandı; özellikle koroner arter baypas greftleme yapılan hastalarda akut böbrek hasarı insidansı yüksek bulundu (P=0.041). Çalışmamızda, cerrahi, anestezi ve kros klemp süreleri açısından hasta grupları arasında anlamlı farklar saptanmıştır; cerrahi, anestezi ve kros klemp sürelerinin her biri akut böbrek hasarı gelişen grupta (GRUP 2) anlamlı olarak daha yüksek bulunmuştur. Çalışmamızda, perioperatif eritrosit, taze donmuş plazma ve trombosit süspansiyonu kullanımı açısından hasta grupları kıyaslandığında, GRUP 1'e ait hastalarda her üç ürün için de transfüzyon gereksiniminin GRUP 2'e ait hastalara oranla anlamlı olarak düşük olduğu bulundu (P<0.001). İntraoperatif diürez açısından gruplar kıyaslandığında, GRUP 1'deki hastaların diürez miktarının GRUP 2'deki hastalara göre anlamlı olarak yüksek olduğu bulundu (P<0.001). İkiden fazla inotropik veya vazopressör ajan desteği gereksiniminin, akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'de akut böbrek hasarı gelişen hastaları içeren GRUP 2'e oranla anlamlı olarak daha düşük olduğu gözlendi (P<0.001). Çalışmamızda, postoperatif dönemde düşük kardiyak debi insidansının akut böbrek hasarı gelişen hastaları içeren GRUP 2'de akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'e oranla anlamlı olarak daha yüksek olduğu gözlendi (P<0.001). Postoperatif dönemde ilk 24 saat içerisinde kan transfüzyonu, toraks drenajı ve sıvı dengesinin, akut böbrek hasarı gelişen hastaları içeren GRUP 2'de akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'e oranla anlamlı olarak daha yüksek olduğu gözlendi (sırasıyla, P<0.001, P<0.001 ve P=0.006). Çalışmamızda, postoperatif ilk hafta içerisinde üre ve kreatinin değerlerinin her birinin, akut böbrek hasarı gelişen hastaları içeren GRUP 2'de akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'e oranla anlamlı olarak daha yüksek olduğu gözlendi (P<0.001). Postoperatif ilk hafta içerisinde GFR değeri ≥ 60 mL/dk/1.73 m2 olan hasta sayısı, akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'de, akut böbrek hasarı gelişen hastaları içeren GRUP 2'e oranla anlamlı olarak daha yüksek bulundu (P<0.001). Postoperatif ilk hafta içerisinde GFR değeri < 60 mL/dk/1.73 m2 olan hasta sayısı ise, akut böbrek hasarı gelişen hastaları içeren GRUP 2'de akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'e oranla anlamlı olarak daha yüksek bulundu (P<0.001). Postoperatif mekanik ventilasyon süresi, yoğun bakım ünitesinde yatış süresi ve hastanede yatış süresinin her birinin akut böbrek hasarı gelişen hastaları içeren GRUP 2'de akut böbrek hasarı gelişmeyen hastaları içeren GRUP 1'e oranla anlamlı olarak daha yüksek olduğu gözlendi (sırasıyla, P<0.001, P<0.001 ve P=0.013). Çalışmamızda, retrospektif olarak dosyası taranan hastaların akut böbrek hasarı evresi yükseldikçe hemodiyaliz ya da renal replasman tedavisi gereksiniminde artış olduğu bulundu (P<0.001). Çalışmamızda, KDİGO skorlamasına ait evresi 2'nin altında olan hastaların mortalite oranlarının KDİGO skoru 2 ve üzeri olan hastalara oranla daha düşük olduğu tespit edildi. Çalışmamıza dahil edilen hastalar Lojistik Regresyon Analizi'ne göre değerlendirildiğinde, preoperatif hemoglobin değerinin düşük olmasının ve cerrahi sürenin uzamasının postoperatif hemodiyaliz gereksinimini belirgin olarak arttırdığı bulundu. Çalışmamız sonucunda ileri yaş, Diabetes Mellitus ve hipertansiyon tanıları, EuroSCORE değerinin yüksek olması, preoperatif hemoglobin değerinin düşük olması (<12 g/dL), intraoperatif kan ürünü transfüzyon miktarının yüksek olması, kros klemp, kardiyopulmoner baypas, cerrahi ve anestezi sürelerinin uzun olması, postoperatif kardiyak debinin düşük olması ve ikiden fazla inotropik ajan infüzyonu gereksinimi, postoperatif ilk 24 saat içerisinde kan transfüzyonu, toraks drenajı ve sıvı dengesinin yüksek olması ve postoperatif mekanik ventilasyon, yoğun bakım ve hastanede yatış sürelerinin uzaması akut böbrek hasarı tanısı ile ilişkili risk faktörleri olarak bulunmuştur.
Following the approval of Ege University Faculty of Medicine Ethics Committee, adult patients who underwent elective open heart surgery (coronary artery bypass grafting and heart valve surgery) under general anesthesia between 01.01.2017 - 31.12.2017 in the Department of Cardiovascular Surgery were included in the study, files were scanned retrospectively. Patients with major organ failure (severe liver failure or renal failure / hemodialysis dependent patients), who underwent emergency surgery or "redo" surgery, underwent surgical intervention in large vessels such as the aorta, who were operated with off-pump surgical technique without the use of cardiopulmonary bypass, Patients under 18 years of age who underwent surgical intervention were not included in our study. In our study, each patient whose file was scanned retrospectively was evaluated in terms of possible acute kidney damage in the perioperative period according to the KDIGO scoring system, staged if it met the criteria for kidney damage, and whether renal replacement therapy or hemodialysis was required was recorded. The patients were grouped as those with a KDIGO value of 0, those without acute renal damage (GROUP 1), and those with acute kidney damage (GROUP 2) with a value of 1, 2 or 3. Preoperative, intraoperative, and postoperative determinants or risk factors that may be associated with acute kidney injury were investigated in both groups. Possible systemic complications of the perioperative period were investigated and recorded by retrospectively scanning the files of the patients. SPSS 21.0 (SPSS for Windows. IL, USA) program was used for statistical calculations. Data were expressed as median and percentage (%). For statistical analysis, Chi-square and Fisher Exact tests were used for categorical variables, independent samples t test and Mann-Whitney U test were used for quantitative variables. Kolmogorov-Smirnov test will be applied to detect normal distribution. P <0.05 was considered statistically significant. Acute kidney injury was found in 75 patients according to the KDIGO scoring system in the patients included in our study. Among 75 patients with acute renal damage, 34 patients (45.3%) who met the stage 1 criteria, 23 (30.7%) who met the stage 2 criteria, and 18 (24%) who met the stage 3 criteria were found. It was found that hemodialysis was required in 26 patients (34.6%) and renal replacement therapy was required in 8 patients (10.6%) among patients with acute renal damage. In ou study, a significant difference was found between the groups in terms of patient age; The age median value of GROUP 1 was 62 years, and the median age value of GROUP 2 was 67 years (P <0.001). There was a significant difference between patient groups in terms of EuroSCORE value; It was observed that the higher the Euroscore value, the higher the incidence of acute kidney injury (P <0.001). There were significant differences between the patient groups in terms of the incidence of hypertension (P = 0.023) and Diabetes Mellitus (P <0.001). There were significant differences between patient groups in terms of preoperative urea, creatinine and GFR values (P <0.001). Significant differences were found between patient groups in terms of preoperative hemoglobin value; The preoperative median hemoglobin value was 13.8 g / dL in GROUP 1 and 12.4 g / dL in GROUP 2 (P = 0.002). In our study, a significant difference was found between patient groups in terms of surgery type; The incidence of acute kidney injury was found to be high, especially in patients undergoing coronary artery bypass grafting (P = 0.041). In our study, significant differences were found between the patient groups in terms of surgery, anesthesia and cross-clamp times; The durations of surgery, anesthesia, and cross clamping were significantly higher in the acute kidney injury group (GROUP 2) each. In our study, when the patient groups were compared in terms of the use of perioperative erythrocyte, fresh frozen plasma and thrombocyte suspension, it was found that the need for transfusion for all three products in the group 1 patients was significantly lower than in the group 2 patients (P <0.001). When the groups were compared in terms of intraoperative diuresis, it was found that the amount of diuresis of the patients in GROUP 1 was significantly higher than that of the patients in GROUP 2 (P <0.001). It was observed that the need for more than two inotropic or vasopressor agent support was significantly lower in GROUP 1, which includes patients without acute kidney damage, compared to GROUP 2, which includes patients with acute kidney injury (P <0.001). In our study, it was observed that the incidence of low cardiac output in the postoperative period was significantly higher in GROUP 2, which includes patients with acute kidney damage, compared to GROUP 1, which includes patients without acute kidney damage (P <0.001). In the postoperative period (first 24 hours), blood transfusion, thoracic drainage, and fluid balance were significantly higher in GROUP 2, including patients with acute kidney injury, compared to GROUP 1, including patients without acute renal damage (P <0.001, P, respectively). <0.001 and P = 0.006). In our study, it was observed that urea and creatinine values were significantly higher in GROUP 2, which includes patients with acute kidney damage, compared to GROUP 1, which includes patients with acute kidney damage in the first postoperative week (P <0.001). The number of patients with GFR <60 mL / min / 1.73 m2 in the first postoperative week was found to be significantly higher in GROUP 2, which includes patients with acute kidney damage, compared to GROUP 1, which includes patients without acute kidney damage (P <0.001). Postoperative mechanical ventilation time, length of stay in the intensive care unit, and duration of hospitalization were significantly higher in GROUP 2, which included patients with acute kidney injury, compared to GROUP 1, which included patients without acute kidney damage (P <0.001, respectively, P <0.001 and P = 0.013). In our study, it was found that the need for hemodialysis or renal replacement therapy increased as the stage of acute kidney injury increased in patients (P <0.001). In our study, it was found that the mortality rates of patients with stage less than 2 for the KDIGO scoring were lower than the patients with a KDIGO score of 2 and above. When the patients included in our study were evaluated according to the Logistic Regression Analysis, it was found that the low preoperative hemoglobin value and the prolongation of the surgical time significantly increased the need for postoperative hemodialysis. As a result of our study, advanced age, diabetes mellitus and hypertension diagnoses, high EuroSCORE value, low preoperative hemoglobin value (<12 g / dL), high intraoperative blood product transfusion, cross clamp, cardiopulmonary bypass, surgery and anesthesia times, Low postoperative cardiac output and the need for more than two inotropic agent infusions, blood transfusion, high thoracic drainage and fluid balance in the first 24 hours postoperatively, and prolonged postoperative mechanical ventilation, intensive care and hospital stay were found to be risk factors associated with the diagnosis of acute kidney injury.
Following the approval of Ege University Faculty of Medicine Ethics Committee, adult patients who underwent elective open heart surgery (coronary artery bypass grafting and heart valve surgery) under general anesthesia between 01.01.2017 - 31.12.2017 in the Department of Cardiovascular Surgery were included in the study, files were scanned retrospectively. Patients with major organ failure (severe liver failure or renal failure / hemodialysis dependent patients), who underwent emergency surgery or "redo" surgery, underwent surgical intervention in large vessels such as the aorta, who were operated with off-pump surgical technique without the use of cardiopulmonary bypass, Patients under 18 years of age who underwent surgical intervention were not included in our study. In our study, each patient whose file was scanned retrospectively was evaluated in terms of possible acute kidney damage in the perioperative period according to the KDIGO scoring system, staged if it met the criteria for kidney damage, and whether renal replacement therapy or hemodialysis was required was recorded. The patients were grouped as those with a KDIGO value of 0, those without acute renal damage (GROUP 1), and those with acute kidney damage (GROUP 2) with a value of 1, 2 or 3. Preoperative, intraoperative, and postoperative determinants or risk factors that may be associated with acute kidney injury were investigated in both groups. Possible systemic complications of the perioperative period were investigated and recorded by retrospectively scanning the files of the patients. SPSS 21.0 (SPSS for Windows. IL, USA) program was used for statistical calculations. Data were expressed as median and percentage (%). For statistical analysis, Chi-square and Fisher Exact tests were used for categorical variables, independent samples t test and Mann-Whitney U test were used for quantitative variables. Kolmogorov-Smirnov test will be applied to detect normal distribution. P <0.05 was considered statistically significant. Acute kidney injury was found in 75 patients according to the KDIGO scoring system in the patients included in our study. Among 75 patients with acute renal damage, 34 patients (45.3%) who met the stage 1 criteria, 23 (30.7%) who met the stage 2 criteria, and 18 (24%) who met the stage 3 criteria were found. It was found that hemodialysis was required in 26 patients (34.6%) and renal replacement therapy was required in 8 patients (10.6%) among patients with acute renal damage. In ou study, a significant difference was found between the groups in terms of patient age; The age median value of GROUP 1 was 62 years, and the median age value of GROUP 2 was 67 years (P <0.001). There was a significant difference between patient groups in terms of EuroSCORE value; It was observed that the higher the Euroscore value, the higher the incidence of acute kidney injury (P <0.001). There were significant differences between the patient groups in terms of the incidence of hypertension (P = 0.023) and Diabetes Mellitus (P <0.001). There were significant differences between patient groups in terms of preoperative urea, creatinine and GFR values (P <0.001). Significant differences were found between patient groups in terms of preoperative hemoglobin value; The preoperative median hemoglobin value was 13.8 g / dL in GROUP 1 and 12.4 g / dL in GROUP 2 (P = 0.002). In our study, a significant difference was found between patient groups in terms of surgery type; The incidence of acute kidney injury was found to be high, especially in patients undergoing coronary artery bypass grafting (P = 0.041). In our study, significant differences were found between the patient groups in terms of surgery, anesthesia and cross-clamp times; The durations of surgery, anesthesia, and cross clamping were significantly higher in the acute kidney injury group (GROUP 2) each. In our study, when the patient groups were compared in terms of the use of perioperative erythrocyte, fresh frozen plasma and thrombocyte suspension, it was found that the need for transfusion for all three products in the group 1 patients was significantly lower than in the group 2 patients (P <0.001). When the groups were compared in terms of intraoperative diuresis, it was found that the amount of diuresis of the patients in GROUP 1 was significantly higher than that of the patients in GROUP 2 (P <0.001). It was observed that the need for more than two inotropic or vasopressor agent support was significantly lower in GROUP 1, which includes patients without acute kidney damage, compared to GROUP 2, which includes patients with acute kidney injury (P <0.001). In our study, it was observed that the incidence of low cardiac output in the postoperative period was significantly higher in GROUP 2, which includes patients with acute kidney damage, compared to GROUP 1, which includes patients without acute kidney damage (P <0.001). In the postoperative period (first 24 hours), blood transfusion, thoracic drainage, and fluid balance were significantly higher in GROUP 2, including patients with acute kidney injury, compared to GROUP 1, including patients without acute renal damage (P <0.001, P, respectively). <0.001 and P = 0.006). In our study, it was observed that urea and creatinine values were significantly higher in GROUP 2, which includes patients with acute kidney damage, compared to GROUP 1, which includes patients with acute kidney damage in the first postoperative week (P <0.001). The number of patients with GFR <60 mL / min / 1.73 m2 in the first postoperative week was found to be significantly higher in GROUP 2, which includes patients with acute kidney damage, compared to GROUP 1, which includes patients without acute kidney damage (P <0.001). Postoperative mechanical ventilation time, length of stay in the intensive care unit, and duration of hospitalization were significantly higher in GROUP 2, which included patients with acute kidney injury, compared to GROUP 1, which included patients without acute kidney damage (P <0.001, respectively, P <0.001 and P = 0.013). In our study, it was found that the need for hemodialysis or renal replacement therapy increased as the stage of acute kidney injury increased in patients (P <0.001). In our study, it was found that the mortality rates of patients with stage less than 2 for the KDIGO scoring were lower than the patients with a KDIGO score of 2 and above. When the patients included in our study were evaluated according to the Logistic Regression Analysis, it was found that the low preoperative hemoglobin value and the prolongation of the surgical time significantly increased the need for postoperative hemodialysis. As a result of our study, advanced age, diabetes mellitus and hypertension diagnoses, high EuroSCORE value, low preoperative hemoglobin value (<12 g / dL), high intraoperative blood product transfusion, cross clamp, cardiopulmonary bypass, surgery and anesthesia times, Low postoperative cardiac output and the need for more than two inotropic agent infusions, blood transfusion, high thoracic drainage and fluid balance in the first 24 hours postoperatively, and prolonged postoperative mechanical ventilation, intensive care and hospital stay were found to be risk factors associated with the diagnosis of acute kidney injury.
Açıklama
Anahtar Kelimeler
Açık Kalp Cerrahisi, Akut Böbrek Hasarı, Genel Anestezi, KDIGO, Open Heart Surgery, Acute Kidney Injury, General Aneshesia, KDIGO
