成人脊柱结核术后并发急性肾损伤的影响因素分析

doi:10.3969/j.issn.1000-6621.2019.08.009

摘要/Abstract

摘要：

目的探讨术前肾功能正常的成年脊柱结核患者行椎体结核病灶清除术后发生急性肾功能损伤(acute kidney injury, AKI)的危险因素。方法采用回顾性病例对照研究方法,搜集2009—2018年首都医科大学附属北京胸科医院收治的年龄≥18岁、术前肾功能正常,且行脊柱结核手术(后路病灶清除+椎间植骨融合+内固定术)治疗的成人脊柱结核患者2535例,参照排除标准最终纳入2068例。依据全球改善肾脏病预后组织(kidney disease improving global outcomes,KDIGO)指南,最终以术后发生AKI的31例患者作为并发AKI组,以未发生AKI的62例患者(与AKI组按1∶2匹配同期、同手术部位及同手术方式的患者)作为对照组。采用单因素和多因素logistic 回归分析两组患者的临床资料[年龄、性别、体质量指数(BMI),术前高血压、糖尿病、心脏病、吸烟史、慢性阻塞性肺疾病(COPD)、抗结核药物治疗时间、血肌酐(Scr)、尿素氮(BUN)、血红蛋白(Hb)、尿酸、白蛋白、C-反应蛋白(CRP)、估算的肾小球滤过率(eGFR),以及术中ASA分级、麻醉方式、有无高血压、有无低血压、手术时间、术中用药、胶体量、氯化钠注射液补液量、输血量、失血量、尿量,术后肺部感染、住院时间、院内死亡例数]与术后发生AKI的相关性。结果单因素分析结果显示,并发AKI组患者年龄≥60岁[64.52%(20/31)]、BMI>25[58.06%(18/31)]、术前高血压病史[54.84%(17/31)]、高尿酸血症[87.10%(27/31)]、贫血[54.84%(17/31)]、术中失血量≥600ml[64.52%(20/31)]等方面明显高于对照组[分别为41.94%(26/62)、30.65%(19/62)、29.03%(18/62)、67.74%(42/62)、19.35%(12/62)、35.48%(22/62)](χ²值分别为4.216、5.864、6.486、4.043、12.126、7.034,P值分别为0.040、0.011、0.015、0.044、0.001、0.008);而术前eGFR≥90ml·min^-1·(1.73m²)^-1 [67.74%(21/31) ]、术中使用右美托咪定[41.94%(13/31)]明显低于对照组[分别为87.10%(54/62)、64.52%(40/62)](χ²值分别为4.960、4.299, P值分别为0.026、0.038)。多因素logistic回归分析结果显示,术前BMI>25 [Wald χ²=4.916,P=0.027,OR(95%CI):4.391 (1.187~16.238)]、高尿酸血症[Wald χ²=4.412,P=0.036,OR(95%CI):5.896 (1.126~30.874)]、贫血[Wald χ²=9.396,P=0.002,OR(95%CI):8.173 (2.133~31.314)]、eGFR≥90ml·min^-1·(1.73m²)^-1 [Wald χ²=4.283,P=0.039,OR(95%CI):0.213(0.049~0.921)]是术后发生AKI的影响因素。结论术前肾功能正常的脊柱结核患者行椎体结核病灶清除术,术前BMI>25、并发高尿酸血症和贫血是术后发生AKI的危险因素,而术前高eGFR水平是保护性因素。

关键词: 结核, 脊柱, 外科手术, 手术后并发症, 急性肾功能不全, 因素分析,统计学

Abstract:

Objective To explore risk factors of acute kidney injury (AKI) after surgical treatment in adult spinal tuberculosis patients whose preoperative renal function were normal.Methods A retrospective study was conducted in spinal tuberculosis patients undergoing debridement surgery (posterior debridement and interbody fusion with internal fixation) in Beijing Chest Hospital Attached to Capital Medical University from 2009 to 2018, all the patients aged ≥18 years and their preoperative renal function were normal. According to exclusion criteria, 2068 of 2535 spinal tuberculosis patients were enrolled. Based on the inclusion criteria and guidelines of kidney disease improving global outcomes (KDIGO), 31 cases with AKI after surgery were selected as AKI group, and 62 cases with the same surgical treatment were control group. Data including age, gender, body mass index (BMI), preoperative hypertension, diabetes, heart disease, smoking history, chronic obstructive pulmonary disease (COPD), anti-tuberculosis drug treatment time, serum creatinine (Scr), blood urea nitrogen (BUN), hemoglobin (Hb), uric acid, albumin, C-reactive protein (CRP), estimated glomerular filtration rate (eGFR), ASA classification, anesthesia, hypertension, hypotension, surgical duration, intraoperative medication, Hydroxyethyl starch 130/0.4 sodium chloride injection, fluid volume, blood transfusion, blood loss, urine, postoperative pulmonary infection, postoperative hospital stay, number of deaths in the hospital, were analyzed using multivariate logistic regression, in order to explore the relationship of them and postoperative AKI.Results Univariate analysis showed that the preoperative age ≥60 years old (64.52% (20/31) vs. 41.94% (26/62), χ ²=4.216, P=0.040), BMI >25 (58.06% (18/31) vs. 30.65% (19/62), χ ²=6.486, P=0.011), history of hypertension (54.84% (17/31) vs. 29.03% (18/62), χ ²=5.864, P=0.015), hyperuricemia (87.10% (27/31) vs. 67.74% (42/62), χ ²=4.043, P=0.044), anemia (54.84% (17/31) vs. 19.35% (12/62), χ ²=12.126, P=0.001), and intraoperative blood loss ≥600 ml (64.52% (20/31) vs. 35.48% (12/62), χ ²=7.034, P=0.008) were in AKI group significantly higher than those in the control group;while preoperative eGFR ≥90 ml·min ^-1·(1.73m ²) ^-1 (67.74% (21/31) vs. 87.10% (54/62), χ ²=4.960, P=0.026) and intraoperative dexmedetomidine (41.94% (13/31) vs. 64.52% (40/62), χ ²=4.299, P=0.038) were significantly lower than those in the control group. According to multivariate logistic regression analysis, BMI >25 (Wald χ ²=4.916,P=0.027,OR(95%CI):4.391 (1.182-16.238)), hyperuricemia (Wald χ ²=4.412,P=0.036,OR(95%CI):5.896 (1.126-30.874)), eGFR≥90 ml·min ^-1·(1.73m ²) ^-1 (Wald χ ²=4.283,P=0.039,OR(95%CI):0.213 (0.049-0.921)), and anemia (Wald χ ²=9.396,P=0.002,OR(95%CI):8.173 (2.133-31.314)) before surgery were risk factors for postoperative AKI. Conclusion For postoperative AKI in the spinal tuberculosis patients with normal preoperative renal function, BMI >25 and preoperative hyperuricemia and anemia are risk factors; while preoperative high eGFR are protective factors.

Key words: Tuberculosis,spinal, Surgical procedures,operative, Postoperative complications, Acute kidney injury, Factor analysis,statistical

李坤,罗太君,王菲,贾红彦,张宗德,刘伟. 成人脊柱结核术后并发急性肾损伤的影响因素分析[J]. 中国防痨杂志, 2019, 41(8): 848-856. doi: 10.3969/j.issn.1000-6621.2019.08.009

Kun LI,Tai-jun LUO,Fei WANG,Hong-yan JIA,Zong-de ZHANG,Wei LIU. Risk factors of acute kidney injury after surgery in adult spinal tuberculosis[J]. Chinese Journal of Antituberculosis, 2019, 41(8): 848-856. doi: 10.3969/j.issn.1000-6621.2019.08.009

图/表 5

表1

术前部分临床观察指标在两组患者中的统计情况

临床观察指标	并发AKI组(31例)	对照组(62例)	统计值	P值
Scr(μmol/L, $x ˉ$ ±s)	62.21±13.17	56.13±11.61	t=2.274	0.025
eGFR [ml·min^-1·(1.73m²)^-1, $x ˉ$ ±s]	97.12±13.18	105.42±19.36	t=-3.355	0.001
BUN(mmol/L, $x ˉ$ ±s)	4.37±1.46	4.54±1.89	t=0.724	0.250
白蛋白(g/L, $x ˉ$ ±s)	34.77±4.18	34.80±5.25	t=-0.627	0.864
CRP[mg/L,M(Q₁,Q₃)]	15.4(6.4,30.3)	22.8(12.7,51.3)	U=699.000	0.175
抗结核药物治疗时间[d,M(Q₁,Q₃)]	21.0(0.0,60.0)	20.5(0.0,60.0)	U=948.500	0.917
手术时间(min, $x ˉ$ ±s)	164.83±52.33	172.48±60.02	t=-0.602	0.548
胶体量[ml,M(Q₁,Q₃)]	1000.0(1000.0,1000.0)	1000.0(1000.0,1000.0)	U=855.500	0.292
补液量[ml,M(Q₁,Q₃)]	2900.0(2000.0,3500.0)	2800.0(2375.0,3300.0)	U=935.500	0.834
失血量[ml,M(Q₁,Q₃)]	600.0(500.0,1000.0)	500.0(387.5,600.0)	U=628.000	0.006
输血量[ml,M(Q₁,Q₃)]	600.0(0.0,800.0)	200.0(0.0,400.0)	U=652.500	0.007
尿量 [ml,M(Q₁,Q₃)]	200.0(200.0,320.0)	200.0(137.0,362.0)	U=926.500	0.776
术后住院时间[d,M(Q₁,Q₃)]	14.0(10.0,16.0)	14.0(13.0,17.0)	U=844.000	0.334
补液量[ml,M(Q₁,Q₃)]	2900.0(2000.0,3500.0)	2800.0(2375.0,3300.0)	U=935.500	0.834

表1

表2

表3

表4

表5

影响术后发生AKI的多因素logistic回归分析

变量	β值	s $x ˉ$ 值	Wald χ²值	P值	OR(95%CI)值
常数项	-0.101	1.192	0.007	0.932	-
BMI>25	1.480	0.667	4.916	0.027	4.391(1.187~16.238)
并发高尿酸血症	1.774	0.845	4.412	0.036	5.896(1.126~30.874)
并发贫血	2.101	0.685	9.396	0.002	8.173(2.133~31.314)
eGFR≥90ml·min^-1·(1.73m²)^-1	-1.545	0.747	4.283	0.039	0.213(0.049~0.921)

表5

参考文献 29

[1]	兰汀隆, 秦世炳 . 严格掌握脊柱结核手术指征并选择合适的手术时机和方式. 中国防痨杂志, 2017,39(4):327-328.
[2]	Thakar CV . Perioperative acute kidney injury. Adv Chronic Kidney Dis, 2013,20(1):67-75.
[3]	American Society of Anesthesiologists. Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques: An Updated Report by the American Society of Anesthesiologists Task Force on Infectious Complications Associat. Anesthesio-logy, 2017,126(4):585-601.
[4]	National Collaborating Centre for Chronic Conditions (UK), Centre for Clinical Practice at NICE (UK). Tuberculosis: Clinical diagnosis and management of tuberculosis, and mea-sures for its prevention and control. London:National Institute for Health and Clinical Excellence(UK), 2011.
[5]	Khwaja A . KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract, 2012,120(4):c179-184.
[6]	张勇, 郭惠明, 叶智明 . 心脏外科手术后并发急性肾损伤276例回顾性分析. 岭南心血管病杂志, 2013,19(2):137-141.
[7]	Levey AS, Stevens LA, Schmid CH , et al. A new equation to estimate glomerular filtration rate. Ann Intern Med, 2009,150(9):604-612.
[8]	中国医师协会肾脏内科医师分会. 中国肾脏疾病高尿酸血症诊治的实践指南(2017版). 中华医学杂志, 2017,97(25):1927-1936.
[9]	DeLoughery TG . Iron Deficiency Anemia. The Med Clini North Am, 2017,101(2):319-332.
[10]	Grams ME, Sang Y, Coresh J , et al. Acute Kidney Injury after Major Surgery: A Retrospective Analysis of Veterans Health Administration Data. Am J Kidney Dis, 2016,67(6):872-880.
[11]	Uchino S, Bellomo R, Bagshaw SM , et al. Transient azotaemia is associated with a high risk of death in hospitalized patients. Nephrolo Dial Transplant, 2010,25(6):1833-1839.
[12]	Greenberg JH, Coca S, Parikh CR . Long-term risk of chronic kidney disease and mortality in children after acute kidney injury: a systematic review. BMC Nephrol, 2014,15:184.
[13]	Li S, Wang S, Priyanka P , et al. Acute Kidney Injury in Critically Ⅲ Patients After Noncardiac Major Surgery: Early Versus Late Onset. Crit Care Med, 2019,47(6):e437-444.
[14]	Ponte B, Felipe C, Muriel A , et al. Long-term functional evolution after an acute kidney injury: a 10-year study. Nephrolo Dial Transplant, 2008,23(12):3859-3866.
[15]	Coca SG, Yusuf B, Shlipak MG , et al. Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis, 2009,53(6):961-973.
[16]	Naik BI, Colquhoun DA, McKinney WE , et al. Incidence and risk factors for acute kidney injury after spine surgery using the RIFLE classification. J Neurosurg Spine, 2014,20(5):505-511.
[17]	Chaudery H, MacDonald N, Ahmad T , et al. Acute Kidney Injury and Risk of Death After Elective Surgery: Prospective Analysis of Data From an International Cohort Study. Anesth Analg, 2019,128(5):1022-1029.
[18]	Haanschoten MC, van Straten AH, Bouwman A , et al. Impact of postoperative renal replacement therapy on long-term outcome after cardiac surgery increases with age. J Card Surg, 2014,29(4):464-469.
[19]	Ejaz AA, Dass B, Lingegowda V , et al. Effect of uric acid lowering therapy on the prevention of acute kidney injury in cardiovascular surgery. Int Urol Nephrol, 2013,45(2):449-458.
[20]	Cho W, Hwang TY, Choi YK , et al. Diastolic dysfunction and acute kidney injury in elderly patients with femoral neck fracture. Kidney Res Clin Pract, 2019,38(1):33-41.
[21]	Kang DH, Park SK, Lee IK , et al. Uric acid-induced C-reactive protein expression: implication on cell proliferation and nitric oxide production of human vascular cells. J Am Soc Nephrol, 2005,16(12):3553-3562.
[22]	Shimada M, Dass B, Ejaz AA . Paradigm shift in the role of uric acid in acute kidney injury. Semin Nephrol, 2011,31(5):453-458.
[23]	Kaufeld T, Foerster KA , Schilling,et al.Preoperative serum uric acid predicts incident acute kidney injury following cardiac surgery. BMC Nephrol, 2018,19(1):161.
[24]	Candela-Toha Á, Pardo MC, Pérez T , et al. Estimated glomeru-lar filtration rate is an early biomarker of cardiac surgery-associated acute kidney injury. Nefrologia, 2018,38(6):596-605.
[25]	Hsu CY, Ordoñez JD, Chertow GM , et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int, 2008,74(1):101-107.
[26]	Nagu TJ, Spiegelman D, Hertzmark E , et al. Anemia at the initiation of tuberculosis therapy is associated with delayed sputum conversion among pulmonary tuberculosis patients in Dar-es-Salaam, Tanzania. PLoS One, 2014,9(3):e91229.
[27]	Gil-Santana L, Cruz LAB, Arriaga MB , et al. Tuberculosis-associated anemia is linked to a distinct inflammatory profile that persists after initiation of antitubercular therapy. Sci Rep, 2019,9(1):1381.
[28]	Karkouti K, Wijeysundera DN, Yau TM , et al. Influence of erythrocyte transfusion on the risk of acute kidney injury after cardiac surgery differs in anemic and nonanemic patients. Anesthesiology, 2011,115(3):523-530.
[29]	Iyigun M, Aykut G, Tosun M , et al. Perioperative risk factors of acute kidney injury after non-cardiac surgery: A multicenter,prospective, observational study in patients with low grade American Society of Anesthesiologists physical status. Am J Surg, 2019.pii: S0002-9610(18)31643-X.

临床观察指标(变量)	并发AKI组(31例)		对照组(62例)		χ²值		P值
年龄(岁)					4.216		0.040
<60	11(35.48)		36(58.06)
≥60	20(64.52)		26(41.94)
性别					0.195		0.658
男	15(48.39)		27(43.55)
女	16(51.61)		35(56.45)
BMI					6.486		0.011
<18	0(0.00)		0(0.00)
18~	13(41.94)		43(69.35)
>25	18(58.06)		19(30.65)
既往史^a
高血压	17(54.84)		18(29.03)		5.864		0.015
糖尿病	7(22.58)		6(9.68)		1.889		0.169
心脏病	8(25.81)		13(20.97)		0.277		0.796
吸烟史	10(32.26)		27(43.55)		1.100		0.294
COPD	3(9.68)		5(8.06)		0.001		1.000
抗结核药物治疗时间(d)					0.087		0.769
<21	16(51.61)		34(54.84)
≥21	15(48.39)		28(45.16)
临床观察指标(变量)		并发AKI组(31例)		对照组(62例)		χ²值	P值
Scr(μmol/L)						0.087	0.769
<56		15(48.39)		28(45.16)
≥56		16(51.61)		34(54.84)
eGFR[ml·min^-1·(1.73m²)^-1]						4.960	0.026
<90		10(32.26)		8(12.90)
≥90		21(67.74)		54(87.10)
BUN(mmol)						0.351	0.551
<4.5		19(61.29)		34(54.84)
≥4.5		12(38.71)		28(45.16)
白蛋白(g/L)						0.087	0.768
≤35		13(41.94)		28(45.16)
>35		18(58.06)		34(54.84)
CRP(mg/L)						2.225	0.136
<15		16(51.61)		22(35.48)
≥15		15(48.39)		40(64.52)
高尿酸血症						4.043	0.044
有		27(87.10)		42(67.74)
无		4(12.90)		20(32.26)
贫血						12.126	0.001
有		17(54.84)		12(19.35)
无		14(45.16)		50(80.65)

临床观察指标(变量)	并发AKI组(31例)		对照组(62例)	χ²值	P值
ASA分级				1.902	0.168
Ⅱ	17(54.84)		43(69.35)
Ⅲ	14(45.16)		19(30.65)
麻醉方式				0.605	0.437
静脉滴注	19(61.29)		43(69.35)
静脉滴注+吸入	12(38.71)		19(30.65)
高血压^a	15(48.39)		18(29.03)	3.384	0.066
低血压^a	21(67.74)		38(61.29)	0.373	0.543
临床观察指标(变量)		并发AKI组(31例)	对照组(62例)	χ²值	P值
术中用药^b
糖皮质激素		11(35.48)	28(45.16)	0.795	0.373
乌司他丁		8(25.81)	21(33.87)	0.626	0.429
磷酸肌酸		10(32.26)	14(22.58)	1.011	0.315
氨甲环酸		10(32.26)	31(50.00)	2.639	0.104
非甾体类抗炎药		8(25.81)	22(35.48)	0.886	0.347
右美托咪定		13(41.94)	40(64.52)	4.299	0.038
手术时间(min)				0.086	0.769
<160		17(54.84)	32(51.61)
≥160		14(45.16)	30(48.39)
胶体量(ml)				3.219	0.073
<1000		29(93.55)	49(79.03)
≥1000		2(6.45)	13(20.97)
补液量(ml)				0.086	0.769
<2900		14(45.16)	30(48.39)
≥2900		17(54.84)	32(51.61)
失血量(ml)				7.034	0.008
<600		11(35.48)	40(64.52)
≥600		20(64.52)	22(35.48)
输血量(ml)				3.635	0.057
<400		11(35.48)	35(56.45)
≥400		20(64.52)	27(43.55)
尿量(ml)				0.022	0.883
<200		17(54.84)	35(56.45)
≥200		14(45.16)	27(43.55)
术后肺部感染				0.079	0.779
有		8(25.80)	12(19.35)
无		23(74.20)	50(80.65)
术后住院时间(d)				0.092	0.762
<14		11(35.48)	24(38.71)
≥14		20(64.52)	38(61.29)
治疗转归				0.486	0.215
死亡		1(3.23)	0(0.00)
存活		30(96.77)	62(100.00)

变量	赋值	变量	赋值
X₁年龄(岁)	1=≥60;2=<60	X₁₇麻醉方式	1=静脉滴注;2=静脉滴注+吸入
X₂性别	1=男;2=女	X₁₈低血压	1=有;2=无
X₃ BMI	1=>25;2=18~25	X₁₉高血压	1=有;2=无
X₄术前高血压	1=有;2=否	X₂₀激素用药	1=使用;2=未使用
X₅术前糖尿病	1=有;2=否	X₂₁乌司他丁	1=使用;2=未使用
X₆术前心脏病	1=有;2=否	X₂₂磷酸肌酸	1=使用;2=未使用
X₇术前吸烟史	1=有;2=无	X₂₃氨甲环酸	1=使用;2=未使用
X₈抗结核药物治疗时间(d)	1=≥21;2=<21	X₂₄右美托咪定	1=使用;2=未使用
X₉血肌酐(μmol/L)	1=≥56;2=<56	X₂₅非甾体类抗炎药	1=使用;2=未使用
X₁₀ eGFR[ml·min^-1·(1.73m²)^-1]	1=<90;2=≥90	X₂₆失血量(ml)	1=≥600;2=<600
X₁₁高尿酸血症	1=有;2=否	X₂₇输血量(ml)	1=≥400;2=<400
X₁₂贫血	1=有;2=否	X₂₈尿量(ml)	1=<200;2=≥200
X₁₃尿素氮(mmol/L)	1=≥4.5;2=<4.5	X₂₉术后肺部感染	1=有;2=无
X₁₄白蛋白(g/L)	1=≤35;2=>35	X₃₀术后住院天数(d)	1=≥14;2=<14
X₁₅ CRP(mg/L)	1=>15;2=0~15	X₃₁死亡例数	1=有;2=无
X₁₆ ASA分级	1=Ⅱ级;2=Ⅲ级	Y急性肾损伤	1=发生;2=未发生