术前风险及低血压与术后急性肾损伤的关系
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Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury
背景与目的
尽管急性肾损伤对医疗结局有重大影响，但人们对预防知之甚少。单中心数据表明低血压与术后急性肾损伤的发生有关。这一发现的概括性以及低血压和基线患者疾病负担之间的相互作用仍不清楚。作者试图确定术中低血压和急性肾损伤之间的联系是否随术前风险的不同而不同。
方 法
本研究回顾了2008至2015年在8家医院行非心脏外科手术的成年患者。采用推导和验证队列，并根据合并症和手术方式将病例分层为术前风险四分位数。将术前风险进行分层后，分析术中低血压与急性肾损伤的关系。低血压定义为平均动脉压达到最低范围超过10分钟；范围定义为绝对范围(MmHg)或相对范围(较基线下降的百分比)。
结 果
在138 021例患者中，12 431例（9.0%）发生术后急性肾损伤。主要危险因素包括贫血、估计的肾小球滤过率、手术类型、ASA分级和预期的麻醉时间。利用这些因素和其他因素进行风险分层，基线风险较低的患者显示术中低血压与急性肾损伤之间没有相关性。中等风险患者显示术中严重低血压（平均动脉压小于50 mmHg）与急性肾损伤之间存在相关性（校正比值比，2.62；95%CI，1.65-4.16）。在高风险患者中，轻度低血压范围（平均动脉压位于55-59 mmHg之间）与急性肾损伤相关（校正比值比，1.34；95%CI，1.16-1.56）。与绝对低血压相比，相对低血压与急性肾损伤的相关性较弱，在验证队列中不能复制。
结 论
根据术前危险因素分层，接受非心脏手术的成人患者与不同程度的低血压有不同的相关性。特定水平的绝对低血压，而不是相对低血压，是急性肾损伤的一个重要的独立危险因素。
原始文献摘要
Mathis MR, Naik BI, Freundlich RE, et al. Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury[J]. Anesthesiology, 2019, undefined: undefined.
Background: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk.
Methods: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline).
Results: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort.
Conclusions: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.
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贵州医科大学高鸿教授课题组
翻译：何幼芹 编辑：冯玉蓉 审校：王贵龙