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Article(id=1202979639888142915, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1202979639087030850, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.1440.2023.0131, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1656345600000, receivedDateStr=2022-06-28, revisedDate=null, revisedDateStr=null, acceptedDate=1663603200000, acceptedDateStr=2022-09-20, onlineDate=1764742296430, onlineDateStr=2025-12-03, pubDate=1690473600000, pubDateStr=2023-07-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1764742296430, onlineIssueDateStr=2025-12-03, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1764742296430, creator=13701087609, updateTime=1764742296430, updator=13701087609, issue=Issue{id=1202979639087030850, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='7', pageStart='749', pageEnd='870', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1764742296239, creator=13701087609, updateTime=1764742346610, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1202979850442203282, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1202979639087030850, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1202979850442203283, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1202979639087030850, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=802, endPage=808, ext={EN=ArticleExt(id=1202979640131412552, articleId=1202979639888142915, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Data platform-based analysis of risk factors for acute renal injury after non-cardiac surgery under general anesthesia, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To analyze the possible risk factors for postoperative acute kidney injury (AKI) in patients undergoing non-cardiac surgery under general anesthesia. Methods Based on anesthesia and perioperative medical specialty data platform, the clinical data were retrospectively collected of patients with general anesthesia grade Ⅲ-Ⅳ non-cardiac surgery who were admitted to the Guangdong Second Provincial General Hospital from January 2019 to May 2021. According to the AKI diagnostic criteria of Kidney Disease: Improving Global Outcomes (KDIGO), 205 patients with relatively complete data were screened and set as postoperative AKI group, and 251 patients without postoperative AKI were set as non-postoperative AKI group.Univariate and multivariate logistic regression analysis were performed to identify the risk factors of postoperative AKI. Results Compared with non-postoperative AKI group, patients in postoperative AKI group had lower preoperative erythrocytes, hemoglobin, albumin and initial mean arterial pressure (P<0.05). Preoperative creatinine, D-dimer, C-reactive protein (CRP), fibrinogen, total intraoperative output and American Society of Anesthesiologists (ASA) physical status classification were higher (P<0.05).Multivariate logistic regression analysis showed that preoperative hemoglobin, initial mean arterial pressure and preoperative creatinine level were independent risk factors for postoperative AKI (OR=0.958, 0.976 and 1.021 respectively, P<0.05). Conclusion The occurrence of postoperative AKI in patients undergoing non-cardiac surgery of grade III-IV under general anesthesia is related to preoperative hemoglobin level, preoperative creatinine level and initial mean arterial pressure, which is worth further big data research.

, correspAuthors=Hui Zhang, authorNote=null, correspAuthorsNote=
* E-mail:
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目的 分析全麻非心脏手术患者术后发生急性肾损伤(AKI)的危险因素。方法 基于麻醉与围手术期医学专科数据平台，回顾性收集2019年1月－2021年5月广东省第二人民医院收治的全麻Ⅲ－Ⅳ级非心脏手术患者的临床资料。根据改善全球肾脏病预后组织(KDIGO)的AKI诊断标准，筛选出数据相对完整的205例术后发生AKI(设为术后AKI组)和251例术后无AKI患者(设为术后无AKI组)，采用单因素及多因素logistic回归分析术后AKI的危险因素。结果 与术后无AKI组比较，术后AKI组术前红细胞计数，血红蛋白、白蛋白水平，以及初始平均动脉压较低(P<0.05)；术前肌酐、D-二聚体、C反应蛋白(CRP)、纤维蛋白原水平，术中总出量，以及美国麻醉医师协会(ASA)分级Ⅲ－Ⅳ级比例较高(P<0.05)。多因素logistic回归分析显示，术前血红蛋白水平、初始平均动脉压及术前肌酐水平是术后AKI的独立危险因素(OR=0.958、0.976、1.021，P<0.05)。结论 全麻非心脏Ⅲ－Ⅳ级手术患者术后AKI的发生与术前血红蛋白水平、术前肌酐水平及初始平均动脉压有关，值得进一步大数据研究。

, correspAuthors=张辉, authorNote=null, correspAuthorsNote=
张辉，E-mail：
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郭耸，硕士研究生，主要从事麻醉与围手术期器官功能保护方面的研究

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郭耸，硕士研究生，主要从事麻醉与围手术期器官功能保护方面的研究

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郭耸，硕士研究生，主要从事麻醉与围手术期器官功能保护方面的研究

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Anesthesiology, 2020, 132(3): 461-475., articleTitle=Preoperative risk and the association between hypotension and postoperative acute kidney injury, refAbstract=null), Reference(id=1203005083723194486, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, doi=null, pmid=null, pmcid=null, year=2017, volume=126, issue=1, pageStart=47, pageEnd=65, url=null, language=null, rfNumber=[14], rfOrder=15, authorNames=Salmasi V, Maheshwari K, Yang D, journalName=Anesthesiology, refType=null, unstructuredReference=Salmasi V, Maheshwari K, Yang D, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: a retrospective cohort analysis[J]. 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Anesthesiology, 2020, 132(1): 180-204., articleTitle=Perioperative acute kidney injury, refAbstract=null), Reference(id=1203005084104876172, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, doi=null, pmid=null, pmcid=null, year=2021, volume=75, issue=11, pageStart=e14570, pageEnd=null, url=null, language=null, rfNumber=[18], rfOrder=19, authorNames=Tu MY, Hong S, Lu J, journalName=Int J Clin Pract, refType=null, unstructuredReference=Tu MY, Hong S, Lu J, et al. Effect of strict intraoperative blood pressure management strategy on postoperative acute kidney injury in non-cardiac surgery: a meta-analysis of randomised controlled trials[J]. 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Br J Surg, 2015, 102(11): 1314-1324., articleTitle=Meta-analysis of the association between preoperative anaemia and mortality after surgery, refAbstract=null)], funds=[Fund(id=1203005081751872504, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, awardId=2020B0101130019, language=EN, fundingSource=Guangdong Provincial Key Research and Development Program(2020B0101130019), fundOrder=null, country=null), Fund(id=1203005081860924416, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, awardId=2020B0101130019, language=CN, fundingSource=广东省重点领域研发计划(2020B0101130019), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1203005078518063902, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, xref=null, ext=[AuthorCompanyExt(id=1203005078522258206, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, companyId=1203005078518063902, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Department of Anesthesiology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong 510317, China), AuthorCompanyExt(id=1203005078539035424, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, companyId=1203005078518063902, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=广东省第二人民医院麻醉科，广东广州 510317)])], figs=[ArticleFig(id=1203005080933983176, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, language=EN, label=Tab. 1, caption=

Comparison of preoperative clinical data between the two groups of non-cardiac surgery patients

, figureFileSmall=null, figureFileBig=null, tableContent=
指标术后无AKI组(n=251)术后AKI组(n=205)t/χ²/UP
年龄(岁，$\bar{x}±s$)55.8±14.456.4±13.60.0000.983
性别[例(%)]  3.6300.057
 男152(60.56)105(51.22)
 女99(39.44)100(48.78)
BMI(kg/m2, $\bar{x}±s$)23.04±3.7423.12±3.860.2650.607
合并症[例(%)]
 高血压12(4.78)16(7.81)1.3040.253
 糖尿病7(2.79)5(2.44)0.0040.951
ASA分级[例(%)]  11.3090.023
 Ⅰ级22(8.76)10(4.88)
 Ⅱ级199(79.28)150(73.17)
 Ⅲ级28(11.16)42(20.49)
 Ⅳ级2(0.80)3(1.46)
NYHA心功能分级[例(%)]  7.3480.062
 Ⅰ级192(76.49)138(67.32)
 Ⅱ级57(22.71)60(29.27)
 Ⅲ级2(0.80)6(2.92)
 Ⅳ级01(0.49)
手术等级[例(%)]  0.1710.918
 Ⅲ级81(32.27)65(31.71)
 Ⅳ级170(67.73)140(68.29)
红细胞计数(×1012/L, $\bar{x}±s$)4.73±0.604.25±0.7146.999<0.001
血小板计数(×109/L, $\bar{x}±s$)256.47±73.25271.34±103.150.9640.326
白细胞计数(×109/L, $\bar{x}±s$)7.39±2.617.17±2.701.5380.215
血红蛋白(g/L, $\bar{x}±s$)138.31±12.51122.01±22.7360.925<0.001
白蛋白(g/L, $\bar{x}±s$)40.66±4.8438.23±5.8715.686<0.001
肌酐(μmol/L, $\bar{x}±s$)83.05±26.69103.94±90.928.4840.004
D-二聚体(μg/L, $\bar{x}±s$)0.58±0.821.18±2.0622.899<0.001
CRP(mg/L, $\bar{x}±s$)7.96±13.5914.85±23.3318.704<0.001
纤维蛋白原(g/L, $\bar{x}±s$)3.68±1.114.01±1.336.8960.009
血清钠(mmol/L, $\bar{x}±s$)3.93±0.413.86±0.432.7170.099
血清钾(mmol/L, $\bar{x}±s$)141.16±2.54140.67±3.740.2840.594
), ArticleFig(id=1203005081030452174, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, language=CN, label=表1, caption=

两组非心脏手术患者术前临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标术后无AKI组(n=251)术后AKI组(n=205)t/χ²/UP
年龄(岁，$\bar{x}±s$)55.8±14.456.4±13.60.0000.983
性别[例(%)]  3.6300.057
 男152(60.56)105(51.22)
 女99(39.44)100(48.78)
BMI(kg/m2, $\bar{x}±s$)23.04±3.7423.12±3.860.2650.607
合并症[例(%)]
 高血压12(4.78)16(7.81)1.3040.253
 糖尿病7(2.79)5(2.44)0.0040.951
ASA分级[例(%)]  11.3090.023
 Ⅰ级22(8.76)10(4.88)
 Ⅱ级199(79.28)150(73.17)
 Ⅲ级28(11.16)42(20.49)
 Ⅳ级2(0.80)3(1.46)
NYHA心功能分级[例(%)]  7.3480.062
 Ⅰ级192(76.49)138(67.32)
 Ⅱ级57(22.71)60(29.27)
 Ⅲ级2(0.80)6(2.92)
 Ⅳ级01(0.49)
手术等级[例(%)]  0.1710.918
 Ⅲ级81(32.27)65(31.71)
 Ⅳ级170(67.73)140(68.29)
红细胞计数(×1012/L, $\bar{x}±s$)4.73±0.604.25±0.7146.999<0.001
血小板计数(×109/L, $\bar{x}±s$)256.47±73.25271.34±103.150.9640.326
白细胞计数(×109/L, $\bar{x}±s$)7.39±2.617.17±2.701.5380.215
血红蛋白(g/L, $\bar{x}±s$)138.31±12.51122.01±22.7360.925<0.001
白蛋白(g/L, $\bar{x}±s$)40.66±4.8438.23±5.8715.686<0.001
肌酐(μmol/L, $\bar{x}±s$)83.05±26.69103.94±90.928.4840.004
D-二聚体(μg/L, $\bar{x}±s$)0.58±0.821.18±2.0622.899<0.001
CRP(mg/L, $\bar{x}±s$)7.96±13.5914.85±23.3318.704<0.001
纤维蛋白原(g/L, $\bar{x}±s$)3.68±1.114.01±1.336.8960.009
血清钠(mmol/L, $\bar{x}±s$)3.93±0.413.86±0.432.7170.099
血清钾(mmol/L, $\bar{x}±s$)141.16±2.54140.67±3.740.2840.594
), ArticleFig(id=1203005081101755348, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, language=EN, label=Tab. 2, caption=

Comparison of intraoperative and postoperative clinical data between the two groups of non-cardiac surgery patients

, figureFileSmall=null, figureFileBig=null, tableContent=
指标术后无AKI组(n=251)术后AKI组(n=205)t/χ²/UP
手术时间(min, $\bar{x}±s$)225.28±98.50245.48±108.553.0630.080
麻醉时间(min, $\bar{x}±s$)274.35±106.17295.02±117.832.6020.107
手术种类[例(%)]
 开放性盆腹腔手术39(15.54)36(17.56)0.3360.562
 经腔镜盆腹腔手术90(35.86)89(43.41)2.7030.100
 甲乳外科手术24(9.56)18(8.78)0.0820.774
 神经外科手术23(9.16)14(6.83)0.8250.364
 矫形外科手术35(13.94)19(9.27)2.3630.124
 胸科手术40(15.94)29(14.15)0.2820.596
术中用药
 舒芬太尼(μg, $\bar{x}±s$)18.60±5.0318.63±6.260.0420.838
 顺阿曲库铵(mg, $\bar{x}±s$)12.41±2.7511.95±3.213.0820.079
 去甲肾上腺素[例(%)]11(4.38)12(5.85)0.2490.618
 肾上腺素[例(%)]02(0.98)0.7330.392
 麻黄碱[例(%)]76(30.28)62(30.24)0.0090.925
 多巴胺[例(%)]19(7.57)21(10.24)0.7020.402
 间羟胺[例(%)]5(1.99)7(3.41)0.4230.516
 尼卡地平[例(%)]16(6.37)15(7.32)0.0440.833
 帕瑞昔布钠[例(%)]35(13.94)24(11.71)0.3220.570
 氟比洛芬酯[例(%)]43(17.13)31(15.12)0.2040.625
 酮咯酸氨丁三醇[例(%)]91(36.25)76(37.07)0.0070.934
初始平均动脉压(mmHg, $\bar{x}±s$)78.77±9.5676.74±10.115.6520.017
心率(次/min, $\bar{x}±s$)71.78±9.7873.71±12.720.4600.497
术中低血压[例(%)]8(3.19)9(4.39)0.1820.670
晶体量(ml, $\bar{x}±s$)1627.15±655.621723.59±714.951.6440.200
胶体量(ml, $\bar{x}±s$)346.41±337.53421.95±416.842.8740.090
出血量(ml, $\bar{x}±s$)157.26±243.50193.97±350.120.2760.599
尿量(ml, $\bar{x}±s$)492.26±308.06542.96±413.750.2520.615
总出量(ml, $\bar{x}±s$)569.11±472.22696.45±594.655.7400.017
住院时间(d, $\bar{x}±s$)12.44±9.3012.74±10.380.3600.549
住院费用(万元，$\bar{x}±s$)6.70±3.638.04±7.320.4450.505
), ArticleFig(id=1203005081227584478, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, language=CN, label=表2, caption=

两组非心脏手术患者术中及术后临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标术后无AKI组(n=251)术后AKI组(n=205)t/χ²/UP
手术时间(min, $\bar{x}±s$)225.28±98.50245.48±108.553.0630.080
麻醉时间(min, $\bar{x}±s$)274.35±106.17295.02±117.832.6020.107
手术种类[例(%)]
 开放性盆腹腔手术39(15.54)36(17.56)0.3360.562
 经腔镜盆腹腔手术90(35.86)89(43.41)2.7030.100
 甲乳外科手术24(9.56)18(8.78)0.0820.774
 神经外科手术23(9.16)14(6.83)0.8250.364
 矫形外科手术35(13.94)19(9.27)2.3630.124
 胸科手术40(15.94)29(14.15)0.2820.596
术中用药
 舒芬太尼(μg, $\bar{x}±s$)18.60±5.0318.63±6.260.0420.838
 顺阿曲库铵(mg, $\bar{x}±s$)12.41±2.7511.95±3.213.0820.079
 去甲肾上腺素[例(%)]11(4.38)12(5.85)0.2490.618
 肾上腺素[例(%)]02(0.98)0.7330.392
 麻黄碱[例(%)]76(30.28)62(30.24)0.0090.925
 多巴胺[例(%)]19(7.57)21(10.24)0.7020.402
 间羟胺[例(%)]5(1.99)7(3.41)0.4230.516
 尼卡地平[例(%)]16(6.37)15(7.32)0.0440.833
 帕瑞昔布钠[例(%)]35(13.94)24(11.71)0.3220.570
 氟比洛芬酯[例(%)]43(17.13)31(15.12)0.2040.625
 酮咯酸氨丁三醇[例(%)]91(36.25)76(37.07)0.0070.934
初始平均动脉压(mmHg, $\bar{x}±s$)78.77±9.5676.74±10.115.6520.017
心率(次/min, $\bar{x}±s$)71.78±9.7873.71±12.720.4600.497
术中低血压[例(%)]8(3.19)9(4.39)0.1820.670
晶体量(ml, $\bar{x}±s$)1627.15±655.621723.59±714.951.6440.200
胶体量(ml, $\bar{x}±s$)346.41±337.53421.95±416.842.8740.090
出血量(ml, $\bar{x}±s$)157.26±243.50193.97±350.120.2760.599
尿量(ml, $\bar{x}±s$)492.26±308.06542.96±413.750.2520.615
总出量(ml, $\bar{x}±s$)569.11±472.22696.45±594.655.7400.017
住院时间(d, $\bar{x}±s$)12.44±9.3012.74±10.380.3600.549
住院费用(万元，$\bar{x}±s$)6.70±3.638.04±7.320.4450.505
), ArticleFig(id=1203005081370190824, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, language=EN, label=Tab. 3, caption=

Analysis of the risk factors for postoperative AKI in non-cardiac surgery patients

, figureFileSmall=null, figureFileBig=null, tableContent=
因素单因素分析多因素分析
OR(95%CI)POR(95%CI)P
年龄1.003(0.990～1.017)0.606
性别0.684(0.471～0.993)0.0460.751(0.424～1.328)0.324
BMI1.006(0.958～1.056)0.818
合并症
 高血压1.686(0.779～3.650)0.185
 糖尿病0.871(0.272～2.787)0.817
ASA分级  1.306(0.759～2.246)0.335
 Ⅰ级10.021
 Ⅱ级1.658(0.762～3.607)0.202
 Ⅲ级3.379(1.393～8.196)0.007
 Ⅳ级2.200(0.270～17.924)0.461
NYHA心功能分级
 Ⅰ级10.562
 Ⅱ级1.250(0.828～1.887)0.288
 Ⅲ－Ⅳ级1.996(0.553～7.213)0.292
术前红细胞计数0.289(0.202～0.414)0.0000.754(0.478～1.190)0.225
术前血小板计数1.002(1.000～1.004)0.075
术前白细胞计数0.968(0.902～1.039)0.363
术前血红蛋白0.947(0.934～0.960)0.0000.958(0.939～0.977)0.000
术前白蛋白0.918(0.886～0.952)0.0001.028(0.974～1.084)0.318
术前D-二聚体1.520(1.227～1.882)0.0001.133(0.934～1.374)0.205
术前CRP1.023(1.010～1.037)0.0001.010(0.993～1.027)0.251
术前肌酐1.009(1.003～1.015)0.0031.021(1.011～1.032)0.000
术前纤维蛋白原1.250(1.071～1.459)0.0050.991(0.801～1.226)0.935
术前血清钠0.950(0.894～1.009)0.097
术前血清钾0.647(0.413～1.013)0.057
手术时间1.002(1.000～1.004)0.0491.001(0.999～1.003)0.572
麻醉时间1.002(1.000～1.003)0.051
手术种类
 经腔镜盆腹腔手术1.373(0.941～2.003)0.101
 开放性盆腹腔手术1.158(0.705～1.902)0.562
 甲乳外科手术0.910(0.480～1.728)0.774
 矫形外科手术0.630(0.349～1.139)0.127
 神经外科手术0.727(0.364～1.451)0.365
 胸科手术0.869(0.518～1.459)0.596
术中用药
 舒芬太尼1.001(0.968～1.034)0.962
 顺阿曲库铵0.948(0.891～1.010)0.098
 去甲肾上腺素1.357(0.586～3.142)0.477
 麻黄碱0.998(0.668～1.492)0.994
 多巴胺1.394(0.727～2.670)0.317
 间羟胺1.739(0.544～5.564)0.351
 尼卡地平1.160(0.559～2.406)0.691
 帕瑞昔布钠0.818(0.469～1.426)0.479
 氟比洛芬酯0.862(0.521～1.426)0.563
 酮咯酸氨丁三醇1.036(0.706～1.519)0.857
初始平均动脉压0.979(0.960～0.998)0.0290.976(0.953～0.999)0.043
心率1.015(0.999～1.032)0.070
术中低血压1.395(0.528～3.682)0.502
晶体量1.000(1.000～1.001)0.161
胶体量1.001(1.000～1.001)0.0341.000(1.000～1.001)0.191
出血量1.000(1.000～1.001)0.196
尿量1.000(1.000～1.001)0.137
术中总出量1.000(1.000～1.003)0.0131.000(1.000～1.001)0.055
), ArticleFig(id=1203005081542157292, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1202979639888142915, language=CN, label=表3, caption=

非心脏手术患者术后AKI的危险因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
因素单因素分析多因素分析
OR(95%CI)POR(95%CI)P
年龄1.003(0.990～1.017)0.606
性别0.684(0.471～0.993)0.0460.751(0.424～1.328)0.324
BMI1.006(0.958～1.056)0.818
合并症
 高血压1.686(0.779～3.650)0.185
 糖尿病0.871(0.272～2.787)0.817
ASA分级  1.306(0.759～2.246)0.335
 Ⅰ级10.021
 Ⅱ级1.658(0.762～3.607)0.202
 Ⅲ级3.379(1.393～8.196)0.007
 Ⅳ级2.200(0.270～17.924)0.461
NYHA心功能分级
 Ⅰ级10.562
 Ⅱ级1.250(0.828～1.887)0.288
 Ⅲ－Ⅳ级1.996(0.553～7.213)0.292
术前红细胞计数0.289(0.202～0.414)0.0000.754(0.478～1.190)0.225
术前血小板计数1.002(1.000～1.004)0.075
术前白细胞计数0.968(0.902～1.039)0.363
术前血红蛋白0.947(0.934～0.960)0.0000.958(0.939～0.977)0.000
术前白蛋白0.918(0.886～0.952)0.0001.028(0.974～1.084)0.318
术前D-二聚体1.520(1.227～1.882)0.0001.133(0.934～1.374)0.205
术前CRP1.023(1.010～1.037)0.0001.010(0.993～1.027)0.251
术前肌酐1.009(1.003～1.015)0.0031.021(1.011～1.032)0.000
术前纤维蛋白原1.250(1.071～1.459)0.0050.991(0.801～1.226)0.935
术前血清钠0.950(0.894～1.009)0.097
术前血清钾0.647(0.413～1.013)0.057
手术时间1.002(1.000～1.004)0.0491.001(0.999～1.003)0.572
麻醉时间1.002(1.000～1.003)0.051
手术种类
 经腔镜盆腹腔手术1.373(0.941～2.003)0.101
 开放性盆腹腔手术1.158(0.705～1.902)0.562
 甲乳外科手术0.910(0.480～1.728)0.774
 矫形外科手术0.630(0.349～1.139)0.127
 神经外科手术0.727(0.364～1.451)0.365
 胸科手术0.869(0.518～1.459)0.596
术中用药
 舒芬太尼1.001(0.968～1.034)0.962
 顺阿曲库铵0.948(0.891～1.010)0.098
 去甲肾上腺素1.357(0.586～3.142)0.477
 麻黄碱0.998(0.668～1.492)0.994
 多巴胺1.394(0.727～2.670)0.317
 间羟胺1.739(0.544～5.564)0.351
 尼卡地平1.160(0.559～2.406)0.691
 帕瑞昔布钠0.818(0.469～1.426)0.479
 氟比洛芬酯0.862(0.521～1.426)0.563
 酮咯酸氨丁三醇1.036(0.706～1.519)0.857
初始平均动脉压0.979(0.960～0.998)0.0290.976(0.953～0.999)0.043
心率1.015(0.999～1.032)0.070
术中低血压1.395(0.528～3.682)0.502
晶体量1.000(1.000～1.001)0.161
胶体量1.001(1.000～1.001)0.0341.000(1.000～1.001)0.191
出血量1.000(1.000～1.001)0.196
尿量1.000(1.000～1.001)0.137
术中总出量1.000(1.000～1.003)0.0131.000(1.000～1.001)0.055
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基于数据平台的全麻非心脏手术患者术后急性肾损伤危险因素分析
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郭耸 , 蔺祎 , 刘冰冰 , 王益敏 , 张辉 *
解放军医学杂志 | 临床研究 2023,48(7): 802-808
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解放军医学杂志 | 临床研究 2023, 48(7): 802-808
基于数据平台的全麻非心脏手术患者术后急性肾损伤危险因素分析
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郭耸, 蔺祎, 刘冰冰, 王益敏, 张辉*
作者信息
  • 广东省第二人民医院麻醉科，广东广州 510317

    • 郭耸，硕士研究生，主要从事麻醉与围手术期器官功能保护方面的研究

通讯作者:

张辉，E-mail：
Data platform-based analysis of risk factors for acute renal injury after non-cardiac surgery under general anesthesia
Song Guo, Yi Lin, Bing-Bing Liu, Yi-Min Wang, Hui Zhang*
Affiliations
  • Department of Anesthesiology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong 510317, China
出版时间: 2023-07-28 doi: 10.11855/j.issn.0577-7402.1440.2023.0131
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摘要
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目的 分析全麻非心脏手术患者术后发生急性肾损伤(AKI)的危险因素。方法 基于麻醉与围手术期医学专科数据平台，回顾性收集2019年1月－2021年5月广东省第二人民医院收治的全麻Ⅲ－Ⅳ级非心脏手术患者的临床资料。根据改善全球肾脏病预后组织(KDIGO)的AKI诊断标准，筛选出数据相对完整的205例术后发生AKI(设为术后AKI组)和251例术后无AKI患者(设为术后无AKI组)，采用单因素及多因素logistic回归分析术后AKI的危险因素。结果 与术后无AKI组比较，术后AKI组术前红细胞计数，血红蛋白、白蛋白水平，以及初始平均动脉压较低(P<0.05)；术前肌酐、D-二聚体、C反应蛋白(CRP)、纤维蛋白原水平，术中总出量，以及美国麻醉医师协会(ASA)分级Ⅲ－Ⅳ级比例较高(P<0.05)。多因素logistic回归分析显示，术前血红蛋白水平、初始平均动脉压及术前肌酐水平是术后AKI的独立危险因素(OR=0.958、0.976、1.021，P<0.05)。结论 全麻非心脏Ⅲ－Ⅳ级手术患者术后AKI的发生与术前血红蛋白水平、术前肌酐水平及初始平均动脉压有关，值得进一步大数据研究。

数据平台  /  非心脏手术  /  急性肾损伤  /  危险因素

Objective To analyze the possible risk factors for postoperative acute kidney injury (AKI) in patients undergoing non-cardiac surgery under general anesthesia. Methods Based on anesthesia and perioperative medical specialty data platform, the clinical data were retrospectively collected of patients with general anesthesia grade Ⅲ-Ⅳ non-cardiac surgery who were admitted to the Guangdong Second Provincial General Hospital from January 2019 to May 2021. According to the AKI diagnostic criteria of Kidney Disease: Improving Global Outcomes (KDIGO), 205 patients with relatively complete data were screened and set as postoperative AKI group, and 251 patients without postoperative AKI were set as non-postoperative AKI group.Univariate and multivariate logistic regression analysis were performed to identify the risk factors of postoperative AKI. Results Compared with non-postoperative AKI group, patients in postoperative AKI group had lower preoperative erythrocytes, hemoglobin, albumin and initial mean arterial pressure (P<0.05). Preoperative creatinine, D-dimer, C-reactive protein (CRP), fibrinogen, total intraoperative output and American Society of Anesthesiologists (ASA) physical status classification were higher (P<0.05).Multivariate logistic regression analysis showed that preoperative hemoglobin, initial mean arterial pressure and preoperative creatinine level were independent risk factors for postoperative AKI (OR=0.958, 0.976 and 1.021 respectively, P<0.05). Conclusion The occurrence of postoperative AKI in patients undergoing non-cardiac surgery of grade III-IV under general anesthesia is related to preoperative hemoglobin level, preoperative creatinine level and initial mean arterial pressure, which is worth further big data research.

data platform  /  non-cardiac surgery  /  acute kidney injury  /  risk factors
郭耸, 蔺祎, 刘冰冰, 王益敏, 张辉. 基于数据平台的全麻非心脏手术患者术后急性肾损伤危险因素分析. 解放军医学杂志, 2023 , 48 (7) : 802 -808 . DOI: 10.11855/j.issn.0577-7402.1440.2023.0131
Song Guo, Yi Lin, Bing-Bing Liu, Yi-Min Wang, Hui Zhang. Data platform-based analysis of risk factors for acute renal injury after non-cardiac surgery under general anesthesia[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (7) : 802 -808 . DOI: 10.11855/j.issn.0577-7402.1440.2023.0131
正文
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急性肾损伤(acute kidney injury，AKI)是一种由多种病因引起的肾功能下降，甚至远隔器官功能损伤的常见综合征，由于不同地区人群特征和诊断标准的不同，总体发病率差异较大(1%～66%)[1]。随着外科技术和麻醉监护手段的发展，高风险手术越来越普遍，AKI已成为大手术后常见的并发症。术后AKI的影响因素包括患者合并症、特定的手术、肾毒性药物的使用、液体和血液管理、血流动力学稳定性等，与慢性肾脏病(chronic kidney disease，CKD)的发生发展及围手术期病死率密切相关[2]。心脏和大血管手术是术后AKI的危险因素，高达30%的患者在心脏手术后发生AKI，其中3%的心脏手术后患者需要透析治疗[3]。非心脏手术后AKI的相关研究较少，已有研究认为肝移植可导致术中低血压，且与术后AKI相关[4]。随着医疗信息化向大数据时代迈进，专科数据平台的建设实现了临床医疗数据的有效管理，对围手术期危险因素分析、预测模型建立、并发症预防等相关临床研究具有重要意义[5-6]。本研究基于广东省第二人民医院麻醉科联合信息科临床数据中心建立的麻醉与围手术期医学专科数据平台，探索影响全麻非心脏手术后AKI的危险因素，以期为预防术后AKI的发生提供参考。
1 资料与方法
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1.1 研究对象
本研究为回顾性病例对照研究。基于麻醉与围手术期医学专科数据平台(简称数据平台)，选择2019年1月－2021年5月于广东省第二人民医院接受外科手术的患者作为研究对象。纳入标准：(1)年龄>18岁；(2)全麻下行Ⅲ－Ⅳ级手术。排除标准：(1)接受心脏手术、肝移植、肺移植及部分直接影响肾脏功能的泌尿系统手术；(2)手术时间<120 min；(3)术前CKD 5期[肾小球滤过率<15 ml/(min·1.73 m²)]；(4)术前2周存在AKI病史；(5)术前接受过肾脏替代治疗或体外膜肺氧合治疗；(6)急诊或日间手术；(7)围产期女性；(8)信息不全。本研究经广东省第二人民医院伦理委员会批准(2022-KY-KZ-198-01)。
1.2 资料收集
收集患者的临床资料，包括术前资料[年龄、性别、体重指数(body mass index，BMI)、合并症、纽约心脏病协会(Heart Association of New York，NYHA)心功能分级、美国麻醉医师协会(American Society of Anesthesiologists，ASA)分级、手术级别、红细胞计数、白细胞计数、血小板计数及血红蛋白、白蛋白、肌酐、纤维蛋白原、血清钾、血清钠、C反应蛋白(C-reactive protein，CRP)、D-二聚体水平等]、术中资料[术中用药情况、麻醉时间、手术时间、手术种类、初始平均动脉压、心率、术中低血压、晶体量、胶体量、出血量、尿量、术中总出量(术中总出量为出血量和尿量之和)等]及术后资料(术后血肌酐值、住院时间、住院费用等)。
1.3 数据处理
所有数据预处理和统计分析均在数据平台anaconda环境(https://www.anaconda.com/)下的Python编程语言(版本3.7.5)中完成。通过检索数据平台，共获得5163例患者的临床资料。根据KDIGO指南对AKI的定义和可供分析的数据完整度，筛选出205例术后发生AKI(设为术后AKI组)和251例术后无AKI(设为术后无AKI组)患者的样本，每个样本含有65个变量，以“是否发生术后AKI”为结局变量。分析数据缺失情况，剔除数据缺失率30%以上的变量，对缺失数据进行填补，分类变量用众数，连续变量用均值，最终清洗得到456个样本数据，57个变量。
AKI诊断标准：根据2012年改善全球肾脏病预后组织(Kidney Disease: Improving Global Outcomes，KDIGO)对AKI的定义，符合以下任意一项即认为患者发生AKI：(1)48 h内血肌酐升高≥26.5 μmol/L(0.3 mg/dl)；(2)7 d内血肌酐升高≥基线值的1.5倍；(3)尿量减少，<0.5 ml/(kg·h)且持续6 h以上。血肌酐基线值参考最接近择期手术日期的血肌酐值。
1.4 术后AKI危险因素分析
利用计算机编程语言对两组患者的临床资料进行单因素分析，选取P<0.05的因素纳入多因素logistic回归分析模型，分析围手术期发生AKI的危险因素。
1.5 统计学处理
利用Python计算机编程语言进行统计分析。计量资料以$\bar{x}±s$表示，两组间比较采用t检验或Mann-Whitney U检验。计数资料以例(%)表示，两组间比较采用χ²检验或Fisher精确概率法，等级资料比较采用秩和检验。P<0.05为差异有统计学意义。
2 结果
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2.1 临床资料比较
术前临床资料如表1所示，与术后无AKI组比较，术后AKI组术前红细胞计数及血红蛋白、白蛋白水平较低，术前肌酐、D-二聚体、CRP、纤维蛋白原水平及ASA Ⅲ－Ⅳ级比例较高，差异有统计学意义(P<0.05)。
术中及术后临床资料如表2所示，与术后无AKI组比较，术后AKI组初始平均动脉压较低，术中总出量较多，差异有统计学意义(P<0.05)；两组住院时间、住院费用等其他临床资料比较差异无统计学意义(P>0.05)。
2.2 非心脏手术后AKI危险因素分析
单因素分析结果显示，性别，术前红细胞计数及血红蛋白、白蛋白、D-二聚体、CRP、肌酐、纤维蛋白原水平，以及手术时间、胶体量、术中总出量、初始平均动脉压与非心脏手术后AKI的发生有关(P<0.05)，其余临床指标与非心脏手术后AKI的发生无关(P>0.05，表3)。
将单因素分析中P<0.05的变量纳入多因素logistic回归分析模型，结果显示，术前血红蛋白水平、术前肌酐水平及初始平均动脉压是非心脏手术后AKI发生的独立危险因素(P<0.05，表3)。
3 讨论
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目前围手术期AKI越来越常见，尤其是在接受高风险手术的高危患者中。研究发现，30%～40%的AKI发生在术后，手术患者AKI的发生率为18%～47%；AKI在心脏手术患者中最为常见，但在非心脏手术患者中其发生率仍有1%，即使这些患者术前肾功能正常[7]。术后AKI是一种临床综合征而非单一的疾病，其常见机制包括缺血再灌注损伤、内源性或外源性肾毒素，以及一些理化因素如梗阻、炎性因子、血管收缩和氧化应激等，因此手术过程中各种暴露因素都可能参与了术后AKI的发生发展[8]。研究证实，相较术后无AKI的患者，术后发生AKI的患者更有可能合并其他并发症，在重症监护病房和医院的住院时间更长，医疗费用、住院病死率和90 d病死率更高[9]。准确的围手术期AKI风险评估可为选择合适的手术时机、实施适当的术中管理、及时制定合理的术后干预措施提供依据，进而提高患者生存率，改善患者生活质量。
2012年KDIGO指南基于多项观察性研究总结了非特异性AKI的易感因素，包括脱水或容量不足、高龄、女性、黑色人种、慢性肾病、慢性基础疾病(心、肺、肝等)、糖尿病、肿瘤、贫血等，但这些因素是针对不同的暴露因素如脓毒症、烧伤、循环衰竭、创伤、心脏手术、非心脏大手术、肾毒性药物、造影剂、有毒的动植物研究得出的，涉及不同的损伤类型、严重程度和持续时间，不同人群间的异质性较大[10]。心脏手术相关AKI的危险因素除了与患者自身疾病相关的因素外，还包括手术相关因素如手术类型、体外循环时间、心脏停搏与否、低温时间、血液稀释及是否溶血等[11]。对于非心脏手术后AKI，目前尚缺乏有效的临床工具来对术前患者进行风险分层，这是由于各研究对AKI的诊断标准不一，而且限定于特定的手术。目前经过验证的术后AKI危险因素包括男性、年龄>50岁、糖尿病、高血压、腹水、心力衰竭、急诊手术、腹腔手术、多重药物、高ASA分级，以及使用血管紧张素转换酶抑制剂(ACEI)或血管紧张素受体阻滞剂(ARB)等[8]。
本研究利用麻醉与围手术期医学专科数据平台高效获取临床数据的优势，从大量样本中筛选出非心脏大手术后发生AKI的患者，包含了多种手术类型且分布具有可比性，通过计算机编程语言对现有临床数据进行前期处理，极大地提高了数据集成和整合效率。多元回归分析结果显示，术前肌酐水平、术前血红蛋白水平和初始平均动脉压与术后AKI的发生有关。本组术后AKI患者的术前肌酐基线值较高，而术前肌酐值是目前应用最广泛的衡量患者基础肾功能的指标[12]，提示若患者术前肾脏储备功能下降，在经历大手术的打击后更容易发生AKI，临床上应对此类患者的肌酐水平进行动态监测，尤其是在高风险手术后。
既往研究显示，术中低血压也是术后AKI的危险因素，尤其是对于合并术前危险因素的患者[13]。Mathis等[13]对主要危险因素如贫血、肾小球滤过率、手术类型、ASA分级及预计麻醉时间进行分层后，发现非心脏手术的中风险患者术中严重低血压(平均动脉压<50 mmHg)与AKI之间存在相关性，而高风险患者轻度低血压(平均动脉压55～59 mmHg)与A K I相关。有研究发现，术中平均动脉压<65 mmHg或较术前基础值降低20%即可引起肾损伤和心肌损伤[14]，临床相关的术中低血压持续时间被认为是10 min以上[15-16]。本研究通过数据平台提取所有患者的术中血压值，根据既往文献[13-16]对肾损伤相关术中低血压的研究结果，以术中平均动脉压<65 mmHg且持续时间超过10 min作为术中低血压的判定标准，发现术中低血压发生率低，两组间差异无统计学意义。此外，两组患者循环管理相关指标如晶胶体量、血管活性药物使用率、出血量及尿量差异亦无统计学意义，这可能与本研究未纳入血流动力学波动较大的手术类型有关。围手术期AKI的发生发展机制较为复杂，其中手术引起的灌注不足、炎症和神经内分泌反应是影响肾灌注的常见机制，低血压和肾灌注不足是围手术期低血容量的常见后果，也是麻醉血管扩张和心脏抑制作用的常见后果[17]。与既往研究不同，本研究纳入了术前初始平均动脉压(即患者入室后在麻醉诱导前测得的血压)作为研究指标，结果发现术后AKI组该指标较术后无AKI组低，这可能是由于术前禁饮禁食导致低血容量，加上麻醉的心血管抑制作用，导致初始平均动脉压低的患者更容易发生肾前性AKI。因此，术中严格的血压管理对预防术后AKI的发生具有积极作用[18]。
无论是心脏手术还是非心脏手术，术前血红蛋白水平均是术后AKI的重要影响因素。部分观察性研究认为，心脏手术前贫血是术中输注红细胞和术后并发症(包括AKI、卒中、感染和死亡)的危险因素[19-20]。一项纳入904例非心脏高风险手术患者的多中心队列研究显示，术前贫血(血红蛋白<100 g/L)与术后AKI存在相关性[21]。另一项纳入24项观察性研究共949 445例外科手术患者的荟萃分析显示，术前贫血与术后AKI、感染和死亡相关[22]，其机制可能与氧转运能力降低和组织缺氧有关[21-22]。本研究以非心脏大手术患者为研究对象，发现术前血红蛋白是术后AKI的危险因素，虽然未以贫血为界值进行分组分析，但术后AKI组术前血红蛋白水平低于术后无AKI组，与既往大数据分析和大样本观察性研究的趋势一致，提示对于术前血红蛋白，低水平较高水平更容易产生不利影响，而并非一定要达到贫血的程度。因此，临床医师应该关注动态的数据变化而并非固定的贫血标准，及时制定合理的管理策略，以减少术后AKI的发生。
本研究仍存在一定的局限性：(1)为单中心研究，样本量有限，与具有不同分布特征和不同机构的大型数据集有一定差异，后期有待于利用数据平台的优势扩大样本量进一步验证；(2)为回顾性研究，临床诊疗行为的一致性难以控制，因此对所获数据的精确性和完整度有一定影响；(3)未对一些连续性观测值进行分层分析，后期可利用更大样本的数据建立风险预测模型，探索性分析一些新的生化指标；(4)研究结果虽具有一定的参考价值，但并不能得出危险因素与临床结局的因果关系，尚需前瞻性队列研究进一步验证。
综上所述，本研究利用麻醉与围手术期医学专科数据平台对全麻非心脏大手术患者进行分析，发现术后AKI的危险因素为术前血红蛋白水平、术前肌酐水平和初始平均动脉压，该结果为临床针对性干预提供了依据。未来可通过数据平台获取更完善的数据，进一步开展前瞻性随机对照研究，以期为围手术期器官功能保护提供新方法。
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  • 广东省重点领域研发计划(2020B0101130019)
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2023年第48卷第7期
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doi: 10.11855/j.issn.0577-7402.1440.2023.0131
  • 接收时间：2022-06-28
  • 首发时间：2025-12-03
  • 出版时间：2023-07-28
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  • 收稿日期：2022-06-28
  • 录用日期：2022-09-20
基金
Guangdong Provincial Key Research and Development Program(2020B0101130019)
广东省重点领域研发计划(2020B0101130019)
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    广东省第二人民医院麻醉科，广东广州 510317

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张辉，E-mail：
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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