Research Of Acute Kidney Injury After Total Arch Replacement

Part Ⅰ:Comparison of the Clinical Risk Score Systems in predicting acute renal injury after total arch replacementObjective:To evaluate the efficacy of several clinical risk scores in predicting acute kidney injury(AKI)after total arch replacement,and to find the most optimal predictive score systems for early diagnosis of postoperative AKI.Methods:A total of 258 patients who were diagnosed with type Ⅰ aortic dissection and underwent total arch replacement at the cardiovascular surgery department of Guangzhou General Hospital of Guangzhou Military Command from March 2007 to March 2017 were collected and retrospectively analyzed.123 of them had postoperative AKI,the 123 patients were assigned into the AKI group,and the rest were assigned into the none AKI group(n=135).Five Clinical Risk Score Systems:SCRS,AKSCI,SRI,STS,Cleveland Clinic were analysed using Hosemer-Lemeshow test to evaluate the goodness-of-fit of these scores.The ROC curves of these systems were drawn and then the area under the curve(AUC)of each score were compared.Results:There were no statistically significant differences in baseline data between AKI group and none AKI group,Hosmer-Lemeshow test results showed the P value of the SRI score was above 0.05,and the rest were all under 0.05.The area under the curve is calculated as follows:SCRS=0.771;STS=0.730;Cleveland Clinic=0.769;AKSCI=0.728;SRI=0.655,SRI score was significantly lower than the other scores and the differences were statistically significant,(P<0.05).The comparing of AKSCI score and Cleveland Clinic score was also statistically significant and the differences between the rest were not statistically significant.Conclusion:Clinical risk score is simple to use and provide a reference for the early diagnosis of postoperative AKI after total arch replacement.Hosmer-Lemshow test results showed that all these scores had a poor sensitivity except SRI scores.No test alone is adequate in both accuracy and sensitivity in predicting AKI.Comprehensive use of these clinical score systems may help early diagnosis of AKI.It is hoped that in the future,more targeted scores could be developed for patients with AKI after total arch replacement.Part Ⅱ:Risk factors of renal replacement therapy after total arch ReplacementObjective:To identify risk factors of renal replacement therapy(RRT)use after total arch replacement and its predictive effect.Methods:A total of 258 patients(215 males and 43 females,at a mean age of 47.78±8.81 years)with type I aortic dissection undergoing total arch replacement at the cardiovascular surgery department of Guangzhou General Hospital of Guangzhou Military Command from March 2007 to March 2017 were collected and retrospectively analyzed.Forty-six patients having to receive RRT due to severely damaged renal function were assigned into the RRT group,and the other patients were included in the non-RRT group(n=212).The perioperative data were reviewed.Risk factors were identified by univariate analysis and further confirmed by logistic regression.The predictive values of identified risk factors were evaluated based on the area under the receiver operating characteristic(ROC)curve.Results:Univariate analysis identified preoperative sepsis,bilateral renal artery dissection,preoperative serum creatinine level,operation time,cardiopulmonary bypass time,intraoperative red blood cell infusion>10 units are risk factors of RRT after total arch replacement.Logistic regression analysis further identified preoperative serum creatinine level,operation time and intraoperative red blood cell infusion>10 units as independent risk factors.ROC curve analysis showed that the area under the curve of preoperative serum creatinine was 0.675～95%CI:0.586-0.765,P<0.001;the area under the curve of intraoperative red blood cell infusion>10 units was 0.623,95%CI:0.530-0.716,P=0.009;the area under the curve of operation time was 0.728,95%CI:0.,648-0.809,P<0.001;the area under the curve of the three risk factors was 0.839,95%confidence interval was 0.786～0.892.Conclusion:Preoperative creatinine level,operation time and intraoperative red blood cell infusion are independent risk factors of RRT after total arch replacement,and can provide references for the patients with postoperative acute kidney injury after total arch replacement.Part Ⅲ:Risk factors of in hospital mortality in patients with acute kidney injury after total arch replacementObjective:Analysis of risk factors of in hospital mortality in patients with postoperative acute kidney injury(AKI)after total arch replacement and to provide a reference for the treatment of patients during hospitalization.Methods:A total of 258 patients with type I aortic dissection undergoing total arch replacement at the cardiovascular surgery department of Guangzhou General Hospital of Guangzhou Military Command from March 2007 to March 2017 were collected and retrospectively analyzed.123 of them had postoperative AKI(age:47.15±8.52 yrs).Among them,23 patients died during hospitalization and were assigned in the death group,the remaining 100 patients were discharged smoothly and were assigned in the survival group.Preoperative,intraoperative and postoperative data were analysed.After univariate analysis,the risk factors were analysed using COX regression analysis.According to the AKI classification,the survival rate were analyzed by Kaplan-Meier curves.Results:The average length of hospital stay was 37.89 days.The COX regression analysis showed that preoperative serum creatinine(HR value:1.013,95%CI:1.003～1.023,P=0.011),diabetes mellitus(HR value:4.291,95%CI:1.079～17.063,P=0.039),re-operation for bleeding(HR value:4.412,95%CI:1.579～12.327,P=0.005),postoperative hypoxemia(HR value:5.634,95%CI:2.284～13.893,P<0.001)are independent risk factors of in hospital mortality in patients with postoperative AKI after total arch replacement,(P<0.05).Kaplan-Meier curve showed that AKI Ⅲ patients had a significant increase in mortality in comparison with AKI Ⅰ patients,(P<0.05),and there is no significant difference in hospital morality between AKI Ⅱ and AKI Ⅰ,or between AKI Ⅱ and AKI Ⅲ,(P>0.05).Conclusion:Preoperative creatinine,diabetes mellitus,re-operation for bleeding,and postoperative hypoxemia are independent risk factors for in hospital mortality in patients with postoperative AKI after total arch replacement.The AKI Ⅲ patients have the highest mortality rate among all AKI classifications.