腹腔镜保留肾单位手术后急性肾损伤的危险因素分析及临床意义

吴颖; 张跃; 钱伟伟; 孙欣; 马嘉兴; 于德新; 张涛

doi:10.16766/j.cnki.issn.1674-4152.003145

腹腔镜保留肾单位手术后急性肾损伤的危险因素分析及临床意义

doi: 10.16766/j.cnki.issn.1674-4152.003145

安徽医科大学第二附属医院泌尿外科，安徽合肥 230601

基金项目:

安徽省自然科学基金项目 2008085MH290

安徽医科大学基础与临床合作研究提升计划资助项目 2021xkjT036

安徽省转化医学研究院科研基金项目 2021zhyx-C43

安徽医科大学第二附属医院临床研究培育计划项目 2020LCYB20

安徽医科大学校基金资助项目 2021xkj036

详细信息

通讯作者:
张涛，E-mail: Zhangtao@ahmu.edu.cn

中图分类号: R737.11 R692
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- 被引次数: 0
出版历程
- 收稿日期: 2022-12-15
- 网络出版日期: 2023-10-19

Risk factors analysis and clinical significance of acute kidney injury after laparoscopic nephron sparing surgery

Department of Urology, the Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230601, China

摘要

摘要: 目的分析肾脏肿瘤患者行腹腔镜保留肾单位手术(LNSS)后发生急性肾损伤(AKI)的相关危险因素。方法回顾性分析2010年1月—2022年9月在安徽医科大学第二附属医院泌尿外科接受LNSS治疗的442例肾脏患者的临床资料。AKI的诊断标准采用2012年KDIGO指南。根据患者术后是否发生AKI分为AKI组和非AKI组。统计2组患者的一般资料、术前血尿生物标志物数据、肾动脉阻断时间、肿瘤最大径、术后病理结果、RENAL评分等临床资料。采用logistic回归分析术后发生AKI的相关危险因素。结果术后发生AKI的患者有129例，发生率为29.2%(129/442)，其中AKIⅠ期115例(89.2%)，Ⅱ期12例(9.3%)，Ⅲ期2例(1.5%)。单因素分析结果显示，2组患者体重指数(BMI，P=0.018)、术前合并冠心病(P=0.042)、血清胱抑素C(CysC，P=0.004)、肾动脉阻断时间(P=0.006)、手术时间(P < 0.001)、肿瘤最大径(P=0.003)、RENAL评分(P < 0.001)比较，差异有统计学意义(均P＜0.05)。多因素logistic回归分析结果显示，术前合并冠心病(P=0.042)、血清CysC高(P=0.013)、手术时间长(P=0.004)和RENAL评分高(P < 0.001)是术后AKI的独立危险因素。结论 LNSS术后发生AKI的相关危险因素有BMI、术前合并冠心病、血清CysC、肾动脉阻断时间、手术时间、肿瘤最大径、RENAL评分。对于合并以上危险因素的肾脏肿瘤患者，LNSS术前需格外关注并制定应对策略。
- 急性肾损伤 /
- 腹腔镜保留肾单位手术 /
- 危险因素 /
- 肾肿瘤
Abstract: Objective To investigate the risk factors of postoperative acute kidney injury (AKI) after laparoscopic nephron sparing surgery (LNSS) in renal tumor patients. Methods Clinical data of 442 patients who received LNSS in Urology Department of the Second Affiliated Hospital of Anhui Medical University from January 2010 to September 2022 were retrospectively analyzed. The diagnosis of AKI according to the 2012 kidney disease improving global outcomes standard. Patients were divided into AKI group and non-AKI group according to whether they had postoperative AKI. Clinical parameters of the two groups were collected, including general data, preoperative blood and urine biomarker data, renal artery clamping time, maximum tumor diameter, pathology results, RENAL score, etc. The risk factors for AKI after LNSS were analyzed by univariate and multivariate logistic regression. Results There were 129 patients with postoperative AKI, with an incidence of 29.2% (129/442), including 115 patients (89.2%) with stage Ⅰ AKI, 12 patients (9.3%) with stage Ⅱ AKI and 2 patients (1.5%) with stage Ⅲ AKI. The univariate analysis showed that there were significant differences in body mass index (BMI, P=0.018), preoperative coronary heart disease (P=0.042), serum cystatin C (CysC) level (P=0.004), renal artery clamping time (P=0.006), surgery time (P < 0.001), maximum tumor diameter (P=0.003), and RENAL score (P < 0.001) between the two groups (all P < 0.05). Multivariate logistic regression analysis showed that preoperative coronary heart disease (P=0.042), high serum CysC level (P=0.013), long surgery time (P=0.004) and high RENAL score (P < 0.001) were independent risk factors for AKI after LNSS. Conclusion The risk factors of AKI after LNSS include BMI, preoperative coronary heart disease, serum CysC level, renal artery clamping time, surgery time, maximum tumor diameter, and RENAL score. For renal tumor patients with the above risk factors, special attention and coping strategies should be given before LNSS.
- Acute kidney injury /
- Laparoscopic nephron sparing surgery /
- Risk factors /
- Renal tumor

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表 1 AKI组和非AKI组患者一般资料比较

Table 1. Comparison of general data between AKI group and non-AKI group

项目	AKI组 (n=129)	非AKI组 (n=313)	统计量	P值	项目	AKI组 (n=129)	非AKI组 (n=313)	统计量	P值
性别[例(%)]			2.243^a	0.135	ALB(x±s, g/L)	40.56±3.91	40.28±4.00	-0.680^b	0.497
男性	92(71.3)	200(63.9)			CysC[M(P₂₅, P₇₅), mg/L]	0.86(0.76，1.07)	0.85(0.66，0.97)	-2.886^c	0.003
女性	37(28.7)	113(36.1)			BUN[M(P₂₅, P₇₅), mmol/L]	5.60(4.91，6.89)	5.47(4.50，6.79)	-1.372^c	0.324
年龄(x±s，岁)	57.42±11.92	54.93±12.55	-1.923^b	0.055	UA(x±s, μmol/L)	345.40±99.23	329.68±87.10	-1.654^a	0.099
BMI(x±s)	25.09±3.09	24.19±3.12	-2.406^b	0.017	eGFR[x±s, mL/(min·1.73 m²)]	130.00±46.71	125.26±32.22	-0.896^a	0.315
既往史[例(%)]					术前Hb(x±s, g/L)	134.81±15.66	134.15±17.54	-0.368^a	0.713
吸烟史	43(33.3)	102(32.6)	0.023^a	0.880	术前WBC(x±s, ×10⁹/L)	6.19±1.87	6.01±1.70	-0.973^a	0.312
饮酒史	37(28.7)	88(28.1)	0.014^a	0.904	RENAL评分[M(P₂₅, P₇₅)，分]	7.00(6.00，8.00)	5.00(5.00，6.00)	-7.745^c	< 0.001
基础疾病[例(%)]					肾动脉阻断时间(x±s，min)	18.85±6.50	17.08±5.79	-2.823^a	0.005
糖尿病	21(16.3)	41(13.1)	0.766^a	0.383	手术时间(x±s，min)	143.20±46.79	123.66±38.01	-4.210^a	< 0.001
高血压	62(48.1)	125(39.5)	2.471^a	0.116	肿瘤最大径(x±s，cm)	3.60±1.43	3.21±1.17	-3.026^a	0.003
冠心病	13(10.1)	15(4.8)	4.300^a	0.038	术式[例(%)]			4.930^b	0.387
脑血管病	8(6.2)	10(3.2)	2.114^a	0.147	经腰	101(78.3)	252(80.5)
TG[M(P₂₅, P₇₅), mmol/L]	1.33(0.99，1.78)	1.42(0.97，1.89)	-0.226^c	0.499	经腹	26(20.2)	61(19.5)
CHO(x±s, mmol/L)	4.50±1.01	4.59±1.00	0.718^b	0.474	腰腹联合	2(1.6)	0
尿蛋白质[例(%)]			0.793^c	0.891	缺血类型[例(%)]			0.828^b	0.364
阴性	87(67.4)	218(69.6)			热缺血	129(100.0)	311(99.4)
±	30(23.3)	62(19.8)			冷缺血	0	2(0.6)
+	9(7.0)	7(2.2)
+++	3(2.3)	7(2.2)
注：^a为χ²值，^b为t值，^c为Z值。

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表 2 变量赋值方法

Table 2. Variable assignment methods

变量	赋值方法
因变量
AKI	无=0，有=1
自变量
性别	男性=0，女性=1
既往史	无=0，有=1
基础疾病	无=0，有=1
尿蛋白质	阴性=0，“±”=1，“+”=2，“++”=3
术式	经腰=(0, 0)，经腹=(1, 0)，腰腹联合=(0, 1)
缺血类型	热缺血=0，冷缺血=1

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表 3 行LNSS患者术后并发AKI的单因素logistic回归分析

Table 3. Univariate logistic regression analysis of postoperative AKI in LNSS patients

变量	B	SE	Wald χ²	P值	OR值	95% CI
BMI	0.084	0.036	5.611	0.018	1.088	1.015~1.167
冠心病	0.800	0.394	4.118	0.042	2.226	1.028~4.823
CysC	1.159	0.399	8.416	0.004	3.186	1.456~6.970
肾动脉阻断时间	0.048	0.017	7.691	0.006	1.049	1.014~1.086
手术时间	0.011	0.003	18.873	< 0.001	1.011	1.006~1.006
肿瘤最大径	0.242	0.082	8.653	0.003	1.273	1.084~1.496
RENAL评分	0.612	0.084	52.776	< 0.001	1.845	1.564~2.176

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表 4 行LNSS患者术后AKI的多因素logistic回归分析

Table 4. Multivariate logistic regression analysis of postoperative AKI in LNSS patients

变量	B	SE	Wald χ²	P值	OR值	95% CI
心脏病	0.880	0.433	4.126	0.042	2.410	1.031~5.631
CysC	1.100	0.445	6.123	0.013	3.006	1.257~7.186
手术时间	0.008	0.003	8.107	0.004	1.008	1.003~1.014
RENAL评分	0.648	0.102	40.435	< 0.001	1.913	1.566~2.336

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参考文献(19)

[1]	KOPITKO C, MEDVE L, GONDOS T, et al. Mediators of regional kidney perfusion during surgical pneumo-peritoneum creation and the risk of acute kidney injury-a review of basic physiology[J]. J Clin Med, 2022, 11(10): 2728. DOI: 10.3390/jcm11102728.
[2]	RONCO C, BELLOMO R, KELLUM J A. Acute kidney injury[J]. Lancet, 2019, 394(10212): 1949-1964. doi: 10.1016/S0140-6736(19)32563-2
[3]	MARTINI A, CUMARASAMY S, BEKSAC A T, et al. A nomogram to predict significant estimated glomerular filtration rate reduction after robotic partial nephrectomy[J]. Eur Urol, 2018, 74(6): 833-839. doi: 10.1016/j.eururo.2018.08.037
[4]	范春玲, 刘永哲. 腹腔镜下肾部分切除术后急性肾损伤的危险因素及其预测价值[J]. 解放军医学杂志, 2022, 47(5): 493-499. https://www.cnki.com.cn/Article/CJFDTOTAL-JFJY202205010.htm FAN C L, LIU Y Z. Risk factors and predictive value of acute kidney injury after laparoscopic partial nephrectomy[J]. Medical Journal of Chinese People's Liberation Army, 2022, 47(5): 493-499. https://www.cnki.com.cn/Article/CJFDTOTAL-JFJY202205010.htm
[5]	ZHU Z, HU J, CHEN Z, et al. Transition of acute kidney injury to chronic kidney disease: role of metabolic reprogramming[J]. Metabolism, 2022, 131: 155194. DOI: 10.1016/j.metabol.2022.155194.
[6]	STEVENS P E, LEVIN A. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline[J]. Ann Intern Med, 2013, 158(11): 825-830. doi: 10.7326/0003-4819-158-11-201306040-00007
[7]	黄金, 刘训芹, 李昂庆, 等. 个性化血压管理策略对老年胃肠手术后急性肾损伤的影响[J]. 中华全科医学, 2022, 20(7): 1098-1101. doi: 10.16766/j.cnki.issn.1674-4152.002532 HUANG J, LIU X Q, LI A Q, et al. Influence of individualised blood pressure management strategy on postoperative acute kidney injury in the elderly patients who underwent gastrointestinal surgery[J]. Chinese Journal of General Practice, 2022, 20(7): 1098-1101. doi: 10.16766/j.cnki.issn.1674-4152.002532
[8]	SRIPERUMBUDURI S, CLARK E, HIREMATH S. New insights into mechanisms of acute kidney injury in heart disease[J]. Can J Cardiol, 2019, 35(9): 1158-1169. doi: 10.1016/j.cjca.2019.06.032
[9]	ZANOLI L, LENTINI P, BRIET M, et al. Arterial stiffness in the heart disease of CKD[J]. J Am Soc Nephrol, 2019, 30(6): 918-928. doi: 10.1681/ASN.2019020117
[10]	HONG C, ZHU Q, LI Y, et al. Acute kidney injury defined by cystatin C may be superior for predicting the outcomes of liver cirrhosis with acute gastrointestinal bleeding[J]. Ren Fail, 2022, 44(1): 398-406. doi: 10.1080/0886022X.2022.2043903
[11]	JANA S, MITRA P, ROY S. Proficient novel biomarkers guide early detection of acute kidney injury: a review[J]. Diseases, 2022, 11(1): 8. doi: 10.3390/diseases11010008
[12]	热那提·依马木, 叶尔买克·唐沙哈尔, 亚生江·玉苏甫, 等. Stanford A型主动脉夹层术后早期发生急性肾损伤的影响因素[J]. 中华实用诊断与治疗杂志, 2021, 35(1): 15-18. https://www.cnki.com.cn/Article/CJFDTOTAL-HNZD202101004.htm Renati·Yimamu, Yeermake·Tangshahaer, Yashengjiang·Yusupu, et al. Influencing factors of early acute kidney injury after surgery for Stangord type A aorited issection[J]. Journal of Chinese Practical Diagnosis and Therapy, 2021, 35(1): 15-18. https://www.cnki.com.cn/Article/CJFDTOTAL-HNZD202101004.htm
[13]	ZHU K, SONG H, ZHANG Z, et al. Acute kidney injury in solitary kidney patients after partial nephrectomy: incidence, risk factors and prediction[J]. Transl Androl Urol, 2020, 9(3): 1232-1243. doi: 10.21037/tau.2020.03.45
[14]	BIGLARNIA A R, HUBER-LANG M, MOHLIN C, et al. The multifaceted role of complement in kidney transplantation[J]. Nat Rev Nephrol, 2018, 14(12): 767-781. doi: 10.1038/s41581-018-0071-x
[15]	YANG C C, SUNG P H, CHIANG J Y, et al. Combined tacrolimus and melatonin effectively protected kidney against acute ischemia-reperfusion injury[J]. FASEB J, 2021, 35(6): e21661. DOI: 10.1096/fj.202100174R.
[16]	KUTIKOV A, UZZO R G. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth[J]. J Urol, 2009, 182(3): 844-853. doi: 10.1016/j.juro.2009.05.035
[17]	PIRAMIDE F, KOWALEWSKI K F, CACCIAMANI G, et al. Three-dimensional model-assisted minimally invasive partial nephrectomy: a systematic review with meta-analysis of comparative studies[J]. Eur Urol Oncol, 2022, 5(6): 640-650. doi: 10.1016/j.euo.2022.09.003
[18]	LIU Q, BAI B, LIU F, et al. Long-term trends in risk factor management in respondents with chronic kidney disease in the USA[J]. Am J Nephrol, 2022, 53(8-9): 614-623. doi: 10.1159/000525733
[19]	WANG M, WANG Z, CHEN Y, et al. Kidney damage caused by obesity and its feasible treatment drugs[J]. Int J Mol Sci, 2022, 23(2): 747. doi: 10.3390/ijms23020747