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| 肝移植患儿术中血流动力学变化与急性肾损伤的相关性 |
| Association between hemodynamic in pediatric liver transplantation and acute kidney injury |
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| DOI：10.12089/jca.2021.04.002 |
| 中文关键词: 儿童 肝移植 急性肾损伤 血流动力学 |
| 英文关键词: Child Liver transplantation Acute kidney injury Hemodynamics |
| 基金项目:天津市自然科学基金面上项目（18JCYBJC27500） |
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| 中文摘要: |
目的 探讨肝移植术中患儿血流动力学的变化与急性肾损伤（AKI）的相关性。
方法 选择2019年1—12月接受亲体肝移植术患儿112例，男62例，女50例，年龄5～24个月，体重5～12 kg，ASA Ⅲ或Ⅳ级，肝功能Child-Pugh评分B级50例，C级62例。根据2012年改善全球肾脏病预后组织（KDIGO）诊断标准将患儿分为两组：术后急性肾损伤组（AKI组）和无急性肾损伤组（nAKI组）。术中均采用压力记录分析法（PRAM）进行血流动力学的实时监测，包括CVP、心指数（CI）、MAP、左心室收缩力指数（dp/dtmax）、心动周期效率（CCE），记录再灌注早期（门静脉开放5 min内）各指标最大波动值（ΔCVPmax、ΔCImax、ΔMAPmax、Δdp/dtmax、ΔCCEmax）。采用多因素Logistic回归分析血流动力学最大波动值与术后AKI的相关性，并通过受试者工作曲线（ROC）分析各相关因素的AUC下面积。
结果 所有患儿中共有45例发生AKI，发生率为40.18%。AKI组再灌注早期（门静脉开放5 min）内MAP、CI及dp/dtmax一过性迅速下降，最大下降值（ΔCImax、ΔMAPmax、Δdp/dtmax）明显大于nAKI组（P<0.05）。多因素Logistic回归分析结果显示，ΔCImax、ΔMAPmax、Δdp/dtmax与术后AKI具有相关性，ROC曲线下面积分别为0.74（0.65～0.83）、0.74（0.65～0.84）和0.76（0.68～0.85），截断值分析结果显示当上述指标分别大于0.25 L·min-1·m-2、0.10 mmHg/ms及20 mmHg时AKI的风险明显升高。
结论 肝移植术中再灌注早期患儿出现严重心肌抑制及心排量、血压明显下降与术后AKI具有独立正相关性，实时连续的血流动力学监测，稳定心功能维持血流动力学稳定能减少术后AKI的发生。 |
| 英文摘要: |
Objective To investigate the correlation between hemodynamic instability during pediatric liver transplantation and acute renal injury(AKI)after operation.
Methods A total of 112 children who underwent pediatric liver transplantation from January 2019 to December 2019 were collected, including 62 males and 50 females, aged 5-24 months, weighing 5-12 kg, falling into ASA physical stutas Ⅲ or Ⅳ, with a Child-Pugh score of B in 50 children and C in 62 children. According to the diagnostic criteria of Kidney Disease Improving Global Outcomes (KDIGO) in 2012, the children were divided into acute kidney injury group (AKI group) and non-acute kidney injury group (nAKI group). Pressure recording analytical method (PRAM) was used to monitor the hemodynamic parameters, including CVP, cardiac index (CI),MAP, index of left ventricular contractility (dp/dtmax), cardiac cycle efficiency (CCE), the maximum fluctuation value of each index in 5 minutes after reperfusion (ΔCVPmax, ΔCImax, ΔMAPmax, Δdp/dtmax, ΔCCEmax) were recorded. Multivariate logistic regression analysis was performed on the relevant indicators, and receiver operating characteristic curve was used. ROC was used to analyze the predictive efficacy of each relevant factor.
Results Forty-five children of AKI occurred in all children, with an incidence rate of 40.18%. MAP, CI and dp/dtmax decreased rapidly in the early stage of reperfusion (5 minutes within portal vein opening) in the AKI group transiently, and the maximum decrease values of ΔCImax, ΔMAPmax and Δdp/dtmax were significantly greater than those in the nAKI group (P < 0.05). The results of multi-factor logistic regression analysis showed that ΔCImax, and ΔMAPmax, Δdp/dtmax were correlated with postoperative AKI, and the area under the ROC curve was 0.74 (0.65-0.83), 0.74 (0.65-0.84), and 0.76 (0.68-0.85) respectively, when the above indicators were greater than 0.25 L·min-1·m-2, 0.10 mmHg/ms and 20 mmHg respectively, the risk of AKI was significantly higher.
Conclusion Severe myocardial depression, significant decreased in cardiac output and blood pressure in the early phase of reperfusion during pediatric liver transplantation are independently correlated with postoperative AKI. Real-time continuous hemodynamic monitoring and stabilization of cardiac function maintaining hemodynamic stability can reduce the occurrence of postoperative AKI. |
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