终末期肾病患者行开胸心脏外科手术的临床分析

摘要

目的 分析行开胸心脏外科手术的终末期肾病(End-stage renal disease,ESRD)患者的临床特征及转归,探讨患者围手术期肾脏替代治疗的方式.方法:对北京大学第一医院在2004年9月至2011年1月期间行开胸心脏手术的终末期肾脏病病例进行单中心回顾性分析.结果 共有16例(ESRD)患者行开胸心脏外科手术.8例患者行冠状动脉搭桥术(coronary artery bypass grafting,CABG),5例患者行瓣膜置换术,3例患者同时行CABG和瓣膜置换术.14例患者术后 6.7±5.1h开始行床旁持续性肾脏替代治疗(延长低效血液透析滤过)(4.83±2.95)次,平均每次治疗时间(9.71± 3.75)h,单次治疗总置换液量(33.0±11.6)L.手术当日行无肝素治疗,术后第2d根据病情选择抗凝方式和药物.病情稳定后转为常规血液透析/滤过.患者住院死亡率25%(4/16),死亡原因分别为围手术期心肌梗死(1例)、心包填塞(1例)和低排综合征(2例).存活的12例患者术后随访33个月(3-65 个月),3例患者分别因肝癌、脑出血和心力衰竭死亡.结论 经过强化肾脏替代治疗和其他综合支持治疗,ESRD患者经过充分准备可以耐受心脏外科开胸手术并达到长期存活;心血管病变和外科手术复杂的高龄患者围手术期死亡率较高.%Objectives To investigate the clinical characteristics and outcome of end-stage renal disease (ESRD) patients undergoing cardiac surgery, and to explore the optimal protocol for peri-operative renal replacement therapy. Methods A single-center retrospective analysis was conducted in dialysis patients who were managed with coronary artery bypass grafting (CABG) and/or cardiac valve replacement (VR) during the period between September, 2004 and January, 2011. Results Sixteen patients who met our inclusion criteria were studied. CABG was performed in 8 patients, VR in 5 patients, and CABG + VR in 3 patients. Extended low-efficiency hemodiafiltration commenced 6.7±5.1 hours after operation. Every hemodiafiltration session lasted 9.71 ± 3.75 hours and consumed 33.0 ± 11.6 liters of replacement fluid. The average hemodiafiltration sessions were 4.83 ± 2.95 times for a patient before they were converted to regular hemodi-alysis or hemodiafiltration. The in-hospital mortality was 25% (4/16), and the causes of death were peri-operative myocardial infarction (one patient), pericardial temponade (one patient) and low output syndrome (2 patients). Survival patients were followed up for 33 (3~65) months, and during that period 3 patients died of hepatic carcinoma, cerebral hemorrhage or heart failure. Conclusions Dialysis-dependent patients undergoing cardiac surgery could achieve better successful rate with long-term survival when intensive peri-operative renal replacement therapy was used. In-hospital mortality was high in elder patients managed with CABG and VR simultaneously.