Abstract

OBJECTIVES

Acute kidney injury (AKI) following surgery involving the heart-lung-machine is associated with high mortality and morbidity. In addition to the known mechanisms, thrombotic microangiopathy (TMA) triggered by the dysregulation of complement activation was recently described as another pathophysiological pathway for AKI following aortic surgery. The aim of this retrospective study was to analyse incidence, predictors and outcome in these patients.

METHODS

Between January 2018 and September 2019, consecutive patients undergoing aortic surgery requiring hypothermic circulatory arrest were retrospectively reviewed. If suspected, diagnostic algorithm was initiated to identify a TMA and its risk factors, and postoperative outcome parameters were comparably investigated.

RESULTS

The incidence of TMA in the analysed cohort (n = 247) was 4.5%. Multivariable logistic regression indicated female gender {odds ratio (OR) 4.905 [95% confidence interval (CI) 1.234–19.495], P = 0.024} and aortic valve replacement [OR 8.886 (95% CI 1.030–76.660), P = 0.047] as independent predictors of TMA, while cardiopulmonary bypass, X-clamp and hypothermic circulatory arrest times showed no statistically significance. TMA resulted in postoperative AKI (82%), neurological disorders (73%) and thrombocytopaenia [31 (interquartile range 25–42) G/l], corresponding to the diagnostic criteria. Operative mortality and morbidity were equal to patients without postoperative TMA, despite a higher incidence of re-exploration for bleeding (27 vs 6%; P = 0.027). After 6 months, survival, laboratory parameters and need for dialysis were comparable between the groups.

CONCLUSIONS

TMA is a potential differential diagnosis for the cause of AKI following aortic surgery regardless of the hypothermic circulatory arrest time. Timely diagnosis and appropriate treatment resulted in a comparable outcome concerning mortality and renal function.

中文翻译：

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主动脉手术伴低温停循环后的血栓性微血管病：一个被低估的急性肾功能衰竭原因的单中心经验

摘要

目标

涉及心肺机的手术后的急性肾损伤 (AKI) 与高死亡率和发病率有关。除了已知的机制外，由补体激活失调引发的血栓性微血管病 (TMA) 最近被描述为主动脉手术后 AKI 的另一种病理生理途径。这项回顾性研究的目的是分析这些患者的发病率、预测因素和结果。

方法

在 2018 年 1 月至 2019 年 9 月期间，对连续接受需要低温停循环的主动脉手术的患者进行了回顾性分析。如果怀疑，则启动诊断算法以识别 TMA 及其风险因素，并对术后结果参数进行比较研究。

结果

分析队列（ n = 247）中 TMA 的发生 率为 4.5%。多变量逻辑回归表明女性{优势比 (OR) 4.905 [95% 置信区间 (CI) 1.234–19.495], P  =  0.024} 和主动脉瓣置换术 [OR 8.886 (95% CI 1.030–76.660), P  = 0.047] 作为 TMA 的独立预测因子，而体外循环、X 钳和低温停循环时间无统计学意义。TMA 导致术后 AKI (82%)、神经系统疾病 (73%) 和血小板减少 [31 (四分位距 25-42) G/l]，符合诊断标准。手术死亡率和发病率与没有术后 TMA 的患者相同，尽管再次探查出血的发生率较高（27% vs 6%；P  =  0.027）。6 个月后，各组之间的生存率、实验室参数和透析需求具有可比性。

结论

无论低温停循环时间如何，TMA 都是主动脉手术后 AKI 病因的潜在鉴别诊断。及时的诊断和适当的治疗在死亡率和肾功能方面产生了可比的结果。