本文選題：先天性心臟病 + 兒童　； 參考：《第三軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：據(jù)統(tǒng)計(jì),先天性心臟病(以下簡(jiǎn)稱先心病)發(fā)病率達(dá)到了9‰,手術(shù)治療是先心病的主要治療方式,而術(shù)后急性腎損傷(acute kidney injury,AKI)是先心病術(shù)后的一個(gè)嚴(yán)重并發(fā)癥,其發(fā)病率為5~33%。目前術(shù)后AKI的治療效果不確切,因此術(shù)后AKI的早期預(yù)防、及時(shí)診斷對(duì)降低AKI發(fā)生率和嚴(yán)重程度,以及降低術(shù)后通氣時(shí)間、ICU時(shí)長(zhǎng)、住院天數(shù)、在院死亡率具有重要意義。目前先心病術(shù)后AKI的研究得到越來(lái)越多人的重視,但是先心病患者是個(gè)年齡跨度很大的群體,其中小兒由于腎功能尚未發(fā)育完善,與成人相比,疾病特征存在顯著差異,術(shù)后AKI風(fēng)險(xiǎn)較成人更高,但目前這方面的研究很少,因此我們將4歲的患兒作為研究對(duì)象,探討先心病患兒術(shù)后急性腎損傷的疾病特點(diǎn)。一、先天性心臟病小兒術(shù)后急性腎損傷之臨床危險(xiǎn)因素對(duì)高風(fēng)險(xiǎn)患兒進(jìn)行甄別是實(shí)現(xiàn)先心病術(shù)后AKI早期預(yù)防、早期診斷的必要條件,因此探討術(shù)后發(fā)生AKI的危險(xiǎn)因素以期幫助臨床醫(yī)師及時(shí)發(fā)現(xiàn)高風(fēng)險(xiǎn)患兒,對(duì)于降低術(shù)后AKI發(fā)生率、改善患者預(yù)后非常重要。目前國(guó)內(nèi)外已經(jīng)有一些研究探討了先心術(shù)后AKI的危險(xiǎn)因素,但結(jié)果不盡一致,除了納入研究對(duì)象的就診機(jī)構(gòu)以及研究本身納入的分析因素不一樣外,納入對(duì)象的年齡段不同可能是一個(gè)主要原因。年齡越小,患兒腎功能越不成熟,先心術(shù)后發(fā)生AKI的幾率越大,因此本研究我們將4歲患兒作為研究對(duì)象,探討術(shù)后AKI發(fā)生的危險(xiǎn)因素。目的:分析4歲先心病患兒術(shù)后發(fā)生AKI的危險(xiǎn)因素。方法:收集2015年4月至2016年4月于新橋醫(yī)院行先心病手術(shù)治療4歲患兒的相關(guān)資料,以改良兒童腎臟疾病風(fēng)險(xiǎn)分級(jí)(pediatric risk injury failure loss and end stage kidney diseases,pRIFLE)作為AKI的診斷標(biāo)準(zhǔn),統(tǒng)計(jì)患兒行先心病手術(shù)后AKI的發(fā)生率,比較術(shù)后發(fā)生AKI的患兒與未發(fā)生AKI(N-AKI)患兒之間的差異,利用多因素Logistic回歸篩選先心病患兒術(shù)后發(fā)生AKI的臨床危險(xiǎn)因素。結(jié)果:本研究共納入298例患兒,其中107例(35.91%)患兒術(shù)后發(fā)生AKI,分別是危險(xiǎn)期82例(27.52%),損傷期16例(5.37%),衰竭期9例(3.02%)。與N-AKI組相比,在術(shù)前情況上,AKI組患兒的平均身高、年齡、體質(zhì)量更低,術(shù)前合并紫紺和其他重要疾病的比率更高,而術(shù)前血清肌酐(serum creatinine,Scr)含量更低;在手術(shù)情況上,AKI組患兒的術(shù)前ASA分級(jí)更高,手術(shù)時(shí)間、主動(dòng)脈鉗閉時(shí)間(aortic clamping time,ACT)、體外循環(huán)(cardiopulmonary bypass,CPB)時(shí)間更長(zhǎng);在術(shù)后情況上,AKI組患兒的術(shù)后平均尿素(Urea)、Scr、尿酸(uric acid,Ua)、視黃醇結(jié)合蛋白值(retinal conjugated protein,RBP)、胱抑素(cystatin-C,CystC)更高,肌酐清除率(estimated creatinine clearance,eCCl)更低;在預(yù)后上,AKI組患兒的平均住院時(shí)長(zhǎng)、死亡率更高。將組間差異顯著的指標(biāo)納入回歸分析,結(jié)果發(fā)現(xiàn)其中年齡1歲、術(shù)前合并紫紺、術(shù)前Scr低、手術(shù)時(shí)間較長(zhǎng)是4歲患兒行先心手術(shù)后發(fā)生AKI的獨(dú)立危險(xiǎn)因素。結(jié)論:年齡1歲、術(shù)前合并紫紺、術(shù)前Scr低的患兒術(shù)后發(fā)生AKI的風(fēng)險(xiǎn)較高,同時(shí)手術(shù)時(shí)間延長(zhǎng)也會(huì)顯著增加先心病患兒術(shù)后AKI的發(fā)生風(fēng)險(xiǎn)。二、先天性心臟病小兒術(shù)后急性腎損傷之體液平衡對(duì)診斷、住院天數(shù)的影響Scr含量測(cè)定受到年齡、肌肉含量與質(zhì)量、蛋白分解代謝、腎功能、心輸出量、體液容量等因素的影響,而受到手術(shù)治療、體液治療的影響,先心病患兒體液容量從術(shù)間到術(shù)后ICU期間可產(chǎn)生較大波動(dòng),體液容量波動(dòng)可造成測(cè)定的Scr也產(chǎn)生波動(dòng),那么體液平衡是否可能通過影響Scr水平而改變術(shù)后AKI的診斷結(jié)果,甚至影響患兒的預(yù)后?為此,我們以簡(jiǎn)單公式校正Scr,探討體液平衡校正Scr對(duì)AKI診斷結(jié)果的影響,同時(shí)以住院天數(shù)作為預(yù)后指標(biāo),研究體液平衡是否會(huì)通過改變先心病患兒術(shù)后AKI的診斷結(jié)果對(duì)住院天數(shù)造成影響。目的:研究體液平衡對(duì)先心病患兒術(shù)后AKI診斷、住院天數(shù)的影響。方法:收集2015年4月~2016年4月于新橋醫(yī)院行先心病手術(shù)治療的4歲患兒資料,以pRIFLE分級(jí)作為AKI的診斷標(biāo)準(zhǔn),探討使用體液平衡校正Scr前后AKI發(fā)生率的差異;利用多元逐步線性回歸排除年齡、NYHA分級(jí)、合并疾病、RACHS-1分級(jí)等因素的干擾,比較體液平衡校正后新增的AKI或N-AKI組患兒與其他患兒住院天數(shù)的差異,研究體液平衡是否會(huì)通過影響AKI診斷影響患兒預(yù)后。結(jié)果:本研究共納入286例患兒,與校正Scr前相比,169體液正平衡患兒Scr校正后AKI發(fā)生率更高,117例體液負(fù)平衡患兒Scr校正后AKI發(fā)生率更低,但總體而言,AKI發(fā)生率不受體液平衡校正Scr的影響;同時(shí)多元逐步線性回歸分析也顯示體液平衡校正后新增的AKI或N-AKI組患兒與其他患兒住院天數(shù)沒有差異。結(jié)論:與校正Scr前相比,校正Scr后pRIFLE標(biāo)準(zhǔn)診斷的AKI發(fā)生率更高,體液正平衡掩蓋AKI的發(fā)生;體液負(fù)平衡校正Scr后診斷的AKI發(fā)生率更低;體液平衡不會(huì)通過影響AKI診斷結(jié)果影響患兒住院天數(shù)。
[Abstract]:According to statistics, the incidence of congenital heart disease (hereinafter referred to as congenital heart disease) reached 9 per thousand, surgical treatment is the main treatment of congenital heart disease, and postoperative acute renal injury (acute kidney injury, AKI) is a serious complication after congenital heart disease, the incidence of the incidence of AKI after 5~33%. preoperation is not accurate, so the early stage of postoperative AKI Prevention, timely diagnosis to reduce the incidence of AKI and severity, and reduce postoperative ventilation time, ICU length, the number of days in hospital, the hospital mortality is of great significance. At present, the study of AKI after congenital heart disease has been paid more and more attention, but the patients with congenital heart disease are a large age group, among which children have not been able to have renal function. There are significant differences in disease characteristics compared with adults, and the risk of postoperative AKI is higher than that of adults, but at present there are few studies in this area. Therefore, 4 year old children are used as research subjects to explore the characteristics of acute renal injury in children with congenital heart disease. First, the clinical risk factors of acute renal injury after congenital heart disease. Screening for high-risk children is a necessary condition for early prevention and early diagnosis of AKI after congenital heart disease. Therefore, it is very important to explore the risk factors of AKI after operation to help clinicians to find high-risk children in time. It is very important to reduce the incidence of postoperative AKI and improve the prognosis of patients. The risk factors of AKI after the first heart operation are not the same, but the age segment of the subjects may be a major cause in addition to the medical institutions and the analysis factors involved in the study. The younger the age, the less mature the renal function is, the greater the probability of AKI after the first heart operation, so this study is my study. We studied the risk factors of postoperative AKI in children with 4 years of age. Objective: to analyze the risk factors of AKI in children with congenital heart disease after 4 years of age. Methods: to collect related data of 4 year old children in new bridge hospital from April 2015 to April 2016, in order to improve the risk classification of children's kidney disease (pediatric risk injury) Failure loss and end stage kidney diseases, pRIFLE), as a diagnostic criterion for AKI, to count the incidence of AKI in children with congenital heart disease, compare the difference between children with AKI after operation and those without AKI. 298 children were included in 298 cases, of which 107 cases (35.91%) had 82 cases (27.52%), 16 cases (5.37%) and 9 (3.02%) in the period of failure. Compared with group N-AKI, the average height, age, and body mass of group AKI were lower, and the rate of cyanosis and other important diseases was higher before operation, and the pre operation blood was higher than that of group AKI. The content of serum creatinine (Scr) was lower, and in the operation, the preoperative ASA classification was higher in the group AKI, the operation time, the time of the aortic clamping (aortic clamping time, ACT), and the extracorporeal circulation (cardiopulmonary bypass, CPB) longer. The value of retinol binding protein (retinal conjugated protein, RBP), cystatin (cystatin-C, CystC) was higher, the creatinine clearance rate (estimated creatinine clearance, eCCl) was lower; in the prognosis, the average length of hospitalization and higher mortality in the AKI group were higher. The results of the difference between groups were included in the regression analysis. The results were found to be 1 years old and preoperatively. Cyanosis, with low preoperative Scr and longer operation time, is an independent risk factor for AKI after 4 years of pre operation. Conclusion: age 1 years old, cyanosis before operation, high risk of AKI in children with low Scr before operation, and the prolonged operation time will significantly increase the risk of AKI in children with Preoperation. Two, congenital heart disease. Influence of Scr content on age, muscle content and quality, protein catabolism, renal function, cardiac output, body fluid volume and so on, and affected by surgical treatment and fluid therapy, the fluid volume of children with congenital heart disease can be measured from the operation to the postoperative ICU period. If the fluctuation of the body fluid volume can cause the fluctuation of the measured Scr, is it possible for the body fluid balance to change the diagnostic results of the postoperative AKI by affecting the Scr level and even affect the prognosis of the children? For this reason, we use a simple formula to correct the Scr and explore the influence of the body fluid balance correction Scr on the results of the AKI diagnosis, and at the same time in the hospital days As a prognostic indicator, study whether body fluid balance will affect the number of days of hospitalization by changing the diagnostic results of AKI in children with congenital heart disease. Objective: To study the effect of body fluid balance on postoperative AKI diagnosis and the number of days in hospital for children with congenital heart disease. Methods: to collect 4 year old children who were treated with congenital heart disease in Xinqiao Hospital in April, April 2015. Data, using pRIFLE classification as a diagnostic criterion for AKI, the difference in the incidence of AKI before and after the use of body fluid balance to correct Scr was investigated. The interference of factors such as age, NYHA classification, disease and RACHS-1 classification were excluded by multiple stepwise linear regression, and the difference of the number of days of hospitalization between children with AKI or N-AKI group and other children was compared after the correction of body fluid balance. Whether or not the body fluid balance could affect the prognosis of children by affecting the AKI diagnosis. Results: 286 children were included in this study. Compared with the corrected Scr, the incidence of AKI was higher after the correction of Scr in children with positive balance of body fluid, and the incidence of AKI was lower in 117 cases with negative balance of body fluid after Scr correction, but overall, the AKI incidence rate of non receptor fluid balance corrected Scr. The multiple stepwise linear regression analysis also showed that the number of children in the new AKI or N-AKI group after correction of body fluid balance was not different from that of other children. Conclusion: compared with the correction of Scr before the correction of Scr, the incidence of AKI was higher after the correction of Scr, the positive balance of the body fluid concealed the occurrence of AKI, and the negative balance of body fluid corrected the AKI hair after Scr. Lower birth rate; humoral balance does not affect the length of hospital stay in children by affecting AKI diagnostic results.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R726.5

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相關(guān)期刊論文 前3條

1 溫昱鵬;常誠(chéng);王仲倫;鄭捷;;兒童非紫紺型先心病體外循環(huán)術(shù)后急性腎損傷相關(guān)危險(xiǎn)因素分析[J];天津醫(yī)藥;2015年05期

2 余章斌;韓樹萍;陳小慧;孫小凡;董小s，

本文編號(hào)：1935931