Кардиоренальный синдром в ранние сроки коронарного шунтирования
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Материалы и методы. Обследовано 90 больных, перенесших КШ, в возрасте 58±7 лет с длительностью ИБС 6±6 лет. Ранее перенесли инфаркт миокарда 80% пациентов. Хроническая сердечная недостаточность в рамках II функционального класса (ФК) выявлена у 53,3%, III ФК – у 46,7% больных. Многососудистое коронарное поражение имели 75,6% пациентов. КШ на работающем сердце выполнено 11,1%, в условиях искусственного кровообращения – 88,9% больных. Уровень креатинина в крови определяли по методу Jaffe, cкорость клубочковой фильтрации (СКФ) рассчитывали по формуле СКD-EPI. ОПП диагностировали с учетом критериев KDIGO 2012 г.
Результаты и обсуждение. Частота транзиторного ОПП после КШ составила 33,3%, пФП – 17,8%, пФП среди лиц с ОПП – 20%. Развитие ОПП ассоциировано с более высокими уровнями тропонина Т после КШ (медиана [25-й; 75-й перцентили] – 0,36 [0,24; 0,99] против 0,28 [0,11; 0,50] нг/мл; р=0,037), более частым применением инотропных средств (60 и 25%; р=0,002), большей длительностью инотропной терапии (2,0 [1,0; 2,5] против 1,0 [0; 1,0] дней; р=0,001). Доля больных, имевших пФП, среди лиц с ОПП и без такового существенно не различалась (20 и 16,7%; р=0,7). Снижение СКФ <39 [29,8; 45,7] мл/мин/1,73 м2 после КШ – наиболее значимый фактор риска пФП у больных ИБС с ОПП.
Ключевые слова: коронарное шунтирование, острое почечное повреждение, послеоперационная фибрилляция предсердий.
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doi: 10.1161/hc4901.101760
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25. Fried L, Solomon C, Shlipak M, et al. Inflammatory and prothrombotic markers and progression of renal disease in elderly individuals. J Am Soc Nephrol. 2004;15:3184-91. doi: 10.1097/01.asn.0000146422. 45434.35
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1. [Shabalkin BV. Formation and development of coronary surgery. Grudnaya i Serdechno-Sosudistaya Khirurgiya = Thoracic and Cardiovascular Surgery. 2001;(2):4-7 (In Russ.)].
2. Al-Ruzzeh S, George S, Yacoub V, Amrani M. The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients. Eur J Cardiothorac Surg. 2001;20:1152-6. doi: 10.016/s1010-7940(01) 00978-2
3. [Arutyunyan LA, Nelaew VS, Mashkin AM, et al. Markers of fatal and non-fatal risk complications in surgical myocardial revascularization operations. Meditsinskaya Nauka i Obrazovanie Urala = Medical Science and Education in the Urals. 2015;(2):65-9 (In Russ.)].
4. Watanabe H, Watanabe T, Sasaki S. Close bidirectional relationship between chronic kidney disease and atrial fibrillation: the Niigata preventive medicine study. Am Heart J. 2009;158(4):629-36. doi: 10.1016/ j.ahj.2009.06.031
5. Iguchi Y, Kimura K, Kobayashi K. Relation of atrial fibrillation to glomerular filtration rate. Am J Cardiol. 2008;102(8):1056-9.
doi: 10.1016/j.amjcard.2008.06.018
6. Tsagalis G, Bakirtzi N, Manios E, et al. Atrial fibrillation in chronic hemodialysis patients: prevalence, types, predictors, and treatment practices in Greece. Artif Organs. 2011;35:916-22. doi: 10.1111/j.1525-1594.2011.01229.x
7. Bos MG, Koudstaal PI, Hofman A, Breteler MM. Decreased glomerular filtration rate is a risk factor for hemorrhagic but not for ischemic Stroke: the Rotterdam Study. Stroke. 2007;38:3127-32. doi: 10.1161/ strokeaha.107.489807
8. Go AS, Fang MC, Udaltsova N, et al. ATRIA Study Investigators. Impact of proteinuria and glomerular filtration rate on risk thromboembolism in atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Circulation. 2009;119:1363-9.
doi: 10.1161circulationaha.108.816082
9. Alonso A, Lopez FL, Matsushita K, et al. Chronic kidney disease is associated wich the incidence of atrial fibrillation: the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2011;123(25):2946-53. doi: 10.1161/circulationaha.111.020982
10. [2014 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2014;35:2541-619. doi: 10.1093/eurheartj/ehu278].
11. Comments on KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:622-3. doi: 10.1038/ki2013.243
12. Fliser D, Laville M, Covic A, et al. A European Renal Best Practice (ERBP) position statement of the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines on Acute Kidney
Injury. Part 1. Definition, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant. 2012:0:1-10. doi: 10.1093/ndt/ gfs375
13. [Iskenderov BG, Sisina ON. Predictive value of Renal Dysfunction for Early and Long-Term Outcomes of Coronary Bypass Grafting. Kardiology. 2015;(11):73-8 (In Russ.)]. doi: 10.18565/cardio.2015.11.73-78
14. [Kremneva LV, Abaturova OV, Shalaev SV. Frequency of in-hospital cardiovascular сomplications in patients with postoperative renal dysfunction after surgical myocardial revascularization. Angiologiya i Sosudistaya Khirurgiya = Angiology and Vascular Surgery. 2016;(4): 124-8. (In Russ.)].
15. Zeng X, McMahon GM, Brunelli SM, et al. Incidence, Outcomes, and Comparisons arcoss Definitions of AKI in Hospitalized Individuals. Clin J Am Soc Nephrol. 2013;9:12-20. doi: 10.2215/cjn.02730313
16. [Smirnov AV, Dobronravov VA, Rumyantsev AS, et al. National recommendations. Acute renal injury: basic principles of diagnosis, prevention and therapy. Nephrology. 2016;20(1):79-104 (In Russ.)]. doi: 10.22141/2307-1257.3.17.2016.76539
17. [Bokeriya LA, Goluhova EZ, Merzlyakov VU, Farafonova TN. Prognostic actors for the development of arrhythmias in the early period after coronary artery bypass grafting in conditions of artificial blood circulation and a beating heart. Annaly Aritmologii = The Annals of Arrhythmology. 2006;2:72-7 (In Russ.)].
18. [Shorohova IV, Shalaev SV. Atrial fibrillation as a complication of surgical myocardial revascularization, predictors of its development. Meditsinskaya Nauka i Obrazovanie Urala = Medical Science and Education in the Urals. 2009;(1):132-8 (In Russ.)].
19. Zaman AG, Archbold RA, Helft G. Atrial fibrillation after coronary artery bypass surgery: A model for pre-operative risk stratification. Circulation. 2000;101:1403-8. doi: 10.1067/mhj.2000.105102
20. Мurphy GI, Ascione R, Caputo M, Angelini GD. Operative factors that contribute to post-operative atrial fibrillation: Insights from a prospective randomized trial. Card Electrophysiol Rev. 2003;7(2):136-9.
doi: 10.1023/a:1027407431834
21. Ng RR, Tan GH, Liu W, et al. The Association of Acute Kidney Injury and Atrial Fibrillation after Cardiac Surgery in an Asian Prospective Cohort Study. Medicine (Baltimore). 2016;95(12):e3005. doi: 10.1097/ MD.0000000000003005
22. Albarani MJ, Swaminathan M, Phillips-Bute B, et al. Postcardiac surgery complications: association of acute renal dysfunction and atrial fibrillation. Anesth Analg. 2003;96:637-43. doi: 10.1213/01.ane. 0000047886.81598.2c
23. Chung MK, Martin DO, Sprecher D, et al. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation. 2001;104:2886-91.
doi: 10.1161/hc4901.101760
24. Shlipak MG, Fried LF, Crump C, et al. Elevations of inflammatory and procoagulant biomarkers in elderly persons with renal insufficiency. Circulation. 2003;107:87-92. doi: 10.1161/01.cir.0000042700. 48769.59
25. Fried L, Solomon C, Shlipak M, et al. Inflammatory and prothrombotic markers and progression of renal disease in elderly individuals. J Am Soc Nephrol. 2004;15:3184-91. doi: 10.1097/01.asn.0000146422. 45434.35
ФГБОУ ВО «Тюменский государственный медицинский университет» Минздрава России, Тюмень, Россия
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L.V. Kremneva, O.V. Abaturova, A.Y. Efanov, S.V. Shalaev
Tyumen State Medical University, Ministry of Health of Russia, Tyumen, Russia