Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury: A Meta-analysis of Randomized and Observational Studies
Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury: A Meta-analysis of Randomized and Observational Studies
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DOI：
10.1053/j.ajkd.2009.01.267
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发表时间：
2009-09-01
影响因子：
13.2
通讯作者：
Thakar, Charuhas V.
中科院分区：
文献类型：
--
作者：
Nigwekar, Sagar U.;Kandula, Praveen;Thakar, Charuhas V.
背景：冠状动脉旁路移植术（CABG）后的急性肾损伤（阿基）与显著的发病率和死亡率相关。关于非体外循环技术是否可以减少CABG术后肾损伤存在争议。研究设计：系统回顾和荟萃分析。设置和人群：接受CABG的成人患者。研究选择标准：MEDLINE、EMBASE、科克伦肾脏图书馆，于2008年5月在Google和Google Scholar中检索比较非体外循环CABG（OPCAB）与传统CABG（CAB）的随机对照试验（RCT）和观察性研究肾脏结果。排除了涉及长期肾脏替代治疗（RRT）患者的研究。干预：OPCAB。结局：主要结局为总体阿基和需要RRT的阿基。结果：22项研究（6项RCT和16项观察性研究），包括27，806例患者，符合纳入标准。两个研究队列的汇总效应显示总体阿基显著降低（比值比[OR]，0.57; 95%置信区间[CI]，0.43至0.76;效应P < 0.001; I（2）= 67%;异质性P < 0.001）和需要RRT的阿基OPCAB组与CAB组相比（OR，0.55; 95% CI，0.43 - 0.71;效应P < 0.001; I（2）= 0%;异质性P = 0.5）。在RCT中，OPCAB组的总体阿基显著降低（OR，0.27; 95% CI，0.13 - 0.54）;然而，在需要RRT的阿基中未观察到统计学显著差异（OR，0.31; 95% CI，0.06 - 1.59）。在观察性队列中，OPCAB组的总体阿基（OR，0. 61; 95% CI，0. 45 - 0. 81）和需要RRT的阿基（OR，0. 54; 95% CI，0. 40 - 0. 73）均显著较少。随机对照试验被认为是不够有力的，并偏向于招募低风险患者。局限于高质量研究的敏感性分析显示阿基显著减少。局限性：纳入研究中缺乏统一的阿基定义，阿基总体结局的异质性。结论：对当前证据的分析表明，使用OPCAB技术可减少阿基;然而，研究在定义阿基方面缺乏一致性。现有RCT的效力不足，无法检测需要RRT的阿基差异;观察性研究的证据表明RRT需求减少。未来的研究应采用阿基的标准定义，并以高风险人群为目标。美国肾脏病杂志54：413-423。(C)2009年，美国国家肾脏基金会（National Kidney Foundation，Inc.）爱思唯尔公司出版All rights reserved.
Background: Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with significant morbidity and mortality. Controversy exists regarding whether an off-pump technique can reduce post-CABG renal injury.Study Design: Systematic review and meta-analysis.Setting & Population: Adult patients undergoing CABG.Selection Criteria for Studies: MEDLINE, EMBASE, Cochrane Renal Library, and Google Scholar were searched in May 2008 for randomized controlled trials (RCTs) and observational studies comparing off-pump CABG (OPCAB) with conventional CABG (CAB) for renal outcomes. Studies involving patients on long-term renal replacement therapy (RRT) were excluded.Intervention: OPCAB.Outcomes: Primary outcomes were overall AKI and AKI requiring RRT.Results: 22 studies (6 RCTs and 16 observational studies) comprising 27,806 patients met the inclusion criteria. The pooled effect from both study cohorts showed a significant reduction in overall AKI (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.43 to 0.76; P for effect < 0.001; l(2) = 67%; P for heterogeneity < 0.001) and AKI requiring RRT (OR, 0.55; 95% Cl, 0.43 to 0.71; P for effect < 0.001; l(2) = 0%; P for heterogeneity = 0.5) in the OPCAB group compared with the CAB group. In RCTs, overall AKI was significantly reduced in the OPCAB group (OR, 0.27; 95% Cl, 0.13 to 0.54); however, no statistically significant difference was noted in AKI requiring RRT (OR, 0.31; 95% Cl, 0.06 to 1.59). In the observational cohort, both overall AKI (OR, 0.61; 95% Cl, 0.45 to 0.81) and AKI requiring RRT (OR, 0.54; 95% Cl, 0.40 to 0.73) were significantly less in the OPCAB group. RCTs were noted to be underpowered and biased toward recruiting low-risk patients. Sensitivity analysis restricted to good-quality studies showed a significant reduction in AKI.Limitations: Lack of uniform AKI definition in the included studies, heterogeneity for overall AKI outcome.Conclusions: Analysis of the current evidence suggests a reduction in AKI using the OPCAB technique; however, studies lack consistency in defining AKI. Available RCTs are underpowered to detect a difference in AKI requiring RRT; evidence from observational studies suggests a reduction in RRT requirement. Future studies should apply a standard definition of AKI and target a high-risk population. Am J Kidney Dis 54:413-423. (C) 2009 by the National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.