Clinical and Financial Impact of Chronic Kidney Disease in Emergency General Surgery Operations
Jun 05, 2023
Abstract
1. Taw qhia
Cov kab mob raum tsis zoo no feem ntau ntsib hauv kev kho mob thiab feem ntau yuav tsum muaj cov tswv yim tswj xyuas ntau dua. Txawm li cas los xij, nws qhov cuam tshuam rau cov txiaj ntsig ntawm cov neeg mob tau lees paub qhov kev phais mob xwm txheej ceev tsis tau ua kom zoo. Txoj kev tshawb fawb tam sim no tau tshuaj xyuas lub koom haum ntawm cov kab mob raum ntev ntawm cov txiaj ntsig hauv tsev kho mob thiab kev nyeem ntawv tom qab kev phais mob xwm txheej ceev uas siv ib pawg neeg sawv cev hauv tebchaws.
2. Cov txheej txheem
Lub 2016-2018 Nationwide Readmissions Database tau nug los txheeb xyuas tag nrho cov neeg laus mus pw hauv tsev kho mob rau 1 ntawm 6 qhov kev ua haujlwm phais mob xwm txheej ceev. Cov neeg mob tau stratified los ntawm qhov mob raum mob hnyav rau theem 1-3, theem 4-5, kab mob raum kawg, thiab lwm yam (mob raum tsis mob). Regression qauv tau siv los tshuaj xyuas cov xwm txheej cuam tshuam nrog kev tuag, kev nyeem ntawv, thiab cov nqi.
3. Cov txiaj ntsig
Ntawm qhov kwv yees li ntawm 985,101 cov neeg mob uas raug kev phais mob xwm txheej ceev, 60,949 (6.2 feem pua) tau kuaj pom tus kab mob raum ntev (1–3: 67.1 feem pua , 4–5: 11.5 feem pua , cov kab mob raum kawg : 23.4 feem pua). Unadjusted tus nqi ntawm cov neeg tuag tau nce nrog rau mob raum nyob rau hauv ib tug stepwise yam (2.1 feem pua ntawm cov kab mob raum uas tsis yog-kho rau 16.9 nyob rau hauv endstage kab mob, P < .001), raws li tau ua 90- hnub nyeem ntawv (9.2 feem pua rau 29.7 feem pua , raws li, P <.001). Tom qab hloov kho, tag nrho cov theem ntawm cov kab mob raum ntev tau nthuav tawm qhov kev pheej hmoo-hloov tus nqi ntawm cov neeg tuag (ntau: 0.2 feem pua ntawm cov kab mob raum ntev 1-3 txog 12.2 feem pua ntawm cov kab mob hauv lub raum, P < .001). Cov txheeb ze rau cov kab mob raum tsis zoo, cov kab mob hauv lub raum kawg tau muaj tus nqi loj tshaj plaws rau cov neeg uas tab tom phais me me (ntxiv rau $ 83,600) thiab tsawg kawg hauv cholecystectomy (ntxiv rau $ 30,400).
4. Cov lus xaus
Kev mob raum mob hnyav yog cuam tshuam nrog kev nce qib hauv kev tuag, nqi tsev kho mob, thiab 90- hnub nyeem ntawv. Peb qhov kev tshawb pom yuav zoo dua qhia txog kev txiav txim siab sib koom thiab muaj feem cuam tshuam rau kev ntsuas ntsuas. Cov kev tshawb fawb ntxiv rau cov tswv yim tswj kom zoo hauv pab pawg muaj kev pheej hmoo siab yog xav tau.
Nyem qhov no kom tau txaiscov teebmeem ntawm Cistanche
Taw qhia
Txawm hais tias kev siv zog los txo cov teebmeem ntawm kev kub siab thiab ntshav qab zib, qhov ua rau lub raum tsis ua haujlwm hauv Tebchaws Meskas, kab mob raum ntev (CKD) tseem nce ntxiv. CKD cuam tshuam nrog kev siv nyiaj kho mob tseem ceeb thiab txo qis lub neej zoo, nrog rau theem kawg ntawm lub raum kab mob ib leeg raug nqi ntau dua $ 30 nphom hauv cov nqi tshaj rau cov neeg tau txais txiaj ntsig Medicare [1]. Tsis tas li ntawd, CKD muaj feem cuam tshuam nrog cov neeg tuag coob thiab mob hnyav tom qab ntau yam kev cuam tshuam kev ua haujlwm [2–6].
Perioperative mob raum tsis ua haujlwm tau cuam tshuam nrog cov xwm txheej tsis zoo thiab kev rov ua haujlwm ntev tom qab ua haujlwm loj hauv plab. Tsis tas li ntawd, kev phais mob xwm txheej ceev (EGS) ua rau muaj kev pheej hmoo ntau dua rau kev ua haujlwm ntawm lub raum tsis zoo vim hypoperfusion, ntim poob, thiab mob [7,8]. Ntxiv mus, kev kho kom zoo dua qub thiab kev siv cov kev tiv thaiv los txo cov mob raum raug mob (AKI) feem ntau tsis muaj peev xwm ua tau hauv qhov xwm txheej kub ntxhov. Txawm li cas los xij, tam sim no tau lees paub dav dav tias lub raum tsis ua haujlwm ua ntej yog cuam tshuam nrog kev pheej hmoo ntau dua ntawm kev ua haujlwm tom qab AKI [9,10].
Txawm hais tias kev tshawb fawb tsawg tau tshuaj xyuas qhov cuam tshuam ntawm CKD ntawm cov txiaj ntsig ntawm appendectomy thiab kev ua haujlwm rau perforated ulcers, ib qho kev ua haujlwm zoo ntawm lub koom haum no rau tag nrho EGSs ntawm lub teb chaws tsis muaj. Yog li ntawd, qhov kev tshawb fawb tam sim no tau siv lub teb chaws tam sim no
cohort los qhia txog kev sib koom ua ke ntawm ntau theem ntawm CKD ntawm cov txiaj ntsig kho mob thiab kev siv peev txheej hauv qab EGS.
Cov txheej txheem
1. Kawm Tsim.
Lub 2016-2018 Nationwide Readmissions Database (NRD) tau nug kom txheeb xyuas txhua tus neeg laus (Ntau dua lossis sib npaug li 18 xyoo) tsev kho mob rau ib qho ntawm 6 qhov kev ua haujlwm EGS hauv qab no: kev phais plab loj, kev phais me me, cholecystectomy, kho lub perforated. ulcer, lysis ntawm adhesions, thiab appendectomy. NRD yog qhov loj tshaj plaws, tag nrho cov neeg them nyiaj cov ntaub ntawv rau kev nyeem ntawv hauv tebchaws thiab tau tswj hwm los ntawm Lub Chaw Haujlwm Saib Xyuas Kev Noj Qab Haus Huv thiab Kev Ua Haujlwm Zoo raws li ib feem ntawm Cov Nqi Kho Mob thiab Kev Siv Khoom Siv. Siv cov txheej txheem kev soj ntsuam-hnyav, NRD muab kev kwv yees tseeb rau kwv yees li 60 feem pua ntawm tag nrho US tsev kho mob [11]. Cov neeg mob tau taug qab thoob plaws hauv tsev kho mob hauv txhua lub xyoo, ua kom yooj yim rau kev kawm txog kev nyeem ntawv.
Cov neeg mob uas tau txais EGS nyob rau hauv 2 hnub ntawm kev txais neeg tsis raug xaiv tau raug txheeb xyuas los ntawm cov txheej txheem International Classification of Diseases, 10th Edition (ICD-10) raws li tau piav qhia yav dhau los [12]. Cov neeg mob uas muaj qhov qhia txog kev raug mob (4.4 feem pua) nrog rau cov uas tsis muaj cov ntaub ntawv tseem ceeb (2.5 feem pua) suav nrog hnub nyoog, poj niam txiv neej, kev tuag, thiab cov nqi raug cais tawm. Cov neeg mob tom qab ntawd tau stratified los ntawm CKD theem siv cov kev kuaj mob ICD yav dhau los: tsis yog CKD, CKD 1–3, CKD 4–5, thiab kab mob raum kawg (ESRD) [2].
Cistanche ntxiv thiab Cistanche tshuaj
2. Kev hloov pauv thiab cov txiaj ntsig kev kawm.
Cov yam ntxwv ntawm tus neeg mob thiab tsev kho mob tau tshaj tawm raws li tau hais tseg los ntawm NRD Data Dictionary thiab suav nrog cov kev hloov pauv hauv qab no; hnub nyoog, poj niam txiv neej, xwm txheej pov hwm, tsev neeg cov nyiaj tau los txhua xyoo, qhov loj ntawm lub txaj pw hauv tsev kho mob, thiab kev qhia hauv tsev kho mob. Kev hloov kho van Walraven ntawm Elixhauser Comorbidity Index tau siv los txheeb xyuas tag nrho lub nra ntawm comorbidities [13]. Cov neeg mob comorbidities tshwj xeeb tau txhais ntxiv siv ICD-10 cov lej kuaj mob. Tag nrho cov nqi rau EGS tsev kho mob tau suav los ntawm kev siv tsev kho mob tshwj xeeb tus nqi-rau-tus nqi sib piv thiab kho rau kev nce nqi siv 2018 Tus Kheej Kev Noj Qab Haus Huv Index [14].
Cov txiaj ntsig tseem ceeb ntawm kev txaus siab yog kev tuag hauv tsev kho mob thiab cov xwm txheej tsis zoo (AE). Peb txhais AE raws li kev sib xyaw ua ke ntawm ib qho teeb meem hauv qab no: mob plawv (nrawm thiab ventricular arrhythmias), ua pa (pneumonia, pneumothorax, mob ua pa nyuaj, ua pa tsis ua haujlwm, lub tshuab ua pa ntev), kab mob (kab mob tom qab phais, thiab qhov chaw phais mob) , cerebrovascular (stroke), thiab venous thromboembolism. Cov txiaj ntsig thib ob suav nrog tus cwj pwm ntawm cov teeb meem tshwj xeeb suav nrog AKI; cov nqi kho mob hauv tsev kho mob; tsis muaj tsev nyob; thiab tsis muaj npe, 90- hnub nyeem ntawv.
3. Kev Tshawb Fawb Txog Kev Tshawb Fawb.
Categorical variables tau tshaj tawm raws li feem pua (feem pua) thiab muab piv siv qhov kev xeem χ2. Cov xwm txheej txuas ntxiv raug tshaj tawm raws li qhov txhais tau tias nrog tus qauv sib txawv (SD) lossis nruab nrab nrog qhov sib txawv ntawm qhov sib txawv (IQRs) yog tias tsis yog ib txwm faib. Kev hloov pauv tsis tu ncua tau muab piv nrog kev hloov kho Wald thiab Mann-Whitney U, raws li qhov tsim nyog. Multivariable regression qauv tau tsim los txheeb xyuas lub koom haum ywj pheej ntawm covariates nrog cov txiaj ntsig ntawm kev txaus siab. Kev xaiv sib txawv tau ua los ntawm qhov tsawg kawg nkaus shrinkage thiab xaiv tus neeg teb xov tooj. Luv luv, qhov tsawg kawg nkaus shrinkage thiab xaiv tus neeg teb xov tooj yog cov txheej txheem kev kawm tshuab uas txo cov qauv overfitting thiab txhim kho qhov tsis zoo ntawm cov qauv siv rau kev xaiv covariate [15]. Thaum kawg, cov qauv raug ntsuas los ntawm kev siv tus neeg teb xov tooj tus yam ntxwv nkhaus (ROC) lossis Akaike thiab Bayesian Cov Ntaub Ntawv Txheej Txheem raws li qhov tsim nyog. Ib lub sij hawm sib cuam tshuam ntawm qeb CKD thiab EGS pawg ua haujlwm tau suav nrog los piav qhia txog qhov cuam tshuam ntawm CKD hla cov kev ua haujlwm subtypes ntawm cov txiaj ntsig kev kawm. Tom qab regression, qhov txaus ntshai-kho qhov tshwm sim raug suav nrog siv STATA margins hais kom ua [16]. Regression outputs tau tshaj tawm raws li kev hloov pauv qhov sib txawv (AORs) lossis beta coefficients (s) nrog 95 feem pua ntawm kev ntseeg siab (95 feem pua CIs) rau logistic thiab linear regressions, feem. Txoj kev Kaplan–Meier tau siv los kawm txog kev nyeem ntawv tsis muaj npe nyob mus txog 90 hnub thoob plaws hauv pab pawg. Kev txheeb xyuas cov ntaub ntawv tau ua tiav siv Stata 16.0 (StataCorp, College Station, TX). Lub Tsev Haujlwm Saib Xyuas Kev Ruaj Ntseg ntawm University of California, Los Angeles, suav tias txoj kev kawm no raug zam los ntawm kev tshuaj xyuas tag nrho.
Cistanche extract thiab Cistanche hmoov
Kev sib tham
Txawm hais tias CKD tau cuam tshuam nrog cov txiaj ntsig tsis zoo tom qab ntau yam kev ua haujlwm thiab kev xaiv lub plab zom mov, cov ntaub ntawv txwv tsis pub muaj txog nws qhov cuam tshuam rau cov txiaj ntsig tom qab EGS. Ua ntej, peb pom CKD muaj feem cuam tshuam nrog nce tus nqi ntawm kev pheej hmoo-hloov kev tuag thiab AE hauv ib kauj ruam tom qab EGS. Qhov thib ob, peb txoj kev tshawb fawb pom tias CKD muaj feem cuam tshuam nrog kev nce ntxiv ntawm ntau yam teeb meem, suav nrog cerebrovascular, kis, thiab AKI. Qhov thib peb, tag nrho cov qib ntawm CKD tau cuam tshuam nrog kev nce nqi hauv tsev kho mob. ESRD kuj tseem cuam tshuam nrog qhov muaj feem ntau ntawm kev tso tawm tsis nyob hauv tsev thiab qhov tsis sib xws ntawm 90- hnub nyeem ntawv. Ntau qhov kev tshawb pom no tseem ceeb rau kev sib tham ntxiv.
Hauv txoj kev tshawb fawb tam sim no, peb pom tias qhov tsis hloov pauv ntawm cov neeg tuag tau nce siab vim tias CKD qhov hnyav nce ntxiv. Tom qab stratifying los ntawm EGS kev khiav hauj lwm, kho cov nqi ntawm cov neeg tuag tau nyob twj ywm siab ntawm CKD pawg. Peb cov txiaj ntsig tau zoo ib yam nrog kev ua haujlwm ua ntej uas koom nrog ESRD nrog kev tuag ntau dua tom qab kev phais mob thiab kho cov kab mob hauv plab perforated gastroduodenal [3,4] thaum txuas lub koom haum no mus rau 4 qhov kev ua haujlwm EGS ntxiv. Cov kev pom zoo hauv kev pheej hmoo-hloov kev tuag nrog kev mob hnyav ntawm CKD tuaj yeem cuam tshuam nrog kev cuam tshuam ntawm homeostatic tswj cov txheej txheem, platelet tsis ua haujlwm, electrolyte imbalances, thiab oxidative kev nyuaj siab thib ob rau lub raum tsis ua haujlwm. Zoo ib yam li kev ua haujlwm ua ntej, peb pom CKD muaj feem cuam tshuam nrog AE thiab cov teeb meem tshwj xeeb [5,8,17,18], suav nrog 1.2-paj nce hauv kev mob stroke thiab 3-fold nce hauv AKI . Yog li, kev txhim kho hauv kev tswj hwm perioperative ntawm cov neeg mob no thiab kev paub txog kev ua haujlwm ntawm lub raum tsis zoo tuaj yeem txhim kho kev rov ua haujlwm tom qab.
Peb kuj tau sau tseg tag nrho cov qhab nia ntawm CKD yuav cuam tshuam nrog cov nqi tsev kho mob ntau dua piv rau lwm tus. Cov kev tshawb pom no tuaj yeem cuam tshuam txog kev saib xyuas ntau dua uas xav tau los tswj cov neeg mob no, xws li kev nkag mus rau hauv tsev kho mob lossis hauv tsev kho mob. Lwm cov kev tshawb fawb tau pom CKD yog vim li cas $1,000–$65,000 hauv cov nqi nruab nrab ntawm cov neeg mob nkag mus [2,19]. Hauv peb txoj kev tshawb fawb, cov neeg mob CKD muaj ntau dua ntawm kev tso tawm tsis nyob hauv tsev, ntxiv rau kev siv peev txheej tom qab pw hauv tsev kho mob. ESRD tau cuam tshuam nrog kev nce ntxiv ntawm 90- hnub nyeem ntawv zoo ib yam li lwm cov kev tshawb fawb [2,20,21]. Cov kev tshawb pom no qhia tias kev txhim kho kev npaj tawm thiab kev soj ntsuam cov neeg mob nyob ze dua tuaj yeem txo tus nqi ntau dua thiab txo tus nqi nyeem ntawv.
Txoj haujlwm tam sim no muaj ntau qhov kev txwv vim nws qhov kev tsim rov qab. Raws li qhov tshwj xeeb creatinine lossis glomerular filtration tus nqi tsis muaj nyob hauv peb cov ntaub ntawv, peb siv cov lej siv tau rau theem CKD los faib peb cov pab pawg hauv pawg kawm. Ib yam li ntawd, peb tsis tuaj yeem txiav txim siab lub sijhawm ntawm lub raum kab mob, uas tuaj yeem cuam tshuam cov txiaj ntsig kev kho mob. Tus neeg mob tus cim tsis raug taug qab thoob plaws xyoo daim ntawv teev npe lossis nyob rau hauv qhov chaw kho mob sab nraud, uas tuaj yeem ua rau muaj qhov tsis txaus ntseeg ntawm kev tuag thiab kev nyeem ntawv. Kev sib piv ntawm cov nqi nyeem ntawv thoob plaws EGS cov pab pawg yog raws li kev ua piv txwv thiab tej zaum yuav tsis tag nrho lub nra hnyav ntawm CKD rau kev ua haujlwm siab dua. Txawm li cas los xij, peb tau siv cov ntaub ntawv tam sim no hauv lub tebchaws los kawm txog qhov cuam tshuam ntawm CKD ntawm kev tuag, cov teeb meem perioperative, thiab cov nqi pw hauv tsev kho mob thiab kev nyeem ntawv tom qab 6 kev ua haujlwm EGS.
Standardized Cistanche
Hauv kev xaus, peb pom CKD muaj feem cuam tshuam nrog qhov muaj feem cuam tshuam ntawm kev tuag perioperative teeb meem, thiab cov nqi tsev kho mob ntau dua. Tsis tas li ntawd, ESRD tau cuam tshuam nrog kev nce ntxiv ntawm kev tso tawm tsis nyob hauv tsev thiab 90- hnub nyeem ntawv. Txoj kev tshawb fawb sawv cev hauv tebchaws no tsim los ntawm cov ntaub ntawv uas twb muaj lawm thiab muab kev pom zoo rau kev pheej hmoo ntau dua ntawm cov txiaj ntsig tsis zoo tom qab EGS ntawm cov neeg muaj CKD. Cov kev tshawb pom no tau lees paub kev tshawb fawb ntxiv txog kev cuam tshuam los txhim kho qhov tshwm sim ntawm kev phais thiab txo qis kev nyeem ntawv hauv cov neeg mob CKD uas xav tau EGS.
Cov ntaub ntawv
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Vishal Dobaria, BS, Joseph Hadaya, MD, Shannon Richardson, MS, Cory Lee, DO, Zachary Tran, MD, Arjun Verma, Yas Sanaiha, MD, Peyman Benharash, MD
