Prevalence and Influence Factors of Renal Function Impairment in Patients Following Radical Cystectomy：A Systematic Review and Meta-analysis
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摘要:
目的 系统评价根治性膀胱切除术患者术后肾功能损害的发生率及影响因素。 方法 检索维普、万方、中国知网、中国生物医学文献数据库、The Cochrane Library、PubMed、Web of Science和Embase数据库中与根治性膀胱切除术患者术后肾功能损害有关的队列研究与病例对照研究。检索时限为建库至2023年9月30日。由2名研究者按照纳入与排除标准独立进行文献筛选、文章质量评价并数据进行提取。采用Stata14.0软件对文献进行Meta分析。 结果 共纳入11篇文献，Meta分析显示，纳入研究的异质性较大（I 2 = 92.5%，P < 0.001），基于随机效应模型得出根治性膀胱切除术后患者肾功能损害发生率为32%[95%CI （0.25，0.35），P < 0.001]，亚组分析显示，研究时长在5 a及其以上30%[95%CI （0.24，0.37），P < 0.001]、研究地区为亚洲35%[95%CI （0.28，0.42），P < 0.001]、以术后估计肾小球滤过率<45 mL/（min·1.73 m2）为评价肾功能损害的标准33%[95%CI （0.29，0.36），P < 0.001]、队列研究39%[95%CI （0.26，0.52），P < 0.001]肾功能损害发生率更高。术后发生肾功能损害的影响因素为年龄[HR = 1.03，95%CI （1.02，1.04）]、高血压[HR = 2.14，95%CI （1.32，3.40）]、肾积水[HR = 1.89，95%CI （1.50，2.36）]、尿路感染[HR = 1.35，95%CI （1.13，1.61）]和吻合口狭窄[HR = 2.53，95%CI （1.77，3.61）]。 结论 根治性膀胱切除术后肾功能损害发生率较高，且与年龄、高血压病史、术后肾积水、尿路感染及吻合口狭窄密切相关，医护人员应加强对此类患者术后肾功能的监测，针对相关影响因素制定有效措施，以降低肾功能损害的发生率。 Abstract:Objective To systematically evaluate the incidence and influencing factors of postoperative renal dysfunction in patients undergoing radical cystectomy. Methods The cohort studies and case-control studies related to postoperative renal function damage of patients undergoing radical cystectomy were retrieved from China HowNet, VIP, Wanfang, China Biomedical Literature Database, The Cochrane Library, PubMed, Web of Science and Embasedatabases. The retrieval time is from the establishment of the database to September 30, 2023. Two researchers independently conducted literature screening and article quality assessment based on predefined inclusion and exclusion criteria. Mata analysis was carried out on the literature with Stata14.0 software. Results A total of 11 articles were included. Meta-analysis showed that the heterogeneity of the included studies was large （I 2 = 92.5%, P < 0.001）. Based on the random effect model, the incidence of renal function damage after radical cystectomy was 32%[95%CI （0.25, 0.35）, P < 0.001], and subgroup analysis showed that the research duration was 5 years or more 30%[95%CI （0.24, 0.37）, P < 0.001], the study area was Asia35%[95%CI （0.28, 0.42） in Asia, P < 0.001] , the postoperative estimated glomerular filtration rate was < 45 mL/（min·1.73m2） as the evaluation standard of renal function damage 33%[95%CI （0.29, 0.36）, P < 0.001]and cohort studies 39%[95%CI （0.26, 0.52）, P < 0.001]is higher. The influencing factors of postoperative renal dysfunction were age[HR = 1.03, 95%CI （1.02, 1.04）], hypertension [HR = 2.14, 95%CI （1.32, 3.40）], hydronephrosis [HR = 1.89, 95%CI （1.50, 2.36）], urinary tract infection[HR = 1.35, 95%CI （1.13, 1.61）] and Anastomotic stenosis [HR = 2.53, 95%CI （1.77, 3.61）]. Conclusion The incidence of renal function damage after radical cystectomy is high, which is closely related to age, history of hypertension, postoperative hydronephrosis, urinary tract infection and anastomotic stenosis. Medical staff should strengthen the monitoring of postoperative renal function and formulate effective measures for related influencing factors to reduce the incidence of renal function damage. -
Key words:
- Renal function damage /
- Radical cystectomy /
- Influencing factors /
- Systematic review /
- Meta analysis
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图 3 根治性膀胱切除术后肾功能损害发生率森林图
Figure 3. Forest plot of incidence of renal impairmentafter radical cystectomy
图 4 根治性膀胱切除术后肾功能损害发生率漏斗图
Figure 4. Funnel plot of the incidence of renal impairment after radical cystectomy
表 1 纳入研究的基本特征及方法学质量评价（n = 11）
Table 1. Basic characteristics of the included studies and methodological quality assessment （n = 11）
纳入研究 国家 研究设计 样本量/中位
随访时间（月）尿流改道方式 结局指标
[mL/（min·1.73m2）]肾功能损伤
发生率（%）影响因素 NOS评分 陈少豪等
2017[9]中国 病例对照 156/89
（60～130）35.9%ONB，43.6%IC，
20.5%CU双肾总eGFR
下降≥25%41.70 ③⑤⑦ 7 Ahmadi等
2022[10]美国 病例对照 508/44
（11～85）/ eGFR下降≥10% 12.60 ①④⑨ 7 Elsayed等
2020[11]美国 病例对照 442/25
（12～59）87%IC，13%其他 术后eGFR< 45 37.10 ③④⑥⑦
⑫⑬⑮7 Eisenberg等
2014[12]美国 病例对照 1631 /126
（85～183）23%ONB，76%IC，
1%CUeGFR下降≥10% 27.00 ①④⑤
⑩⑫⑥7 Nishikawa等
2014[13]日本 队列研究 169/103.8±9.8 24.8%CU，23.7%IC，
51.5%ONB双肾总eGFR
下降≥25%46.20 ⑤⑥⑩ 7 Gershman等
2015[14]美国 队列研究 1383 /12073.8%IC，18.7%ONB，
7.5%其他eGFR下降≥10% / ①⑤⑩
⑪⑫7 郑玮等
2018[15]中国 病例对照 103/16
（3～36）48.5%ONB，23.3%IC，
28.2%CU术后eGFR< 60 38.90 ②④⑧ 7 Hatakeyama
等2016[16]日本 病例对照 115/97
（70～125）59.1%ONB，14.8%IU，
26.1%CU术后eGFR< 45 32.20 ①②④⑩ 7 Kwon等
2016[17]韩国 病例对照 866/
49.8
（1～231.4）/ 术后eGFR< 60 25.60 ①④⑨⑬ 8 Lone等
2021[18]美国 队列研究 644/32
（12～56）72%IC，17%ONB，
11%其他术后eGFR< 45 33.00 ④⑪⑫ 7 金滨等
2023[19]中国 病例对照 46/20
（12～67）45.7%IC，54.3%CU 双肾总eGFR
下降≥25%39.10 ⑥⑯ 7 注：影响因素：①年龄；②尿流改道方式；③糖尿病；④术前肾功能；⑤高血压;⑥尿路感染;⑦身体质量指数（body mass index，BMI）；⑧术后早期肾功能（术后30 d内eGFR）；⑨化疗；⑩术后肾积水；⑪肿瘤分期；⑫吻合口狭窄；⑬急性肾损伤；⑭吻合口狭窄；⑮放疗；⑯围手术期输血缩略式：输尿管皮肤造口（cutaneous ureterostomy，CU）；回肠膀胱术（ileal conduit，IC）；原位新膀胱（orthotopic neobladder，ONB）；开放式根治性膀胱切除术（open radical cystectomy，ORC）；机器人辅助腹腔镜根治性膀胱切除术（robotic-assisted radical cystectomy，RARC）。 
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表 2 根治性膀胱切除术后肾功能损害亚组分析结果
Table 2. Subgroup analysis of renal impairment after radical cystectomy
亚组 纳入研究（项） 异质性检验结果 效应模型 Meta分析结果 I 2（%） P 患病率（%） 95%CI P 研究时长 1 a[12，15，19] 3 70.4 0.034* 随机效应 33 [0.24，0.43] <0.001* 5 a及其以上[9−13，16−18] 7 94.7 <0.001* 随机效应 35 [0.29，0.41] <0.001* 地区 亚洲[9，13，15−17，19] 6 86.5 <0.001* 随机效应 37 [0.28，0.45] <0.001* 欧美[10−12，18] 4 96.1 <0.001* 随机效应 27 [0.19，0.36] <0.001* 结局指标
[mL/（min·1.73m2）]eGFR下降≥25%[9，13，16，19] 4 55.9 0.078 随机效应 40 [0.36，0.45] <0.001* 术后eGFR下降≥10% [10−12] 3 96.9 <0.001* 随机效应 26 [0.24，0.28] <0.001* 术后eGFR<60 [15，17] 2 79.7 <0.001* 随机效应 27 [0.24，0.30] <0.001* 术后eGFR<45 [18] 1 33 [0.29，0.36] <0.001* 研究设计 病例对照[9−12，15−17，19] 8 92.0 <0.001* 随机效应 29 [0.23，0.35] <0.001* 队列研究[13，18] 2 90.1 0.001* 随机效应 39 [0.26，0.52] <0.001* *P < 0.05。
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表 3 根治性膀胱切除术后肾功能损害影响因素的Meta分析
Table 3. Meta-analysis of influencing factors of renal impairment after radical cystectomy
影响因素 纳入文献（项） 异质性检验结果 效应模型 Meta分析结果 I 2（%） P OR 95%CI P 年龄[10，12，14，16-17] 5 9.3 0.353 固定效应 1.03 [1.02，1.04] <0.001* 高血压[9，12−14] 4 71.9 0.014* 随机效应 1.70 [1.17，2.47] 0.005* 术前eGFR[10−12，15−18] 7 98.3 <0.001* 随机效应 0.99 [0.93，1.05] 0.660 肾积水[11−14，16] 5 74.5 0.004* 随机效应 1.84 [1.28，2.36] 0.001* 尿路感染[11−13，19] 4 79.4 0.002* 随机效应 2.34 [1.20，4.59] 0.013* 吻合口狭窄[11-12，14，18] 3 73.3 0.011* 随机效应 2.20 [1.55，3.12] <0.001* *P < 0.05。
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表 4 根治性膀胱切除术后肾功能损害影响因素的Meta分析（剔除异质性来源后）
Table 4. Meta-analysis of factors influencing renal impairment after radical cystectomy （after exclusion of sources of heterogeneity）
影响因素 纳入文献（项） 异质性检验结果 效应模型 Meta分析结果 I 2（%） P OR 95%CI P 年龄[10，12，14，16，17] 5 9.3 0.353 固定效应 1.03 [1.02，1.04] <0.001* 高血压[9，13-14] 3 47.1 0.150 固定效应 2.14 [1.32，3.40] 0.002* 术前eGFR[10−12，15−18] 7 98.3 <0.001* 随机效应 0.99 [0.93，1.05] 0.660 肾积水[11，13-14，16] 4 48.4 0.121 固定效应 1.89 [1.50，2.36] <0.001* 尿路感染[11-12，19] 3 31.0 0.229 固定效应 1.35 [1.13，1.61] <0.001* 吻合口狭窄[11-12，14，18] 3 49.1 0.14 固定效应 2.53 [1.77，3.61] <0.001* *P < 0.05。
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