【目的】分析白蛋白与球蛋白比值（Albumin to globulin ratio，AGR）对急性A型主动脉夹层（Acute type A aortic dissection，ATAAD）患者术后急性肾损伤（Acute kidney injury，AKI）的预测价值。使用AGR作为分层指标，分析高、低危组中弓部处理方式对ATAAD患者术后AKI的影响。

【方法】回顾性纳入2016年1月至2018年12月于南京鼓楼医院接受外科手术治疗的551名ATAAD患者，其中139人发生术后AKI。收集并分析患者术前、术中与术后资料，分析并比较两组的早、中期预后，使用Logistic回归模型分析患者术后AKI的独立危险因素。进一步筛选接受主动脉弓手术的患者共546人，按照不同弓部处理方式分为次全弓置换组（Hemi-arch replacement，HAR）、全弓置换组（Total arch replacement，TAR）和主动脉弓支架组。使用AGR截断值将纳入患者分为高、低危组，使用Logistic回归模型确定高、低危组中弓部处理方式对ATAAD术后AKI的影响。

【结果】与非AKI组相比，AKI组患者术前血小板计数（146.00, 98.00-176.00 vs. 153.95， 120.00-193.75 x10⁹ /L，p=0.008）和纤维蛋白原浓度（2.00，1.48-2.50 vs. 2.20，1.60-3.10 g/L，p=0.021）更低，氯离子浓度（104.10，101.68-106.60 vs. 102.90，100.10-105.70 mmol/L，p=0.019）和AGR（1.75，1.66-2.04 vs. 1.50，1.21-1.58， p<0.001）更高。AKI组患者体外循环时间（252.00，208.00-303.00 vs. 232.00，194.25-270.00 min， p=0.013）和升主动脉阻断时间（178.00，145.00-220.00 vs. 164.00，129.25-198.00 min，p=0.015）更长。术前AGR水平对术后AKI具有良好的预测能力（AUC=0.817，p<0.001）。取1.65为AGR的截断值，AGR>1.65是ATAAD患者术后AKI的独立危险因素（OR：22.721，95% CI：13.336，38.710，p<0.001）。根据截断值将患者分为AKI高危组和低危组，亚组分析提示高危组中接受TAR手术的患者术后AKI发生率更高（63.3% vs. 39.3%，p=0.003）。接受TAR手术是高危组患者术后发生AKI的独立危险因素（All p<0.05）。

【结论】在接受手术治疗的ATAAD患者中，术前高水平的AGR与术后AKI有关。对于高危人群，TAR手术可能会给患者带来二次打击，增加术后AKI的发生风险。

Objective: This study aimed to analyze the predictive value of albumin to globulin ratio (AGR) for postoperative acute kidney injury (AKI) in patients with acute type A aortic dissection (ATAAD). Using AGR as a stratification indicator, the effect of different types of aortic arch surgery on AKI in the high- and low- risk groups was further analyzed, respectively.

Methods: A total of 551 patients with ATAAD who underwent surgical treatment at Nanjing Drum Tower Hospital from January 2016 to December 2018 were retrospectively included, of whom 139 developed postoperative AKI and 412 did not. Preoperative, intraoperative, and postoperative data of the patients were collected and analyzed to compare the early and midterm prognoses of the two groups. The independent risk factors for postoperative AKI in ATAAD patients were analyzed using logistic regression model. Furthermore, 546 patients who underwent aortic arch surgery were selected and divided into the hemi-arch replacement (HAR), total arch replacement (TAR) and aortic arch stent implantation groups according to the different types of arch procedures. The included patients were categorized into high- and low-risk groups using the AGR cut-off value, and the effect of aortic arch management on postoperative AKI after ATAAD in two groups was determined using logistic regression model.

Results: Compared with the non-AKI group, preoperative platelet count (146.00, 98.00-176.00 vs. 153.95, 120.00-193.75 x109 /L, p=0.008) and fibrinogen concentration (2.00, 1.48-2.50 vs. 2.20, 1.60-3.10 g/L, p=0.021) were lower, while chloride concentration (104.10, 101.68-106.60 vs. 102.90, 100.10-105.70 mmol/L, p=0.019) and AGR (1.75, 1.66-2.04 vs. 1.50, 1.21-1.58, p<0.001) were higher. Patients in the AKI group had longer cardiopulmonary bypass time (252.00, 208.00-303.00 vs. 232.00, 194.25-270.00 min, p=0.013) and aortic cross-clamping time (178.00, 145.00-220.00 vs. 164.00, 129.25-198.00 min, p=0.015). The preoperative AGR level had a good predictive ability for postoperative AKI (AUC=0.817, p<0.001). Taking 1.65 as the cut-off value, AGR>1.65 was an independent risk factor for postoperative AKI in ATAAD patients (OR: 22.721, 95% CI: 13.336, 38.710, p<0.001). Patients were then categorized into AKI high- and low- risk groups based on AGR cut-off value, and subgroup analyses further suggested a higher incidence of postoperative AKI in the high-risk group in patients who underwent TAR surgery (63.3% vs. 39.3%, p=0.003). Undergoing TAR surgery was the independent risk factor for postoperative AKI in the high-risk group (All p=0.018).

Conclusion: A high level of preoperative AGR is associated with postoperative AKI in patients undergoing ATAAD surgery. In high-risk populations, TAR surgery may bring a second blow to the patients, raising the risk of postoperative AKI.