Barcenas Camilo G., Jones Peter, Solomon Stuart, Van Reet Richard, Cooley Denton A.
Nephrology, Department of Medicine, and the Cardiovascular Surgery Department of St. Luke's Episcopal Hospital and the Texas Heart Institute, Houston, Texas.
Cardiovasc Dis. 1979 Sep;6(3):298-307.
Although previous reports have attributed acute renal failure (ARF) following cardiovascular surgery to acute tubular necrosis (ATN), little emphasis has been placed on renal failure due to congestive heart failure (CARF). Of 100 cases of ARF studied prospectively over an 18-month period, 36 occurred after open-heart surgery. Nineteen of these cases were associated with heart failure. The remaining 17 had ATN as manifested by high urinary sodium, low urine/plasma creatinine, and abnormal urinary sediment. At the onset of CARF, intravascular volume expansion was universally present, and oliguria with pulmonary edema was common. Urinary chemistries were (mean +/- SD): sodium (mEq/L) 8 +/- 7, U/P creatinine 72 +/- 45, and FENa (%) 0.1 +/- 0.1. Therapy consisted of digoxin, furosemide (F), vasopressors (V), and, when indicated, intraaortic balloon counterpulsation. Survivors of CARF responded more frequently to F and required less V. Ultimately, survival depended upon improvement in cardiac performance. All oliguric ATN patients failed to respond to F. Mortality for the CARF group was 52%. In contrast, 82% of the oliguric ATN group expired, whereas overall ATN mortality was 60%. Cardiogenic acute renal failure is a frequent cause of ARF after open-heart surgery in our institution. It is characterized by prerenal urinary chemistries, has a high mortality, and may be reversible.
尽管先前的报告将心血管手术后的急性肾衰竭（ARF）归因于急性肾小管坏死（ATN），但对充血性心力衰竭所致肾衰竭（CARF）的关注较少。在18个月期间前瞻性研究的100例ARF病例中，36例发生在心脏直视手术后。其中19例与心力衰竭有关。其余17例表现为高尿钠、低尿/血肌酐及异常尿沉渣，诊断为ATN。CARF发病时普遍存在血管内容量扩张，少尿伴肺水肿常见。尿化学指标（均值±标准差）为：钠（mEq/L）8±7，尿/血肌酐72±45，滤过钠排泄分数（%）0.1±0.1。治疗包括地高辛、呋塞米（F）、血管升压药（V），必要时行主动脉内球囊反搏。CARF幸存者对呋塞米反应更频繁，血管升压药用量更少。最终，生存率取决于心脏功能的改善。所有少尿型ATN患者对呋塞米均无反应。CARF组死亡率为52%。相比之下，少尿型ATN组82%患者死亡，而ATN总体死亡率为60%。在我们机构，心源性急性肾衰竭是心脏直视手术后ARF的常见原因。其特点是肾前性尿化学指标，死亡率高，且可能可逆。
