Lemaire Scott A, Jones Marisa M, Conklin Lori D, Carter Stacey A, Criddell Monique D, Wang Xing Li, Raskin Steven A, Coselli Joseph S
Texas Heart Institute at St Luke's Episcopal Hospital, Houston, Texas, USA.
J Vasc Surg. 2009 Jan;49(1):11-9; discussion 19. doi: 10.1016/j.jvs.2008.08.048. Epub 2008 Nov 22.
More effective adjuncts are needed to reduce the incidence of acute renal injury after thoracoabdominal aortic aneurysm (TAAA) repair. The purpose of this randomized trial was to determine whether renal perfusion with cold blood provides better protection against renal ischemia than perfusion with cold crystalloid in patients undergoing TAAA repair with left heart bypass.
One hundred seventy-two patients were enrolled. Strict inclusion criteria were used, including planned Crawford extent II or III TAAA repair with left heart bypass. The patients were randomly assigned to receive intermittent renal perfusion with either 4 degrees C lactated Ringer's solution (n = 86) or 4 degrees C blood (n = 86). Renal complications within 10 days of operation were stratified by renal dysfunction score (RDS). Postoperative changes in the levels of five urinary biomarkers-retinol binding protein, alpha-1 microglobulin, microalbumin, N-acetyl-beta-D-glucosaminidase, and intestinal alkaline phosphatase-were compared to assess potential differences in subclinical renal injury.
Although total ischemic times were longer in the cold blood group, unprotected ischemic times were similar between the two groups. Twenty-seven patients in the cold blood group (31%) and 21 patients in the cold crystalloid group (24%) had peak RDS >or=2 (serum creatinine >50% above baseline; P = .4). There were no differences between the cold blood and cold crystalloid groups in the incidence of early death (7/86 [8%] vs 5/86 [6%], respectively; P = .8) or renal failure requiring hemodialysis (3/86 [3%] in both groups). Changes in renal biomarker levels were also similar in the two groups. Spinal cord deficits developed in 5 patients in the cold blood group (6%); there were no such deficits in the cold crystalloid group (P = .06).
Cold renal perfusion during TAAA repair provides effective protection against renal injury. Using cold blood instead of cold crystalloid does not enhance renal protection.
需要更有效的辅助手段来降低胸腹主动脉瘤（TAAA）修复术后急性肾损伤的发生率。本随机试验的目的是确定在接受左心转流的TAAA修复患者中，冷血肾灌注是否比冷晶体液灌注能更好地保护肾脏免受缺血损伤。
纳入172例患者。采用严格的纳入标准，包括计划行CrawfordⅡ或Ⅲ级TAAA修复并采用左心转流。患者被随机分配接受用4℃乳酸林格液（n = 86）或4℃血液（n = 86）进行间歇性肾灌注。术后10天内的肾脏并发症按肾功能障碍评分（RDS）分层。比较五种尿生物标志物（视黄醇结合蛋白、α-1微球蛋白、微量白蛋白、N-乙酰-β-D-葡萄糖苷酶和肠碱性磷酸酶）水平的术后变化，以评估亚临床肾损伤的潜在差异。
尽管冷血组的总缺血时间较长，但两组的无保护缺血时间相似。冷血组27例患者（31%）和冷晶体液组21例患者（24%）的RDS峰值≥2（血清肌酐高于基线50%以上；P = 0.4）。冷血组和冷晶体液组在早期死亡发生率（分别为7/86 [8%] 对5/86 [6%]；P = 0.8）或需要血液透析的肾衰竭发生率（两组均为3/86 [3%]）方面无差异。两组肾生物标志物水平的变化也相似。冷血组有5例患者（6%）出现脊髓损伤；冷晶体液组未出现此类损伤（P = 0.06）。
TAAA修复术中冷肾灌注可有效保护肾脏免受损伤。使用冷血而非冷晶体液并不能增强肾脏保护作用。
