Nigwekar Sagar U, Navaneethan Sankar D, Parikh Chirag R, Hix John K
Rochester General Hospital, University of Rochester School of Medicine and Dentistry, 1425 Portland Ave, Rochester, NY, USA, 14621.
Cochrane Database Syst Rev. 2009 Oct 7(4):CD006028. doi: 10.1002/14651858.CD006028.pub2.
Acute kidney injury (AKI) is common in hospitalised patients and is associated with significant morbidity and mortality. Despite recent advances, outcomes have not substantially changed in the last four decades. Atrial natriuretic peptide (ANP) has shown promise in animal studies, however randomised controlled trials (RCTs) have shown inconsistent clinical benefits.
To assess the benefits and harms of ANP for preventing and treating AKI.
We searched CENTRAL, MEDLINE and EMBASE and reference lists of retrieved articles.
RCTs that investigated all forms of ANP versus any other treatment in adult hospitalised patients with or "at risk" of AKI.
Results were expressed as risk ratios (RR) with 95% confidence intervals (CI) or mean difference (MD). Outcomes were analysed separately for low and high dose ANP for preventing or treating AKI.
Nineteen studies (11 prevention, 8 treatment; 1,861 participants) were included. There was no difference in mortality between ANP and control in either the low or high dose prevention studies. Low (but not high) dose ANP was associated with a reduced need for RRT in the prevention studies (RR 0.32, 95% CI 0.14 to 0.71). Length of hospital and ICU stay were significantly shorter in the low dose ANP group. For established AKI, there was no difference in mortality with either low or high dose ANP. Low (but not high) dose ANP was associated with a reduction in the need for RRT (RR 0.54, 95% CI 0.30 to 0.98). High dose ANP was associated with more adverse events (hypotension, arrhythmias). After major surgery there was a significant reduction in RRT requirement with ANP in the prevention studies (RR 0.56, 95% CI 0.32 to 0.99), but not in the treatment studies. There was no difference in mortality between ANP and control in either the prevention or treatment studies. There was a reduced need for RRT with low dose ANP in patients undergoing cardiovascular surgery (RR 0.35, 95% CI 0.18 to 0.70). ANP was not associated with outcome improvement in either radiocontrast nephropathy or oliguric AKI.
AUTHORS' CONCLUSIONS: ANP may be associated with improved outcomes when used in low doses for preventing AKI and in managing postsurgery AKI and should be further explored in these two settings. There were no significant adverse events in the prevention studies, however in the high dose ANP treatment studies there were significant increases hypotension and arrhythmias.
急性肾损伤（AKI）在住院患者中很常见，且与显著的发病率和死亡率相关。尽管最近有进展，但在过去四十年里，其治疗结果并未有实质性改变。心房利钠肽（ANP）在动物研究中显示出前景，然而随机对照试验（RCT）的临床益处并不一致。
评估ANP预防和治疗AKI的益处和危害。
我们检索了Cochrane系统评价数据库、医学期刊数据库（MEDLINE）和荷兰医学文摘数据库（EMBASE）以及检索到文章的参考文献列表。
针对成年住院患者中所有形式的ANP与任何其他治疗方法对比，这些患者患有AKI或“有风险”患AKI的随机对照试验。
结果以风险比（RR）及95%置信区间（CI）或均值差（MD）表示。分别分析低剂量和高剂量ANP预防或治疗AKI的结果。
纳入了19项研究（11项预防研究，8项治疗研究；1861名参与者）。在低剂量或高剂量预防研究中，ANP组和对照组的死亡率无差异。在预防研究中，低剂量（而非高剂量）ANP与减少肾脏替代治疗（RRT）需求相关（RR 0.32，95%CI 0.14至0.71）。低剂量ANP组的住院时间和重症监护病房（ICU）停留时间显著更短。对于已确诊的AKI，低剂量或高剂量ANP的死亡率无差异。低剂量（而非高剂量）ANP与减少RRT需求相关（RR 0.54，95%CI 0.30至0.98）。高剂量ANP与更多不良事件（低血压、心律失常）相关。在预防研究中，大手术后使用ANP可显著降低RRT需求（RR 0.56，95%CI 0.32至0.99），但在治疗研究中并非如此。在预防或治疗研究中，ANP组和对照组的死亡率无差异。接受心血管手术的患者使用低剂量ANP可减少RRT需求（RR 0.35，95%CI 0.18至0.70）。ANP在造影剂肾病或少尿型AKI中均未改善预后。
低剂量使用ANP预防AKI以及处理术后AKI可能改善预后，应在这两种情况下进一步探索。在预防研究中无显著不良事件，但在高剂量ANP治疗研究中，低血压和心律失常显著增加。
