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急性肾衰竭并不是“急性肾成功”——急性肾损伤中肾氧供/需关系的临床研究。

Acute renal failure is NOT an "acute renal success"--a clinical study on the renal oxygen supply/demand relationship in acute kidney injury.

机构信息

Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.

出版信息

Crit Care Med. 2010 Aug;38(8):1695-701. doi: 10.1097/CCM.0b013e3181e61911.

Abstract

OBJECTIVES

Acute kidney injury occurs frequently after cardiac or major vascular surgery and is believed to be predominantly a consequence of impaired renal oxygenation. However, in patients with acute kidney injury, data on renal oxygen consumption (RVO2), renal blood flow, glomerular filtration, and renal oxygenation, i.e., the renal oxygen supply/demand relationship, are lacking and current views on renal oxygenation in the clinical situation of acute kidney injury are presumptive and largely based on experimental studies.

DESIGN

Prospective, two-group comparative study.

SETTING

Cardiothoracic intensive care unit of a tertiary center.

PATIENTS

Postcardiac surgery patients with (n = 12) and without (n = 37) acute kidney injury were compared with respect to renal blood flow, glomerular filtration, RVO2, and renal oxygenation.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Data on systemic hemodynamics (pulmonary artery catheter) and renal variables were obtained during two 30-min periods. Renal blood flow was measured using two independent techniques: the renal vein thermodilution technique and the infusion clearance of paraaminohippuric acid, corrected for renal extraction of paraaminohippuric acid. The filtration fraction was measured by the renal extraction of Cr-EDTA and the renal sodium resorption was measured as the difference between filtered and excreted sodium. Renal oxygenation was estimated from the renal oxygen extraction. Cardiac index and mean arterial pressure did not differ between the two groups. In the acute kidney injury group, glomerular filtration (-57%), renal blood flow (-40%), filtration fraction (-26%), and sodium resorption (-59%) were lower, renal vascular resistance (52%) and renal oxygen extraction (68%) were higher, whereas there was no difference in renal oxygen consumption between groups. Renal oxygen consumption for one unit of reabsorbed sodium was 2.4 times higher in acute kidney injury.

CONCLUSIONS

Renal oxygenation is severely impaired in acute kidney injury after cardiac surgery, despite the decrease in glomerular filtration and tubular workload. This was caused by a combination of renal vasoconstriction and tubular sodium resorption at a high oxygen demand.

摘要

目的

心脏或大血管手术后常发生急性肾损伤,据信主要是由于肾氧合作用受损所致。然而,在急性肾损伤患者中,关于肾氧消耗(RVO2)、肾血流、肾小球滤过和肾氧合的数据(即肾氧供/需关系)尚缺乏,目前对急性肾损伤临床情况下肾氧合的看法是推测性的,主要基于实验研究。

设计

前瞻性、两组比较研究。

设置

三级中心心胸重症监护病房。

患者

心脏手术后有(n=12)和无(n=37)急性肾损伤的患者,比较肾血流、肾小球滤过、RVO2 和肾氧合。

干预

无。

测量和主要结果

在两个 30 分钟期间获得了系统血流动力学(肺动脉导管)和肾变量的数据。肾血流使用两种独立的技术进行测量:肾静脉热稀释技术和对氨基马尿酸的输注清除率,对氨基马尿酸的肾提取进行校正。滤过分数通过 Cr-EDTA 的肾提取来测量,通过过滤和排泄的钠之间的差异来测量肾钠吸收。从肾氧提取来估计肾氧合。心指数和平均动脉压在两组之间无差异。在急性肾损伤组中,肾小球滤过率(-57%)、肾血流(-40%)、滤过分数(-26%)和钠吸收(-59%)降低,肾血管阻力(52%)和肾氧提取(68%)升高,而两组之间的肾氧消耗无差异。急性肾损伤时,每单位重吸收的钠消耗的氧为 2.4 倍。

结论

尽管肾小球滤过率和肾小管工作量下降,但心脏手术后急性肾损伤的肾氧合严重受损。这是由肾血管收缩和高氧需求下的肾小管钠吸收相结合引起的。

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