All authors: Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden.
Crit Care Med. 2013 Oct;41(10):2328-35. doi: 10.1097/CCM.0b013e31828e946a.
Acute kidney injury develops in a large proportion of patients after cardiac surgery because of the low cardiac output syndrome. The inodilator levosimendan increases cardiac output after cardiac surgery with cardiopulmonary bypass, but a detailed analysis of its effects on renal perfusion, glomerular filtration, and renal oxygenation in this group of patients is lacking. We therefore evaluated the effects of levosimendan on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen demand/supply relationship, i.e., renal oxygen extraction, early after cardiac surgery with cardiopulmonary bypass.
Prospective, placebo-controlled, and randomized trial.
Cardiothoracic ICU of a tertiary center.
Postcardiac surgery patients (n=30).
The patients were randomized to receive levosimendan, 0.1 µg/kg/min after a loading dose of 12 µg/kg (n=15), or placebo (n=15).
The experimental procedure started 4-6 hours after surgery in the ICU during propofol sedation and mechanical ventilation. Systemic hemodynamic were evaluated by a pulmonary artery thermodilution catheter. Renal blood flow and glomerular filtration rate were measured by the renal vein retrograde thermodilution technique and by renal extraction of Cr-EDTA, respectively. Central venous pressure was kept constant by colloid/crystalloid infusion. Compared to placebo, levosimendan increased cardiac index (22%), stroke volume index (15%), and heart rate (7%) and decreased systemic vascular resistance index (21%), whereas mean arterial pressure was not affected. Levosimendan induced significant increases in renal blood flow (12%, p<0.05) and glomerular filtration rate (21%, p<0.05), decreased renal vascular resistance (18%, p<0.05) but caused no significant changes in filtration fraction, renal oxygen consumption, or renal oxygen extraction, compared to placebo.
After cardiac surgery with cardiopulmonary bypass, levosimendan induces a vasodilation, preferentially of preglomerular resistance vessels, increasing both renal blood flow and glomerular filtration rate without jeopardizing renal oxygenation. Due to its pharmacodynamic profile, levosimendan might be an interesting alternative for treatment of postoperative heart failure complicated by acute kidney injury in postcardiac surgery patients.
体外循环心脏手术后，由于低心排综合征，很大一部分患者会发生急性肾损伤。正性肌力药左西孟旦增加体外循环心脏手术后的心输出量，但缺乏对该组患者肾灌注、肾小球滤过率和肾氧合作用的详细分析。因此，我们评估了左西孟旦对体外循环心脏手术后早期肾血流、肾小球滤过率、肾氧耗量和肾氧供需关系（即肾氧摄取）的影响。
前瞻性、安慰剂对照、随机试验。
三级中心心胸重症监护病房。
心脏手术后患者（n=30）。
患者随机接受负荷剂量 12μg/kg 后以 0.1μg/kg/min 的左西孟旦（n=15）或安慰剂（n=15）治疗。
实验程序在 ICU 中手术后 4-6 小时开始，在异丙酚镇静和机械通气期间进行。通过肺动脉热稀释导管评估全身血流动力学。通过肾静脉逆行热稀释技术和肾摄取 Cr-EDTA 分别测量肾血流和肾小球滤过率。通过胶体/晶体输注保持中心静脉压恒定。与安慰剂相比，左西孟旦增加了心指数（22%）、每搏指数（15%）和心率（7%），降低了全身血管阻力指数（21%），而平均动脉压不受影响。与安慰剂相比，左西孟旦可显著增加肾血流（12%，p<0.05）和肾小球滤过率（21%，p<0.05），降低肾血管阻力（18%，p<0.05），但对滤过分数、肾氧耗量或肾氧摄取无显著影响。
体外循环心脏手术后，左西孟旦引起血管扩张，优先作用于肾小球前阻力血管，增加肾血流和肾小球滤过率，而不损害肾氧合。由于其药效学特性，左西孟旦可能是治疗心脏手术后并发急性肾损伤的术后心力衰竭患者的一种有趣的替代药物。
