Vives Marc, Wijeysundera Duminda, Marczin Nandor, Monedero Pablo, Rao Vivek
Department of Anesthesia and Pain Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada.
Interact Cardiovasc Thorac Surg. 2014 May;18(5):637-45. doi: 10.1093/icvts/ivu014. Epub 2014 Feb 16.
Acute kidney injury develops in up to 30% of patients who undergo cardiac surgery, with up to 3% of patients requiring dialysis. The requirement for dialysis after cardiac surgery is associated with an increased risk of infection, prolonged stay in critical care units and long-term need for dialysis. The development of acute kidney injury is independently associated with substantial short- and long-term morbidity and mortality. Its pathogenesis involves multiple pathways. Haemodynamic, inflammatory, metabolic and nephrotoxic factors are involved and overlap each other leading to kidney injury. Clinical studies have identified predictors for cardiac surgery-associated acute kidney injury that can be used effectively to determine the risk for acute kidney injury in patients undergoing cardiac surgery. High-risk patients can be targeted for renal protective strategies. Nonetheless, there is little compelling evidence from randomized trials supporting specific interventions to protect or prevent acute kidney injury in cardiac surgery patients. Several strategies have shown some promise, including less invasive procedures in those at greatest risk, natriuretic peptide, fenoldopam, preoperative hydration, preoperative optimization of anaemia and postoperative early use of renal replacement therapy. The efficacy of larger-scale trials remains to be confirmed.
接受心脏手术的患者中，高达30%会发生急性肾损伤，其中高达3%的患者需要透析。心脏手术后的透析需求与感染风险增加、在重症监护病房的住院时间延长以及长期透析需求相关。急性肾损伤的发生与显著的短期和长期发病率及死亡率独立相关。其发病机制涉及多种途径。血流动力学、炎症、代谢和肾毒性因素均有参与且相互重叠，导致肾损伤。临床研究已确定了心脏手术相关急性肾损伤的预测因素，这些因素可有效用于确定接受心脏手术患者发生急性肾损伤的风险。高危患者可作为肾脏保护策略的目标人群。尽管如此，随机试验中几乎没有令人信服的证据支持针对心脏手术患者保护或预防急性肾损伤的特定干预措施。几种策略已显示出一定前景，包括对风险最高的患者采用侵入性较小的手术、使用利钠肽、非诺多泮、术前补液、术前优化贫血状况以及术后早期使用肾脏替代疗法。大规模试验的疗效仍有待证实。
