Campassi María Luz, Gonzalez María Cecilia, Masevicius Fabio Daniel, Vazquez Alejandro Risso, Moseinco Miriam, Navarro Noelia Cintia, Previgliano Luciana, Rubatto Nahuel Paolo, Benites Martín Hernán, Estenssoro Elisa, Dubin Arnaldo
Serviço de Terapia Intensiva, Sanatorio Otamendi y Miroli, Buenos Aires, Argentina.
Serviço de Terapia Intensiva, Hospital General de Agudos "General San Martín", La Plata, Argentina.
Rev Bras Ter Intensiva. 2014 Jan-Mar;26(1):13-20. doi: 10.5935/0103-507x.20140003.
An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the effects on vancomycin concentrations and dosing in a series of intensive care unit patients.
We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120mL/min/1.73m), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered.
Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p<0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations.
In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing.
在一些危重症患者群体中已观察到肾脏清除率增加的情况，这可能导致主要通过肾小球滤过清除的药物（主要是抗生素）浓度未达最佳。目前缺乏关于其发生率及决定因素的研究。我们的目标是确定一系列重症监护病房患者中肾脏清除率增加的发生率及相关因素，以及其对万古霉素浓度和给药剂量的影响。
我们对1年内入住临床外科重症监护病房的363例患者进行了前瞻性研究。排除血清肌酐>1.3mg/dL的患者。通过收集24小时尿液计算肌酐清除率。根据是否存在肾脏清除率增加（肌酐清除率>120mL/min/1.73m²）对患者进行分组，并采用双变量和逻辑回归分析来分析可能的危险因素。对于接受万古霉素治疗的患者，记录其剂量和血浆浓度。
103例患者（28%）存在肾脏清除率增加；他们更年轻（48±15岁 vs 65±17岁，p<0.0001），产科入院（16% vs 7%，p=0.0006）和创伤入院（10% vs 3%，p=0.016）更频繁，合并症更少。肾脏清除率增加的唯一独立决定因素是年龄（OR 0.95；p<0.0001；95%CI 0.93 - 0.96）和无糖尿病（OR 0.34；p=0.03；95%CI 0.12 - 0.92）。46例接受万古霉素治疗的患者中有12例存在肾脏清除率增加，尽管剂量更高，但浓度更低。
在这组危重症患者中，肾脏清除率增加是常见现象。年龄和无糖尿病是仅有的独立决定因素。因此，更年轻且既往健康的患者可能需要更大剂量的万古霉素。
