From the Department of Epidemiology and Preventive Medicine, The Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Australia (M.B., C.L.H., A.F., R.B.); Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand (S.M., R.P.); Department of Nephrology and Hypertension, Diabetes, and Endocrinology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany (M.H., A.H.-F.); and Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada (S.M.B.).
Anesthesiology. 2015 Feb;122(2):294-306. doi: 10.1097/ALN.0000000000000547.
The effect of urinary alkalinization in cardiac surgery patients at risk of acute kidney injury (AKI) is controversial and trial findings conflicting. Accordingly, the authors performed a prospectively planned individual patient data meta-analysis of the double-blind randomized trials in this field.
The authors studied 877 patients from three double-blind, randomized controlled trials enrolled to receive either 24 h of intravenous infusion of sodium bicarbonate or sodium chloride. The primary outcome measure was a postoperative increase in serum creatinine concentration of greater than 25% or 0.5 mg/dl (> 44 μM/L) within the first five postoperative days. Secondary outcomes included the raw change in serum creatinine, greater than 50% and greater than 100% rises in serum creatinine, developing AKI (Acute Kidney Injury Network criteria), initiation of renal replacement therapy, morbidity, and mortality.
Patients were similar in demographics, comorbidities, and cardiac procedures. Sodium bicarbonate increased plasma bicarbonate (P < 0.001) and urine pH (P < 0.001). There were no differences in the development of the primary outcome (Bicarbonate 45% [39-51%] vs. Saline 42% [36-48%], P = 0.29). This result remained unchanged when controlling for study and covariates (odds ratio [OR], 99% confidence interval [CI]: Bicarbonate vs. Control, 1.11 [0.77-1.60], P = 0.45). There was, however, a significant study-adjusted benefit in elective coronary artery bypass surgery patients in terms of renal replacement therapy (Bicarbonate vs. Control, OR: 0.38 [99% CI: 0.25-0.58], P < 0.0001) and the development of an Acute Kidney Injury Network grade = 3 (Bicarbonate vs. Control, OR: 0.45 [99% CI: 0.43-0.48], P < 0.0001).
Urinary alkalinization using sodium bicarbonate infusion is not associated with an overall lower incidence of AKI; however, it reduces severe AKI and need for renal replacement therapy in elective coronary artery bypass patients.
在有急性肾损伤（AKI）风险的心脏手术患者中，尿液碱化的效果存在争议，且试验结果相互矛盾。因此，作者对该领域的三项双盲随机试验进行了前瞻性个体化患者数据荟萃分析。
作者研究了来自三项双盲随机对照试验的 877 名患者，这些患者被纳入接受 24 小时静脉输注碳酸氢钠或氯化钠。主要观察指标为术后 5 天内血清肌酐浓度升高>25%或>0.5mg/dl (>44 μM/L)。次要结局包括血清肌酐的原始变化、>50%和>100%的血清肌酐升高、急性肾损伤（急性肾损伤网络标准）的发生、肾脏替代治疗的开始、发病率和死亡率。
患者在人口统计学、合并症和心脏手术方面相似。碳酸氢钠增加了血浆碳酸氢盐（P < 0.001）和尿液 pH 值（P < 0.001）。主要结局的发生没有差异（碳酸氢盐组 45% [39-51%] vs. 生理盐水组 42% [36-48%]，P = 0.29）。当控制研究和协变量时，结果仍然不变（碳酸氢盐与对照组的比值比[OR]，99%置信区间[CI]：碳酸氢盐 vs. 对照组，1.11 [0.77-1.60]，P = 0.45）。然而，在择期冠状动脉旁路移植手术患者中，碳酸氢盐治疗在肾脏替代治疗方面具有显著的研究调整获益（碳酸氢盐 vs. 对照组，OR：0.38 [99% CI：0.25-0.58]，P < 0.0001）和急性肾损伤网络分级=3 的发生（碳酸氢盐 vs. 对照组，OR：0.45 [99% CI：0.43-0.48]，P < 0.0001）。
使用碳酸氢钠输注进行尿液碱化与 AKI 的总体发生率降低无关；然而，它减少了择期冠状动脉旁路移植患者的严重 AKI 和肾脏替代治疗的需要。
