Kakajiwala Aadil, Kim Ji Young, Hughes John Z, Costarino Andrew, Ferguson John, Gaynor J William, Furth Susan L, Blinder Joshua J
Department of Pediatrics, Division of Pediatric Nephrology, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Pediatrics, Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Clinical Translational Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2017 Oct;104(4):1388-1394. doi: 10.1016/j.athoracsur.2017.03.015. Epub 2017 May 9.
This was a retrospective study to determine whether lack of furosemide responsiveness (LFR) predicts acute kidney injury (AKI) after cardiopulmonary bypass surgery in infants.
Infants (less than 1 year of age) undergoing cardiopulmonary bypass surgery, receiving routine postoperative furosemide (0.8 to 1.2 mg/kg per dose between 8 and 24 hours after surgery) were included. Urine output was measured 2 and 6 hours after furosemide dose. Lack of furosemide responsiveness was defined a priori as urine output less than 1 mL · kg · h after furosemide. Serum creatinine was corrected for fluid balance. Acute kidney injury was determined using changes in uncorrected and corrected serum creatinine. The predictive utility of LFR was assessed using receiver-operating characteristics curve analysis.
We analyzed 568 infants who underwent cardiopulmonary bypass. Eighty-one (14.3%) had AKI using uncorrected serum creatinine; AKI occurred in 41 (7.2%) after correcting for fluid overload. Patients with AKI had a lower response to furosemide (median urine output 2 hours: 1.2 versus 3.4 mL · kg · h, p = 0.01; median urine output 6 hours: 1.3 versus 2.9 mL · kg · h, p = 0.01). After creatinine correction, LFR predicts AKI development (area under receiver-operating characteristics curve of 0.74 at 2 hours and 0.77 at 6 hours). After adjusting for surgical complexity using The Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery mortality categories, the area under the receiver-operating characteristics curve was 0.74 at 2 hours and 0.81 at 6 hours. Patients with urine output greater than 1 mL · kg · h were unlikely to have AKI (negative predictive value, 97%).
After correcting serum creatinine for fluid balance and adjusting for surgical complexity, LFR performs fairly at 2 hours, whereas at 6 hours, LFR is a good AKI predictor. Prospective studies are needed to validate whether diuretic responsiveness predicts AKI.
这是一项回顾性研究，旨在确定呋塞米反应缺乏（LFR）是否可预测婴儿体外循环手术后的急性肾损伤（AKI）。
纳入接受体外循环手术、术后常规使用呋塞米（术后8至24小时每剂0.8至1.2 mg/kg）的婴儿（小于1岁）。在给予呋塞米后2小时和6小时测量尿量。呋塞米反应缺乏预先定义为给予呋塞米后尿量小于1 mL·kg·h。血清肌酐根据液体平衡进行校正。使用未校正和校正后的血清肌酐变化来确定急性肾损伤。使用受试者工作特征曲线分析评估LFR的预测效用。
我们分析了568例接受体外循环的婴儿。使用未校正的血清肌酐时，81例（14.3%）发生AKI；校正液体超负荷后，41例（7.2%）发生AKI。AKI患者对呋塞米的反应较低（2小时时尿量中位数：1.2 vs 3.4 mL·kg·h，p = 0.01；6小时时尿量中位数：1.3 vs 2.9 mL·kg·h，p = 0.01）。校正肌酐后，LFR可预测AKI的发生（2小时时受试者工作特征曲线下面积为0.74，6小时时为0.77）。使用胸外科医师协会/欧洲心胸外科学会死亡率分类对手术复杂性进行校正后，2小时时受试者工作特征曲线下面积为0.74，6小时时为0.81。尿量大于1 mL·kg·h的患者不太可能发生AKI（阴性预测值为97%）。
在对血清肌酐进行液体平衡校正并对手术复杂性进行校正后，LFR在2小时时表现尚可，而在6小时时，LFR是AKI的良好预测指标。需要进行前瞻性研究来验证利尿剂反应性是否可预测AKI。
