1 Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.
2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Am J Respir Crit Care Med. 2018 Nov 15;198(10):1279-1287. doi: 10.1164/rccm.201710-2150OC.
No medical intervention has been identified that decreases acute kidney injury and improves renal outcome at 1 year after cardiac surgery.
To determine whether administration of nitric oxide reduces the incidence of postoperative acute kidney injury and improves long-term kidney outcomes after multiple cardiac valve replacement requiring prolonged cardiopulmonary bypass.
Two hundred and forty-four patients undergoing elective, multiple valve replacement surgery, mostly due to rheumatic fever, were randomized to receive either nitric oxide (treatment) or nitrogen (control). Nitric oxide and nitrogen were administered via the gas exchanger during cardiopulmonary bypass and by inhalation for 24 hours postoperatively.
The primary outcome was as follows: oxidation of ferrous plasma oxyhemoglobin to ferric methemoglobin was associated with reduced postoperative acute kidney injury from 64% (control group) to 50% (nitric oxide group) (relative risk [RR], 0.78; 95% confidence interval [CI], 0.62-0.97; P = 0.014). Secondary outcomes were as follows: at 90 days, transition to stage 3 chronic kidney disease was reduced from 33% in the control group to 21% in the treatment group (RR, 0.64; 95% CI, 0.41-0.99; P = 0.024) and at 1 year, from 31% to 18% (RR, 0.59; 95% CI, 0.36-0.96; P = 0.017). Nitric oxide treatment reduced the overall major adverse kidney events at 30 days (RR, 0.40; 95% CI, 0.18-0.92; P = 0.016), 90 days (RR, 0.40; 95% CI, 0.17-0.92; P = 0.015), and 1 year (RR, 0.47; 95% CI, 0.20-1.10; P = 0.041).
In patients undergoing multiple valve replacement and prolonged cardiopulmonary bypass, administration of nitric oxide decreased the incidence of acute kidney injury, transition to stage 3 chronic kidney disease, and major adverse kidney events at 30 days, 90 days, and 1 year. Clinical trial registered with ClinicalTrials.gov (NCT01802619).
在心脏手术后，尚无任何医学干预措施可以降低急性肾损伤的发生率并改善 1 年时的肾脏预后。
确定一氧化氮的应用是否可以降低心脏手术后需要长时间体外循环的复发性多瓣膜置换术后急性肾损伤的发生率，并改善长期肾脏结局。
244 例择期接受多瓣膜置换术的患者（主要病因是风湿热），随机分为一氧化氮（治疗）组或氮气（对照）组。在体外循环期间和术后 24 小时内，通过气体交换器向患者输注一氧化氮和氮气。
主要结局如下：氧化亚铁血红素的高铁血红蛋白的形成与术后急性肾损伤的降低有关，从对照组的 64%降至治疗组的 50%（相对风险 [RR]，0.78；95%置信区间 [CI]，0.62-0.97；P = 0.014）。次要结局如下：90 天时，对照组进展为 3 期慢性肾脏病的患者比例为 33%，而治疗组为 21%（RR，0.64；95%CI，0.41-0.99；P = 0.024），1 年时，从 31%降至 18%（RR，0.59；95%CI，0.36-0.96；P = 0.017）。一氧化氮治疗降低了 30 天（RR，0.40；95%CI，0.18-0.92；P = 0.016）、90 天（RR，0.40；95%CI，0.17-0.92；P = 0.015）和 1 年（RR，0.47；95%CI，0.20-1.10；P = 0.041）时的主要不良肾脏事件发生率。
在接受多瓣膜置换术和长时间体外循环的患者中，给予一氧化氮可降低急性肾损伤、进展为 3 期慢性肾脏病以及 30 天、90 天和 1 年时的主要不良肾脏事件的发生率。该临床试验已在 ClinicalTrials.gov 注册（NCT01802619）。
