Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada.
Ann Vasc Surg. 2021 Jul;74:419-430. doi: 10.1016/j.avsg.2020.12.061. Epub 2021 Feb 4.
To assess the effect of various preventative interventions for reducing the incidence of postoperative acute kidney injury (AKI) in patients undergoing elective abdominal aortic aneurysm (AAA) repair.
We included randomized controlled trials of 10 patients or more which tested a preventative intervention versus standard therapy or placebo in patients undergoing elective AAA repair using the open or endovascular approach. Studies including mixed patient populations such as those with aortic occlusive disease, thoracoabdominal aneurysms or ruptured aneurysms were ineligible for review. We searched Medline (1966-2019), EMBASE (1947-2019), CINAHL (1961-2019), Web of Science (1945-2019), Scopus (1966-2019), and The Cochrane Library (1996-2019) for trials available as published manuscripts in English. Study quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible we pooled the results of similar interventions using random effects meta-analysis.
We included 17 trials involving 1443 participants. Most trials were small, single-center studies, with varying definitions of AKI and a high or moderate risk of bias. The preventative strategies with possible protective effects were mannitol, a composite of antioxidant supplements, an open extraperitoneal approach, and human atrial natriuretic peptide (hANP). Curcumin, methylprednisolone, carbon dioxide contrast medium, hemodynamic monitoring and N-acetylcysteine were found to be ineffective. Six trials with a total of 355 participants reported on remote ischemic preconditioning (RIPC) and our meta-analysis showed no statistically significant difference between RIPC and standard treatment (OR 1.20, 95% CI 0.37, 3.89); although the results should be interpreted with caution due to considerable statistical heterogeneity (I = 70%). None of the interventions studied significantly reduced receipt of renal replacement therapy (RRT).
Interventions that have shown some potential to reduce AKI after AAA repair include mannitol, a composite of antioxidant supplements, an open extraperitoneal approach and hANP. These conclusions are limited by the small size, high risk of bias and inconsistency of the included trials. Large, high quality, multi-center randomized trials will help determine which interventions are effective in reducing the incidence of postoperative AKI among patients undergoing elective AAA repair.
评估各种预防干预措施对降低择期腹主动脉瘤（AAA）修复术后急性肾损伤（AKI）发生率的影响。
我们纳入了 10 例或以上患者的随机对照试验，这些试验测试了预防干预措施与标准治疗或安慰剂在使用开放或血管内方法进行择期 AAA 修复的患者中的效果。包括混合患者人群（如主动脉闭塞性疾病、胸腹主动脉瘤或破裂性动脉瘤患者）的研究不符合审查条件。我们检索了 Medline（1966-2019 年）、EMBASE（1947-2019 年）、CINAHL（1961-2019 年）、Web of Science（1945-2019 年）、Scopus（1966-2019 年）和 The Cochrane Library（1996-2019 年），以获取以英文发表的试验。使用 Cochrane 协作风险偏倚工具评估研究质量。在可能的情况下，我们使用随机效应荟萃分析汇总了类似干预措施的结果。
我们纳入了 17 项涉及 1443 名参与者的试验。大多数试验是规模较小的单中心研究，AKI 的定义不同，偏倚风险较高或中等。具有潜在保护作用的预防策略包括甘露醇、抗氧化剂补充剂的组合、开放腹膜外入路和人心房利钠肽（hANP）。姜黄素、甲基强的松龙、二氧化碳对比剂、血流动力学监测和 N-乙酰半胱氨酸被发现无效。六项总共有 355 名参与者的试验报告了远程缺血预处理（RIPC），我们的荟萃分析显示 RIPC 与标准治疗之间没有统计学上的显著差异（OR 1.20，95%CI 0.37, 3.89）；尽管由于存在相当大的统计异质性（I = 70%），结果应谨慎解释。研究中没有任何干预措施显著减少肾脏替代治疗（RRT）的应用。
在 AAA 修复术后显示出降低 AKI 潜力的干预措施包括甘露醇、抗氧化剂补充剂的组合、开放腹膜外入路和 hANP。这些结论受到纳入试验规模小、高偏倚风险和不一致性的限制。大型、高质量、多中心随机试验将有助于确定哪些干预措施在降低择期 AAA 修复术后 AKI 发生率方面有效。
