Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China.
Outcomes Research Consortium, Cleveland, OH, USA.
BMC Anesthesiol. 2021 Mar 3;21(1):67. doi: 10.1186/s12871-021-01288-8.
The incidence of acute kidney injury (AKI) remains high after partial nephrectomy. Ischemia-reperfusion injury produced by renal hilum clamping during surgery might have contributed to the development of AKI. In this study we tested the hypothesis that goal-directed fluid and blood pressure management may reduce AKI in patients following partial nephrectomy.
This was a pilot randomized controlled trial. Adult patients who were scheduled to undergo partial nephrectomy were randomized into two groups. In the intervention group, goal-directed hemodynamic management was performed from renal hilum clamping until end of surgery; the target was to maintain stroke volume variation < 6%, cardiac index 3.0-4.0 L/min/m and mean arterial pressure > 95 mmHg with crystalloid fluids and infusion of dobutamine and/or norepinephrine. In the control group, hemodynamic management was performed according to routine practice. The primary outcome was the incidence of AKI within the first 3 postoperative days.
From June 2016 to January 2017, 144 patients were enrolled and randomized (intervention group, n = 72; control group, n = 72). AKI developed in 12.5% of patients in the intervention group and in 20.8% of patients in the control group; the relative reduction of AKI was 39.9% in the intervention group but the difference was not statistically significant (relative risk 0.60, 95% confidence interval [CI] 0.28-1.28; P = 0.180). No significant differences were found regarding AKI classification, change of estimated glomerular filtration rate over time, incidence of postoperative 30-day complications, postoperative length of hospital stay, as well as 30-day and 6-month mortality between the two groups.
For patients undergoing partial nephrectomy, goal-directed circulatory management during surgery reduced postoperative AKI by about 40%, although not significantly so. The trial was underpowered. Large sample size randomized trials are needed to confirm our results.
Clinicaltrials.gov identifier: NCT02803372 . Date of registration: June 6, 2016.
肾部分切除术后急性肾损伤（AKI）的发病率仍然很高。手术中肾门夹闭引起的缺血再灌注损伤可能导致 AKI 的发生。在这项研究中，我们检验了一个假设，即目标导向的液体和血压管理可能会降低肾部分切除术后患者的 AKI 发生率。
这是一项前瞻性随机对照试验。计划行肾部分切除术的成年患者被随机分为两组。在干预组中，从肾门夹闭到手术结束进行目标导向的血流动力学管理；目标是通过晶体液输注和多巴酚丁胺及/或去甲肾上腺素输注，维持每搏量变异度＜6%、心指数 3.0-4.0L/min/m2和平均动脉压＞95mmHg。在对照组中，根据常规实践进行血流动力学管理。主要结局是术后 3 天内 AKI 的发生率。
2016 年 6 月至 2017 年 1 月，共纳入并随机分配 144 例患者（干预组 n=72；对照组 n=72）。干预组有 12.5%的患者发生 AKI，对照组有 20.8%的患者发生 AKI；干预组 AKI 的相对减少率为 39.9%，但差异无统计学意义（相对风险 0.60，95%置信区间 [CI] 0.28-1.28；P=0.180）。两组间 AKI 分级、肾小球滤过率随时间的变化、术后 30 天并发症发生率、术后住院时间以及 30 天和 6 个月死亡率均无显著差异。
对于接受肾部分切除术的患者，术中目标导向的循环管理可将术后 AKI 减少约 40%，但差异无统计学意义。本试验的样本量不足。需要更大样本量的随机临床试验来证实我们的结果。
Clinicaltrials.gov 标识符：NCT02803372。注册日期：2016 年 6 月 6 日。
