Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Belgium.
Department of Anesthesiology, Intensive Care & Perioperative Medicine, Assistance Publique Hôpitaux de Paris. Paris Saclay University, Paris, France.
Curr Opin Crit Care. 2024 Dec 1;30(6):542-547. doi: 10.1097/MCC.0000000000001213. Epub 2024 Sep 18.
To discuss the role of hemodynamic management in critically ill patients with acute kidney injury.
Acute kidney injury (AKI) may be associated with persistent alterations in renal perfusion, even when cardiac output and blood pressure are preserved. The effects of interventions aiming at increasing renal perfusion are best evaluated by renal Doppler or contrast enhance ultrasound. However, limited data have been acquired with these techniques and the essential of the literature is based on surrogates of renal function such as incidence of use of renal replacement therapy. Fluids may increase renal perfusion but their effects are quite unpredictable and can be dissociated from their impact on cardiac output and arterial pressure. Inotropes can also be used in selected conditions. At the de-escalation phase, fluid withdrawal should be considered. Safe fluid withdrawal may be achieved when applied in selected patients with preserved tissue perfusion presenting signs of fluid intolerance. When applied, stopping rules should be set. Dobutamine, milrinone and levosimendan increase renal perfusion in AKI associated with cardiac failure or after cardiac surgery. However, the impact of these agents in sepsis is not well defined. Regarding vasopressors, norepinephrine is the first-line vasopressor agent, but vasopressin derivative may limit the requirement of renal replacement therapy. Angiotensin has promising effects in a limited size post-Hoc analysis of a RCT, but these data need to be confirmed. While correction of severe hypotension is associated with improved renal perfusion and function, the optimal mean arterial pressure (MAP) target level remains undefined, Systematic increase in MAP results in variable changes in renal perfusion. It sounds reasonable to individualize MAP target, paying attention to central venous and intraabdominal pressures, as well as to the response to an increase in MAP.
Recent studies have refined the impact of the various hemodynamic interventions on renal perfusion and function in critically ill patients with AKI. Though several of these interventions improve renal perfusion, their impact on renal function is more variable.
讨论血流动力学管理在伴有急性肾损伤的危重病患者中的作用。
急性肾损伤（AKI）可能与肾灌注持续改变有关，即使心输出量和血压得到维持。旨在增加肾灌注的干预措施的效果最好通过肾多普勒或对比增强超声来评估。然而，这些技术获得的数据有限，文献的基础主要是肾功能的替代物，如肾脏替代治疗的使用发生率。液体可以增加肾灌注，但它们的作用是相当不可预测的，并且可以与它们对心输出量和动脉压的影响分开。儿茶酚胺也可以在选定的情况下使用。在降级阶段，应考虑液体撤离。当应用于在组织灌注得到保留的情况下出现液体不耐受迹象的选定患者时，安全的液体撤离是可以实现的。当应用时，应设置停止规则。多巴酚丁胺、米力农和左西孟旦可增加与心力衰竭或心脏手术后相关的 AKI 患者的肾灌注。然而，这些药物在脓毒症中的作用尚未得到很好的定义。关于血管加压药，去甲肾上腺素是一线血管加压药，但血管加压素衍生物可能会限制肾脏替代治疗的需求。血管紧张素在 RCT 的事后有限大小的分析中有良好的效果，但这些数据需要进一步确认。虽然纠正严重低血压与改善肾灌注和功能有关，但最佳平均动脉压（MAP）目标水平仍未确定，MAP 的系统增加导致肾灌注的可变变化。根据需要个性化 MAP 目标，注意中心静脉压和腹腔内压，以及对 MAP 增加的反应，这是合理的。
最近的研究已经细化了各种血流动力学干预措施对伴有 AKI 的危重病患者肾灌注和功能的影响。尽管这些干预措施中的几种可以改善肾灌注，但它们对肾功能的影响更为多变。
