Baiardo Redaelli Martina, Monaco Fabrizio, Bradic Nikola, Scandroglio Anna Mara, Ti Lian Kah, Belletti Alessandro, Viscido Cristina, Licheri Margherita, Guarracino Fabio, Pruna Alessandro, Pisano Antonio, Pontillo Domenico, Federici Francesco, Losiggio Rosario, Serena Giovanni, Tomasi Enrico, Silvetti Simona, Ranucci Marco, Brazzi Luca, Cortegiani Andrea, Landoni Giovanni, Mastroroberto Pasquale, Paternoster Gianluca, Gaudino Mario F L, Zangrillo Alberto, Bellomo Rinaldo
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Clinic of Anesthesiology, Resuscitation and Intensive Care, University Hospital Dubrava, Zagreb, Croatia; University North, Department of Nursing, Varazdin, Croatia.
Anesthesiology. 2025 May 1;142(5):818-828. doi: 10.1097/ALN.0000000000005336. Epub 2024 Dec 19.
In the PROTECTION trial (Intravenous Amino Acid Therapy for Kidney Protection in Cardiac Surgery), intravenous amino acids decreased the occurrence of acute kidney injury in cardiac surgery patients with cardiopulmonary bypass. Recruitment of renal functional reserve may be responsible for such protection. However, patients with chronic kidney disease have diminished renal functional reserve, and amino acids may be less protective in such patients. Thus, a separate investigation of such patients is warranted.
For this study chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 ml · min -1 · 1.73 m -2 , and patients with estimated glomerular filtration rates greater than or equal to 60 ml · min -1 · 1.73 m -2 served as controls. The primary outcome was the occurrence of acute kidney injury. Secondary outcomes included severity of acute kidney injury, need for and duration of renal replacement therapy, and all-cause mortality.
Among chronic kidney disease patients (n = 812), compared with placebo, amino acids significantly decreased the rate of acute kidney injury (43.1% vs 50.3%; relative risk, 0.86; 95% CI, 0.74 to 0.99; P = 0.041; number needed to treat = 14) with a median percentage increase in estimated glomerular filtration rate from baseline to postoperative day 3 of 12.7% versus 6.5% ( P = 0.002). In estimated glomerular filtration rate-based chronic kidney disease subgroups (30 to 39, 40 to 49, and 50 to 59 ml · min -1 · 1.73 m -2 ), the amino acid effect was similar (interaction P = 0.50). Finally, amino acid infusion decreased the occurrence of severe (stage 3) acute kidney injury (2.7% vs . 5.6%; relative risk 0.48; 95% CI, 0.24 to 0.98; P = 0.038).
Amino acid infusion protected chronic kidney disease patients undergoing cardiopulmonary bypass from developing acute kidney injury, with an absolute risk reduction of 7% and a number needed to treat of 14 in a cohort with a greater than 45% rate of acute kidney injury. Moreover, it delivered a greater than 50% relative risk reduction in severe acute kidney injury.
在“保护”试验（心脏手术中静脉输注氨基酸对肾脏的保护作用）中，静脉输注氨基酸可降低接受体外循环心脏手术患者急性肾损伤的发生率。肾功能储备的调动可能是这种保护作用的原因。然而，慢性肾脏病患者的肾功能储备减少，氨基酸对这类患者的保护作用可能较弱。因此，有必要对这类患者进行单独研究。
在本研究中，慢性肾脏病定义为估算肾小球滤过率低于60 ml·min⁻¹·1.73 m⁻²，估算肾小球滤过率大于或等于60 ml·min⁻¹·1.73 m⁻²的患者作为对照。主要结局是急性肾损伤的发生情况。次要结局包括急性肾损伤的严重程度、肾脏替代治疗的需求及持续时间，以及全因死亡率。
在慢性肾脏病患者（n = 812）中，与安慰剂相比，氨基酸显著降低了急性肾损伤的发生率（43.1% 对50.3%；相对危险度，0.86；95%可信区间，0.74至0.99；P = 0.041；需治疗人数 = 14），从基线到术后第3天估算肾小球滤过率的中位数百分比增加为12.7%，而安慰剂组为6.5%（P = 0.002）。在基于估算肾小球滤过率的慢性肾脏病亚组（30至39、40至49和50至59 ml·min⁻¹·1.73 m⁻²）中，氨基酸的作用相似（交互作用P = 0.50）。最后，输注氨基酸降低了严重（3期）急性肾损伤的发生率（2.7%对5.6%；相对危险度0.48；95%可信区间，0.24至0.98；P = 0.038）。
输注氨基酸可保护接受体外循环的慢性肾脏病患者不发生急性肾损伤，在急性肾损伤发生率超过45%的队列中，绝对风险降低7%，需治疗人数为14。此外，它使严重急性肾损伤的相对风险降低超过50%。
