Green J, Better O S
J Am Soc Nephrol. 1995 May;5(11):1853-71. doi: 10.1681/ASN.V5111853.
The association between obstructive jaundice and postoperative acute renal failure has been originally described more than eight decades ago and is now a well-established clinical phenomenon. Acute renal failure occurs in 8 to 10% of patients requiring surgery for relief of obstructive jaundice and contributes to eventual mortality in 70 to 80% of those who develop it. A major factor that may underlie the susceptibility to renal failure in patients with obstructive jaundice is cardiovascular instability manifested as systemic hypotension and defective vascular reactivity. This article outlines the scope of the clinical association between jaundice and renal failure and reviews the clinical and experimental studies that have contributed to our understanding of the underlying pathophysiologic mechanisms for this phenomenon. A growing body of evidence emanating from these studies indicates that bile constituents (e.g., bile acids, bilirubin, cholesterol) do not exert a direct nephrotoxic effect. Rather, the retention of bile during cholestatic jaundice has deleterious effects on cardiovascular function and on blood volume. This, in turn, sensitizes the kidney to prerenal failure and acute tubular necrosis in postsurgical patients with obstructive jaundice. The institution of prophylactic measures based on the appreciation of these underlying pathogenic mechanisms may result in an improvement in the overall prognosis of jaundiced patients undergoing surgery.
梗阻性黄疸与术后急性肾衰竭之间的关联早在八十多年前就已被首次描述，如今已成为一种公认的临床现象。在因梗阻性黄疸而需要手术缓解症状的患者中，8%至10%会发生急性肾衰竭，而在发生急性肾衰竭的患者中，70%至80%最终会死亡。梗阻性黄疸患者易患肾衰竭的一个主要因素是心血管不稳定，表现为全身低血压和血管反应性缺陷。本文概述了黄疸与肾衰竭之间临床关联的范围，并回顾了有助于我们理解这一现象潜在病理生理机制的临床和实验研究。这些研究中越来越多的证据表明，胆汁成分（如胆汁酸、胆红素、胆固醇）不会产生直接的肾毒性作用。相反，胆汁淤积性黄疸期间胆汁的潴留会对心血管功能和血容量产生有害影响。这进而使梗阻性黄疸术后患者的肾脏对肾前性肾衰竭和急性肾小管坏死更加敏感。基于对这些潜在致病机制的认识而采取预防性措施，可能会改善接受手术的黄疸患者的总体预后。
