Brivet F, Loirat P
Presse Med. 1996 Feb 17;25(6):227-9.
Mortality due to acute renal failure has remained high over the last three decades despite a better understanding of the pathophysiologic mechanics involved and advances in the management of critically ill patients. This paradoxical situation raises many questions concerning the criteria used to assess treatment and disease severity as well as the effectiveness of certain recently proned "advances". In the 1980s, much progress was made in preventing and/or limiting the extent of acute renal failure. The use of very early and vigorous fluid administration associated with alkaline diuresis prevents traumatic rhabdomyolysis; saline hydration before and after radiocontrast administration protects against the acute decrease in renal function in high-risk patients; maintenance of an adequate intravascular volume and of blood pressure helps prevent acute renal failure. After the onset of acute failure, low-dose dopamine can increase urine output, whereas dobutamine improves creatinine clearance but there is no evidence that increasing urine output lowers morbidity or mortality. New techniques have been proposed for acute renal replacement therapy, but except for use of bicarbonate dialysis and biocompatible membranes, none have been shown to be superior. It has been claimed, on the basis of uncontrolled or retrospective studies, that continuous hemofiltration or hemodiafiltration could have a beneficial effect on survival and/or the course of infectious complications. However, convincing evidence of this beneficial effect is lacking since these techniques are incompatible with clinically pertinent removal of proinflammatory cytokines. The type of renal support may have no effect on outcome. Can further progress be expected in the future? Antagonists of NO receptors and growth factors have a protective effect on renal function in animal models, results which may be of clinical relevance. Their clinical potential should be evaluated in prospective randomized trials involving patients where severity of illness is assessed at inclusion using a multiparametric model combining a severity score and relevant prognostic factors.
在过去三十年中，尽管对急性肾衰竭所涉及的病理生理机制有了更深入的了解，并且危重症患者的管理也取得了进展，但急性肾衰竭导致的死亡率仍然居高不下。这种矛盾的情况引发了许多问题，涉及用于评估治疗和疾病严重程度的标准，以及某些最近备受推崇的“进展”的有效性。在20世纪80年代，在预防和/或限制急性肾衰竭的程度方面取得了很大进展。极早期且积极的液体输注联合碱性利尿可预防创伤性横纹肌溶解；在使用放射性造影剂之前和之后进行生理盐水水化可防止高危患者肾功能急性下降；维持足够的血管内容量和血压有助于预防急性肾衰竭。急性肾衰竭发作后，低剂量多巴胺可增加尿量，而多巴酚丁胺可改善肌酐清除率，但没有证据表明增加尿量可降低发病率或死亡率。已经提出了用于急性肾替代治疗的新技术，但除了使用碳酸氢盐透析和生物相容性膜外，没有一种技术被证明更具优势。基于非对照或回顾性研究，有人声称连续性血液滤过或血液透析滤过可能对生存和/或感染性并发症的病程有有益影响。然而，由于这些技术与临床上相关的促炎细胞因子清除不相容，因此缺乏这种有益效果的令人信服的证据。肾脏支持的类型可能对结局没有影响。未来还能期待进一步的进展吗？一氧化氮受体拮抗剂和生长因子在动物模型中对肾功能有保护作用，这些结果可能具有临床相关性。它们的临床潜力应在涉及患者的前瞻性随机试验中进行评估，在纳入时使用结合严重程度评分和相关预后因素的多参数模型评估疾病严重程度。
