Does furosemide prevent renal dysfunction in high-risk cardiac surgical patients? Results of a double-blinded prospective randomised trial
Does furosemide prevent renal dysfunction in high-risk cardiac surgical patients? Results of a double-blinded prospective randomised trial
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DOI：
10.1016/j.ejcts.2007.12.030
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发表时间：
2008-03-01
影响因子：
3.4
通讯作者：
Pigott, David
中科院分区：
文献类型：
--
作者：
Mahesh, Balakrishnan;Yim, Boyd;Pigott, David
目的：心脏手术后的肾功能障碍在既有肾功能不全、糖尿病和左心功能受损的高危患者中更为明显，并伴随复杂的长时间体外循环(CPB)手术。这项前瞻性随机、双盲、安慰剂对照研究的目的是评估小剂量速尿输注在这一高危人群中的肾脏保护作用。方法：术前血肌酐130mU/g/L(1·4 mg/dl)、左室射血分数<50%、充血性心力衰竭、糖尿病或体外循环时间延长的患者随机分为生理盐水组(n=21)和速尿组(n=21)。麻醉诱导后开始输液，术后持续输液12h。肾功能不全定义为术后血肌酐升高50%，或130Mol/L(1.4 mg/dl)，或需要进行血液透析，或全部这些。在术前血清肌酐130mU/t、>；较术前水平升高50%的患者中，用来定义术后肾功能不全。结果：心脏手术后接受速尿治疗的患者尿量较高(速尿组和安慰剂组分别为3.4mT/kg/h和1.2mT/kg/h；P<0.001)，术后液体需求量较高(速尿组和安慰剂组分别为46.31359ml/m in和37143±/-87ml，p=0.011)，尿肌酐较低(速尿组和安慰剂组分别为2+/-1.3mU/L和5.9mU/-2.5mU/L，P=0.011)；0.001)。两组患者的视黄醇结合蛋白/肌酐比值均显著升高(速尿组视黄醇结合蛋白/肌酐比值分别为7·2±-6和3,152±1,411；安慰剂组分别为4·9±-2·1和2,809±-1125；P<；0.001)和血肌酐峰值显著升高(速尿组为98±-33，P<；安慰剂组为96+/-20,143 87 mot/t；P<；心脏手术后肌酐峰值清除率显著下降(速尿组64.3±29.4mlmin至39.1±16.6mlmin；安慰剂组65.5mlmin±38.6mlmin至41.8mlmin；p<；0.001)，提示心脏手术后肾损伤严重。两组峰值肌酐水平(速尿+/-123mU/L和安慰剂组143.87mU/L，P=0.35)和峰值肌酐清除量(39.1+/-16.6ml/min和41.8±17.8ml/min，P=0.61)相似。重要的是，速尿组(9/21)和对照组(8/21)的肾功能不全发生率没有差异(相对危险度1.1，95%可信区间0.6-2.2；p=0.99)。结论：我们的随机试验没有显示在心脏手术高危患者术后输注速尿有任何益处。尽管速尿增加了尿量，但肾损伤并没有减少，肾功能障碍的发生率也没有减少。(C)2008年欧洲胸心外科协会。爱思唯尔出版，版权所有。
Objective: Renal dysfunction following cardiac surgery is more apparent in high-risk patients with pre-existing renal dysfunction, diabetes and impaired left-ventricutar function, and following complicated procedures involving prolonged cardiopulmonary bypass (CPB). The aim of this prospectively randomised double-blinded placebo-controlled study was to evaluate reno-protective effect of low-dose furosemide infusion in this high-risk group. Methods: Patients with preoperative serum creatinine > 130 mu mol/l (1.4 mg/dl), left-ventricular ejection fraction < 50%, congestive heart failure, diabetes, or procedures involving prolonged CPB were randomised to receive either saline at 2 ml/h (n = 21), or furosemide at 4 mg/h (n = 21). Infusion was commenced after induction of anaesthesia and continued for 12 h postoperatively. Renal dysfunction was defined as > 50% increase in serum creatinine postoperatively, or > 130 mu mol/l (1.4 mg/dl), or requirement for haemodialysis, or all of these. In patients with preoperative serum creatinine > 130 mu mol/t, > 50% increase over preoperative levels was used to define postoperative renal dysfunction. Results: Following cardiac surgery, patients receiving furosemide had a higher urine output (3.4 +/- 1.2 mt/kg/h in furosemide group and 1.2 +/- 0.5 mt/kg/h in placebo group; p < 0.001), higher postoperative fluid requirement (4631 1359 ml/min in furosemide group and 37143 +/- 87 ml. in placebo group, p = 0.011), and lower urinary-creatinine (2 +/- 1.3 mu mol/l in furosemide group and 5.9 +/- 2.5 mu mol in placebo group p < 0.001). Both groups had significant increase in retinol binding protein /creatinine ratio (7.2 +/- 6 to 3152 +/- 1411 in furosemide group; 4.9 +/- 2.1 to 2809 +/- 1125 in placebo group; p < 0.001) and peak serum creatinine (98 +/- 33 to 177 +/- 123 mu mol/l in furosemide group; 96 +/- 20 to 143 87 mot/t in placebo group; p < 0.001), and a significant decrease in peak creatinine-clearance (64.3 +/- 29.4 to 39.1 +/- 16.6 ml/min in furosemide group; 65.5 +/- 38.6 to 41.8 +/- 17.8 ml/min in placebo group; p < 0.001) following cardiac surgery, implying significant renal injury following cardiac surgery. Peak creatinine levels (177 +/- 123 mu mol/l in furosemide group and 143 87 mu mol/l in placebo group; p = 0.35) and peak creatinine-clearance (39.1 +/- 16.6 ml/min in furosemide group and 41.8 17.8 ml/min in placebo group; p = 0.61) were similar in the two groups. Importantly, there was no difference in incidence of renal dysfunction between the furosemide group (9/21) and the control group (8/21) (relative risk 1.1, 95% confidence interval 0.6-2.2; p = 0.99). Conclusions: Our randomised trial did not demonstrate any benefit of furosemide-infusion postoperatively in high-risk cardiac surgical patients. Although urinary output increased with furosemide, there was no decrease in renal injury, and no decrease in incidence of renal dysfunction. (c) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.