Comparison of high- and low-dose corticosteroid regimens for organ donor management
Comparison of high- and low-dose corticosteroid regimens for organ donor management
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DOI：
10.1016/j.jcrc.2012.04.015
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发表时间：
2013-02-01
影响因子：
3.7
通讯作者：
Wright, Robert
中科院分区：
文献类型：
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作者：
Dhar, Rajat;Cotton, Colleen;Wright, Robert
目的：脑死亡后应用糖皮质激素可促进血流动力学稳定，减少炎性器官损伤。根据与未经治疗/既往对照的比较，大剂量(HD)甲基强的松龙已成为标准方案。然而，该方案可能会加剧高血糖。我们的目的是比较小剂量(LD)类固醇方案(在肾上腺功能不全和脓毒症时足以稳定血流动力学)和传统HD方案在脑死亡器官捐赠者管理中的作用。方法：我们评估了连续132例脑死亡器官捐赠者在激素方案从15 mg/kg甲基强的松龙(HD)改为300 mg氢化可的松(LD)前后的治疗。主要观察指标为血糖控制、氧合、血流动力学稳定性和器官移植。结果：除LD队列中基线PaO2无明显升高外，其余各组均达到平衡。最终的PaO2仍然较高(394毫米汞LD比333毫米汞HD，P=.03)；但氧合改善相似(+37毫米汞LD比+28毫米汞HD，P=.43)，能够停止血管加压药支持的比例(39%LD比47%HD，P=.38)。两组的肺(44%比33%)和心脏(31%比27%)的移植比例相似。排除糖尿病患者后，使用LD类固醇的患者4小时血糖中位数(170 mmol/L vs188 mmol/L，P=0.06)和终末胰岛素需要量(2.9U/h vs8.4U/h，P=0.01)较低，更多的患者停止胰岛素输注(74%LDvs53%HD，P=0.02)。结论：与传统HD方案相比，小剂量皮质类固醇方案不会导致供者肺或心功能恶化，移植的器官与传统HD方案相当。胰岛素需求和血糖控制都得到了改善。可能不需要大剂量的甲基强的松龙来支持脑死亡的捐赠者。(C)2013 Elsevier Inc.保留所有权利。
Purpose: Corticosteroids are used to promote hemodynamic stability and reduce inflammatory organ injury after brain death. High-dose (HD) methylprednisolone has become the standard regimen based on comparisons to untreated/historical controls. However, this protocol may exacerbate hyperglycemia. Our objective was to compare a lower-dose (LD) steroid protocol (adequate for hemodynamic stabilization in adrenal insufficiency and sepsis) to the traditional HD regimen in the management of brain-dead organ donors.Methods: We evaluated 132 consecutive brain-dead donors managed before and after changing the steroid protocol from 15 mg/kg methylprednisolone (HD) to 300 mg hydrocortisone (LD). Primary outcome measures were glycemic control, oxygenation, hemodynamic stability, and organs transplanted.Results: Groups were balanced except for nonsignificantly higher baseline PaO2 in the LD cohort. Final PaO2 remained higher (394 mm Hg LD vs 333 mm Hg HD, P=.03); but improvement in oxygenation was comparable (+37 mm Hg LD vs +28 mm Hg HD, P=.43), as was the proportion able to come off vasopressor support (39% LD vs 47% HD, P=.38). Similar proportions of lungs (44% vs 33%) and hearts (31% vs 27%) were transplanted in both groups. After excluding diabetics, median glucose values at 4 hours (170 mmol/L vs 188 mmol/L, P=.06) and final insulin requirements (2.9 U/h vs 8.4 U/h, P=.01) were lower with LD steroids; and more patients were off insulin infusions (74% LD vs 53% HD, P=.02).Conclusions: A lower-dose corticosteroid protocol did not result in worsened donor pulmonary or cardiac function, with comparable organs transplanted compared with the traditional HD regimen. Insulin requirements and glycemic control were improved. High-dose methylprednisolone may not be required to support brain-dead donors. (c) 2013 Elsevier Inc. All rights reserved.