围术期急性肾损伤的研究进展

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Update on Perioperative Acute Kidney Injury

明确的AKI风险因素对外科手术患者来说很重要。手术，尤其是重症患者的重大和急诊手术可能会引起AKI。某些合并症是AKI的重要危险因素，如慢性肾病和慢性心衰。此外，利尿剂、造影剂和肾毒性药物常用于围手术期，可能导致大量的院内AKI。

术前及术中，建议麻醉医生应该在预防和治疗血容量不足和纠正贫血方面优化患者生理条件时，必须避免术中低血压的发生，即使是短时间的低血压也与AKI风险增加有关。术中，在没有肾损伤或有肾损伤或肾损伤已出现伴或不伴有液体反应性的情况下，尿量可能会减少。因此，应小心使用液体以避免血容量不足或过多。

改善全球肾病预后指南建议实施高风险患者的预防策略，包括改善血流动力学、恢复循环容量、加强血流动力学监测、避免肾毒性药物和高血糖。最近发表的两项研究表明，在高风险患者中实施这一系列措施可减少围术期AKI的发生。另有学者发现远端缺血预处理的应用有可能降低围手术期AKI的发生率。

原始文献摘要

Zarbock A, Koyner JL, EAJ H, Kellum JA；Update on Perioperative Acute Kidney Injury；Anesth Analg；2018. 127(5): 1236-1245.

Acute kidney injury (AKI) in the perioperative period is a common complication and is associated with increased morbidity and mortality. A standard definition and staging system for AKI has been developed, incorporating a reduction of the urine output and/or an increase of serum creatinine. Novel biomarkers may detect kidney damage in the absence of a change in function and can also predict the development of AKI. Several specific considerations for AKI risk are important in surgical patients. The surgery, especially major and emergency procedures incritically ill patients, may cause AKI. In addition, certain comorbidities, such as chronic kidney disease and chronic heart failure, are important risk factors for AKI. Diuretics, contrast agents,and nephrotoxic drugs are commonly used in the perioperative period and may result in a significant amount of in-hospital AKI. Before and during surgery, anesthetists are supposed to optimize the patient, including preventing and treating a hypovolemia and correcting an anemia. Intraoperative episodes of hypotension have to be avoided because even short periods of hypotension are associated with an increased risk of AKI. During the intraoperative period, urine output might be reduced in the absence of kidney injury or the presence of kidney injury with or without fluid responsiveness. Therefore, fluids should be used carefully to avoid hypovolemia and hypervolemia. The Kidney Disease: Improving Global Outcomes guidelines suggest implementing preventive strategies in high-risk patients, which include optimization of hemodynamics, restoration of the circulating volume, institution of functional hemodynamic monitoring, and avoidance of nephrotoxic agents and hyperglycemia. Two recently published studies found that implementing this bundle in high-risk patients reduced the occurrence of AKI in the perioperative period. In addition, the application of remote ischemic preconditioning has been studied to potentially reduce the incidence of perioperative AKI. This review discusses the epidemiology and pathophysiology of surgery-associated AKI, highlights the importance of intraoperative oliguria, and emphasizes potential preventive strategies. 

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