右美托咪定对主动脉术后急性肾损伤的影响:单中心随机对照试验

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Effect of dexmedetomidine on acute kidney injury after aortic surgery: a single-centre, placebo-controlled, randomised controlled trial

背景与目的

急性肾损伤（AKI）是体外循环（CPB）下主动脉手术后常见严重并发症。右美托咪定是一种选择性α-2肾上腺素受体激动剂，其交感神经阻滞作用和抗炎作用可预防缺血-再灌注损伤，从而减少AKI发生。本项安慰剂随机对照试验旨在探讨右美托咪定对CPB 下主动脉手术后AKI的影响。

方  法

本研究共纳入108名患者，并于麻醉诱导后24h内开始以0.4mg kg-1h-1速率随机输注右美托咪定或生理盐水。主要结果是AKI的发生率，根据KDIGO标准定义。次要结果包括谵妄和主要并发症。安全性结果为药物相关不良事件（心动过缓、低血压）。

结 果  

右美托咪定组受试者AKI发生率为7/54（13%），而生理盐水组受试者AKI发生率为17/54（31%）（OR 0.32; 95%CI 0.12~0.86; P=0.026）。右美托咪定组（16/54[30%]与生理盐水组（22[41%]）之间次要结果(卒中、死亡率和谵妄)相似（OR 0.61; 95%CI 0.28~1.36）。两组之间心动过缓(14/54 [26%] vs. 17/54 [32%]; OR 0.76; 95%CI 0.33~1.76)和低血压(29/54 [54%] vs. 36/54 [67%]; OR 0.58; 95%CI 0.27~1.26)发生率相似。右美托咪定组住院时间（12[10~17]天）短于生理盐水组（15[11~21]天; P=0.039）。

结 论

麻醉诱导后24h内预先输注右美托咪定可降低CPB下主动脉手术后AKI发生率，且未出现任何与其镇静或交感神经阻滞作用相关的不良副作用。

原始文献来源及摘要

Soh S, Shim JK, Song JW, et al. Effect of dexmedetomidine on acute kidney injury after aortic surgery: a single-centre, placebo-controlled, randomised controlled trial.[J]. Br J Anaesth 2020 Jan 29.

Background: Acute kidney injury (AKI) is a frequent and serious complication after aortic surgery requiring cardiopulmonary bypass (CPB). Dexmedetomidine, a selective α-2 adrenoreceptor agonist, may reduce AKI because of its sympatholytic and anti-inflammatory effects against ischaemia-reperfusion injury. We investigated the effect of dexmedetomidine administration on AKI after aortic surgery requiring CPB in a placebo-controlled randomised controlled trial.

Methods: A total of 108 patients were randomly assigned to an infusion of dexmedetomidine or saline at a rate of 0.4 mg kg-1 h-1 for 24 h starting after anaesthetic induction. The primary outcome was the incidence of AKI, as defifined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The secondary outcomes included delirium and major morbidity. Safety outcomes were drug-related adverse events (bradycardia, hypotension).

Results: AKI occurred in 7/54 (13%) subjects randomised to dexmedetomidine, compared with 17/54 (31%) subjects randomised to saline infusion (odds ratio=0.32; 95% confifidence interval [CI], 0.12~0.86; P=0.026). Secondary outcomes, including stroke, mortality, and delirium, were similar between subjects randomised to dexmedetomidine (16/54 [30%] or saline control (22 [41%]; odds ratio=0.61 [95% CI, 0.28~1.36]). The incidence of bradycardia and hypotension was similar between groups (14/54 (26%) vs. 17/54 (32%) (odds ratio:0.76 (95%CI:0.33~1.76) and 29/54 (54%) vs. 36/54 (67%) (odds ratio:0.58 (95%CI:0.27~1.26), respectively). The length of hospital stay was shorter in the dexmedetomidine group (12 [10~17] days) vs saline control (15 [11~21] days; P=0.039).

Conclusions: Pre-emptive dexmedetomidine administration for 24h starting after induction of anaesthesia reduced the incidence of AKI after aortic surgery requiring CPB, without any untoward side-effects related to its sedative or sympatholytic effects.

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