[每周一问]NO.36-perioperative assessment of renal function(part3)
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This week we'll preoperative risk factors for renal dysfunction.
1.What is the single greatest preoperative risk factor for renal dysfunction?
2.Can age alone be considered a risk factor for developing postoperative renal dysfunction?
3.What agents contribute to postoperative renal insufficiency?
4.Are there any significant systemic processes that contribute to postoperative renal failure?
1 术前肾功不全最大的独立危险因素是什么？
2 年龄是否可单独被认为是发生术后肾功不全的危险因素？
3 哪些药物可导致术后肾功不全？
4 是否有一些明显的全身性变化过程会引起术后肾功衰竭？
参考答案（请战友指正)
1 术前肾功不全最大的独立危险因素是什么？
尽管建立术前肾功不全危险因素的标准存在争议。但近期研究提示术前有肾功不全指征，如血浆肌酐升高是术后急性肾功衰竭的独立危险因素。这些研究结果显示如果肌酐高于120-130 mM/L，术后易于发生术后肾功不全。
2 年龄是否可单独被认为是发生术后肾功不全的危险因素？高龄被认为是发生术后肾功衰竭危险因素，尤其是年龄超过63岁被认为是独立的危险因素，随着年龄增长，肾单位减少，肾脏自身调节能力也逐渐丧失。
3 哪些药物可导致术后肾功不全？
放射性对比剂、氨基糖苷类和环孢霉素 A等药物可引起术后肾功不全，尤其应用于高风险患者时，更易于发生。放射性对比剂被认为可诱导钙介导的血管收缩，肾导致髓质缺血和肾衰.术前检查是否应包括应用放射性对比剂情况 一些专家认为如果应用对比剂后48小时内血浆肌酐升高超过44 mM/L 择期手术应延迟。近期，Wang等假设内皮受体拮抗剂可减轻应用对比剂后血管收缩，在应用对比剂后给予这些药物，随后48小时进行了血浆肌酐浓度监测，与假设相反，应用内皮受体拮抗剂后，肾毒性加重。将来工作应致力于产生此效应的原因以及如何保护肾脏免受放射性对比剂影响。
非甾体抗炎药和肾功失调的关系存在争论。总体而言，对术前肾功正常患者应用非甾体抗炎药不会对术后急性肾衰发病率有影响。
4 是否有一些明显的全身性变化过程会引起术后肾功衰竭？
大的创伤、烧伤和脓毒血症在术后肾衰发病率上扮演着重要角色。上述每种状态都与横纹肌溶解、肾小管内尿肌红蛋白沉积、肾血流异常分布和炎症介质大量产生有关，这些因素都加重了肾功障碍。
英文参考答案
1 What is the single greatest preoperative risk factor for renal dysfunction?Although the criteria for establishing preoperative renal risk factors is controversial, most recent studies suggest that preexisting renal dysfunction, as defined by an increased serum creatinine (see yesterday's Question of the Day for 1/9/2001), is the single greatest risk factor for developing postoperative ARF (1). Such studies tend to note a serum creatinine level of greater than 120-130 mM/L as being associated with renal dysfunction postoperatively.
2 Can age alone be considered a risk factor for developing postoperative renal dysfunction?
Advanced age alone has been noted to be a risk factor for the development of postoperative renal failure (2, 3). More specifically, an age older than 63 years has been identified as an independent variable, and has been speculated to be related to both the decreased nephron mass that routinely occurs with aging and the loss of autoregulatory ability.
3 What agents contribute to postoperative renal insufficiency?
Radiocontrast, aminoglycosides, and cyclosporine are agents which, especially when used in high risk patients, contribute to postoperative renal insufficiency.
Radiocontrast agents are believed to induce calcium mediated vasoconstriction leading to medullary ischemia (4) and renal failure. Should a preoperative workup include a radiocontrast exam, some authors suggest the delay of elective surgery if the serum creatinine level increases more than 44 mM/L within 48 hrs of the exposure (1). Recently, hypothesizing that endothelin receptor antagonists could reduce the vasoconstriction observed with contrast, Wang et al. (4) administered these agents with the radiocontrast material and followed the serum creatinine concentrations for 48 hrs. In contrast to expectations, an exacerbation of nephrotoxicity occurred with endothelin receptor antagonism. Further work into the etiology of this effect and further ways to protect the kidney from radiocontrast must occur in the future.
The relationship between nonsteroidal antiinflammatory drugs (NSAIDS) and renal dysfunction has been controversial. Overall, there appears that with normal preoperative renal function, the use of NSAIDS does not seem to influence the incidence of postoperative ARF (5, 6).
4 Are there any significant systemic processes that contribute to postoperative renal failure?
Major trauma, burns, and sepsis play a significant role in the postoperative renal failure. Each of these states can be associated with rhabdomyolysis, intratubular precipitations of urinary myoglobin, renal blood flow maldistribution, and a significant number of inflammatory mediators (7, 8), all of which increase renal dysfunction.
References:
1.Rothenberg DM. Postoperative renal dysfunction. Problems in Anesthesia 2000;12:314-25.
2.Conlon PJ, Stafford-Smith M, White WD, et al. Acute renal failure following cardiac surgery. Nephrol Dial Transplant. 1999;14(5):1158-62.
3.Mangano CM, Diamondstone LS, Ramsay JG, et al. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. The Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med. 1998;128(3):194-203.
4.Solomon R. Radiocontrast-induced nephropathy. Semin Nephrol 1998;18(5):551-7.
5.Wang A, Holcslaw T, Bashore TM, et al. Exacerbation of radiocontrast nephrotoxicity by endothelin receptor antagonism. Kidney Int 2000;57(4):1675-80.
6.Lee A, Cooper MG, Craig JC, Knight JF, Keneally JP. Effects of nonsteroidal anti-inflammatory drugs on post-operative renal function in adults (Cochrane Review). Cochrane Database Syst Rev 2000;4:CD002765.
7.Brinkmann A, Seeling W, Wolf CF, et al. Ibuprofen does not impair renal function in patients undergoing infrarenal aortic surgery with epidural anaesthesia. Intensive Care Med. 1998;24(4):322-8.
8.Holm C, Horbrand F, von Donnersmarck GH, Muhlbauer W. Acute renal failure in severely burned patients. Burns. 1999;25(2):171-8.
9.Russell JA, Singer J, Bernard GR, et al. Changing pattern of organ dysfunction in early human sepsis is related to mortality. Crit Care Med 2000;28(10):3405-11.
作者: 风雨同
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