腎臟損傷使肺臟移植後的死亡率風險增加


  【24drs.com】根據發表於全國腎臟基金會(NKF)2011年臨床會議的一篇研究,肺臟移植後的前2週如發生急性腎臟損傷(AKI),依據損傷程度不同,會使後來2年的死亡率風險增加2倍、甚至3倍。
  
  第一研究者、亥俄俄州克里夫蘭診所Glickman泌尿與腎臟研究中心Rachel Brock博士表示,即使血清肌酸酐值只有小小改變,對於這些結果仍是相當重要。
  
  Brock博士表示,我們發現,即使是只和原本相差0.3 mg/dL,未來依舊會產生差異。
  
  這篇研究回顧評估了在1997至2009年間接受肺臟移植的657名病患,其中424名(65%)病患有AKI紀錄,根據AKI肌酸酐準則分類,有309人分類為第1期、115人分類為第2或第3期。
  
  追蹤期間中位數為2.2年,追蹤發現有277名(42%)病患死亡,202人曾有AKI病史,有AKI的這組人中,148人有持續的第1期損傷,54人是第2或第3期損傷。
  
  控制年紀、性別、種族、單側或雙側肺移植、慢性阻塞性肺部疾病、估計腎絲球過濾速率、移植後高血壓和糖尿病之後,研究發現AKI是預測死亡率的獨立因子。
  
  任何AKI事件的整體風險比(HR)是2.0,但是隨著AKI的嚴重度,風險顯著增加;因此,第1期AKI的HR是沒有AKI者的1.7倍,第2或第3期AKI者的HR則是2.9倍。
  
  Brock博士表示,雖未探索因果關係,但是研究結果增加了「肺臟移植之後,即使只是輕微的腎臟損傷也要提高警覺」的重要性;她指出,這促使我們必須更仔細監測此類病患在術後的肌酸酐值。
  
  指引工作小組共同主席、賓州匹茲堡大學醫學院重症照護醫學系教授John Kellum醫師表示,這是重要的第一步,且對NKF的國際性計畫:改善全球腎臟疾病預後組織發表新的AKI指引而言有實際影響。
  
  他指出,我們之前並未發現腎臟功能的這些小改變會造成重要的後果,所以我們對於這些病患的治療沒有任何差異。
  
  肺臟移植是導致血液動力學失能與發炎的重大手術,是腎臟損傷風險的常見原因,我們使用的藥物主要是calcineurin抑制劑,會導致腎臟的直接損傷,這種情況可能只見於肺臟移植,因為必須讓病患維持限水,造成容積縮減也會有所影響。
  
  發展這些指引是為了腎臟科之外那些真正負責追蹤這些病患者,所以,如果你是肺臟移植外科醫師、或者是肺臟移植肺部醫師,你卻未警覺急性腎臟損傷,病患的心血管疾病或感染風險將會增加,而你卻未以適當方式監測,但是,如果你有警覺,並不意味著你將病患轉診給腎臟科醫師,而是代表你會檢查病患的腎功能。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6513&x_classno=0&x_chkdelpoint=Y
  
  

Kidney Injury Increases Mortality Risk After Lung Transplant

By Kate Johnson
Medscape Medical News

May 2, 2011 (Las Vegas, Nevada) — Acute kidney injury (AKI) occurring in the first 2 weeks after lung transplantation can double or even triple the risk for mortality over the subsequent 2 years, depending on the severity of the injury, according to a study presented here at the National Kidney Foundation (NKF) 2011 Clinical Meetings.

"Even small changes in serum creatinine levels are becoming more and more important in terms of looking at outcomes," said lead investigator Rachel Brock, DO, from the Cleveland Clinic's Glickman Urological and Kidney Institute, in Ohio.

"We found that even changes as little as 0.3 mg/dL from baseline made a difference down the road," Dr. Brock said.

The study retrospectively evaluated data on 657 patients who underwent lung transplantation between 1997 and 2009. AKI was documented in 424 (65%) patients, and was categorized according to AKI creatinine criteria, with 309 classified as stage 1 and 115 classified as stage 2 or 3.

After a median follow-up of 2.2 years, 277 patients (42%) had died, 202 of whom had a history of AKI. Of this AKI group, 148 had sustained a stage 1 injury and 54 a stage 2 or 3 injury.

Controlling for age, sex, race, single vs double lung transplant, chronic obstructive pulmonary disease, estimated glomerular filtration rate, posttransplant hypertension, and diabetes, the study found that AKI was independently predictive of mortality.

The overall hazard ratio (HR) for any AKI was 2.0, but there was a risk gradient that increased with severity of AKI. Thus, whereas a stage 1 AKI conferred an HR of 1.7 over no AKI, stages 2 and 3 AKI conferred an HR of 2.9.

Without exploring causality, the findings should raise awareness about the significance of even mild kidney injury in the lung transplant population, said Dr. Brock.

"I think certainly it gives us reason to monitor creatinine carefully in patients in this population postoperatively," she said.

Such awareness is a critical first step and is exactly the impetus behind new AKI guidelines from Kidney Disease Improving Global Outcomes, an international program of the NKF, which were announced during the meeting, said John Kellum, MD, cochair of the guideline's workgroup and professor in the Department of Critical Care Medicine at the University of Pittsburgh School of Medicine in Pennsylvania.

"We weren't previously aware that these small changes in renal function can have these critical downstream events, so we didn't treat these patients any differently," he told Medscape Medical News.

"Lung transplants are a common cause of kidney injury. It's a major surgery that results in hemodynamic instability and inflammation, which can put the kidney at risk. The drugs that we use — primarily calcineurin inhibitors — can result in direct injury to the kidney and, maybe unique to lung transplantation, there is a need to keep the patient very dry. Volume depletion might also contribute."

"These guidelines that are being developed are for groups outside of nephrology that really need to be at the frontline of following these patients. So if you're a lung transplant surgeon or a lung transplant pulmonologist and you're not aware that this acute kidney injury that your patient had is going to set them up for an increased risk of cardiovascular disease or infection, then you're not really going to monitor that patient in any appropriate way. But if you're aware — it may not mean you need to refer to them to a nephrologist, but it does mean you will check their kidney function."

Dr. Brock has disclosed no relevant financial relationships. Dr. Kellum reports receiving grant/research support from Gambro and Cytosorbents; serving as a consultant/scientific advisor for Gambro, Baxter, Fresinius, Ebi, Eli Lilly, Spectral, Abbott, Seimens, and Cytosorbents; and serving on the speaker's bureau for Gambro, Baxter, and Fresinius.

National Kidney Foundation (NKF) 2011 Clinical Meetings: Abstract 8. Presented April 28, 2011.

    
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