远程缺血预处理预防开腹全主动脉弓置换术后急性肾损伤：一项双盲、随机、对照试验
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Remote Ischemic Preconditioning Prevents Postoperative Acute Kidney Injury After Open Total Aortic Arch Replacement: A Double-Blind, Randomized, Sham-Controlled Trial
背景与目的
急性肾损伤是开腹全主动脉弓置换术后常见的并发症，但缺乏有效的预防措施。远程缺血预处理对肾脏是否有益存在争议，在急性肾损伤的高危患者中可能有更好的效果。我们研究远程缺血预处理是否能预防全主动脉弓置换术后急性肾损伤。
方 法
我们招收了130名行开腹全主动脉弓置换术的病人,随机分配接受远程缺血预处理(4周期5分钟右上肢缺血和5分钟再灌注)或对照组(4周期5分钟右上肢伪缺血和5分钟再灌注),通过血压袖带来控制收缩和舒张（缺血和再灌注）。主要指标是肾脏疾病定义的术后7天内急性肾损伤的发生率:使用改善全球预后标准评估。次要指标包括短期临床结果。
结 果
与对照组相比，远程缺血预处理的患者术后发生急性肾损伤的患者明显减少(55.4%vs73.8%；绝对风险降低18.5%；95%CI 2.3%-34.6%；P=0.028)。远程缺血预处理显著减少了II-III期急性肾损伤(10.8%vs35.4%；P=.001)。远程缺血预处理缩短了机械通气持续时间(18h[四分位数范围，14-33]vs.25h[四分位数范围，17-48]；P=.01)，而其他次要指标在组间没有显著差异。
结 论
远程缺血预处理可预防全主动脉弓置换术后急性肾损伤，尤其是严重急性肾损伤，缩短机械通气时间。
原始文献摘要
BACKGROUND: Acute kidney injury is a common complication after open total aortic arch replacement but lacks effective preventive strategies. Remote ischemic preconditioning has controversial results of its benefit to the kidney and may perform better in high-risk patients of acute kidney injury. We investigated whether remote ischemic preconditioning would prevent postoperative acute kidney injury after open total aortic arch replacement.
METHODS: We enrolled 130 patients scheduled for open total aortic arch replacement and randomized them to receive either remote ischemic preconditioning (4 cycles of 5-minute right upper limb ischemia and 5-minute reperfusion) or sham preconditioning (4 cycles of 5-minute right upper limb pseudo ischemia and 5-minute reperfusion), both via blood pressure cuff inflation and deflation. The primary end point was the incidence of acute kidney injury within 7 days after the surgery defined by the Kidney Disease: Improving Global Outcomes criteria. Secondary end point included short-term clinical outcomes.
RESULTS: Significantly fewer patients developed postoperative acute kidney injury with remote ischemic preconditioning compared with sham (55.4% vs 73.8%; absolute risk reduction, 18.5%; 95% CI, 2.3%–34.6%; P = .028). Remote ischemic preconditioning significantly reduced acute kidney injury stage II–III (10.8% vs 35.4%; P = .001). Remote ischemic preconditioning shortened the mechanical ventilation duration (18 hours [interquartile range, 14–33] versus 25 hours [interquartile range, 17–48]; P = .01), whereas no significant differences were observed between groups in other secondary outcomes.
CONCLUSIONS: Remote ischemic preconditioning prevented acute kidney injury after open total aortic arch replacement, especially severe acute kidney injury and shortened mechanical ventilation duration. The observed renoprotective effects of remote ischemic preconditioning require further investigation in both clinical research and the underlying mechanism.
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贵州医科大学高鸿教授课题组
翻译：余晓旭 编辑：何幼芹 审校：王贵龙