今日の臨床サポート

急性腎障害

著者: 土井研人 東京大学医学部附属病院 救急部・集中治療部

監修: 岡田浩一 埼玉医科大学 腎臓内科

著者校正/監修レビュー済:2021/12/01

概要・推奨   

  1. 体液量過剰是正以外の目的で、ループ利尿薬を用いるべきでない(推奨度3)。
  1. 保存的治療、薬物治療が奏効しない場合、早期に腎代替療法(renal replacement therapy、RRT)を開始することが検討される(推奨度2)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
土井研人 : 特に申告事項無し[2021年]
監修:岡田浩一 : 講演料(協和キリン,中外製薬,田辺三菱,第一三共),研究費・助成金など(協和キリン),奨学(奨励)寄付など(協和キリン,中外製薬,田辺三菱,第一三共,アステラス,MSD,武田薬品,鳥居薬品,ファイザー,ノバルティス,日本ベーリンガーインゲルハイム,大塚製薬,塩野義,大日本住友)[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 急性腎障害(acute kidney injury、 AKI)は以下のいずれかによって診断する[1][2]
  1. 48時間以内にSCr値が≧0.3 mg/dl 上昇した場合;または
  1. SCr値が7日前以内の既知あるいは予想される基礎値より≧1.5倍の増加があった場合;または
  1. 尿量が6時間にわたって <0.5 ml/kg/時間に減少した場合
  1. AKIと診断した場合、さらに重症度基準によって病期分類する[1]。(表<図表>
  1. AKIは外来患者では年間100万人当たり5,000人に発症し、また、入院患者全体の2%程度に認め、特に重症度の高いICU入室患者では60%以上に認める頻度の高い病態である[3][4][5]
  1. AKIのリスクには血行動態の異常、腎毒性物質への曝露、合併症(心疾患、糖尿病、動脈硬化疾患など)があるが、既存の腎機能低下―慢性腎臓病(chronic kidney disease、CKD)が特に重要である[6]
  1. AKIは軽症(あるいは低いステージ)であっても、腎予後あるいは生命予後に影響する[7]
  1. AKIは必ずしも完全に回復する病態ではなく、腎機能回復が不完全でCKDとなったり、透析が必要な末期腎不全(end-stage kidney disease、 ESKD)となることもある[8]
問診・診察のポイント  
  1. 病態生理の観点からは厳密にはAKIを腎前性、腎性、腎後性と単純に分類することは困難であるが、実地臨床上はこの分類は非常に有用である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
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文献 

著者: C-Y Hsu, C E McCulloch, D Fan, J D Ordoñez, G M Chertow, A S Go
雑誌名: Kidney Int. 2007 Jul;72(2):208-12. doi: 10.1038/sj.ki.5002297. Epub 2007 May 16.
Abstract/Text There is limited information about the true incidence of acute renal failure (ARF). Most studies could not quantify disease frequency in the general population as they are hospital-based and confounded by variations in threshold and the rate of hospitalization. Earlier studies relied on diagnostic codes to identify non-dialysis requiring ARF. These underestimated disease incidence since the codes have low sensitivity. Here we quantified the incidence of non-dialysis and dialysis-requiring ARF among members of a large integrated health care delivery system - Kaiser Permanente of Northern California. Non-dialysis requiring ARF was identified using changes in inpatient serum creatinine values. Between 1996 and 2003, the incidence of non-dialysis requiring ARF increased from 322.7 to 522.4 whereas that of dialysis-requiring ARF increased from 19.5 to 29.5 per 100,000 person-years. ARF was more common in men and among the elderly, although those aged 80 years or more were less likely to receive acute dialysis treatment. We conclude that the use of serum creatinine measurements to identify cases of non-dialysis requiring ARF resulted in much higher estimates of disease incidence compared with previous studies. Both dialysis-requiring and non-dialysis requiring ARFs are becoming more common. Our data underscore the public health importance of ARF.

PMID 17507907  Kidney Int. 2007 Jul;72(2):208-12. doi: 10.1038/sj.ki.5・・・
著者: Orfeas Liangos, Ron Wald, John W O'Bell, Lorilyn Price, Brian J Pereira, Bertrand L Jaber
雑誌名: Clin J Am Soc Nephrol. 2006 Jan;1(1):43-51. doi: 10.2215/CJN.00220605. Epub 2005 Oct 26.
Abstract/Text The aim of this study was to provide a broad characterization of the epidemiology of acute renal failure (ARF) in the United States using national administrative data and describe its impact on hospital length of stay (LOS), patient disposition, and adverse outcomes. Using the 2001 National Hospital Discharge Survey, a nationally representative sample of discharges from nonfederal acute care hospitals in the United States, new cases of ARF were obtained from hospital discharge records coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Multivariate regression analyses were used to explore the relation of ARF to hospital LOS and mortality as well as discharge disposition. Review of discharge data on a projected total of 29,039,599 hospitalizations identified 558,032 cases of ARF, with a frequency of 19.2 per 1000 hospitalizations. ARF was more commonly coded for in older patients; men; black individuals; and the setting of chronic kidney disease, congestive heart failure, chronic lung disease, sepsis, and cardiac surgery. ARF was associated with an adjusted prolongation of hospital LOS by 2 d (P < 0.001) and an adjusted odds ratio of 4.1 for hospital mortality and of 2.0 for discharge to short- or long-term care facilities. In a US representative sample of hospitalized patients, the presence of an ICD-9-CM code for ARF in discharge records is associated with prolonged LOS, increased mortality, and, among survivors, a greater requirement for posthospitalization care. These findings suggest that in the United States, ARF is associated with increased in-hospital and post-hospitalization resource utilization.

PMID 17699189  Clin J Am Soc Nephrol. 2006 Jan;1(1):43-51. doi: 10.221・・・
著者: Eric A J Hoste, Gilles Clermont, Alexander Kersten, Ramesh Venkataraman, Derek C Angus, Dirk De Bacquer, John A Kellum
雑誌名: Crit Care. 2006;10(3):R73. doi: 10.1186/cc4915. Epub 2006 May 12.
Abstract/Text INTRODUCTION: The lack of a standard definition for acute kidney injury has resulted in a large variation in the reported incidence and associated mortality. RIFLE, a newly developed international consensus classification for acute kidney injury, defines three grades of severity--risk (class R), injury (class I) and failure (class F)--but has not yet been evaluated in a clinical series.
METHODS: We performed a retrospective cohort study, in seven intensive care units in a single tertiary care academic center, on 5,383 patients admitted during a one year period (1 July 2000-30 June 2001).
RESULTS: Acute kidney injury occurred in 67% of intensive care unit admissions, with maximum RIFLE class R, class I and class F in 12%, 27% and 28%, respectively. Of the 1,510 patients (28%) that reached a level of risk, 840 (56%) progressed. Patients with maximum RIFLE class R, class I and class F had hospital mortality rates of 8.8%, 11.4% and 26.3%, respectively, compared with 5.5% for patients without acute kidney injury. Additionally, acute kidney injury (hazard ratio, 1.7; 95% confidence interval, 1.28-2.13; P < 0.001) and maximum RIFLE class I (hazard ratio, 1.4; 95% confidence interval, 1.02-1.88; P = 0.037) and class F (hazard ratio, 2.7; 95% confidence interval, 2.03-3.55; P < 0.001) were associated with hospital mortality after adjusting for multiple covariates.
CONCLUSION: In this general intensive care unit population, acute kidney 'risk, injury, failure', as defined by the newly developed RIFLE classification, is associated with increased hospital mortality and resource use. Patients with RIFLE class R are indeed at high risk of progression to class I or class F. Patients with RIFLE class I or class F incur a significantly increased length of stay and an increased risk of inhospital mortality compared with those who do not progress past class R or those who never develop acute kidney injury, even after adjusting for baseline severity of illness, case mix, race, gender and age.

PMID 16696865  Crit Care. 2006;10(3):R73. doi: 10.1186/cc4915. Epub 20・・・
著者: Matthew T James, Brenda R Hemmelgarn, Natasha Wiebe, Neesh Pannu, Braden J Manns, Scott W Klarenbach, Marcello Tonelli, Alberta Kidney Disease Network
雑誌名: Lancet. 2010 Dec 18;376(9758):2096-103. doi: 10.1016/S0140-6736(10)61271-8. Epub 2010 Nov 20.
Abstract/Text BACKGROUND: Low values of estimated glomerular filtration rate (eGFR) predispose to acute kidney injury, and proteinuria is a marker of kidney disease. We aimed to investigate how eGFR and proteinuria jointly modified the risks of acute kidney injury and subsequent adverse clinical outcomes.
METHODS: We did a cohort study of 920,985 adults residing in Alberta, Canada, between 2002 and 2007. Participants not needing chronic dialysis at baseline and with at least one outpatient measurement of both serum creatinine concentration and proteinuria (urine dipstick or albumin-creatinine ratio) were included. We assessed hospital admission with acute kidney injury with validated administrative codes; other outcomes were all-cause mortality and a composite renal outcome of end-stage renal disease or doubling of serum creatinine concentration.
FINDINGS: During median follow-up of 35 months (range 0-59 months), 6520 (0·7%) participants were admitted with acute kidney injury. In those with eGFR 60 mL/min per 1·73 m(2) or greater, the adjusted risk of admission with this disorder was about 4 times higher in those with heavy proteinuria measured by dipstick (rate ratio 4·4 vs no proteinuria, 95% CI 3·7-5·2). The adjusted rates of admission with acute kidney injury and kidney injury needing dialysis remained high in participants with heavy dipstick proteinuria for all values of eGFR. The adjusted rates of death and the composite renal outcome were also high in participants admitted with acute kidney injury, although the rise associated with this injury was attenuated in those with low baseline eGFR and heavy proteinuria.
INTERPRETATION: These findings suggest that information on proteinuria and eGFR should be used together when identifying people at risk of acute kidney injury, and that an episode of acute kidney injury provides further long-term prognostic information in addition to eGFR and proteinuria.
FUNDING: The study was funded by an interdisciplinary team grant from Alberta Heritage Foundation for Medical Research.

Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID 21094997  Lancet. 2010 Dec 18;376(9758):2096-103. doi: 10.1016/S0・・・
著者: Glenn M Chertow, Elisabeth Burdick, Melissa Honour, Joseph V Bonventre, David W Bates
雑誌名: J Am Soc Nephrol. 2005 Nov;16(11):3365-70. doi: 10.1681/ASN.2004090740. Epub 2005 Sep 21.
Abstract/Text The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.

PMID 16177006  J Am Soc Nephrol. 2005 Nov;16(11):3365-70. doi: 10.1681・・・
著者: Steven G Coca, Swathi Singanamala, Chirag R Parikh
雑誌名: Kidney Int. 2012 Mar;81(5):442-8. doi: 10.1038/ki.2011.379. Epub 2011 Nov 23.
Abstract/Text Acute kidney injury may increase the risk for chronic kidney disease and end-stage renal disease. In an attempt to summarize the literature and provide more compelling evidence, we conducted a systematic review comparing the risk for CKD, ESRD, and death in patients with and without AKI. From electronic databases, web search engines, and bibliographies, 13 cohort studies were selected, evaluating long-term renal outcomes and non-renal outcomes in patients with AKI. The pooled incidence of CKD and ESRD were 25.8 per 100 person-years and 8.6 per 100 person-years, respectively. Patients with AKI had higher risks for developing CKD (pooled adjusted hazard ratio 8.8, 95% CI 3.1-25.5), ESRD (pooled adjusted HR 3.1, 95% CI 1.9-5.0), and mortality (pooled adjusted HR 2.0, 95% CI 1.3-3.1) compared with patients without AKI. The relationship between AKI and CKD or ESRD was graded on the basis of the severity of AKI, and the effect size was dampened by decreased baseline glomerular filtration rate. Data were limited, but AKI was also independently associated with the risk for cardiovascular disease and congestive heart failure, but not with hospitalization for stroke or all-cause hospitalizations. Meta-regression did not identify any study-level factors that were associated with the risk for CKD or ESRD. Our review identifies AKI as an independent risk factor for CKD, ESRD, death, and other important non-renal outcomes.

PMID 22113526  Kidney Int. 2012 Mar;81(5):442-8. doi: 10.1038/ki.2011.・・・
著者: Norbert Lameire, Wim Van Biesen, Raymond Vanholder
雑誌名: Lancet. 2005 Jan 29-Feb 4;365(9457):417-30. doi: 10.1016/S0140-6736(05)17831-3.
Abstract/Text This seminar covers the most recent information on definition, epidemiology, and clinical causes of acute renal failure. The mechanisms of acute prerenal failure and the potential interference by commonly used drugs of autoregulation of renal blood flow are discussed. We summarise some basic and recent insights into the haemodynamic and cellular pathophysiological mechanisms, mainly of postischaemic acute renal failure. Recent findings on the repair mechanisms of renal injury and the potential future therapeutic possibilities are discussed. We provide some differential diagnostic approaches for patients with acute renal failure and summarise prevention of the disorder and management of critically ill patients by dialysis and by other means. Finally, some information on the influence of gene polymorphisms on the prognosis of acute renal failure is given.

PMID 15680458  Lancet. 2005 Jan 29-Feb 4;365(9457):417-30. doi: 10.101・・・
著者: Naveen Singri, Shubhada N Ahya, Murray L Levin
雑誌名: JAMA. 2003 Feb 12;289(6):747-51.
Abstract/Text
PMID 12585954  JAMA. 2003 Feb 12;289(6):747-51.
著者: J Gary Abuelo
雑誌名: N Engl J Med. 2007 Aug 23;357(8):797-805. doi: 10.1056/NEJMra064398.
Abstract/Text
PMID 17715412  N Engl J Med. 2007 Aug 23;357(8):797-805. doi: 10.1056/・・・
著者: Josée Bouchard, Sharon B Soroko, Glenn M Chertow, Jonathan Himmelfarb, T Alp Ikizler, Emil P Paganini, Ravindra L Mehta, Program to Improve Care in Acute Renal Disease (PICARD) Study Group
雑誌名: Kidney Int. 2009 Aug;76(4):422-7. doi: 10.1038/ki.2009.159. Epub 2009 May 13.
Abstract/Text Fluid accumulation is associated with adverse outcomes in critically ill patients. Here, we sought to determine if fluid accumulation is associated with mortality and non-recovery of kidney function in critically ill adults with acute kidney injury. Fluid overload was defined as more than a 10% increase in body weight relative to baseline, measured in 618 patients enrolled in a prospective multicenter observational study. Patients with fluid overload experienced significantly higher mortality within 60 days of enrollment. Among dialyzed patients, survivors had significantly lower fluid accumulation when dialysis was initiated compared to non-survivors after adjustments for dialysis modality and severity score. The adjusted odds ratio for death associated with fluid overload at dialysis initiation was 2.07. In non-dialyzed patients, survivors had significantly less fluid accumulation at the peak of their serum creatinine. Fluid overload at the time of diagnosis of acute kidney injury was not associated with recovery of kidney function. However, patients with fluid overload when their serum creatinine reached its peak were significantly less likely to recover kidney function. Our study shows that in patients with acute kidney injury, fluid overload was independently associated with mortality. Whether the fluid overload was the result of a more severe renal failure or it contributed to its cause will require clinical trials in which the role of fluid administration to such patients is directly tested.

PMID 19436332  Kidney Int. 2009 Aug;76(4):422-7. doi: 10.1038/ki.2009.・・・
著者: Nicola Brienza, Maria Teresa Giglio, Massimo Marucci, Tommaso Fiore
雑誌名: Crit Care Med. 2009 Jun;37(6):2079-90. doi: 10.1097/CCM.0b013e3181a00a43.
Abstract/Text OBJECTIVE: Postoperative acute deterioration in renal function, producing oliguria and/or increase in serum creatinine, is one of the most serious complication in surgical patients. Most cases are due to renal hypoperfusion as a consequence of systemic hypotension, hypovolemia, and cardiac dysfunction. Although some evidence suggests that perioperative monitoring and manipulation of oxygen delivery by volume expansion and inotropic drugs may decrease mortality in surgical patients, no study analyzed this approach on postoperative renal dysfunction. The objective of this investigation is to perform a meta-analysis on the effects of perioperative hemodynamic optimization on postoperative renal dysfunction. DATA SOURCES, STUDY SELECTION, DATA EXTRACTION: A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through January 2008 was conducted and 20 studies met the inclusion criteria (4220 participants). Data synthesis was obtained by using odds ratio (OR) with 95% confidence interval (CI) by random-effects model.
DATA SYNTHESIS: Postoperative acute renal injury was significantly reduced by perioperative hemodynamic optimization when compared with control group (OR 0.64; CI 0.50-0.83; p = 0.0007). Perioperative optimization was effective in reducing renal injury defined consistently with risk, injury, failure, and loss and end-stage kidney disease and Acute Kidney Injury Network classifications, and in studies defining renal dysfunction by serum creatinine and/or need of renal replacement therapy only (OR 0.66; CI 0.50-0.88; p = 0.004). The occurrence of renal dysfunction was reduced when treatment started both preoperatively and intraoperatively or postoperatively, was performed in high-risk patients, and was obtained by fluids and inotropes. Mortality was significantly reduced in treatment group (OR 0.50; CI 0.31-0.80; p = 0.004), but statistical heterogeneity was observed.
CONCLUSIONS: Surgical patients receiving perioperative hemodynamic optimization are at decreased risk of renal impairment. Because of the impact of postoperative renal complications on adverse outcome, efforts should be aimed to identify patients and surgery that would most benefit from perioperative optimization.

PMID 19384211  Crit Care Med. 2009 Jun;37(6):2079-90. doi: 10.1097/CCM・・・
著者: E Rivers, B Nguyen, S Havstad, J Ressler, A Muzzin, B Knoblich, E Peterson, M Tomlanovich, Early Goal-Directed Therapy Collaborative Group
雑誌名: N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307.
Abstract/Text BACKGROUND: Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.
METHODS: We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups.
RESULTS: Of the 263 enrolled patients, 130 were randomly assigned to early goal-directed therapy and 133 to standard therapy; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009). During the interval from 7 to 72 hours, the patients assigned to early goal-directed therapy had a significantly higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients assigned to standard therapy (P < or = 0.02 for all comparisons). During the same period, mean APACHE II scores were significantly lower, indicating less severe organ dysfunction, in the patients assigned to early goal-directed therapy than in those assigned to standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P < 0.001).
CONCLUSIONS: Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.

PMID 11794169  N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/・・・
著者: John R Prowle, Jorge E Echeverri, E Valentina Ligabo, Claudio Ronco, Rinaldo Bellomo
雑誌名: Nat Rev Nephrol. 2010 Feb;6(2):107-15. doi: 10.1038/nrneph.2009.213. Epub 2009 Dec 22.
Abstract/Text Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI). However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in whom fluid challenges are frequent and excretion is impaired. In this Review article, we discuss how interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to ongoing organ dysfunction. Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used. However, hypovolemia and renal hypoperfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy. Thus, accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury. Similar randomized, controlled studies in patients with AKI now seem justified.

PMID 20027192  Nat Rev Nephrol. 2010 Feb;6(2):107-15. doi: 10.1038/nrn・・・
著者: Julie Badin, Thierry Boulain, Stephan Ehrmann, Marie Skarzynski, Anne Bretagnol, Jennifer Buret, Dalila Benzekri-Lefevre, Emmanuelle Mercier, Isabelle Runge, Denis Garot, Armelle Mathonnet, Pierre-François Dequin, Dominique Perrotin
雑誌名: Crit Care. 2011;15(3):R135. doi: 10.1186/cc10253. Epub 2011 Jun 6.
Abstract/Text INTRODUCTION: Because of disturbed renal autoregulation, patients experiencing hypotension-induced renal insult might need higher levels of mean arterial pressure (MAP) than the 65 mmHg recommended level in order to avoid the progression of acute kidney insufficiency (AKI).
METHODS: In 217 patients with sustained hypotension, enrolled and followed prospectively, we compared the evolution of the mean arterial pressure (MAP) during the first 24 hours between patients who will show AKI 72 hours after inclusion (AKIh72) and patients who will not. AKIh72 was defined as the need of renal replacement therapy or "Injury" or "Failure" classes of the 5-stage RIFLE classification (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease) for acute kidney insufficiency using the creatinine and urine output criteria. This comparison was performed in four different subgroups of patients according to the presence or not of AKI at the sixth hour after inclusion (AKIh6 as defined as a serum creatinine level above 1.5 times baseline value within the first six hours) and the presence or not of septic shock at inclusion.The ability of MAP averaged over H6 to H24 to predict AKIh72 was assessed by the area under the receiver operating characteristic curve (AUC) and compared between groups.
RESULTS: The MAP averaged over H6 to H24 or over H12 to H24 was significantly lower in patients who showed AKIh72 than in those who did not, only in septic shock patients with AKIh6, whereas no link was found between MAP and AKIh72 in the three others subgroups of patients. In patients with septic shock plus AKIh6, MAP averaged over H6 to H24 or over H12 to H24 had an AUC of 0.83 (0.72 to 0.92) or 0.84 (0.72 to 0.92), respectively, to predict AKIh72 . In these patients, the best level of MAP to prevent AKIh72 was between 72 and 82 mmHg.
CONCLUSIONS: MAP about 72 to 82 mmHg could be necessary to avoid acute kidney insufficiency in patients with septic shock and initial renal function impairment.

PMID 21645384  Crit Care. 2011;15(3):R135. doi: 10.1186/cc10253. Epub ・・・
著者: Pablo Perel, Ian Roberts
雑誌名: Cochrane Database Syst Rev. 2012 Jun 13;6:CD000567. doi: 10.1002/14651858.CD000567.pub5. Epub 2012 Jun 13.
Abstract/Text BACKGROUND: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.
OBJECTIVES: To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.
SEARCH METHODS: We searched the Cochrane Injuries Group Specialised Register (searched 16 March 2012), Cochrane Central Register of Controlled Trials 2011, issue 3 (The Cochrane Library), MEDLINE (Ovid) 1946 to March 2012, Embase (Ovid) 1980 to March 2012, ISI Web of Science: Science Citation Index Expanded (1970 to March 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to March 2012), PubMed (searched 16 March 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles.
SELECTION CRITERIA: Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.
MAIN RESULTS: We identified 74 eligible trials; 66 of these presented mortality data.Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 21 trials compared hydroxyethyl starch with crystalloids, n = 1385 patients. The pooled RR was 1.10 (95% CI 0.91 to 1.32). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloid Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR was 0.91 (95% CI 0.71 to 1.06).
AUTHORS' CONCLUSIONS: There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.

PMID 22696320  Cochrane Database Syst Rev. 2012 Jun 13;6:CD000567. doi・・・
著者: Nor'azim Mohd Yunos, Rinaldo Bellomo, Colin Hegarty, David Story, Lisa Ho, Michael Bailey
雑誌名: JAMA. 2012 Oct 17;308(15):1566-72. doi: 10.1001/jama.2012.13356.
Abstract/Text CONTEXT: Administration of traditional chloride-liberal intravenous fluids may precipitate acute kidney injury (AKI).
OBJECTIVE: To assess the association of a chloride-restrictive (vs chloride-liberal) intravenous fluid strategy with AKI in critically ill patients.
DESIGN, SETTING, AND PATIENTS: Prospective, open-label, sequential period pilot study of 760 patients admitted consecutively to the intensive care unit (ICU) during the control period (February 18 to August 17, 2008) compared with 773 patients admitted consecutively during the intervention period (February 18 to August 17, 2009) at a university-affiliated hospital in Melbourne, Australia.
INTERVENTIONS: During the control period, patients received standard intravenous fluids. After a 6-month phase-out period (August 18, 2008, to February 17, 2009), any use of chloride-rich intravenous fluids (0.9% saline, 4% succinylated gelatin solution, or 4% albumin solution) was restricted to attending specialist approval only during the intervention period; patients instead received a lactated solution (Hartmann solution), a balanced solution (Plasma-Lyte 148), and chloride-poor 20% albumin.
MAIN OUTCOME MEASURES: The primary outcomes included increase from baseline to peak creatinine level in the ICU and incidence of AKI according to the risk, injury, failure, loss, end-stage (RIFLE) classification. Secondary post hoc analysis outcomes included the need for renal replacement therapy (RRT), length of stay in ICU and hospital, and survival. RESULTS Chloride administration decreased by 144 504 mmol (from 694 to 496 mmol/patient) from the control period to the intervention period. Comparing the control period with the intervention period, the mean serum creatinine level increase while in the ICU was 22.6 μmol/L (95% CI, 17.5-27.7 μmol/L) vs 14.8 μmol/L (95% CI, 9.8-19.9 μmol/L) (P = .03), the incidence of injury and failure class of RIFLE-defined AKI was 14% (95% CI, 11%-16%; n = 105) vs 8.4% (95% CI, 6.4%-10%; n = 65) (P <.001), and the use of RRT was 10% (95% CI, 8.1%-12%; n = 78) vs 6.3% (95% CI, 4.6%-8.1%; n = 49) (P = .005). After adjustment for covariates, this association remained for incidence of injury and failure class of RIFLE-defined AKI (odds ratio, 0.52 [95% CI, 0.37-0.75]; P <.001) and use of RRT (odds ratio, 0.52 [95% CI, 0.33-0.81]; P = .004). There were no differences in hospital mortality, hospital or ICU length of stay, or need for RRT after hospital discharge. CONCLUSION The implementation of a chloride-restrictive strategy in a tertiary ICU was associated with a significant decrease in the incidence of AKI and use of RRT.
TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00885404.

PMID 23073953  JAMA. 2012 Oct 17;308(15):1566-72. doi: 10.1001/jama.20・・・
著者: Daniel De Backer, Patrick Biston, Jacques Devriendt, Christian Madl, Didier Chochrad, Cesar Aldecoa, Alexandre Brasseur, Pierre Defrance, Philippe Gottignies, Jean-Louis Vincent, SOAP II Investigators
雑誌名: N Engl J Med. 2010 Mar 4;362(9):779-89. doi: 10.1056/NEJMoa0907118.
Abstract/Text BACKGROUND: Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other.
METHODS: In this multicenter, randomized trial, we assigned patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. When blood pressure could not be maintained with a dose of 20 microg per kilogram of body weight per minute for dopamine or a dose of 0.19 microg per kilogram per minute for norepinephrine, open-label norepinephrine, epinephrine, or vasopressin could be added. The primary outcome was the rate of death at 28 days after randomization; secondary end points included the number of days without need for organ support and the occurrence of adverse events.
RESULTS: The trial included 1679 patients, of whom 858 were assigned to dopamine and 821 to norepinephrine. The baseline characteristics of the groups were similar. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock (P=0.03 for cardiogenic shock, P=0.19 for septic shock, and P=0.84 for hypovolemic shock, in Kaplan-Meier analyses).
CONCLUSIONS: Although there was no significant difference in the rate of death between patients with shock who were treated with dopamine as the first-line vasopressor agent and those who were treated with norepinephrine, the use of dopamine was associated with a greater number of adverse events. (ClinicalTrials.gov number, NCT00314704.)

2010 Massachusetts Medical Society
PMID 20200382  N Engl J Med. 2010 Mar 4;362(9):779-89. doi: 10.1056/NE・・・
著者: C Martin, B Eon, P Saux, P Aknin, F Gouin
雑誌名: Crit Care Med. 1990 Mar;18(3):282-5.
Abstract/Text Twenty-four patients with septic shock (cardiac index [CI] greater than or equal to 4 L.min-1.m-2, systemic vascular resistance index [SVRI] less than or equal to 350 dyne.sec.cm-5.m-2, systolic BP less than or equal to 90 mm Hg, oliguria less than 30 ml/h) were treated with norepinephrine (NE) infused either alone or in combination with dopamine and/or dobutamine. In all patients, NE resulted in either an increase in BP, no change, or an increase in CI and restored SVRI to the normal range. In 20 patients, normalization of systemic hemodynamics was followed by re-establishment of urine flow, decrease in serum creatinine, and increase in creatinine clearance. None of these 20 patients received low dose dopamine or furosemide. Four patients remained oliguric. Two of these four patients died and two developed acute renal failure. These findings suggest that NE infusion does not worsen renal ischemia related to hemodynamic disturbances in septic shock patients, and may have beneficial effects on renal function.

PMID 2302953  Crit Care Med. 1990 Mar;18(3):282-5.
著者: Victor F Seabra, Ethan M Balk, Orfeas Liangos, Marie Anne Sosa, Miguel Cendoroglo, Bertrand L Jaber
雑誌名: Am J Kidney Dis. 2008 Aug;52(2):272-84. doi: 10.1053/j.ajkd.2008.02.371. Epub 2008 Jun 18.
Abstract/Text BACKGROUND: Some studies have suggested that early institution of renal replacement therapy (RRT) might be associated with improved outcomes in patients with acute renal failure (ARF).
STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials and cohort comparative studies to assess the effect of early RRT on mortality in patients with ARF.
SETTING & POPULATION: Hospitalized adult patients with ARF.
SELECTION CRITERIA FOR STUDIES: We searched several databases for studies that compared the effect of "early" and "late" RRT initiation on mortality in patients with ARF. We included studies of various designs.
INTERVENTION: Early RRT as defined in the individual studies.
OUTCOMES: The primary outcome measure was the effect of early RRT on mortality stratified by study design. The pooled risk ratio (RR) for mortality was compiled using a random-effects model. Heterogeneity was evaluated by means of subgroup analysis and meta-regression.
RESULTS: We identified 23 studies (5 randomized or quasi-randomized controlled trials, 1 prospective and 16 retrospective comparative cohort studies, and 1 single-arm study with a historic control group). By using meta-analysis of randomized trials, early RRT was associated with a nonsignificant 36% mortality risk reduction (RR, 0.64; 95% confidence interval, 0.40 to 1.05; P = 0.08). Conversely, in cohort studies, early RRT was associated with a statistically significant 28% mortality risk reduction (RR, 0.72; 95% confidence interval, 0.64 to 0.82; P < 0.001). The overall test for heterogeneity among cohort studies was significant (P = 0.005). Meta-regression yielded no significant associations; however, early dialysis therapy was associated more strongly with lower mortality in smaller studies (n < 100) by means of subgroup analysis.
LIMITATIONS: Paucity of randomized controlled trials, use of variable definitions of early RRT, and publication bias preclude definitive conclusions.
CONCLUSION: This hypothesis-generating meta-analysis suggests that early initiation of RRT in patients with ARF might be associated with improved survival, calling for an adequately powered randomized controlled trial to address this question.

PMID 18562058  Am J Kidney Dis. 2008 Aug;52(2):272-84. doi: 10.1053/j.・・・
著者: Sean M Bagshaw, Dinna N Cruz, R T Noel Gibney, Claudio Ronco
雑誌名: Crit Care. 2009;13(6):317. doi: 10.1186/cc8037. Epub 2009 Nov 11.
Abstract/Text Critically ill patients whose course is complicated by acute kidney injury often receive renal replacement therapy (RRT). For these patients, initiation of RRT results in a considerable escalation in both the complexity and associated cost of care. While RRT is extensively used in clinical practice, there remains uncertainty about the ideal circumstances of when to initiate RRT and for what indications. The process of deciding when to initiate RRT in critically ill patients is complex and is influenced by numerous factors, including patient-specific and clinician-specific factors and those related to local organizational/logistical issues. Studies have shown marked variation between clinicians, and across institutions and countries. As a consequence, analysis of ideal circumstances under which to initiate RRT is challenging. Recognizing this limitation, we review the available data and propose a clinical algorithm to aid in the decision for RRT initiation in critically ill adult patients. The algorithm incorporates several patient-specific factors, based on evidence when available, that may decisively influence when to initiate RRT. The objective of this algorithm is to provide a starting point to guide clinicians on when to initiate RRT in critically ill adult patients. In addition, the proposed algorithm is intended to provide a foundation for prospective evaluation and the development of a broad consensus on when to initiate RRT in critically ill patients.

PMID 19909493  Crit Care. 2009;13(6):317. doi: 10.1186/cc8037. Epub 20・・・
著者: Daniela Ponce, Caroline de Pietro Franco Zorzenon, Nara Yamane dos Santos, André Luís Balbi
雑誌名: Nephrol Dial Transplant. 2011 Oct;26(10):3202-6. doi: 10.1093/ndt/gfr359. Epub 2011 Jul 15.
Abstract/Text BACKGROUND: Patients who develop acute kidney injury (AKI) in the intensive care unit (ICU) have extremely high rates of mortality and morbidity. The objectives of this study were to compare clinical and laboratory characteristics of AKI patients evaluated and not evaluated by nephrologists in ICU and generate the hypothesis of the relationship between timing of nephrology consultation and outcome.
METHODS: We explored associations among presence and timing of nephrology consultation with ICU stay and in-ICU mortality in 148 ICU patients with AKI at a Brazilian teaching hospital from July 2008 to May 2010. Multivariable logistic regression was used to adjust confounding and selection bias.
RESULTS: AKI incidence was 30% and 52% of these AKI patients were evaluated by nephrologists. At multivariable analysis, AKI patients evaluated by nephrologists showed higher Acute Tubular Necrosis-Index Specific Score and creatinine level, more dialysis indications, lower urine output and longer ICU stay. The mortality rate was similar to AKI patients who were not evaluated. Nephrology consultation was delayed (≥ 48 h) in 62.3% (median time to consultation, 4.7 days). Lower serum creatinine levels (P = 0.009) and higher urine output (P = 0.002) were associated with delayed consultation. Delayed consultation was associated with increased ICU mortality (65.4 versus 88.2%, P < 0.001).
CONCLUSIONS: In AKI, patients evaluated by nephrologists seem to be more seriously ill than those not evaluated and present similar mortality rate. The delayed nephrology consultation can be associated with increased ICU mortality.

PMID 21765052  Nephrol Dial Transplant. 2011 Oct;26(10):3202-6. doi: 1・・・
著者: Pascal Meier, Rachel Meier Bonfils, Bruno Vogt, Bernard Burnand, Michel Burnier
雑誌名: Clin J Am Soc Nephrol. 2011 Sep;6(9):2215-25. doi: 10.2215/CJN.01880211. Epub 2011 Aug 4.
Abstract/Text BACKGROUND AND OBJECTIVES: Despite modern treatment, the case fatality rate of hospital-acquired acute kidney injury (HA-AKI) is still high. We retrospectively described the prevalence and the outcome of HA-AKI without nephrology referral (nrHA-AKI) and late referred HA-AKI patients to nephrologists (lrHA-AKI) compared with early referral patients (erHA-AKI) with respect to renal function recovery, renal replacement therapy (RRT) requirement, and in-hospital mortality of HA-AKI.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Noncritically ill patients admitted to the tertiary care academic center of Lausanne, Switzerland, between 2004 and 2008 in the medical and surgical services were included. Acute kidney injury was defined using the Acute Kidney Injury Network (AKIN) classification.
RESULTS: During 5 years, 4296 patients (4.12% of admissions) experienced 4727 episodes of HA-AKI during their hospital stay. The mean ± SD age of the patients was 61 ± 15 years with a 55% male predominance. There were 958 patients with nrHA-AKI (22.3%) and 2504 patients with lrHA-AKI (58.3%). RRT was required in 31% of the patients with lrHA-AKI compared with 24% of the patients with erHA-AKI. In the multiple risk factor analysis, compared with erHA-AKI, nrHA-AKI and lrHA-AKI were significantly associated with worse renal outcome and higher in-hospital mortality.
CONCLUSIONS: These data suggest that HA-AKI is frequent and the patients with nrHA-AKI or lrHA-AKI are at increased risk for in-hospital morbidity and mortality.

PMID 21817132  Clin J Am Soc Nephrol. 2011 Sep;6(9):2215-25. doi: 10.2・・・
著者: Edward D Siew, Josh F Peterson, Svetlana K Eden, Adriana M Hung, Theodore Speroff, T Alp Ikizler, Michael E Matheny
雑誌名: J Am Soc Nephrol. 2012 Feb;23(2):305-12. doi: 10.1681/ASN.2011030315. Epub 2011 Dec 8.
Abstract/Text AKI associates with an increased risk for the development and progression of CKD and mortality. Processes of care after an episode of AKI are not well described. Here, we examined the likelihood of nephrology referral among survivors of AKI at risk for subsequent decline in kidney function in a US Department of Veterans Affairs database. We identified 3929 survivors of AKI hospitalized between January 2003 and December 2008 who had an estimated GFR (eGFR) <60 ml/min per 1.73 m(2) 30 days after peak injury. We analyzed time to referral considering improvement in kidney function (eGFR ≥60 ml/min per 1.73 m(2)), dialysis initiation, and death as competing risks over a 12-month surveillance period. Median age was 73 years (interquartile range, 62-79 years) and the prevalence of preadmission kidney dysfunction (baseline eGFR <60 ml/min per 1.73 m(2)) was 60%. Overall mortality during the surveillance period was 22%. The cumulative incidence of nephrology referral before dying, initiating dialysis, or experiencing an improvement in kidney function was 8.5% (95% confidence interval, 7.6-9.4). Severity of AKI did not affect referral rates. These data demonstrate that a minority of at-risk survivors are referred for nephrology care after an episode of AKI. Determining how to best identify survivors of AKI who are at highest risk for complications and progression of CKD could facilitate early nephrology-based interventions.

PMID 22158435  J Am Soc Nephrol. 2012 Feb;23(2):305-12. doi: 10.1681/A・・・
著者: Sophia Zoungas, Toshiharu Ninomiya, Rachel Huxley, Alan Cass, Meg Jardine, Martin Gallagher, Anushka Patel, Ali Vasheghani-Farahani, Gelareh Sadigh, Vlado Perkovic
雑誌名: Ann Intern Med. 2009 Nov 3;151(9):631-8. doi: 10.7326/0003-4819-151-9-200911030-00008.
Abstract/Text BACKGROUND: Intravenous sodium bicarbonate has been proposed to reduce the risk for contrast-induced nephropathy (CIN).
PURPOSE: To determine the effect of sodium bicarbonate on the risk for CIN.
DATA SOURCES: MEDLINE, PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from 1950 to December 2008; conference proceedings; and ClinicalTrials.gov, without language restriction.
STUDY SELECTION: Randomized, controlled trials of intravenous sodium bicarbonate that prespecified the outcome of CIN as a 25% increase in baseline serum creatinine level or an absolute increase of 44 micromol/L (0.5 mg/dL) after radiocontrast administration.
DATA EXTRACTION: Using standardized protocols, 2 reviewers serially abstracted data for each study.
DATA SYNTHESIS: 23 published and unpublished trials with information on 3563 patients and 396 CIN events were included. The pooled relative risk was 0.62 (95% CI, 0.45 to 0.86), with evidence of significant heterogeneity across studies (I(2) = 49.1%; P = 0.004). Some heterogeneity was due to the difference in the estimates between published and unpublished studies: relative risk, 0.43 (CI, 0.25 to 0.75) versus 0.78 (CI, 0.52 to 1.17), respectively. Meta-regression showed that small, poor-quality studies that assessed outcomes soon after radiocontrast administration were more likely to suggest benefit (P < 0.05 for all). No clear effects of treatment on the risk for dialysis, heart failure, and total mortality were identified.
LIMITATION: Power to assess clinical end points was limited.
CONCLUSION: The effectiveness of sodium bicarbonate treatment to prevent CIN in high-risk patients remains uncertain. Earlier reports probably overestimated the magnitude of any benefit, whereas larger, more recent trials have had neutral results. Large multicenter trials are required to clarify whether sodium bicarbonate has value for prevention of CIN before routine use can be recommended.
PRIMARY FUNDING SOURCE: None.

PMID 19884624  Ann Intern Med. 2009 Nov 3;151(9):631-8. doi: 10.7326/0・・・
著者: Theresia Klima, Andreas Christ, Ivana Marana, Stefan Kalbermatter, Heiko Uthoff, Emanuel Burri, Sabine Hartwiger, Christian Schindler, Tobias Breidthardt, Giancarlo Marenzi, Christian Mueller
雑誌名: Eur Heart J. 2012 Aug;33(16):2071-9. doi: 10.1093/eurheartj/ehr501. Epub 2012 Jan 19.
Abstract/Text AIMS: The most effective regimen for the prevention of contrast-induced nephropathy (CIN) remains uncertain. Our purpose was to compare two regimens of sodium bicarbonate with 24 h sodium chloride 0.9% infusion in the prevention of CIN.
METHODS AND RESULTS: We performed a prospective, randomized trial between March 2005 and December 2009, including 258 consecutive patients with renal insufficiency undergoing intravascular contrast procedures. Patients were randomized to receive intravenous volume supplementation with either (A) sodium chloride 0.9% 1 mL/kg/h for at least 12h prior and after the procedure or (B) sodium bicarbonate (166 mEq/L) 3 mL/kg for 1 h before and 1 mL/kg/h for 6 h after the procedure or (C) sodium bicarbonate (166 mEq/L) 3 mL/kg over 20 min before the procedure plus sodium bicarbonate orally (500 mg per 10 kg). The primary endpoint was the change in estimated glomerular filtration rate (eGFR) within 48 h after contrast. Secondary endpoints included the development of CIN. The maximum change in eGFR was significantly greater in Group B compared with Group A {mean difference -3.9 [95% confidence interval (CI), -6.8 to -1] mL/min/1.73 m2, P = 0.009} and similar between groups C and B [mean difference 1.3 (95% CI, -1.7-4.3) mL/min/1.73 m(2), P = 0.39]. The incidence of CIN was significantly lower in Group A (1%) vs. Group B (9%, P = 0.02) and similar between Groups B and C (10%, P = 0.9).
CONCLUSION: Volume supplementation with 24 h sodium chloride 0.9% is superior to sodium bicarbonate for the prevention of CIN. A short-term regimen with sodium bicarbonate is non-inferior to a 7 h regimen. ClinicalTrials.gov Identifier: NCT00130598.

PMID 22267245  Eur Heart J. 2012 Aug;33(16):2071-9. doi: 10.1093/eurhe・・・

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