羟乙基淀粉对肾移植受体肾功能影响课件

羟乙基淀粉对肾移植受体肾功能影响1（优选）羟乙基淀粉对肾移植受体肾功能影响2透性肾病因静脉滴注高

空泡样变性称为溶液引起肾小管细胞肿胀、透性肾病osmotic-nephrosis，临3床可表现为蛋白尿、血尿、肾功能损害，严重者发生急性肾衰竭.4一般认为大剂量高渗液引起肾小管上皮细胞肿胀，空泡样变致肾小管闭塞引起渗透性肾病，可能与肾小管肾小球反馈机理以及高浓度高渗液引起肾血管痉挛有关。5Effect

of

hydroxyethylstarchinbraindead

kidney

donors

on

renalfunction

in

kidneytransplant

recipients

M

L

Cittanova,

I

Leblanc,

ChLegendre,

C

Mouquet,

B

Riou,

P

Coriat

THE

LANCET

，Vol

348

•

December14,19966Background Hydroxyethylstarch

used

as

aplasmavolume

expander

inbraindeadkidney

donors

has

been

suggested

toinduceosmoticnephrosislike

lesions.7Methods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinatedcontrastmedia

before

brain

deathwereexcluded.869

other

braindead

patients

were

prospectivelyincluded

over

18

months

and

randomised

intotwogroups.9Among

these

69,

multiple

organs

wereobtained

in 29,including

kidneys

in

27

cases.Multiple

organ

procurement was

not

possiblein

40

patients

because

of

relatives’ refusal(25),

cardiac

arrest

(7),

cancer

(1),

sepsis

(2),viral

hepatitis

or HIV

infection

(3),

andcoroner’s

refusal

(2)..10Effect

ofhydroxyethylstarchin

braindead

kidney

donors

on

renal

function

in

kidneytransplant

recipientsMethods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.THE

LANCET

，Vol

348

•

December

14,

1996Background

Hydroxyethylstarch

used

as

a

plasmavolume

expander

in

braindead

kidney

donors

has

been

suggested

toinduceosmoticnephrosislike

lesions.Methods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.羟乙基淀粉致急性肾功能衰竭的病理特征羟乙基淀粉对肾移植受体肾功能影响Interpretation These

data

suggest

that

hydroxyethylstarch

used

as

a

plasmavolume

expander

in

braindead

donors

impairsimmediate

renal

function

in

kidneytransplant

recipients.10

days

after

transplantation,

mean

(SD)

serum

creatinine

was,

respectively,

145

(70)

and

312

(259)

µmol/L.Also,

there

was

no

significant

difference

in

serum

creatinine

level

before

organ

procurement

(mean[SD])

84

[38]

µmol/L

inthe

hydroxyethylstarch

group

versus

89

[29]

µmol/L

in

the

gelatinonly

group.Mostly

proximal

but

also

distal

tubules

were

affected.Effect

ofhydroxyethylstarchin

braindead

kidney

donors

on

renal

function

in

kidneytransplant

recipientsMethods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.一般认为大剂量高渗液引起肾小管上皮细胞肿胀，空泡样变致肾小管闭塞引起渗透性肾病，可能与肾小管肾小球反馈机理以及高浓度高渗液引起肾血管痉挛有关。空泡样变性称为渗透性肾病osmotic-nephrosis，临床可表现为蛋白尿、血尿、肾功能损害，严重者发生急性肾衰竭.We

saw

a

higher

frequency

of

extrarenal

haemodialysis

during

the

first

8

days,

and

increased

serum

creatinine

during

the

first

10days.We

therefore

studied

27organdonors(hydroxyethylstarchgelatin15,gelatinonly

12)

.11In

the

hydroxyethylstarchgelatin

group,patients

received

hydroxyethylstarch

up

to

33mL/kg

for

colloid

plasmavolume

expansion,and

afterwards

received

modified

fluid

gelatin.12In

the

gelatinonly

group,

patients

received

onlymodified

fluid

gelatin

as

colloid

plasmavolumeexpander.13All

organ

donors

received

fluid

expansionaccording to

transoesophageal

echographicdata.

Hypovolaemia was

diagnosed

whenleftventricular

enddiastolic

area

(LVEDa)

wasbelow

5·5

cm

2

/m

2.14

Catecholamine

doses

were

adjusted

toobtain amean

arterial

pressure

between60

and

100

mm

Hg,

after fluid

loading

ifnecessary.15Findings

There

were

nosignificantdifferences

in

the

characteristics

of

patientsbetween

the

two

groups

of

kidney

donors

or

ofrecipients

(except

for

a

small

imbalance

in

sexin

the

recipients)

.16Among

these

69,

multiple

organs

were

obtained

in

29,

including

kidneys

in

27

cases.羟乙基淀粉对肾移植受体肾功能影响MethodsMethods52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.In

this

prospective

randomised

study

we

found

that

administration

ofhydroxyethylstarch

to

braindead

kidney

donors

worsenedthe

prognosis

of

renal

transplantation.Interpretation These

data

suggest

that

hydroxyethylstarch

used

as

a

plasmavolume

expander

in

braindead

donors

impairsimmediate

renal

function

in

kidneytransplant

recipients.THE

LANCET

，Vol

348

•

December

14,

1996羟乙基淀粉致急性肾功能衰竭的病理特征Methods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.羟乙基淀粉致急性肾功能衰竭的病理特征Catecholamine

doses

were

adjusted

to

obtain

a

mean

arterial

pressure

between

60

and

100

mm

Hg,

after

fluid

loading

ifnecessary.空泡样变性称为渗透性肾病osmotic-nephrosis，临床可表现为蛋白尿、血尿、肾功能损害，严重者发生急性肾衰竭.10

days

after

transplantation,mean(SD)serum

creatinine

was,respectively,

145

(70)

and

312

(259)

µmol/L.We

thereforestudied

27organ

donors(hydroxyethylstarchgelatin15,gelatinonly

12).10

days

after

transplantation,

mean

(SD)

serum

creatinine

was,

respectively,

145

(70)

and

312

(259)

µmol/L.THE

LANCET

，Vol

348

•

December

14,

1996In

this

prospective

randomised

study

we

found

that

administration

ofhydroxyethylstarch

to

braindead

kidney

donors

worsenedthe

prognosis

of

renal

transplantation.THE

LANCET

，Vol

348

•

December

14,

1996Background

Hydroxyethylstarch

used

as

a

plasmavolume

expander

in

braindead

kidney

donors

has

been

suggested

toinduceosmoticnephrosislike

lesions.

No

adverse

reaction

to

either

expanderwas

observed.

Also,

there

was

nosignificant

difference in

serum

creatininelevel

before

organ

procurement

(mean[SD])84

[38]

µmol/L

in

the

hydroxyethylstarchgroup

versus

89

[29]

µmol/L

in

the

gelatinonlygroup.19During

the

first

8

days

after

transplantation,nine

of

27

(33%)

patients

requiredextrarenalhaemodialysis

in

the

hydroxyethylstarchgelatingroup

compared

with

one

of

20

(5%)

in

thegelatinonly

group

(p=0·029)

.20Serum

creatinine

concentrations

weresignificantly

lower

in

the

gelatinonlygroupthan

in

the

other

group

(p=0·009)

.

10daysafter

transplantation,

mean

(SD)

serumcreatinine

was,

respectively,

145

(70)

and

312(259)

µmol/L.21

Nine

renalbiopsy

specimens

wereexamined

(six

in

the

gelatinonly

group).All three

specimens

in

thehydroxyethylstarchgelatin

group

hadosmoticnephrosislike

lesions

in

the

tubules.2324一般认为大剂量高渗液引起肾小管上皮细胞肿胀，空泡样变致肾小管闭塞引起渗透性肾病，可能与肾小管肾小球反馈机理以及高浓度高渗液引起肾血管痉挛有关。Also,

there

was

no

significant

difference

in

serum

creatinine

level

before

organ

procurement

(mean[SD])

84

[38]

µmol/L

inthe

hydroxyethylstarch

group

versus

89

[29]

µmol/L

in

the

gelatinonly

group.10

days

after

transplantation,

mean

(SD)

serum

creatinine

was,

respectively,

145

(70)

and

312

(259)

µmol/L.空泡样变性称为渗透性肾病osmotic-nephrosis，临床可表现为蛋白尿、血尿、肾功能损害，严重者发生急性肾衰竭.We

saw

a

higher

frequency

of

extrarenal

haemodialysis

during

the

first

8

days,

and

increased

serum

creatinine

during

the

first

10days.羟乙基淀粉致急性肾功能衰竭的病理特征We

saw

a

higher

frequency

of

extrarenal

haemodialysis

during

the

first

8

days,

and

increased

serum

creatinine

during

the

first

10days.10

days

after

transplantation,

mean

(SD)

serum

creatinine

was,

respectively,

145

(70)

and

312

(259)

µmol/L.羟乙基淀粉致急性肾功能衰竭的病理特征Among

these

69,

multiple

organs

were

obtained

in

29,

including

kidneys

in

27

cases.因静脉滴注高渗溶液引起肾小管细胞肿胀、Also,

there

was

no

significant

difference

in

serum

creatinine

level

before

organ

procurement

(mean[SD])

84

[38]

µmol/L

inthe

hydroxyethylstarch

group

versus

89

[29]

µmol/L

in

the

gelatinonly

group.Among

these

69,

multiple

organs

were

obtained

in

29,

including

kidneys

in

27

cases.In

this

prospective

randomised

study

we

found

that

administration

ofhydroxyethylstarch

to

braindead

kidney

donors

worsenedthe

prognosis

of

renal

transplantation.Findings

There

were

no

significant

differences

in

the

characteristics

of

patients

between

the

two

groups

of

kidney

donors

or

ofrecipients

(except

for

a

small

imbalance

in

sex

in

the

recipients)

.We

thereforestudied

27organ

donors(hydroxyethylstarchgelatin15,gelatinonly

12).All

organ

donors

received

fluid

expansion

according

to

transoesophageal

echographic

data.In

the

hydroxyethylstarchgelatingroup,

patients

receivedhydroxyethylstarch

up

to33

mL/kg

forcolloid

plasmavolume

expansion,andafterwards

received

modified

fluid

gelatin.羟乙基淀粉致急性肾功能衰竭的病理特征Methods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.THE

LANCET

，Vol

348

•

December

14,

1996In

this

prospective

randomised

study

we

foundthat

administration

of

hydroxyethylstarch

tobraindead

kidney

donors

worsened

theprognosis

of

renal

transplantation.25We

saw

a

higher

frequency

ofextrarenalhaemodialysis

during

the

first

8

days,

andincreased

serum

creatinine

during

the

first

10days.26

The

renal

biopsies

in

nine

kidneyrecipients

showed

osmoticnephrosislikelesions

only

in

thehydroxyethylstarchgelatin

group.27Mostly

proximal

but

also

distal

tubuleswere

affected. These

lesions

were

found

inkidneytransplant

biopsy

specimens

as

long

as

2years

after

transplantation

(data

from

ChL),which

suggests

a

thesaurisoma

mechanism.28Interpretation These

data

suggest

thathydroxyethylstarch

used

as

a

plasmavolumeexpander

in

braindead

donors

impairsimmediate

renal

function

inkidneytransplant

recipients.29羟乙基淀粉对肾移植受体肾功能影响THE

LANCET

，Vol

348

•

December

14,

1996Findings

There

were

no

significant

differences

in

the

characteristics

of

patients

between

the

two

groups

of

kidney

donors

or

ofrecipients

(except

for

a

small

imbalance

in

sex

in

the

recipients)

.All

organ

donors

received

fluid

expansion

according

to

transoesophageal

echographic

data.Among

these

69,

multiple

organs

were

obtained

in

29,

including

kidneys

in

27

cases.丁尧海张爱平王艳侠涂晓文张颖玮一般认为大剂量高渗液引起肾小管上皮细胞肿胀，空泡样变致肾小管闭塞引起渗透性肾病，可能与肾小管肾小球反馈机理以及高浓度高渗液引起肾血管痉挛有关。Hypovolaemia

was

diagnosed

when

leftventricular

enddiastolic

area

(LVEDa)

was

below

5·5

cm

2

/m

2

.69

other

braindead

patients

were

prospectively

included

over

18

months

and

randomised

into

two

groups.Methods 52

patients

who

had

receivedhydroxyethylstarch

or

iodinated

contrastmedia

before

brain

death

wereexcluded.Also,

ther