NGAL e KIM-1 como preditores de injúria renal após terapia de reposição volêmica guiada por metas: ensaio clínico randomizado
Carregando...
Arquivos
Data
2021-02-15
Autores
Santos, Murillo Gonçalves
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
Introdução: A reposição volêmica guiada por metas hemodinâmicas utilizando coloides no período intraoperatório é questionável, podendo determinar a evolução perioperatória. Coloides são conhecidos por afetarem negativamente a função renal de pacientes com nefropatia e sepse, mas ainda há controvérsias quanto aos efeitos na função renal de pacientes saudáveis. Este estudo busca avaliar os efeitos na função renal após a administração de coloides em pacientes submetidas a histerectomia, por meio do uso dos biomarcadores lipocalina associada à gelatinase de neutrófilos (NGAL) e molécula de injúria renal-1 (KIM-1). Ainda, avaliou-se o comportamento das variáveis hemodinâmicas quando essas soluções são utilizadas para reposição volêmica em comparação com a expansão da volemia com cristaloides. Métodos: Este estudo clínico randomizado e duplo-cego, incluiu pacientes femininas, entre 18 e 65 anos de idade, estado físico ASA I e II, submetidas a histerectomia abdominal eletiva sob anestesia geral. Pacientes com hipertensão arterial ou diabetes mellitus não-controlados, obesidade II ou superior, em uso de diuréticos ou anti-inflamatórios, com histórico de doenças renais ou coagulopatias pré-operatórias não foram incluídas. Foi realizada randomização em 2 grupos, de acordo com o protocolo de reposição volêmica que se segue: administração de Ringer lactato (2 ml.kg-1.h-1) a todas as pacientes durante a cirurgia para reposição de perdas insensíveis; em caso de pressão arterial média inferior a 60 mmHg, realizou-se expansão volêmica com bolus de 300 ml de Ringer lactato (grupo RL) ou 150 ml Hidroxietilamido 6% (grupo HES), dependendo da alocação da paciente nos grupos. Foram coletadas amostras de sangue e de urina na véspera, 24 horas e 40 dias após a cirurgia para análise da função renal das pacientes. Creatinina plasmática e NGAL e KIM-1 urinárias foram dosados para este fim. Balanço hídrico e suas variantes, variáveis hemodinâmicas intraoperatórias, sangramento, dor e complicações pós-operatórias também foram avaliados. Resultados: As pacientes do grupo RL receberam maior volume de cristaloides (1227 ml ± 812,7 ml vs. 630,4 ml ± 310,2 ml, p = 0,002) com maior balanço hídrico (780 ml ± 720 ml vs. 430 ml ± 440 ml, p = 0,03) e sobrecarga de fluidos (11,7% ± 10,4% vs. 7,0% ± 6,3%, p = 0,03) quando comparadas com as pacientes do grupo HES. NGAL e KIM-1 aumentaram 24 horas após a cirurgia em ambos os grupos, com retorno aos níveis pré-operatórios após 40 dias. Os parâmetros hemodinâmicos avaliados foram semelhantes entre os grupos. Conclusão: A solução Hidroxietilamido 6% teve comportamento semelhante à solução de Ringer lactato em relação às variáveis hemodinâmicas. Hidroxietilamido 6% diminuiu o balanço hídrico e a sobrecarga de fluidos comparado ao Ringer lactato. Os biomarcadores não indicaram pior desfecho renal quando Hidroxietilamido 6% foi utilizado para reposição volêmica neste estudo.
Introduction: Goal-directed fluid therapy using colloids in the perioperative setting is questionable and can determine perioperative outcomes. Colloids are well known to negatively affect the renal function of patients with impaired kidney function and sepsis; however, controversies in regard to their effects on renal function in surgical patients with previous normal kidney function still exists. This study aims to evaluate the hemodynamic effects of the colloids administration in patients undergoing hysterectomy, in addition to evaluating early and late kidney function using the biomarkers neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM1). Methods: This double-blind, randomized study included female patients aged between 18 and 65 years, American Society of Anesthesiologists physical status (ASA) I and II, undergoing elective abdominal hysterectomy under general anesthesia. Patients with uncontrolled hypertension or diabetes mellitus, obesity II or higher, currently using diuretics or anti-inflammatories, with a history of renal diseases or preoperative coagulopathies were not included. The patients were randomized in two groups according to the following fluid replacement protocol: administration of Ringer’s lactate (2 ml.kg-1 .h -1 ) as maintenance fluid replacement to all patients during surgery; volume expansion performed with 300 ml bolus of Ringer’s lactate (RL group) or 150 ml of Hydroxyethyl starch 6% (HES group), depending on the group allocation when the mean arterial pressure was below 60 mmHg. Blood and urine samples were collected the day prior surgery and 24 hours and 40 days after surgery to assess patients’ kidney function. To this end, plasma creatinine and urinary NGAL and KIM-1 were assessed. Fluid balance and its variants, intraoperative hemodynamic variables, total blood loss, postoperative pain score, and postoperative complications were also evaluated. Results: Patients from the RL group received greater crystalloid volume (1,277.0 ml ± 812.7 ml vs. 630.4 ml ± 310.2 ml, p = 0.002) with larger fluid balance (780 ml ± 720 ml vs. 430 ml ± 440 ml, p = 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%, p = 0.04) when compared to patients from the HES group. Although NGAL and KIM-1 values increased 24 hours after surgery in both groups, the biomarkers levels returned to baseline values 40 days after surgery. Similar intraoperative hemodynamic behaviors and similar postoperative complications incidence were observed in both groups. Conclusions: The Hydroxyethyl starch 6% is as effective as Ringer’s lactate in maintain the hemodynamic stability during open hysterectomy in this cohort. Hydroxyethyl starch 6% reduced the fluid overload compared to Ringer’s lactate. The administration of HES did not impaired kidney function in the studied group based on the biomarkers results.
Introduction: Goal-directed fluid therapy using colloids in the perioperative setting is questionable and can determine perioperative outcomes. Colloids are well known to negatively affect the renal function of patients with impaired kidney function and sepsis; however, controversies in regard to their effects on renal function in surgical patients with previous normal kidney function still exists. This study aims to evaluate the hemodynamic effects of the colloids administration in patients undergoing hysterectomy, in addition to evaluating early and late kidney function using the biomarkers neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM1). Methods: This double-blind, randomized study included female patients aged between 18 and 65 years, American Society of Anesthesiologists physical status (ASA) I and II, undergoing elective abdominal hysterectomy under general anesthesia. Patients with uncontrolled hypertension or diabetes mellitus, obesity II or higher, currently using diuretics or anti-inflammatories, with a history of renal diseases or preoperative coagulopathies were not included. The patients were randomized in two groups according to the following fluid replacement protocol: administration of Ringer’s lactate (2 ml.kg-1 .h -1 ) as maintenance fluid replacement to all patients during surgery; volume expansion performed with 300 ml bolus of Ringer’s lactate (RL group) or 150 ml of Hydroxyethyl starch 6% (HES group), depending on the group allocation when the mean arterial pressure was below 60 mmHg. Blood and urine samples were collected the day prior surgery and 24 hours and 40 days after surgery to assess patients’ kidney function. To this end, plasma creatinine and urinary NGAL and KIM-1 were assessed. Fluid balance and its variants, intraoperative hemodynamic variables, total blood loss, postoperative pain score, and postoperative complications were also evaluated. Results: Patients from the RL group received greater crystalloid volume (1,277.0 ml ± 812.7 ml vs. 630.4 ml ± 310.2 ml, p = 0.002) with larger fluid balance (780 ml ± 720 ml vs. 430 ml ± 440 ml, p = 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%, p = 0.04) when compared to patients from the HES group. Although NGAL and KIM-1 values increased 24 hours after surgery in both groups, the biomarkers levels returned to baseline values 40 days after surgery. Similar intraoperative hemodynamic behaviors and similar postoperative complications incidence were observed in both groups. Conclusions: The Hydroxyethyl starch 6% is as effective as Ringer’s lactate in maintain the hemodynamic stability during open hysterectomy in this cohort. Hydroxyethyl starch 6% reduced the fluid overload compared to Ringer’s lactate. The administration of HES did not impaired kidney function in the studied group based on the biomarkers results.
Descrição
Palavras-chave
Hidroxietilamido, Testes de função renal, Histerectomia, Hydroxyethyl starch, kidney function tests, Hysterectomy