晶体液和胶体液对腹部大手术患者术后肾功能和无残疾生存率的远期影响
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Long-term Impact of Crystalloid versus Colloid Solutions on Renal Function and Disability-free Survival after Major Abdominal Surgery
背景与目的
胶体液有助于提高高危患者围术期血流动力学的稳定性，且可避免液体输注过量带来的不利影响。尽管羟乙基淀粉用于许多目标导向液体治疗方案，但其安全性仍存在争议。有研究报道羟乙基淀粉对ICU患者具有潜在的肾毒性，但其在围术期相关研究中并未发现此类现象。本研究旨在探讨术中使用晶体或胶体液对腹部大手术患者术后远期肾功能和无残疾生存率的影响。
方 法
采用世界卫生组织残疾评估表2.0（WHODAS），对早期研究中登记的所有患者在肾功能和残疾手术后1年进行随访。主要观察指标为肾小球滤过率，其他指标包括血清肌酐、尿素、瘙痒和WHODAS评分。在完整的病例分析基础上对各组进行比较，然后用混合模型回归分析比较数据差异性。
结 果
共获得纳入研究的160例患者中129例（81％）的长期肾功能随访数据，114例患者（71％）完整的WHODAS评分数据。。两组患者血清肌酐、尿素氮和肾小球滤过率在术后1年无显著差异。通过WHODAS评分评估残疾率，胶体组显著低于晶体组（分别为2.7 [0-12％]和7.6 [1.3-18％]; P = 0.015）。胶体组（79％）1年无残疾生存率显著高于晶体组（60％）（P = 0.024; 95％CI，2％-39％）。
结 论
对接受腹部大手术的患者，胶体液与晶体液对患者术后远期肾功能的影响无计学差异，但与晶体液相比，术中使用胶体液进行目标导向液体治疗的患者远期无残疾生存率明显增加。
原始文献摘要
Joosten A, Delaporte A, Mortier J, et al. Long-term Impact of Crystalloid versus Colloid Solutions on Renal Function and Disability-free Survival after Major Abdominal Surgery. Anesthesiology. 2018 Nov 9. doi: 10.1097/ALN.0000000000002501
BACKGROUND:The authors recently demonstrated that administration of balanced hydroxyethyl starch solution as part of intraoperative goal-directed fluid therapy was associated with better short-term outcomes than administration of a balanced crystalloid solution in patients having major open abdominal surgery. In the present study, a 1-yr follow-up of renal and disability outcomes in these patients was performed.
METHODS:All patients enrolled in the earlier study were followed up 1 yr after surgery for renal function and disability using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). The main outcome measure was the estimated glomerular filtration rate. Other outcomes were serum creatinine, urea, pruritus, and WHODAS score. Groups were compared on a complete-case analysis basis, and modern imputation methods were then used in mixed-model regressions to assess the stability of the findings taking into account the missing data.
RESULTS: Of the 160 patients enrolled in the original study, follow-up data were obtained for renal function in 129 and for WHODAS score in 114. There were no statistically significant differences in estimated glomerular filtration rate at 1 yr (ml min 1.73 m): 80 [65 to 92] for crystalloids versus 74 [64 to 94] for colloids; 95% CI [-10 to 7], P = 0.624. However, the WHODAS score (%) was statistically significantly lower in the colloid than in the crystalloid group (2.7 [0 to 12] vs. 7.6 [1.3 to 18]; P = 0.015), and disability-free survival was higher (79% vs. 60%; 95% CI [2 to 39]; P = 0.024).
CONCLUSIONS: In patients undergoing major open abdominal surgery, there was no evidence of a statistically significant difference in long-term renal function between a balanced hydroxyethyl starch and a balanced crystalloid solution used as part of intraoperative goal-directed fluid therapy, although there was only limited power to rule out a clinically significant difference. However, disability-free survival was significantly higher in the colloid than in the crystalloid group.
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