Clinical Practice Guidelines For Acute Kidney Injury In ChinaⅣ

Clinical question 6: How to monitor AKI?

1. Hemodynamic monitoring

【Recommendations】

1. For AKI and high-risk patients, it is recommended to closely monitor hemodynamic changes during fluid therapy to ensure effective renal perfusion and avoid adverse consequences due to volume overload (1B).

2. For AKI and high-risk patients, it is recommended to refer to the established hemodynamic and oxygenation parameter management plan and to use dynamic rather than static indicators to predict volume responsiveness to avoid the occurrence, progression, or worsening of AKI (2C).

3. The blood pressure target needs to consider pre-morbid blood pressure, weigh the pros and cons between increased renal perfusion caused by vasoconstriction and hypoperfusion of other organs, and pay attention to the impact of intra-abdominal pressure on renal perfusion pressure (2C).

4. It is recommended that AKI and high-risk patients can use transcutaneous oxygen measurement and the venous-arterial CO2 partial pressure difference (Pv-aCO2)/arterial-venous oxygen content difference (Ca-vO2) ratio (Pv-aCO2/Ca- vO2) measurement and contrast-enhanced ultrasound to make necessary assessments of renal microcirculation and oxygen metabolism (2C).

Click to Cistanche for kidney disease

Insufficient effective circulating volume is a recognized important risk factor for AKI. Adequate fluid resuscitation and optimized volume balance are crucial to the prevention and treatment of AKI. It helps minimize the scope of kidney damage, facilitates recovery from AKI, and reduces the risk of residual renal function. damage. A previous RCT study on 3,000 patients with major abdominal surgery showed that restrictive fluid resuscitation increased the incidence of AKI; similarly, volume overload is also a risk factor for poor prognosis in patients with AKI, including increased incidence of new AKI and Overall mortality. A prospective study in 2017 included observational data of 339 consecutive ICU patients admitted to the hospital, and the results showed that volume overload is an independent risk factor for the occurrence of AKI. Another retrospective cohort study of 8 intensive care units in the United States analyzed the fluid therapy and outcomes of 18,084 critically ill patients. The results showed that compared with the balance state (0~5% body weight) or negative balance state group (<5% Compared with body weight), the 1-year mortality rate in the positive fluid balance group (≥5% body weight) was significantly increased. Therefore, it is recommended that patients with AKI should avoid volume overload and avoid adverse consequences.

It is currently believed that perioperative goal-directed therapy (GDT), that is, formulating plans based on established hemodynamic and oxygenation parameter management goals, can reduce mortality and the risk of AKI. A prospective RCT study recruited 263 patients with severe sepsis or septic shock, and the results showed that early use of GDT can significantly improve patient prognosis. Another meta-analysis of 95 RCT studies (11,659 cases) showed that perioperative GDT can reduce the incidence of complications and mortality. A meta-analysis included 65 studies (9,308 patients) and found that perioperative fluid therapy and the use of vasoactive drugs to optimize hemodynamics and improve tissue oxygenation can improve renal perfusion and oxygenation in patients at high risk for AKI. And significantly reduce the occurrence of postoperative AKI. Therefore, perioperative GDT can improve the benefits of preventing and treating AKI events, but whether it is applicable to other target groups has not yet been determined.

Central venous pressure (CVP) has limited ability to guide volume response in the normal range (8~12 mmHg, 1 mmHg=0.133 kPa). It is not recommended to use CVP alone to guide fluid resuscitation. Other static measurements of left or right heart pressure or volume are not recommended. Indicators suffer from similar shortcomings. The 2016 Sepsis Guidelines recommend that dynamic indicators of volume responsiveness should be used to guide fluid resuscitation in septic shock, such as passive leg raising test (PLR), pulse pressure variability (PVV) or stroke volume variability (SVV), Inferior vena cava variability, etc.

The 2016 sepsis guidelines recommend fluid resuscitation and the use of norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg to ensure renal perfusion and prevent the occurrence of AKI. Numerous studies have shown that using norepinephrine to increase the blood pressure target in septic shock patients to 75~85 mmHg can increase the cardiac output index, but it cannot improve renal function, reduce lactate levels, increase oxygen supply, and reduce mortality. On the contrary, it increases Occurrence of cardiac arrhythmias. Intra-abdominal hypertension (IAH) refers to persistent intra-abdominal pressure >12 mmHg, and abdominal compartment syndrome (ACS) refers to persistent intra-abdominal pressure >20 mmHg, with or without intraperitoneal perfusion pressure <60 mmHg, and with new Organ dysfunction or failure, if not recognized and adequately treated, can lead to reduced organ perfusion, tissue ischemia, organ failure, and death. Elevated CVP, mechanical ventilation, trauma, volume overload, abdominal infection, and surgery in severe patients are all high-risk factors for ACS. Intra-abdominal pressure is an important factor affecting renal perfusion pressure. IAH first reduces renal perfusion by increasing renal vein and renal parenchyma pressure. The continued increase will reduce cardiac output and compress ureters, eventually leading to AKI. Patients at high risk of ACS should undergo routine intra-abdominal pressure monitoring to avoid the occurrence of AKI caused by IAH.

Microcirculation disorder in renal tissue is considered to be an important mechanism in the occurrence and development of AKI. Microcirculation and oxygen metabolism assessment and effective intervention may be the key to the prevention and treatment of AKI. Studies have shown that completing early goal-directed therapy (EGDT) in patients with septic shock does not reduce the incidence of AKI. 46% of patients who maintain central venous oxygen saturation (ScvO2) ≥70% and MAP ≥65 mmHg still develop AKI. Transcutaneous oxygen partial pressure (PtcO2) monitoring can better reflect peripheral tissue and microvascular perfusion. Many studies have found that skin and kidney microcirculation are related, and skin tissue blood flow can simultaneously reflect kidney blood flow. Domestic scholars use 10 minutes ΔPtcO2 [ΔPtcO2=PtcO2 (10 min)-PtcO2 (baseline value)] measured by transcutaneous oxygen load test is used as a hemodynamic index to evaluate whether the microcirculatory perfusion of renal tissue is good. Pv-aCO2/Ca-vO2 is a sensitive indicator that reflects tissue anaerobic metabolism. An increase in the ratio has good sensitivity and specificity in predicting the exacerbation of AKI. Some studies believe that the combined use of arterial blood lactate clearance and Pv-aCO2/Ca- vO2 guides fluid resuscitation in septic shock better than a single indicator. Traditional renal ultrasound can only evaluate the blood flow parameters of the branches above the renal interlobar arteries, and it is very difficult to evaluate the renal cortical blood flow. The emerging contrast-enhanced ultrasound technology can conduct a semi-quantitative assessment of renal microcirculation, using contrast agents to rise in the renal cortex. Time (RT) and mean transit time (MTT) can predict the severity of AKI, and cortical ascending slope (WIS) and medullary peak intensity (PI) are found to be related to AKI recovery.

How Does Cistanche Treat Kidney Disease?

Cistanche is a traditional Chinese herbal medicine used for centuries to treat various health conditions, including kidney disease. It is derived from the dried stems of Cistanche deserticola, a plant native to the deserts of China and Mongolia. The main active components of cistanche are phenylethanoid glycosides, echinacoside, and acteoside, which have been found to have beneficial effects on kidney health.

Kidney disease, also known as renal disease, refers to a condition in which the kidneys are not functioning properly. This can result in a buildup of waste products and toxins in the body, leading to various symptoms and complications. Cistanche may help treat kidney disease ase through several mechanisms.

Firstly, cistanche has been found to have diuretic properties, meaning it can increase urine production and help eliminate waste products from the body. This can help relieve the burden on the kidneys and prevent the buildup of toxins. By promoting diuresis, cistanche may also help Reduce high blood pressure, a common complication of kidney disease.

Moreover, cistanche has been shown to have antioxidant effects. Oxidative stress, caused by an imbalance between the production of free radicals and the body's antioxidant defenses, plays a key role in the progression of kidney disease. ies help neutralize free radicals and reduce Oxidative stress, thereby protecting the kidneys from damage. The phenylethanoid glycosides found in cistanche have been particularly effective in scavenging free radicals and inhibiting lipid peroxidation.

Additionally, cistanche has been found to have anti-inflammatory effects. Inflammation is another key factor in the development and progression of kidney disease. Cistanche's anti-inflammatory properties help reduce the production of pro-inflammatory cytokines and inhibit the activation of inflammation mandatory pathways, thus alleviating inflammation in the kidneys.

Furthermore, cistanche has been shown to have immunomodulatory effects. In kidney disease, the immune system can be dysregulated, leading to excessive inflammation and tissue damage. Cistanche helps regulate the immune response by modulating the production and activity of immune cells, such as T cells and macrophages. This immune regulation helps reduce inflammation and prevent further damage to the kidneys.

Moreover, cistanche has been found to improve renal function by promoting the regeneration of renal tubes with cells. Renal tubular epithelial cells play a crucial role in the filtration and reabsorption of waste products and electrolytes. In kidney disease, these cells can be damaged, leading to damaged renal function. Cistanche's ability to promote the regeneration of these cells helps restore proper renal function and improve overall kidney health.

In addition to these direct effects on the kidneys, cistanche has been found to have beneficial effects on other organs and systems in the body. This holistic approach to health is particularly important in kidney disease, as the condition often affects multiple organs and systems. che has been shown to have protective effects on the liver, heart, and blood vessels, which are commonly affected by kidney disease. By promoting the health of these organs, cistanche helps improve overall kidney function and prevent further complications.

In conclusion, cistanche is a traditional Chinese herbal medicine used for centuries to treat kidney disease. Its active components have diuretic, antioxidant, anti-inflammatory, immunomodulatory, and regenerative effects, which help improve renal function and protect the kidneys from further damage. , cistanche has beneficial effects on other organs and systems, making it a holistic approach to treating kidney disease.