Serebral Ödemli Yoğun Bakım Hastalarında Akut Böbrek Hasarı: Protokol Değişikliği Sonrası Hipertonik Salin ve Mannitol Karşılaştırması

Abstract

Amaç: Mannitol ve hipertonik salin, serebral ödem tedavisinde yaygın olarak kullanılan hiperosmolar ajanlardır; ancak renal güvenlilik profilleri net değildir. Yoğun bakım ünitemizde hipertonik salini önceleyen bir protokol değişikliği sonrasında, bu iki tedavi stratejisi arasında akut böbrek hasarı (ABH) ve yoğun bakım ünitesi (YBÜ) mortalitesi karşılaştırılmıştır.

Materyal ve metod: Bu retrospektif gözlemsel çalışmaya, akut beyin hasarı ve serebral ödem nedeniyle YBÜ'de izlenen ve yalnızca %20 mannitol veya %3 hipertonik salin ile osmoterapi alan erişkin hastalar dahil edilmiştir. Önceden böbrek hastalığı olanlar veya kombine osmoterapi alan hastalar çalışma dışı bırakılmıştır. Birincil sonlanım noktası, KDIGO kriterlerine göre 48. saatte gelişen ABH olarak belirlenmiştir. İkincil sonlanım noktaları ABH şiddeti ve YBÜ mortalitesidir. Çok değişkenli lojistik regresyon analizinde yaş, APACHE II ve SOFA skorları için düzeltme yapılmıştır.

Bulgular: Toplam 77 hasta analiz edilmiştir (hipertonik salin: n=43; mannitol: n=34). Başlangıç demografik özellikleri ve hastalık şiddeti iki grup arasında benzerdi. ABH insidansı mannitol grubunda anlamlı olarak daha yüksekti (%47’ye karşı %8, p=0,003) ve daha ileri ABH evreleriyle seyretmekteydi (p<0,001). YBÜ mortalitesi mannitol grubunda daha yüksek bulundu (%56’ya karşı %19, p=0,002) ve bu ilişki çok değişkenli analizde de bağımsız olarak devam etti (olasılık oranı: 3,09; %95 güven aralığı: 1,09-9,23). Mannitol kullanımı, anlamlı derecede daha yüksek kümülatif sıvı yükü ile ilişkiliydi.

Sonuç: Mannitol tedavisi, hipertonik salin ile karşılaştırıldığında daha yüksek akut böbrek hasarı insidansı ve artmış YBÜ mortalitesi ile ilişkili bulunmuştur. Nörolojik etkinliğin benzer olduğu durumlarda, hiperosmolar ajan seçiminde renal güvenlilik ön planda tutulmalıdır.

Keywords

• Akut böbrek hasarı
• Mannitol
• Hipertonik
• Osmoterapi
• Serebral ödem

Acute Kidney Injury in ICU Patients with Cerebral Edema: A Comparison of Hypertonic Saline and Mannitol After a Protocol Change

Abstract

Background: Mannitol and hypertonic saline are commonly used hyperosmolar agents for the management of cerebral edema, yet their renal safety profiles remain uncertain. Following a protocol change favoring hypertonic saline, we compared acute kidney injury (AKI) and intensive care unit (ICU) mortality between these two strategies.

Materials and Methods: In this retrospective observational study, adult ICU patients with acute brain injury and cerebral edema who received exclusive osmotherapy with either 20% mannitol or 3% hypertonic saline were included. Patients with pre-existing kidney disease or combined osmotherapy were excluded. The primary outcome was AKI at 48 hours, defined by KDIGO criteria. Secondary outcomes were AKI severity and ICU mortality. Multivariable logistic regression adjusted for age, APACHE II, and SOFA scores.

Results: Seventy-seven patients were analyzed (hypertonic saline n=43; mannitol n=34). Baseline characteristics and illness severity were comparable. AKI occurred more frequently in the mannitol group (47% vs. 8%, p=0.003), with more advanced AKI stages (p<0.001). ICU mortality was higher with mannitol (56% vs. 19%, p=0.002) and remained independently associated after adjustment (OR 3.09, 95% CI 1.09–9.23). Mannitol use was associated with significantly greater cumulative fluid exposure.

Conclusions: Mannitol therapy was associated with increased AKI and ICU mortality compared with hypertonic saline. When neurological efficacy is comparable, renal safety should guide hyperosmolar agent selection.

Keywords

• Acute kidney injury
• Mannitol
• Hypertonic
• Osmotherapy
• Cerebral edema

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