摘要
目的比较延长每日血液透析(EDD)和延长每日血液滤过(EDHF)治疗原位心脏移植术后急性肾损伤(AKI)的有效性和安全性。方法回顾性分析原位心脏移植术后发生AKI行肾脏替代治疗的20例患者,其中行EDD治疗9例,EDHF治疗11例。所有患者均采用临时深静脉置管作为血液透析通路,应用床旁血透机治疗,血流量为200～250 mL/min。EDD组应用1.4 m2聚醚砜膜透析器,治疗时间≥8 h/d。EDHF组应用1.7 m2高通量聚醚砜膜透析器,置换总量>48 L/d,治疗剂量约为25 mL.kg-1.h-1,治疗时间≥8 h/d。动态随访两组肾脏替代治疗前和开始治疗后24、72 h的血尿素氮、血肌酐、心率、平均动脉压、急性生理功能和慢性健康状况评分系统Ⅱ(APACHEⅡ)评分,并比较两组患者的住院病死率、肾脏替代治疗天数、重症监护病房停留时间及肾脏替代治疗直接费用。结果肾脏替代治疗前,EDD组与EDHF组间年龄、性别、体重、血肌酐、尿素氮、心率、中心静脉压、APACHEⅡ评分等基线资料的差异均无统计学意义(P值均>0.05),但EDD组的平均动脉压为(81.9±7.1)mmHg(1 mmHg=0.133 kPa),显著高于EDHF组的(73.9±9.1)mmHg(P<0.05)。EDD组治疗24 h后的中心静脉压为(16.6±3.1)cmH2O(1 cmH2O=0.098 kPa),显著低于治疗前的(19.6±4.2)cmH2O(P<0.05)。EDHF组治疗24 h后的中心静脉压、APACHEⅡ评分分别为(16.5±3.3)cmH2O、15.5±4.2,均显著低于治疗前的(20.8±5.0)cmH2O和16.9±4.6(P值均<0.05)。治疗72 h后,EDD、EDHF组的中心静脉压分别为(14.7±2.4)、(14.5±3.3)cmH2O,均较同组治疗24 h时显著下降(P值均<0.05),EDHF组治疗72 h时的APACHEⅡ评分为14.1±4.6,亦较同组治疗24 h时显著降低(P<0.05)。此外,两组肾脏替代治疗前、治疗后24、72 h时的血尿素氮、血肌酐水平均保持稳定,两组间差异也均无统计学意义(P值均>0.05)。两组间肾脏替代治疗天数、重症监护病房停留时间、住院期间病死率的差异均无统计学意义(P值均>0.05),但EDD组的肾脏替代治疗直接费用为(9 600±2 700)元,显著低于EDHF组的(15 300±4 800)元(P<0.01)。结论EDD和EDHF治疗原位心脏移植术后非脓毒症相关性AKI的疗效相当,但EDD治疗费用较低。
Objective To investigate the effectiveness and safety of extended daily hemodialysis （EDD） and extended daily hemofiltration （EDHF） in treatment of patients with acute kidney injury after orthotopic cardiac transplantation （OCT）. Methods From May 2000 to September 2008, 20 patients with post-OCT acute kidney injury were included in this retrospective study. Nine patients received EDD and 11 received EDHF. Temporary deep venous was used as dialysis pathway in all patients with a bedside hemodialyzer at a blood rate of 200--250 mL/min. EDD group used 1.4 m^2 poly（ether sulfone） and the treatment time was ≥8 h/d. EDHF group used 1.7 m^2 high-throughput poly（ether sulfone）, with the total replacement volume being 〉48 L/d and the treatment dose being 25 mL·kg^-1·h^-1 and treatment time being ≥ 8 h/d. Parameters such as urea nitrogen, serum creatinine, heart rate （HR）, mean artery pressure （MAP）, central venous pressure （OVP）, and acute physiology and chronic health evaluation （APACHE） Ⅱ scores were observed before and 24 h and 72 h after treatment. The hospital mortality, length of IOU stay, length of RRT and the direct cost of RRT were compared between groups. Results Before treatment there was no significant difference in the general data between 2 groups except that the MAP of EDHF group was lower than that of EDD group （[81.9±7.1] mmHg vs. [73.9±9.1] mmHg, 1 mmHg= 0. 133 kPa, P〈0. 05）. 24 h after treatment, there was no significant difference of urea nitrogen, serum creatinine, HR, MAP, CVP and APACHE Ⅱscores between the two groups; CVP values of both groups were significantly improved compared with those before treatment （[16.6± 3.1] mmH2O vs. [20.8±5.0] cmH2O, 1 cmH2O= 0.098 kPa, P〈0.05）; the APACHE Ⅱ scores of EDHF group was significantly improved compared with that before treatment （ 15.5 ± 4.2 vs. 14.7 ± 2.4, P〈0. 05） ; and the urea nitrogen, serum creatinine, HR, and MAP kept stable. 72 h after treatment, the OVP values of both groups were further improved compared with that at 24 h after treatment [14.7±2.4 vs. 16.6±3.1;[14.5±3.3] cmH2O vs. [16.5±3.3] cmH2O, P〈0.05）. The APACHE II scores of EDHF group was also further improved compared with those at 24h after treatment （ 14.1± 4.6 vs. 15.5 ± 4.2, P〈0. 05）. The urea nitrogen, serum creatinine, HR, and MAP also kept stable. There was no significant difference in hospital mortality, length of ICU stay, length of RRT between the two groups. The direct cost of RRT in EDD group was lower than that of EDHF group （[9 600±2 700] yuan vs. [15 300±4 800] yuan, P〈0. 01）. Conclusion Both EDD and EDHF are effective and safe in treatment of patients with non-septic AKI after OHT. EDD costs less than EDHF. （Shanghai Med J, 2009, 32： 221-225）
出处
《上海医学》
CAS
CSCD
北大核心
2009年第3期221-225,共5页
Shanghai Medical Journal
基金
上海市医学发展基金重点课题(2003ZD001)
上海市自然科学基金(05ZR14026)资助项目
关键词
延长每日血液透析
延长每日血液滤过
原位心脏移植手术
急性肾损伤
Extended daily hemodialysis
Extended daily hemofiltration
Orthotopic cardiac transplantation
Acute kidney injury
