摘要
目的探讨连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)在脓毒血症急性肾损伤治疗中的作用和透析时机。方法选择上海交通大学附属第六人民医院住院脓毒血症AKI患者215例,其中行CRRT治疗组91例,常规药物治疗组124例。收集分析患者的临床指标(收缩压、舒张压、平均动脉压、SPO2、尿量、28天生存率)和生化指标(血红蛋白、白细胞计数、血小板计数、尿素氮、血肌酐、白蛋白、hsCRP、PH),以及血清IL-1β的水平。结果 91例脓毒血症AKI患者中车祸伤32例,占36%,其次为肝胆外科术后(14例,15%),第3为肺部感染(12例,13%)。男性、老年、AKINⅢ期、合并糖尿病和慢性阻塞性肺炎是脓毒血症AKI死亡的独立危险因素(Pearson相关分析,r=0.58,0.63,0.74,0.57,0.52,双尾检验,P<0.05)。CRRT治疗能显著降低AKI患者血肌酐水平,纠正酸中毒。从给升压药到行CRRT治疗间隔时间越短,患者死亡率越低。CRRT治疗组28天存活率31.8%,较常规药物治疗组9.7%显著增高,P<0.05)。AKINⅠ期、Ⅱ期、Ⅲ期行CRRT治疗28天存活率12.1%、18.7%、1.1%,均较未行CRRT组AKIN同期28天存活率7.3%、2.4%、0显著增高(P<0.05)。糖尿病AKI组血IL-1β较非糖尿病组水平显著增高(353.8±53.1pg/ml比321.2±84.6pg/ml,t=0.106,P<0.05),CRRT治疗后无论糖尿病组还是非糖尿病组IL-1β均显著下降(糖尿病组治疗后比治疗前:(261.9±42.5)pg/ml比(353.8±53.1)pg/ml,P<0.05;非糖尿病组治疗后比治疗前:(252.5±73.4)pg/ml比(321.2±84.6)pg/ml,P<0.05)。结论脓毒血症AKI原发病疾病谱和死亡的独立危险因素发生改变。CRRT治疗脓毒症AKI能有效清除潴留的水、代谢废物、炎症因子,维持内环境稳定。AKIN早期行CRRT治疗能显著提高患者28天存活率。
Objective To investigate the effects and the appropriate period of continuous renal replacement therapy （CRRT） in the treatment of severe sepsis complicated with acute kidney injury （AKI）.Methods We retrospectively analyzed 215 cases of severe sepsis complicated with acute kidney injury treated in the Sixth People＇ s Hospital Affiliated to Shanghai Jiaotong University during the period from Oct.2010 to April 2013.They were divided into two groups,CRRT group （n=9l） and regular treatment group （n=124）.Clinical data （SBP,DBP,MAP,SPO2,urinary volume,and survival rate at the 28th day） and blood biochemical parameters （Hb,WBC,PLT,BUN,SCr,ALB,hsCRP,and pH） were collected to observe the differences between the two groups.Serum IL-1β was assayed by using a ELISA kit for diabetic and non-diabetic patients in the CRRT group.Results In the CRRT group,the causes of severe sepsis with AKI were traffic accidents （n=32,36%）,followed hepatobiliary surgery （n=14,15%） and pulmonary infection （n=12,13%）.Male,older age,AKIN stage Ⅲ,complications of diabetes and COPD were the independent risk factors for death （Pearson＇s correlation analysis,r=0.58,0.63,0.74,0.57 and 0.52,respectively,two tailed test,P〈0.05）.After CRRT,SCr reduced and acidosis improved.Mortality rate was lower in those patients who had shorter interval between the beginning of vasopressor infusion and the initiation of CRRT.The 28-day survival rate was 31.8% in the CRRT group,higher than that in the regular treatment group （9.7%; x2 test,P〈0.05）.In patients at AKIN stage Ⅰ,Ⅱ and Ⅲ,the 28-day survival rate was 12.1%,18.7% and 1.1%,respectively,in the CRRT group,and was 7.3%,2.4% and 0%,respectively,in the regular treatment group （x2 test,P〈0.05）.Serum IL-1β was significantly higher in diabetic patients than in non-diabetic patients （353.8±53.1 pg/ml vs.321.2±84.6 pg/ml; P〈0.05）.After CRRT,serum IL-1β decreased in both diabetic patients （353.8±53.1 pg/ml vs.261.9±42.5 pg/ml; P〈0.05） and non-diabetic patients （321.2±84.6 pg/ml vs.252.5±73.4 pg/ml; P〈0.05）.Conclusions The primary causes and independent risk factors for death have been significantly changed in severe sepsis with AKI.CRRT can remove excess water,metabolic waste and inflammatory factors,and is effective to maintain the interior environment.CRRT can significantly improve the 28-day survival rate in patients at AKIN earlier stages.
出处
《中国血液净化》
2013年第12期646-650,共5页
Chinese Journal of Blood Purification
基金
国家自然基金面上项目(81270824)
上海市国际科技合作基金项目(11410708500)
上海市科委课题(114119a6100)
上海市科委课题(11DZ1921904)
上海市科委课题(124119a8400)
上海市科委基础研究重大项目(11DJ1400101)
上海市科委重大课题(11DZ1973103)科研基金
上海交大医学院科技基金(11xj21058)资助
