摘要
目的探讨连续性肾脏替代治疗(CRRT)在脓毒血症患者中的有效性和安全性,以及不同治疗剂量对脓毒血症患者预后的影响。方法选取上海交通大学医学院附属仁济医院肾脏科发生脓毒血症,并行CRRT治疗的住院患者53例。所有患者均采用CVVHF治疗模式,根据滤出液剂量,将患者分成2组:①CVVHF-A组(26例):滤出液剂量:≥35 ml/(kg·h);②CVVHF-B组(27例):滤出液剂量:<35 ml/(kg·h)。观察所有患者透析前后生命体征及血液指标的变化,以及在治疗前、治疗第四天和治疗结束后用APACHE II评分评估疾病严重性,评价CRRT在脓毒血症患者中的有效性和安全性。同时,评估不同治疗剂量的2组患者在15天和30天时的患者生存率和肾存活率,观察治疗剂量对脓毒血症患者预后的影响。结果单次治疗后所有患者的体温(T)、心率(HR)、血PH、PO2、HCO3-、K+、BUN、Scr和WBC均较治疗前显著改善(P<0.05),而平均动脉压(MAP)、血Na+、血红蛋白(Hb)、血白蛋白(ALB)和血糖(Glu)在治疗前后差异均无统计学意义(P>0.05)。CVVHF-A组和CVVHF-B组的平均滤出液剂量分别为43.47±7.29和23.90±6.30ml/(kg·h),其差异有统计学意义(P<0.0001)。治疗前2组患者除血小板(PLT)在CVVHF-A组患者中高于CVVH-B组(P=0.031),其余指标2组均相匹配(P>0.05)。Kaplan-Meier生存曲线分析结果显示:CVVH-A组患者15天和30天生存率分别为57.7%和42.3%;CVVH-B组患者15天和30天生存率分别为18.5%和14.8%。Log-Rank检验显示2组患者的生存率有统计学意义(P=0.017),而肾脏存活率未显示出有统计学意义(P=0.393)。结论在脓毒血症患者中,CVVHF不仅能有效的清除小分子溶质、纠正电解质及酸碱平衡紊乱,而且对血流动力学和营养状况影响不大。在患者存活上,35ml/(kg·h)及以上的治疗剂量较低于35ml/(kg·h)相比,显示出更大的优势。
Objective To investigate the efficacy and safety of continuous renal replacement therapy （CRRT）,and the prognosis of septic patients under different therapeutic doses of CRRT.Methods A total of 53 patients （33 males and 20 females,22-80 years old with the mean age of 62.64± 14.56 years） treated with CRRT were recruited in this study.Continuous veno-venous hemofiltration （CVVHF） was used as the CRRT method.Patients were divided into two groups according to the ultrafiltration rate,CVVHF-A group （ultrafiltration rate ≥35 ml/（kg · h）,n=26） and CVVHF-B group [ultrafiltration rate 〈35 ml/（kg · h）,n=27].To evaluate the efficacy and safety of CRRT in the treatment of septic patients,we observed vital signs and blood biochemical parameters before and after CRRT,and obtained APACHE Ⅱ scores before CRRT,at the fourth day during CRRT and after CRRT.To evaluate the therapeutic doses of CRRT on the prognosis of sepsis patients,survival rate and renal survival at the 15th and 30th days were compared between the two groups.Re sults Acute kidney injury （AKI） occurred in 49 （92.5%） of the 53 septic patients.After CRRT,body temperature,heart rate,serum K＋,blood urea nitrogen,serum creatinine and white blood cells reduced significantly,pH,PO2 and HCO3 increased significantly （P〈0.05）,but mean arterial pressure,serum Na＋,hemoglobin,albumin and glucose remained unchanged （P〉0.05）.APACHE Ⅱ score improved significantly at the end of CRRT （23.8±6.56 vs.19.77±7.79,P=0.011）.Ultrafiltration rate was significantly higher in CVVHF-A group than in CVVHF-B group [43.47±7.29 ml/（kg · h） [vs.23.90±6.30 ml/kg · h） P〈0.0001].Gender,age,chronic kidney disease,diabetes mellitus,body temperature,heart rate,mean arterial pressure,blood gas analyses,renal function,routine blood examinations,biochemical parameters,APACHE Ⅱ score and urinary output were similar （P〉0.05） between the two groups at the baseline period,but platelet was higher in CVVHF-A group than in CVVHF-B group （P=0.031）.Kaplan-Meier survival analysis showed that the survival rate at 15th and 30th days was 57.7% and 42.3%,respectively,in the CVVHF-A group and was 18.5% and 14.8%,respectively,in the CVVHF-B group （log-rank test,P=0.017）.However,renal survival rate was indifferent between the two groups （P=0.393）.Conclusions CVVHF could remove small molecule solutes,correct metabolic acidosis,and maintain hemodynamic stability without influences on nutritional status in septic patients.CVVHF with the ultrafiltration rate of 〉35 ml/kg/h may improve the prognosis of septic patients.
出处
《中国血液净化》
2013年第12期651-656,共6页
Chinese Journal of Blood Purification
基金
国家自然科学基金(81070548)
国家自然科学基金(81170687)
上海市科委基础研究重大项目(12DJ1400200)
上海市科委医学引领项目(134119a2300)~~
关键词
脓毒血症
肾脏替代治疗
持续静脉静脉血液滤过
滤出液剂量
预后
Sepsis
Renal replacement therapy
Continuous veno-venous hemofiltration
Ultrafiltration rate
Prognosis
