脓毒症导致急性肾损伤血液净化方式和时机的选择

The appropriate period and blood purification method for the treatment of acute kidney injury caused by sepsis

目的探讨运用急性肾损伤(acute kidney injury,AKI)的RIFLE标准和APACHEⅡ评分选择脓毒症导致AKI的血液净化方式和时机。方法回顾性分析2004年3月～2006年9月收住于天津市天和医院ICU的96例脓毒症导致AKI的患者;依据血液净化方式分为连续性肾脏替代疗法(CRRT)组(54例)和间歇性血液透析(IHD)组(42例),将CRRT组参照RIFLE标准分为Ⅰ期(14例)、Ⅱ期(19例)、Ⅲ期(21例);评价患者生命体征、实验室指标、APACHEII评分动态变化和患者的不同预后。结果①CRRT组与IHD组治疗前APACHEⅡ评分、血肌酐差异没有统计学意义(P>0.05),治疗结束后CRRT组患者APACHEⅡ评分低于IHD组患者;CRRT组患者平均动脉压、血氧饱和度较IHD组低(P<0.05),治疗后MAP、SpO2有所上升(P<0.05);②CRRT组与IHD组病死率分别为51.9%和52.4%(P>0.05),而肾功能恢复率分别为92.3%与65.0%(P<0.05);③CRRT组中Ⅰ期患者存活率78.6%、治疗前APACHEII评分(25.4±2.5)、肾功能恢复率90.9%、APACHEII变化(-13.6±4.3),而Ⅲ期患者上诉指标分别为38.1%、(36.1±5.7)、62.5%、(-7.1±4.2),差异有统计学意义(P<0.05)。结论运用AKI的RIFLE诊断标准结合APACHEⅡ评分选择合适的治疗时机,采用CRRT是防治脓毒症导致急性肾损伤的有效手段。

Objective To evaluate the appropriate period and blood purification method for the treatment of sepsis-induced acute kidney injury by using Risk, Injury, Failure, Loss, and End-stage Kidney Classification for acute kidney injury （RIFLE criteria for AKI） and APACHE Ⅱ score. Methods We retrospectively analyzed 96 sepsis-induced acute kidney injury patients treated in the ICU of Tianjin Tianhe Hospital during the period from March 2004 through September 2006. They were assigned in the continuous renal replacement therapy （CRRT） group （54 cases） or the intermittent hemodialysis （IHD） group （42 cases）. In the CRRT group, patients were evaluated by RIFLE criteria for AKI, from which 14 cases were at stage Ⅰ, 19 cases at stage Ⅱ, and 21 cases at stage Ⅲ. Their vital signs, laboratory parameters, dynamic change of APACHE Ⅱ score and prognosis were observed. Results ① Before the treatment, there were no differences in APACHE Ⅱ score and serum creatinine level between the two groups （P〉0.05）. After the treatment, APACHE Ⅱ score, mean arterial pressure and oxygen saturation rate were lower in the CRRT group than in the IHD group （P〈0.05）. The lowered mean arterial pressure and oxygen saturation rate improved after the treatment （P〈0.05）. ② The mortality rate was 51.9% and 52.4% （P〉0.05）, and the recovery rate of renal function was 92.3% and 65.0% （P〈0.05）, in the CRRT group and the IHD group, respectively.③ In the CRRT group, the survival rate was 78.6% and 38.1%, APACHE Ⅱ score before the treatment was （25.4±2.5） and （36.1 ±5.7）, recovery rate of renal function was 90.9% and 62.5%, the range of APACHE Ⅱ score change was -13.6±4.3 and -7.1±4.2, in patients at stage Ⅰ and stage Ⅲ, respectively. These differences were statistically significant （P〈0.05）. Conclusion RIFLE criteria of AKI in association with APACHE Ⅱ score are useful to estimate the appropriate time for blood purification. CRRT is an effective method to prevent and treat sepsis-induced acute kidney injury.