高容量血液滤过治疗心脏手术后急性肾损伤的疗效观察

Effects of high volume hemofiltration on acute kidney injury in patients with cardiotomy

目的：观察高容量血液滤过（high volume hemofiltration,HVHF）对心脏外科手术后急性肾损伤（acute kidney injury,AKI）患者的治疗作用,以及HVHF用于不同程度AKI患者对预后的影响.方法：25例心脏手术后AKI患者,男性16例,女性9例,平均年龄15～80（56.4±16.80）岁.根据患者开始HVHF时血肌酐（SCr）及尿量水平分为三组：组Ⅰ（AKI Ⅰ期,n=6）,SCr增长≥0.3 mg/dl（≥26.4 μmol/L）或增长超过基础值的150%～200%（1.5～2倍）,或尿量＜0.5 ml/（kg·h）持续超过6 h;组Ⅱ（AKI Ⅱ期,n=6）,SCr增长超过基础值的200%～300%（2～3倍）,或尿量＜0.5（ml/kg·h）持续超过12 h;组Ⅲ（AKI Ⅲ期,n=7）,SCr增长超过基础值的300%（3倍）[或SCr≥4.0 mg/dl（≥354 μmo/L）,并急性升高≥0.5 mg/dl（44 μmol/L）],尿量＜0.3 ml/（kg·h）持续24 h,或无尿12h.血管通路采用中心静脉置管,血流量200～250 ml/min,置换液流速4 000 ml/h,前稀释输入.滤器为AV600（聚砜膜,1.6 m2）.低分子肝素联合枸橼酸抗凝.每30 min记录血压、心率、体温等生命体征,观察患者神经精神系统体征的变化.HVHF前和治疗后每24h,留取标本查血常规、肝肾功能、电解质、血气分析等.以APACHE Ⅱ评分判断患者整体病情的变化.结果：患者总死亡率为57.9%,组Ⅰ（AKI Ⅰ期）患者死亡率低于组Ⅲ（AKI Ⅲ期）（50% vs 71.4%）.组Ⅰ患者较组Ⅲ更为危重,其体外循环断流时间[（244.2±170.46） vs （154.3±73.58）分]和主动脉夹闭时间[（93.2±43.21） vs （82±59.59）分]均长于组Ⅲ,且术后接受主动脉球囊反搏（IABP）者明显多于组Ⅲ（66.7% vs 28.6%）.HVHF治疗12 h后患者高热状态明显改善（P＜0.05）,心率及平均动脉压在HVHF过程中波动于正常范围,SCr及尿素氮水平在治疗24 h后显著下降（P＜0.05）,存活患者肾功能均恢复正常.APACHE Ⅱ评分经治疗后明显改善（P＜0.05 vs after 60h）.结论：本研究发现HVHF是救治心脏手术后AKI患者的有效手段,在AKI Ⅰ期开始HVHF治疗,患者存活率明显提高.此结果仍需扩大样本进一步研究.

Objective ：To evaluate the efficiency of high volume hemofiltration （HVHF） in the treatment of acute kidney injury（AKI） in patients with cardiotomy, and investigate the impact of therapy on prognosis in the different stage of AKI. nethodology：HVHF was performed in 25 patients with AKI after cardiotomy, including 16 males and 9 females, with average age of 15 ～80（56. 4±16. 80） years. Except 6 of the patients quitted in early stage of HVHF for economics, the remaining 19 patients were divided into three groups. They were group Ⅰ （ AKI Ⅰ stage,n =6） received HVHF when SCr was ≥0. 3 mg/dl （ 〉/26.4 μmol/L） or increased to 〉/150% - 200% （ 1.5- to 2-fold） from baseline, or 〈 0. 5 ml/（kg·h） for〉6 hours, group U （AKI Ⅱ stage,n =6）, HVHF was started when SCr 〉200% -300% （2- to 3-fold） from baseline, or 〈0. 5 ml/（kg·h） for 〉 12 hours, and group Ⅲ （AKI Ⅲ ,n =7） had HVHF when SCr 〉 300% （3-fold） from baseline （SCr≥4.0 mg/dl （ ≥354μmo/L） with an acute increase of at least 0. 5 mg/dl（44μmol/L）, or 〈0. 5 ml/（kg·h） for 〉 12 hours. HVHF was performed with AV600 hemofilter （ polysulfone, 1.6 m^2 ）. The rate of substitute fluid was at 4 000 ml/h by a pre-dilution route, and the rate of blood flow was 200 - 250 ml/min. Low molecular weight heparin and/or citrate were used for anticoagulation. The general conditions of each patients including blood pressure （ BP）, heart rate （HR）, and temperature （T） were monitored every 30 minutes, and the blood gas analysis, serum biochemistry test were detected before and every 24 hours after the initiation of HVHF. APACHE Ⅱ scores were evaluated every 12 hours during HVHF. Results： HVHF was well tolerated in all patients and the hospital mortality of 57.9%. The mortality of group I was lower than group III（50% vs 71.4% ）while the patients in group I were more severe： the cardiopulmonary bypass （CPB） time [ （244. 2 ± 170. 46） vs （ 154. 3± 73.58 ） ] and x-clamp time [ （93. 2± 43.21 ） vs （ 82 ± 59.59） ] were beth longer than group III,and more patients accepted IABP （66. 7% vs 28.6% ）. After 12 hours＇HVHF treatment, the high fever of patients was improved obviously （ P 〈 0. 05 ）, while heart rate and MAP was maintained in normal range. After 24 hours＇therapy, the serum creatinine and blood urea were beth decreased （P 〈0. 05）, and all survival patients had renal function recovered. After HVHF （60 hrs）, we also found APACHE Ⅱ scores improved significantly （P 〈 0. 05 ）. Conclusion：HVHF is technically possible in AKI patients after cardiotomy, which was an important treatment to post-cardiac operation patients with AKI and MODS. We also found that early HVHF performed in AKI Ⅰ stage was better, which had lower mortality.