不同急性肾损伤分期的MODS患者连续肾脏替代治疗预后分析

The effectiveness of continuous renal replacement therapy for patients with multiple organ dysfunction syndrome and different severity of acute kidney injury

目的探讨RIFLE标准的急性肾损伤(AKI)分期与连续性肾脏替代治疗(CRRT)的多器官功能障碍综合征(MODS)患者预后的关系。方法回顾性分析第四军医大学西京医院肾脏病科2004年以来行连续性静脉-静脉血液滤过(CVVH)治疗的240例MODS患者,按RIFLE标准分为AKIⅠ期、Ⅱ期和Ⅲ期,对比分析不同AKI分期患者的医院死亡率和器官衰竭数,并将CVVH治疗前和治疗24h后的APACHEII评分、SOFA评分、平均动脉压(MAP)、氧合指数、血尿素氮(BUN)和血肌酐(Scr)等指标进行比较。结果①全部患者死亡率为38.75%,AKIⅢ期患者医院死亡率高于AKIⅠ期和Ⅱ期患者(P<0.05)。②随着AKI分期的加重,患者器官衰竭数增加(P=0.001)。发生脏器衰竭≥4个的患者医院死亡率明显高于脏器衰竭数≤3个的患者,(75.5%vs13.4%,P<0.05)。③CVVH治疗24h后,患者MAP、氧合指数、BUN和Scr均明显改善;APACHE II评分和SOFA评分在AKII期和II期患者显著降低,在AKI III期患者中则变化无显著性。结论CVVH是防治MODS合并重症ARF患者的有效手段,RILFE标准对AKI早期诊断和判断预后有指导意义。必须强调CVVH时机的选择,早期(AKIⅠ期和Ⅱ期)行CVVH可以明显改善MODS患者的预后。

Objective To investigate the prognosis of patients with multiple organ dysfunction syndrome （MODS） using continuous renal replacement therapy for the treatment of their acute kidney injury （AKI） in different severity. Methods We retrospective studied 240 patients with MODS treated with continuous veno-venous hemofiltration （CVVH） in the period of Jan. 2004 to Dec. 2006. The severity of AKI in these patients was classified as AKI of phase Ⅰ, Ⅱ and Ⅲ according to the RIFLE criteria. The mortality rate in hospital and the number of failed organs were compared among patients with different severity of AKI. Their APACHE Ⅱ score, sequential organ failure assessment （SOFA） score, mean arterial pressure, oxygenate index, blood urea nitrogen and serum creatinine were also compared before and after CVVH for 24 hours. Results （1） The overall mortality rate in hospital was 38.75%. The rate was higher in patients with AKI of phase Ⅲ than those with phase Ⅰ and Ⅱ （P 〈0.05）. （2） The number of failed organs was higher in patients with severe AKI. Patients with more failed organs had significantly higher mortality rate in hospital. Patients presenting ≥ 4 failed organs had higher mortality rate in hospital than those showing ≤ 3 failed organs （75.5% vs 13.4%, P〈 0.05）. （3） After CVVH for 24 hours, mean arterial pressure, oxygenate index, blood urea nitrogen and serum creatinine improved significantly in all patients. APACHE Ⅱ score and SOFA score decreased significantly in patients with AKI of phase Ⅰ and Ⅱ, but insignificantly in those with AKI of phase Ⅲ. Conclusions CVVH is an effective measure for MODS patients complicated with severe acute renal failure. RIFLE criteria is useful for the early diagnosis and prognosis prediction of AKI. CVVH remarkably improves the prognosis of MODS with AKI of phase Ⅰ or Ⅱ.