连续性血液净化治疗心血管术后急性肾功能衰竭的时机探讨

Opportunity for treatment of acute renal failure after cardiac vascular operation using continuous blood purification

目的探讨连续性血液净化（CBP）治疗心血管术后急性肾功能衰竭（ARF）的疗效。方法将入选病人按CBP实施前的病情严重程度分为全身炎症反应综合征（SIRS）组13例，多器官功能障碍（MODS）组12例；进行APACHEⅢ评分及常规检测血尿素氮（BUN）和血肌酐（Scr）水平，同时采用放射免疫分析法检测病人血浆中炎症介质白细胞介素（IL）6、肿瘤坏死因子8、（TNF-α）水平。结果CBP实施24h后APACHEⅢ评分、血BUN、血Scr，IL-6、8、TNF-α均较CBP实施前显著降低[（分另Ⅱ为（61±15）vs（81±20），（19±5）mmol／Lvs（26±5）mmol／L，（312±87）μmol／Lvs（458±107）μmol／L，（544±154）ng／Lvs（842±132）ng／L，（18±7）ng／Lvs（25±8）ng／L，（43±15）ng／Lvs（59±17）ng／L]。SIRS、MODS组病人的存活率分别为84．62％、41．67％（P〈0．05）；CBP实施前和实施24h后MODS组ARF病人的APACHEⅢ评分、血BUN、血Scr，血清IL6、IL8均显著高于SIRS组。结论APACHEⅢ评分为60～90分时可能是心血管术后发生ARF实施CBP治疗的较理想时机。

Objective To evaluate the effect and timing of continuous blood purification （CBP） in treatment of acute renal failure （ARF） following cardiac-vascular surgery. Methods Twenty-five patients with ARF following cardlac-vascular surgery were divided into systematic inflammatory response syndrome （SIRS） Group （ n = 13 ） and multiple organ dysfunction syndrome （MODS） Group （ n = 12 ） according to the illness state prior to CBP and were divided into Group A （n = 5, with the APACHE HI score prior to CBP≤60）, Group B （n =9, with the APACHE Ill score 61 -90） , and Group C （n = 11, with the APACHE HI score 〉 90 ） . All of the 25 patients underwent continuous veno-venous hemofiltration （CVVH）. Before and 24h after the CVVH APACHEⅢ score was calculated and [ peripheral; blood samples were collected to detect the levels of blood urea nitrogen （BUN） and serum creatinine （Scr） and the plasma levels of interleukin-6 （IL-6） , interleukin-8 （1L-8） , and tumor necrosis factor-α （TNF-α）. Results The APACHEⅢ score, BUN, Ser, 11.6, ILS, and TNFα 24 h after the CBP of the 25 patients were 61 ± 15 mmol/L, （19±5） mmol/L, （312 ±87） μmol/L, （544 ±154） ng/L, （18 ±7） ng/L, and（ 43 ±15 ）ng/ L respectively, all significantly lower than those before CBP （81 ±20, 26 ±5 mmol/L, 458 ± 107 μmol/L, （ 842 ± 132） ng/L, （25 ± 8 ） ng/L, and （ 59 ± 17 ） ng/L respectively, all P = 0.000）. The survival rate of SIRS Group was 84.62% , significantly higher than that of MODS Group （ 41.67% , P 〈 0.05 ）. The APACHEⅢ score, and the levels of BUN, Ser, 11.6, ILS, and TNF-α of Group MODS were significantly higher than those of Group SIRS. The higher the level of Ser, 11.6, ILS, and TNF-α and the APACHE Ⅲ score the lower the survival rate. Conclusion CBP has a positive effect on ARF following cardiac-vascular surgery. The APACHE Ⅲ score 60 to 90 reflects an opportunity to treat the ARF following cardiac-vascular surgery using CBP.