日间CRRT在急重患者治疗中的作用

Impacts of the daytime continuous renal replacement therapy on the treatment of critical patients

目的研究日间连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)在急重患者治疗中的应用和影响预后的因素及血流动力学不稳定患者CRRT模式选择对患者转归的影响。方法回顾性分析同济大学附属东方医院应用日间CRRT的32例急重患者临床特点、CRRT模式和影响预后的因素。结果18例(56.3%)患者度过疾病的急性期(存活组),APACHEⅡ评分为(18.2±6.5);14例(43.7%)患者在急性期死亡(死亡组),APACHEⅡ评分为(24.5±7.8);对两组患者的临床资料,肾功能衰竭的特点、疾病的严重程度等因素进行分析,发现死亡组患者应用CRRT时间较短,患者年龄大、病情重,需要机械通气患者数多;血流动力学不稳定的30例患者中,CVVH模式治疗15例,死亡5例,CVVH组死亡率为33.3%,CVVHDF模式治疗15例,死亡9例,CVVHDF组死亡率为60%,CVVH模式治疗较CVVHDF模式治疗,患者死亡率下降,差异有统计学意义(P<0.01)。结论日间CRRT可提高急重患者存活率;急重患者预后受患者年龄、病情严重程度等因素影响;CVVH模式较CVVHDF模式比较,更适用于血流动力学不稳定患者,应用CVVH模式治疗可提高急重患者存活率。

Objective Controversies exist on time choice in continuous renal replacement therapy （CRRT） on critical patients, on CRRT model selection and anticoagulant choice, and on how to decrease the complication of CRRT. This study was to investigate the application of CRRT and its factors affecting prognosis in critical patients, and to discuss the effects of CRRT models on prognosis of patients with unstable hemodynamics. Methods The clinical features, CRRT models, and factors affecting prognosis were retrospectively analyzed in 32 critical patients who received daytime CRRT in this hospital from May 2004 to May 2009. Results Eighteen patients （56.3 % ） survived the acute phase of their illness, APACHE Ⅱ score being （ 18.2±6.5） ; whereas fourteen patients （43.7%） died during the acute phase, APACHE 11 score being （24.5 ± 7. 8 ）. The clinical data, characteristics of renal failure, and severity of the illness were analyzed in patients of both groups. The outcomes revealed that patients in the dead group, being older and more severely sick, received shorter CRRT than those in the survival group. The members in the dead group were in much more need for mechanical ventilation. Among the 30 patients with unstable hemodynamics, fifteen patients were treated with continuous veno-venous hemofiltration （CVVH）, with five deaths and the mortality was 33.3%; another fifteen patients were treated with continuous veno-venous hemodiafiltration （CVVHDF）, with nine death and fatality rate was 60%. The statistical analysis showed that CVVH model was associated with lower fatality rate than that of CVVHDF model （ P 〈 0.01 ）. Conclusion Patients＇ survival rate can be raised if they are treated by daytime CRRT. The prognosis of critical patients is affected by patients＇ age, previous health status and illness severity. The comparison of CVVH and CVVHDF has demonstrated that CVVH is more suitable for patients with unstable hemodynamics than CVVHDF, and patients＇ survival rate will be raised if they are treated with CVVH.