探讨连续性血液透析在心脏术后急性肾功能衰竭中的应用

Application of continuous blood purification to severe acute renal failure after cardiac surgery

目的探讨连续性血液净化(CBP)治疗心脏术后急性肾衰竭(ARF)的有效性及最佳时机。方法 21例患者心脏术后因急性肾衰竭接受连续性血液净化(CBP)治疗,根据预后分为生存组(n=13)和死亡组(n=8),对其临床资料进行回顾性分析比较。对两组患者治疗前进行APACHEⅢ评分,并分别观察两组患者治疗前、治疗12、24、48和72 h后肾功能(BUN、Cr)、心肌酶(AST、CPK、LDH)、左心射血分数(LVEF)、心脏输出量(CO)、心脏指数(CI)的变化以及平均动脉压(MAP)、心率(HR)、氧合指数(PaO2/FiO2)、血乳酸(Lac)、WBC和P1t等指标,观察治疗前及治疗期间的白细胞介素6(IL-6),白细胞介素8(IL-8),肿瘤坏死因子(TNF-α)等炎症因子的变化。结果 21例患者中存活13例,死亡8例。两组患者治疗前APACHEⅢ评分、MAP、Lac、BUN、Cr及CPK、AST差异存在统计学意义(P<0.05)。经CBP后两组患者BUN、Cr和心肌酶、MAP、PaO2/FiO2、CO、CI、LVEF较治疗前均有明显改善(P<0.05),而HR、WBC和P1t治疗前后变化不明显(P>0.05),IL-6、IL-8、TNF-α等炎症介质明显下降(P<0.05)。结论 CBP能显著改善肾功能以及心脏功能,减少炎症因子的释放。早期诊断ARF,尽早进行CBP治疗有助于减少其他并发症的发生,提高生存率。

Objective To evaluate the effect of continuous blood purification（CBP） on acute renal failure（ARF） following cardiac surgery.Methods According to the prognosis,21 patients with ARF after cardiac surgery who underwent CBP from August 2005 to May 2010 were divided into the live group（n=13） and the dead group（n=8）.Clinical data from the two groups were reviewed.APACHEⅢ scores were evaluated before CBP.Blood urea nitrogen（BUN）,creatinine（Cr） and myocardial enzymes,aspartate aminotransferase（AST）,creatine phosphokinase（CPK）,and lactate dehydrogenase（LDH） as well as left ventricular ejection fraction（LVEF）,cardiac output（CO）,cardiac index（CI）,mean arterial pressure（MAP）,heart rate（HR）,oxygenic index（PaO2/FiO2）,blood lactate（Lac）,white blood cell count（WBC）,platelet count（Plt）,interleukin-6（IL-6）,interleukin-8（IL-8） and tumor necrosis factor-α（TNF-α） were determined before and 12,24,48 and 72 hours after CBP.Results 13 patients were alive and 8 were dead in the end.APACHEⅢ scores in the dead group were significantly higher than those in the live group before CBP（P0.05）.Compared with the live group,there were significant differences in LVEF,CO,CI,MAP,Lac,BUN, Cr,CPK and AST in the dead group before CBP（P0.05）.After CBP,there was a significant improvement in BUN,Cr,myocardial enzymes,LVEF,CO,CI,MAP,PaO2/FiO2,and a significant decrease in IL-6,IL-8 and TNF-α（P 0.05）,while there was no significant difference in HR,WBC and Plt（P0.05）.Conclusions CBP is an effective treatment for ARF following cardiac surgery,improving cardiac and renal function and decreasing release of inflammatory mediators.The earlier diagnosis of ARF after cardiac surgery and earlier treatment with CBP might greatly reduce the incidence of other complications,such as multiple organ dysfunction syndrome,and increase survival of patients.