连续性肾脏替代治疗严重感染合并急性肾损伤最佳时机的研究

Optimal time of continuous renal replacement therapy for treatment of sepsis-induced patients with acute kidney injury

目的研究RIFLE标准的急性肾损伤(AKI)分期与连续性肾脏替代治疗(CRRT)感染导致的多器官功能障碍综合征患者预后的关系,从而找出急性肾损伤患者最合适的治疗时机。方法采用前瞻性随机对照研究方法,收集医院2008年1月-2011年1月121例严重感染导致的AKI患者,按照急性肾功能衰竭的RIFLE诊断标准分为Ⅰ、Ⅱ、Ⅲ期组;比较3组患者的住院死亡率和肾功能恢复率,同时比较不同组患者CRRT治疗前和治疗48h的SOFA评分、APACHEⅡ评分、需要血管活性药物例数、降钙素原(PCT)、平均动脉压、氧合指数。结果AKIⅠ、Ⅱ、Ⅲ期患者的住院死亡率分别为21.4%、25.6%和47.5%,Ⅲ期患者的死亡率明显比Ⅰ、Ⅱ期高;AKIⅠ、Ⅱ、Ⅲ期患者肾功能恢复率分别为76.2%、53.8%和22.5%,Ⅰ期和Ⅱ期患者的肾功能恢复率明显比Ⅲ期高,CVVH治疗48h后,APACHEⅡ评分、SOFA评分和PCT在AKIⅠ期和Ⅱ期组患者显著降低,差异均有统计学意义(P<0.05);在AKIⅢ期患者中则变化不明显(P>0.05)。结论 CRRT是治疗感染导致的多器官功能障碍综合征患者的有效手段,CRRT在RILFE标准早期(AKIⅠ、Ⅱ期)可明显改善感染导致的多器官功能障碍综合征患者的预后,而在RIFLE标准晚期(AKIⅢ期)行CRRT则对患者预后影响不大,故临床上必须重视CRRT时机的选择。

OBJECTIVE To evaluate the relationship between the classification for acute kidney injury（AKI） in RIFLE criteria and the prognosis of sepsis-induced patients with multiple organ dysfunction syndrome（MODS） due to continuous renal replacement therapy（CRRT） so as to find the optimal time to start the CRRT for AKI patients.METHODS We prospectively studied 121 sepsis-induced patients with AKI from Jan 2008 to Jan 2011 by using random and case-control survey.These patients,according to the RIFLE criteria,were divided into three groups：AKI of phase I,Ⅱ and Ⅲ;we compared the mortality rate in hospital and the recovery rate of renal function among the three groups;at the same time,their sequential organ failure assessment（SOFA） score,APACHE Ⅱ score,the patients needing vasoactive agent,procalcitonin（PCT）,mean arterial pressure,oxygenate index were also compared 48 hours before and after CVVH.RESULTS The mortality rates in hospital among AKI of phase I,Ⅱ and Ⅲ were 21.4%,25.6% and 47.5%;the mortality rate was significantly higher in patients with AKI of phase Ⅲ than in those with phase I and Ⅱ;the recovery rates of renal function among AKI of phase I,Ⅱ and Ⅲ were 76.2%,53.8% and 22.5%,the recovery rate of renal function was significantly higher in patients with AKI of phase I and Ⅱ than in those with phase Ⅲ;APACHE Ⅱ score,SOFA score and PCT decreased significantly in patients with AKI of phase I and Ⅱ 48 hours after CVVH,the differences were statistically significant（P0.05）;there was no significant change in those with AKI of phase Ⅲ（P0.05）.CONCLUSION CRRT is effective in the treatment of sepsis-induced MODS.Using CRRT during AKI of phase I,Ⅱ can significantly improve the prognosis of sepsis-induced patients with MODS,on the contrary,the prognosis of sepsis-induced patients with MODS can not be improved during the AKI of phase Ⅲ.The optimal timing of CRRT is very important during the clinical practice.