早期血液净化治疗苯酚烧伤并发急性肾损伤的临床观察

Clinical observation on the treatment of phenol burn patients complicated by acute kidney injury with early blood purification

目的观察早期血液净化治疗苯酚烧伤并发急性肾损伤（AKI）的临床效果。方法2010年1月-2014年7月，笔者单位收治符合入选标准的5例苯酚烧伤并发AKI患者。伤后24h内，快速补液扩容；积极处理创面；采用血液灌流（HP）联合连续性静脉一静脉血液滤过疗法（CVVH）治疗2～3h，停用HP，持续CVVH治疗16—21h。HP4-CVVH治疗2、3次后停用HP，继续行CVVH治疗12～22d。伤后1、3、5、7、14、21d，抽取患者静脉血，检测尿素氮、肌酐、ALT、AST、总胆红素（TBIL）、直接胆红素（DBIL）；记录液体总人量、尿量、超滤量、液体总出量；ELISA法测定血清IL-6、IL-10、TNF—α浓度。记录患者一般情况。对数据行单因素方差分析、LSD．t检验。结果（1）伤后1d，患者尿素氮、肌酐分别为（9．0±3．2）mmol／L、（115±24）μmol／L，较正常值（分别为2．9～8．2mmol／L、45～104μmol／L）明显升高。伤后3、5、7、21d，患者尿素氮分别为（12．5±4．1）、（11．2±5．6）、（8．7±2．3）、（6．4±3．9）mmol／L，与伤后1d接近（t值分别为1．53、0．76、0．17、1．17，P值均大于0．05）；伤后14d，患者尿素氮为（15．8±3．3）mmol／L，明显高于伤后1d（t=3．29，P=0．023）。伤后3、5、7、14d，患者肌酐分别为（248±67）、（224±87）、（276±59）、（307±77）μmol／L，明显高于伤后ld（t值分别为4．17、2．70、5．65、5．32，P值均小于0．01）；伤后21d，患者肌酐为（78±28）μmol／L，明显低于伤后1d（t=2．23，P=0．041）。患者ALT、AST、TBIL、DBIL伤后1d开始较正常值升高，伤后3、5、7、14d均高于正常值，伤后21d与正常值接近。（2）伤后1、3、5、7、14、21d，患者能够保持液体总人量与液体总出量比为1：1～2：1；伤后1、3、5、7、14d，患者尿量虽有波动，但仍小于400mL／d，超滤量呈现先降低后升高趋势；伤后21d，患者尿量增加，超滤量降低。（3）伤后1d，患者血清IL-6、TNF—α浓度升高，IL-10浓度下降；伤后3、5、7d，患者血清IL-6、TNF—α浓度下降，IL-10浓度升高；伤后14d，患者血清IL-6、TNF—α浓度又有所升高，但没有出现明显的高峰值，IL-10浓度下降，但数值仍高于伤后1d；伤后21d，患者血清IL-6、TNF-α浓度明显下降，IL-10浓度明显上升。（4）伤后21—28d创面愈合；患者均治愈，伤后28～45d出院。随访6个月～3年，患者无慢性中毒症状，肝、肾功能基本恢复。结论早期血液净化治疗是救治苯酚烧伤并发AKI患者的有效手段，可为创面的修复及肾功能恢复提供保障。

Objective To observe the clinical effects of early blood purification in the treatment of phenol burn patients complicated by acute kidney injury （AKI）. Methods Five phenol burn patients complicated by AKI, matched with the inclusion criteria, were hospitalized from January 2010 to July 2014. Within post injury hour 24, patients received rapid liquid support, positive wound management, and he- moperfusion （HP） combined with continuous veno-venous hemofihration （CVVH） for 2 to 3 hours, then HP was stopped and CVVH was continued for 16 to 21 hours. HP combined with CVVH was performed for 2 to 3 times, then HP was stopped and CVVH was continued for 12 to 22 days. On post injury day （PID） 1 , 3, 5, 7, 14, and 21, urea nitrogen, creatinine, ALT, AST, total bilirubin （TBIL）, direct bilirubin （DBIL） in serum were determined, and the volume of liquid intake, urine, ultrafihration, and liquid output were recorded, and the concentrations of IL-6, IL-10 and TNF-α in serum were determined by ELISA. General con-ditions of patients were recorded. Data were processed with one-way analysis of variance and LSD- t test. Results （1） On PID 1, the levels of urea nitrogen and creatinine were （9.0±3.2） mmol/L and （115 ± 24） μmol/L respectively, which were obviously higher than normal values （with the values of 2. 9 - 8.2 mmol/L and 45 - 104 μmol/L respectively）. On PID 3, 5, 7 and 21 , the levels of urea nitrogen were （12.5 ±4.1）, （11.2 ±5.6）, （8.7 ±2.3） and （6.4 ±3.9） mmol/L respectively, which were similar with the value of DID 1 （ with t values 1.53, 0. 76, 0.17 and 1.17 respectively, P values above 0.05 ）. On PID 14, the level of urea nitrogen was （ 15.8 ± 3.3） mmol/L, which was obviously higher than the value of PID 1 （ t =3.29,P =0.023）. OnPID3, 5,7 and 14, the levels of creatinine were （248 ±67）, （22± 87 ） , （ 276 ± 59） and （ 307 ± 77 ） μmol/L respectively, which were obviously higher than the value of PID 1 （with t values 4.17, 2.70, 5.65 and 5.32 respectively, P values below 0.01 ）. On PID 21, the level of creatinine was （78 ± 28） μmol/L, which was obviously lower than the value of PID 1 （ t = 2.23, P = 0. 041）. The levels of ALT, AST, TBIL, and DBIL were higher than normal values from PID 1, and the levels were higher than normal values on PID 3, 5, 7, and 14, and they were similar with the normal values on PID 21. （2） On PID 1, 3, 5, 7, 14, and 21, the volume ratio of liquid intake to liquid output main- tained froml： 1 to 2： 1. On PID 1, 3, 5, 7, and 14, although the volume of urine fluctuated, they were still less than 400 mL/d, and the volume for ultrafiltration showed a tendency from declining at first to a rise lat- er. On PID 21 , the volume of urine increased, and the volume for ultrafihration decreased. （3） On PID 1 , the serum concentrations of TNF-α and IL-6 increased, and the serum concentration of IL-10 decreased. On PID 3, 5, and 7, the serum concentrations of TNF-α and IL-6 decreased, and the serum concentration of IL- 10 increased. On PID 14, the serum concentrations of TNF-α and IL-6 were elevated again but without a high peak value, and the serum concentration of IL-10 decreased but still higher than the value of PID 1. On PID 21, the serum concentrations of TNF-α and IL-6 obviously decreased, and the serum concentration of IL-10 obviously elevated. （4） Primary healing of the wound was achieved on PID 21 to 28. Patients were all cured and left hospital on PID 28 to 45. All the patients were followed up for 6 months to 3 years. At the last follow up, patients had no symptoms of chronic poisoning and the functions of liver and kidney were normal. Conclusions Early blood purification treatment is effective for phenol patients phenol burn patients compli- cated by AKI, and wound healing and kidney function recovery were assured.