不同液体复苏对脓毒症患儿肾功能的影响

Effect of different fluid resuscitation on kidney function in pediatric patients with sepsis

目的前瞻性比较不同液体复苏对脓毒症患儿肾功能的影响，为小儿脓毒症的临床治疗提供参考。方法选择2012年6月至2015年6月在郑州市儿童医院重症医学科治疗的118例脓毒症并脓毒性休克需要液体复苏的患儿。采用随机数字表法分成A、B、C组，分别选用羟乙基淀粉、50μg/L清蛋白及9g／L盐水进行液体复苏。监测患儿血清中性粒细胞明胶酶相关载脂蛋白（NGAL）、α-1微球蛋白、尿素氮、肌酐及尿量水平、急性肾损伤（AKI）发生率和接受肾脏替代治疗率，采用SPSS19．0软件对数据进行统计学分析。结果A组患儿NGAL及α-1微球蛋白水平[（103．50±1．23）μg/L、（3．32±0．20）mg／L]最高，与B组[（93．54±1．42）μg/L、（2．71±0．18）mg／L]及C组[（79．57±1．54）μg/L、（2．08±0．14）mg／L]比较，差异均有统计学意义（P均〈0．05）；B组NGAL及α-l微球蛋白水平均较C组高，差异均有统计学意义（P均〈0．05）。A组患儿血清尿素氮及肌酐水平[（5．23±0．34）mmol／L、（112．00±7．12）μmol／L]最高，与B组[（3．56±0．31）mmol／L、（77．25±5．34）μmol／L]及C组[（2．95±0．42）mmol／L、（72．12±6．34）μmol／L]比较，差异均有统计学意义（P均〈0．05）；B组较C组高，但差异无统计学意义（P〉0．05）。尿量监测结果显示：A组尿量[（0．50±0．12）mL／（kg·h）]最低，与B组[（0．90±0．23）mL／（kg·h）]及C组[（1．30±0．14）mL／（kg·h）]比较，差异均有统计学意义（P均〈0．05）；B组较C组低，但差异无统计学意义（P〉0．05）。3组均有患儿发生AKI，其中A组13例（34．2％），B组9例（23．1％），C组8例（19．5％）；C组AKI发生率显著低于A组和B组，差异有统计学意义（X2=12．74、10．43，P均〈0．05）。3组均有患儿接受肾脏替代治疗，其中A组8例（21．1％），B组7例（17．9％），C组6例（14．6％）；C组接受肾脏替代治疗率显著低于A组和B组，差异有统计学意义（X2=11．36、8．73，P均〈0．05）。结论9g／L盐水对患儿肾功能的影响较羟乙基淀粉及50∥L清蛋白小，其中羟乙基淀粉对肾功能影响最大；9g/L盐水是脓毒症患儿液体复苏较好的选择。

Objective To prospectively study the effects of different fluid resuscitation on kidney function in pediatric patients with sepsis. Methods One hundred and eighteen pediatric patients with sepsis shock who needed fluid resuscitation in Intensive Care Unit,Zhengzhou Children＇s Hospital from June 2012 to June 2015 were selected, and they were randomly divided into group A, B and C by random number in the table. The patients received fluid resus- citation of hydroxyethyl starch,50 g/L albumin and 9 g/L saline. After that, neutrophil gelatinase associated lipocalin （NGAL） , a - 1 microglobulin, urea nitrogen, creatinine, urine volume, the incidence of acute kidney injury （ AKI）, and the renal replacement therapy rate accepted by the patients were recorded. Then all the data were analyzed with SPSS 19.0 software. Results Serum levels of NGAL and a - 1 microglobulin in group A [ （ 103.50 -＋ 1.23 ） μg/L, （ 3.32 -＋ 0.20） mg/Ll were higher than those in group B [（93.54-＋ 1.42） μg/L, （2.71 -＋ 0. 18）rag/El and group C [ （ 79.57 -＋ 1.54 ） μg/L, （ 2.08 -＋ 0. 14 ） mg/L ] , which were statistically different （ all P 〈 0.05 ） ; serum levels of NGAL and α- 1 microglobulin in group B were higher than those in group C ,which were statistically different（ all P 〈 0.05 ）. Serum levels of urea nitrogen and ereatinine in group A [ （ 5.23± 0.34 ） retool/L, （ 112.00± 7.12 ） μmoL/L ] were higher than those in group B [ （ 3.56 ± 0.31 ） mmo]/L, （77.25± 5.34 ） p, mol/L ] and group C I （ 2. 95 ± 0.42 ） mmol/L, （ 72.12 ± 6.34 ）μmoL/L ] , which were statistically different （ all P 〈 0.05 ） ; serum levels of urea nitrogen and creatinine in group B were higher than those in group C, which were not statistically different （ P 〉 0.05 ）. The urine volmne in group A I （0.50 ±0.12） mL/（kg h） ] was less than that in group B （0.90 ±0.23） mL/（kg h）] and group CI （ 1.30 ±0.14） mL/（ kg h） ] ,which was statistically different（ all P 〈 0.05 ） ;the urine volume in group B was less than that in group C, which was not statistically different（ P 〉 0.05 ）. In three groups, there were 13 cases （34. 2% ） with AKI in group A,9 cases（23.1% ） with AKI in group B,and 8 cases（ 19.5% ） with AKI in group C, the incidence of AKI in group C was less than that in group B and group C, which was statistically different （X2 = 12. 74,10.43 ;all P 〈 0.05）. All the groups all had children accepted renal replacement therapy, there were 8 cases （21.1%） in group A ,7 cases（ 17.9% ）in group B, and 6 cases （14.6%）in group C, and the cases who accepted renal replacement therapy rate in group C were less than those in group A and group B,which was statistically different （x2 = 11.36,8.73 ; all P 〈 0.05 ）. Conclusions The adverse effect of 9 g/L saline on kidney function is less than hydrox- yethyl starch and 50 g/L albumin,and hydroxyethyl starch has more adverse effects on kidney. Thus,9 g/L saline is a better option for fluid resuscitation in pediatric sepsis patients.