早期强化血液净化治疗重症蜂毒中毒合并急性肾损伤120例疗效观察

Early high- intensity blood purification for severe wasp venom poisoning with acute kidney injury

目的评估早期强化血液净化治疗重症蜂毒中毒合并急性肾损伤（AKI）患者的安全性及有效性。方法回顾性分析四川大学华西医院、简阳市人民医院、资阳市第一人民医院及四川省安岳县人民医院2012—2014年收治的重症蜂毒中毒患者120例，纳入血肌酸激酶（CK）水平，20000IU／L，血乳酸脱氢酶（LDH）〉5000IU／L，且合并AKI的患者为研究对象。根据血液净化治疗方式不同分为强化治疗组（54例）及常规治疗组（66例）。强化治疗组患者早期予以血浆置换（PE）治疗1—3次，同时予以连续性肾脏替代治疗（CRRT）治疗至少48h，病情稳定后转为间歇性血液透析（IHD）。常规治疗组给予IHD治疗，每周3～6次。同时给予患者糖皮质激素、输血、补液等对症支持治疗。收集患者的临床资料及实验室检查结果，观察和比较两组患者的生存率及肾功能恢复情况。结果强化治疗组患者生存率明显高于常规治疗组（92．6％比74．2％，P〈0．05）。在存活的患者中，强化治疗组有3例（5．6％）患者进入慢性肾脏病（CKD）阶段，常规治疗组有11例（16．7％）进入CKD阶段，组间比较差异有统计学意义（P〈0．05）。强化治疗组患者血液净化总治疗时间明显短于常规治疗组[（19．5±6．2）比（28．1±13．4）1d，P〈0．05）。结论早期强化血液净化治疗可提高重症蜂毒中毒合并AKI患者的生存率，改善肾脏预后，减少CKD的发生率。

Objective To evaluate the safety and efficacy of early high intensity blood purification for severe wasp venom poisoning with acute kidney injury （AKI）. Method We retrospectively analyzed 120 patients [（47± 14） year, F/M=68/52] with severe wasp venom poisoning （creatine kinase 〉20,000 IU/L; lactic dehydrogenase 〉5000 IU/L） and AKI who were admitted during 2012-2014 to West China Hospital of Sichuan University, Jianyang People＇s Hospital of Sichuan Provinces, Ziyang First People＇s Hospital of Sichuan Provinces and Anyue People% Hospital of Sichuan Provinces. According to the intensity of blood purification, patients were divided into early high intensity group and conventional group. Patients in early high intensity group received plasmapheresis 1 to 3 times, and continuous renal replacement therapy （CRRT） for at least 48h, and then intermittent hemodialysis （IHD） was performed when patients became stable. Patients in conventional group received IHD 3 to 6 times per week. Meanwhile, all patients received glucocorticoid, blood transfusion and fluid support if necessary. We collected all possible clinical and laboratory data. The primary outcomes were survival rate and kidney function. Results Early high intensity therapy was associated with higher survival rate compared with conventional therapy （92.6% vs 74.2%, P=0.02）. Among survival patients, 3 patients （5.6%） in early high intensity group were progressed to chronic kidney disease （CKD）; instead, 11 patients （16.7%） in conventional group were progressed to CKD, indicating significant difference between two groups （P=0.04）. Moreover, the duration of blood purification was significantly shorter in early high intensity group in comparison with conventional group （19.5±6.2 vs 28.1±13.4 d, P 〈 0.05）. Conclusions Early high intensity blood purification may increase the survival rate of patients with severe wasp venom poisoning and AKI, and may reduce the incidence of CKD.