危重症患儿连续性血液净化与低磷血症的相关性分析

Relationship between continuous renal replacement therapy and hypophosphatemia in critically ill children

目的总结危重症儿童进行连续性血液净化（CBP）治疗时的临床资料，探讨CBP治疗期间低磷血症的发生率以及对预后的影响。方法回顾性研究。对象为2014年5月至2017年4月，收入上海交通大学附属儿童医院儿科重症监护病房（PICU）并接受了CBP治疗的患儿。比较患儿CBP治疗前、治疗48-72 h、治疗结束时、治疗结束次日血磷值变化。并对重度低血磷症患儿补充磷制剂。结果符合入选标准患儿共85例，CBP治疗前、治疗48-72 h、治疗结束时和治疗结束次日血磷值分别为（1.4±0.5）、（0.7±0.3）、（0.8±0.3）、（0.9±0.4）mmol/L，组间比较差异有统计学意义（F=45.21，P〈0.05）。85例危重患儿CBP治疗期间66例（78%）出现低磷血症，中度低磷血症32例（48%），重度低磷血症9例（14%）。CBP置换速度35-49 ml/（kg·h）组共41例，50-70 ml/（kg·h）组共44例；两组患儿在CBP治疗前、治疗48-72 h、治疗结束时、治疗结束次日的血磷值分别是（1.5±0.5）比（1.3±0.5） mmol/L、（0.8±0.4）比（0.5±0.2） mmol/L、（1.0±0.3）比（0.6±0.2） mmol/L、（1.1±0.4）比（0.8±0.2） mmol/L，组间比较在CBP治疗48-72 h、治疗结束时、治疗结束次日差异均有统计学意义（t=7.672、4.060、14.440，P均〈0.05）。9例重度低磷血症患儿予补充甘油磷酸钠治疗。85例患儿中死亡24例（28%），存活病例61例（72%），两组患儿在CBP治疗前、治疗48-72 h、CBP结束时、治疗结束次日血磷值分别为（1.4±0.5）比（1.4±0.5） mmol/L、（0.7±0.3）比（0.7±0.3） mmol/L、（0.7±0.3）比（0.8±0.3） mmol/L、（1.0±0.3）比（0.9±0.3）mmol/L，组间比较差异均无统计学意义（P均〉0.05）。结论CBP过程中容易发生低磷血症，与置换液剂量有一定关系。经对重度低磷血症患儿补充磷制剂后，未观察到低磷血症与危重症病死率相关性。

Objective To investigate the incidence and prognosis of hypophosphatemia in critically ill children treated with continuous blood purification （CBP）. Methods The medical records of the critically ill patients, who were treated with CBP, admitted to pediatric intensive care unit （PICU） of Shanghai Children＇s Hospital from May 2014 to April 2017 were retrospectively analyzed. The serum phosphorus levels were tested before CBP, at 48-72 h during CBP, at the end of CBP and on the next day after CBP finished. Phosphorus supplement was given to the children with severe hypophosphatemia. Results A total of 85 patients met the inclusion criteria. The serum phosphorus levels at the 4 indicated time points were （1.4±0.5）, （0.7±0.3）, （0.8±0.3）, （0.9±0.4） mmol/L, respectively （F=45.21, P〈0.05）. Among the children, 66 cases （78%） had hypophosphatemia during CBP. The incidences of moderate and severe hypophosphatemia were 32 （48%） and 9 （14%）, respectively. There were 41 patients with CBP replacement rates of （35-49） ml/（kg, h）, while 44 patients with CBP replacement rates of 50-70 ml/（kg, h）. There were significant differences at 48-72 h during CBP, the end of CBP and on the next day after CBP （（0.8±0.4） vs. （0.5±0.2）, （1.0±0.3） vs. （0.6±0.2）, and （1.1±0.4） vs. （0,8±0.2） mmol/L; t=7.672, 4.060, 14.440, P〈0.05）. A total of 9 cases were treated with sodium glycerophosphate. Among the 85 children, 24 （28%） patients died while 61 （72%） survived. There were no significant differences between the two groups in serum phosphorus levels at the indicated time points （（1.4±0.5） vs. （1.4±0.5）, （0.7±0.3） vs. （0.7±0.3）, （0.7±0.3） vs. （0.8±0.3）, and （1.0±0.3） vs. （0.9±0.3） mmol/L, respectively, P〉0.05）. Conchtsions Hypophosphatemia is prone to occur during CBP, which probably related to the replacement rate. There was no significant relationship between hypophosphatemia and mortality in critically ill children after giving phosphorus supplementation.