连续性肾脏替代治疗救治新生儿急性肾损伤的时机选择与效果

Timing and effectiveness of continuous renal replacement therapy for neonatal acute kidney injury

目的探讨连续性肾脏替代治疗（continuous renal replacement therapy，CRRT）治疗新生儿急性肾损伤（acute kidney injury，AKI）的理想时机与效果。方法回顾性分析2011年6月至2018年6月本院新生儿重症监护病房（neonatalintensivecareunit，NICU）用CRRT技术治疗的19例AKI患儿的临床资料。采用改良的RIFLE[风险（Risk）、损伤（Injury）、衰竭（Failure）、丧失（Loss）和终末期肾脏病（End-stagerenaldisease）]标准，根据CRRT开始时的肾功能水平，将患儿分为AKI1-2期组和AKI3期组。CRRT模式包括连续性静静脉血液滤过透析和血浆置换。分析19例AKI新生儿CRRT治疗前，治疗12、24和48h，及治疗结束时的血压、肾功能、电解质、酸碱平衡及血流动力学指标的变化；比较2组AKI新生儿CRRT治疗前、治疗12、24和48h及治疗结束时的肾功能指标变化，评价CRRT的效果，并观察19例新生儿的临床转归。采用Kruskal-WallisH检验或t检验对数据进行统计学分析。结果（1）19例AKI新生儿中，AKI1-2期12例，3期7例。17例选用连续性静一静脉血液滤过透析模式，2例选用血浆置换模式。CRRT治疗转流时间49-190h，平均（89．2±33．9）h。（2）19例新生儿经CRRT治疗12h后，血压即可达正常水平（40-60mmHg，lmmHg=0．133kPa），且在治疗期间可维持正常水平。CRRT治疗12h后，血pH值上升至正常范围（7.35-7．45）。CRRT治疗12h后，患儿的氧合指数可达200mmHg；治疗24h后，可升至300mmHg以上。血钾、血尿素氮和血肌酐水平在治疗12h后明显下降，治疗24h可达到正常范围。治疗24h时，患儿尿量增多。（3）AKI1-2期组新生儿CRRT治疗24h后血尿素氮和血肌酐水平明显下降。在CRRT治疗前后各时间点（治疗前、治疗24h和治疗结束），AKI3期新生儿血尿素氮和肌酐水平均高于AKI1-2期新生儿[尿素氮分别为（15．8±4．1）与（10．2±5．1）、（11．5±2．4）与（6．3±2．3）和（9．8±2．1）与（5．1±2．2）mmol／L，t值分别为2．468、2．226和2．17l；肌酐分别为（184±32）与（152±26）、（110±35）与（87±25）和（63±12）与（44±9）pmol／L，t值分别为2．404、2．423和3．972；P值均〈O．05]。（4）19例AKI新生儿静脉置管均顺利完成。并发血小板减少3例，管路堵塞2例，低血压2例。均未发生低体温、出血、血栓形成及感染发生等并发症。（5）19例AKI新生儿中，12例（AKI1-2期10例，AKI3期2例）治愈出院（包括5例重度窒息、5例新生儿脓毒症和2例遗传代谢病代谢危象患儿）。其余7例（AKI1-2期2例，AKI3期5例）经CRRT治疗度过AKI少尿期，但家属放弃治疗后死亡。结论CRRT救治新生儿AKI较为安全，效果较理想，应当可以作为AKI新生儿救治的有效措施。CRRT救治AKI新生儿的理想时机应当是AKI1-2期。

Objective To investigate the timing and efficacy of continuous renal replacement therapy （CRRT） in neonatal acute kidney injury （AKI）. Methods Nineteen AKI neonates treated with CRRT were enrolled during hospitalization in the Department of Neonatology of the Children＇s Hospital of Shanghai from June 2011 to June 2018. Their clinical data were retrospectively analyzed. According to their baseline renal function, these neonates were divided into two groups using an improved RIFLE （Risk, Injury, Failure, Loss and End-stage renal disease） standard： AKI stage 1-2 group and AKI stage 3 group. CRRT included continuous veno-venous hemodiafiltration （CVVHDF） and plasma exchange （PE）. Several parameters included blood pressure （BP）, renal function, electrolyte, blood gas and hemodynamic indicators were analyzed before, 12 h, 24 h, and 48 h after the initiation of CRRT and at the end of CRRT. Changes in neonatal renal function before, 24 h after the initiation of CRRT and at the end of CRRT were compared between the two groups. Efficacy of CRRT was evaluated, and clinical outcomes were analyzed. Kruskal-Wallis H-test or t-test was applied for statistic analysis. Results （1） Among the 19 neonates with AKI, there were 12 in stage 1-2 and seven in stage 3. Seventeen cases were treated with CVVHDF, and the other two underwent plasma exchange. The duration of CRRT was 49 -190 h with an average of （89.2±33.9） h. （2） After 12 h of CRRT, the blood pressure of all 19 AKI neonates returned to normal （40-60 mmHg, 1 mmHg=0.133 kPa） and was maintained at that level during the treatment. The blood pH value also increased to a normal range （7.35-7.45） at the same time. The oxygenation index reached 200 mmHg after 12 h of CRRT and rose to over 300 mmHg after 24 h. The levels of serum potassium, urea nitrogen, and creatinine decreased significantly after 12 h of CRRT and reached the normal range after 24 h of CRRT. After 24 h of CRRT, the urine volume significantly increased. （3） Serum levels of urea nitrogen and creatinine in neonates with AKI stage 1-2 decreased significantly after 24 h of CRRT. At any time points before and after CRRT （24 h before, 24 h after and at the end of CRRT）, serum levels of urea nitrogen and creatinine in AKI stage 3 neonates were higher than those in AKI stage 1-2 neonates [urea nitrogen： （15.8 ±4.1） mmol/L vs （10.2±5.1） mmol/L, （11.5±2.4） mmol/L vs （6.3±2.3） mmol/L, （9.8±2.1） mmol/L vs （5.1±2.2） mmol/L, t=2.468, 2.226 and 2.171, respectively; creatinine： （184±32） umol/L vs （152±26） umol/L, （110±35） umol/L vs （87±25） umol/L, （63±12） umol/L vs （44±9） umol/L, t= 2.404, 2.423 and 3.972, respectively; all P〈0.05]. （4） Venous catheterization was successful in the 19 AKI neonates. Three cases were complicated with thrombocytopenia, two with obstruction and two with hypotension during CRRT. Complications such as hypothermia, hemorrhage, thrombosis, and infection were not reported. （5） Among the 19 AKI neonates, 12 （including five of severe asphyxia, five of septic sepsis and two of inherited metabolic disorders and in metabolic crisis） were cured and discharged. The other seven cases （two in stage 1-2 and five in stage 3） lived through the oliguria stage but died after their family members gave up the treatment. Conclusions CRRT is a safe and effective management for neonatal AKI. The optimal opportunity for CRRT treatment in AKI neonate should be at stage 1-2