连续性肾脏替代治疗在肝移植术后急性肾损伤婴幼儿中的应用

Application of continuous renal replacement therapy in infants with acute kidney injury after liver transplantation

目的探讨连续性肾脏替代治疗(CRRT)在肝移植术后急性肾损伤(AKI)婴幼儿中的临床应用。方法回顾性调查2019年1月1日至2021年6月1日在天津市第一中心医院行肝移植术的婴幼儿患者,对术后1年内出现AKI的患儿,按照是否进行CRRT分为CRRT组和无CRRT组。比较两组患儿的术前、术中情况以及术后并发症,分析肝移植术后AKI患儿进行CRRT的高危因素以及CRRT治疗的基本情况,比较CRRT组和无CRRT组的预后情况。结果①共入选肝移植术患儿512例,术后1年内出现AKI者189例(占36.9%),其中CRTT组18例,无CRRT组171例。②两组患儿术前情况比较差异无统计学意义。与无CRRT组比较,CRRT组肝移植手术时间长(h:8.8±1.5比7.5±1.3),术中平均失血量增加〔mL:370(220~800)比310(200~400)〕;术后并发症发生率增高〔术后非计划手术:8例(44.4%)比14例(8.2%),术后移植肝原发无功能:1例(5.6%)比0例(0%),再次肝移植:3例(16.7%)比0例(0%),肝动脉闭塞:3例(16.7%)比4例(2.3%),肠瘘:2例(11.1%)比2例(1.2%)〕,差异均有统计学意义(均P<0.05)。③CRRT组患儿开始CRRT治疗时间为术后10(1~240)d,人均CRRT治疗次数为3.3(1.0~14.0)次,平均每次治疗时间为10.1(6.0~19.3)h,平均每次血肌酐(SCr)下降率为25.6%(13.5%~45.0%)。④CRRT组有5例死亡,1年及2年生存率均为72.2%;无CRRT组有6例死亡,1年及2年生存率分别为97.1%和96.5%;两组间1年及2年生存率比较差异均有统计学意义(均P<0.01)。结论儿童肝移植术后AKI发生率高,而进行CRRT治疗的患儿多与严重的手术并发症有关;CRRT是清除炎症因子,维持循环及内环境稳定的有力手段,能够有效改善患儿的多器官功能损害。

Objective To investigate the clinical application of continuous renal replacement therapy(CRRT)in infants with acute kidney injury(AKI)after liver transplantation.Methods A retrospective study was conducted on infants with AKI after liver transplantation in Tianjin First Center Hospital from January 1,2019 to June 1,2021.Infants with AKI within 1 year after liver transplantation were divided into CRRT group and non-CRRT group according to whether CRRT was performed.The preoperative and intraoperative condition,the postoperative complications were compared,the risk factors of CRRT for AKI infants,the clinical characteristics of CRRT were analyzed,and the prognosis between CRRT group and non-CRRT group were compared.Results①A total of 512 cases of pediatric liver transplantation were performed.A total of 189 cases(36.9%)developed AKI within 1 year after surgery,including 18 cases in CRRT group and 171 cases in non-CRRT group.②There was no significant difference in preoperative conditions between the two groups.The duration of liver transplantation(hours:8.8±1.5 vs.7.5±1.3)and intraoperative blood loss[mL:370(220-800)vs.310(200-400)]in CRRT group were significantly higher than those in non-CRRT group.CRRT group had significantly higher incidence of postoperative complication[unplanned operation:8 cases(44.4%)vs.14 cases(8.2%),primary nonfunction:1 case(5.6%)vs.0 case(0%),retransplantation:3 cases(16.7%)vs.0 case(0%),hepatic artery thrombosis:3 cases(16.7%)vs.4 cases(2.3%),intestinal fistula:2 cases(11.1%)vs.2 cases(1.2%)]than non-CRRT group(all P<0.05).③The average start time of CRRT was 10(1-240)days.The per capita frequency of CRRT treatment was 3.3(1.0-14.0)times.The average duration of each CRRT treatment was 10.1(6.0-19.3)hours,the average reduction rate of serum creatinine(SCr)was 25.6%(13.5%-45.0%)after CRRT.④In CRRT group,5 patients died,the 1-year and 2-year survival rates were both 72.22%.In non-CRRT group,6 patients died,the 1-year and 2-year survival rates were 97.1%and 96.5%,respectively.There were significant differences in 1-year and 2-year survival rates between the two groups(both P<0.01).Conclusions The incidence of AKI after pediatric liver transplantation was high,and most infants treated with CRRT were associated with serious surgical complications.CRRT was a powerful means to remove inflammatory factors and maintain the stability of circulation and internal environment,which could improve the multi-organ dysfunction effectively.