新型冠状病毒流行下连续性肾脏替代治疗用于维持性血液透析的初探

Application of continuous renal replacement therapy in maintenance hemodialysis in COVID-19 epidemic

目的:探索新型冠状病毒肺炎(COVID-19)疫情背景下,新冠病毒感染高风险的维持性血液透析(MHD)患者行连续性肾脏替代治疗(CRRT)的最佳方案及安全性。方法:纳入2022-04-01~2022-06-30在上海长征医院肾脏病科应急透析中心接受应急CRRT过渡期治疗的COVID-19核酸检测阳性转归阴性的MHD患者,使用Prismaflex的连续性静脉-静脉血液透析滤过(CVVHDF)模式(时长4 h),透析液+置换液总量8000 mL/h(透析液流量4000~7000 mL/h,置换液总量1000~4000 mL/h),留取患者上机前和下机后血液样本计算单室尿素清除指数(spKt/V)和尿素清除率(URR),并与既往常规间断血液透析(IHD)进行比较;通过多因素分析评估spKt/V的影响因素,并完善主观感受问卷评估其治疗耐受度。结果:共纳入患者45例,平均spKt/V为0.86±0.19,URR为50.29%±7.60%,部分患者spKt/V达到1.2。尽管采用4 h CVVHDF模式治疗的spKt/V和URR均显著低于IHD,但患者的水电、酸碱平衡紊乱均得到了良好地纠正。多因素分析提示,性别是spKt/V的独立危险因素。相关分析显示干体重和spKt/V呈显著负相关(R=-0.563,P<0.001)。主观感受问卷提示大部分患者耐受性良好,部分甚至优于常规IHD。结论:在突发公共卫生事件状况下,采用短时高剂量CVVHDF模式治疗具有良好的透析充分性和安全性,或可作为常规IHD的临时替换和补充支持。

Objective:To explore the optimal dialysis treatment regimen and efficiency of continuous renal replacement therapy(CRRT)in maintenance hemodialysis(MHD)patients with“high risk of COVID-19 infection”.Methodology:The high risk MHD patients with COVID-19 who just turned negative from positive for nuclear acid test and received transitional dialysis in the Emergency Dialysis Center of Shanghai Changzheng Hospital from April 1 to June 30,2022 were recruited.The 4h-CRRT therapy was performed with Prismaflex dialysis machine and ST100 suite.We used the continuous venovenous hemodiafiltration(CVVHDF)mode with the total fluid exchange volume of 8000 ml/h,including dialysate and total replacement fluid.We investigated the patients’single-compartment urea clearance index(spKt/V)and urea reduction rate(URR)and compared them to their routine dialysis evaluation by t test and Wilcoxon signed rank test,to evaluate the dialysis efficiency of 4h-CVVHDF.The influential factors of dialysis efficiency were analyzed by Logistic regression.The tolerance to treatment was evaluated by the subjective feeling questionnaire.Results:During the treatment,the mean spKt/V was 0.86±0.19,and the mean URR was 50.29%±7.60%.Although the spKt/V and URR of CVVHDF were significantly lower than those of IHD,the acid-base and electrolyte disturbances were well corrected,with potassium 3.62±0.61 mmol/L,phosphorus 1.37±0.34 mmol/L and carbon dioxide 28.9±2.9 mmol/L after dialysis.Multivariate analysis suggested that gender was an independent risk factor for spKt/V in CVVHDF patients.Correlation analysis showed that there was a significant inverse correlation between dry weight and spKt/V(R=-0.563,P<0.001).Subjective feelings questionnaire indicated that most patients had good tolerance,and some even had better experience than conventional IHD.Conclusion:In the case of public health emergencies,the dialysis adequacy and safetyness of shortterm high doses CVVHDF are acceptable,and may be used as an optimal transitional replacement and support for the routine IHD.