Effects of prostaglandin E combined with continuous renal replacement therapy on septic acute kidney injury

BACKGROUND The effects of prostaglandin E(PGE)combined with continuous renal replacement therapy(CRRT)on renal function and inflammatory responses in patients with septic acute kidney injury(SAKI)remain unclear.AIM To investigate the effects of PGE combined with CRRT on urinary augmenter of liver regeneration(ALR),urinary Na+/H+exchanger 3(NHE3),and serum inflammatory cytokines in patients with SAKI.METHODS The clinical data of 114 patients with SAKI admitted to Yichang Second People's Hospital from May 2017 to January 2019 were collected.Fifty-three cases treated by CRRT alone were included in a control group,while the other 61 cases treated with PGE combined with CRRT were included in an experimental group.Their urinary ALR,urinary NHE3,serum inflammatory cytokines,renal function indices,and immune function indices were detected.Changes in disease recovery and the incidence of adverse reactions were observed.The 28-d survival curve was plotted.RESULTS Before treatment,urinary ALR,urinary NHE3,blood urea nitrogen(BUN),serum creatinine(SCr),CD3+T lymphocytes,CD4+T lymphocytes,and CD4+/CD8+T lymphocyte ratio in the control and experimental groups were approximately the same.After treatment,urinary ALR and NHE3 decreased,while BUN,SCr,CD3+T lymphocytes,CD4+T lymphocytes,and CD4+/CD8+T lymphocyte ratio increased in all subjects.Urinary ALR,urinary NHE3,BUN,and SCr in the experimental group were significantly lower than those in the control group,while CD3+T lymphocytes,CD4+T lymphocytes,and CD4+/CD8+T lymphocyte ratio were significantly higher than those in the control group(P<0.05).After treatment,the levels of tumor necrosis factor-α,interleukin-18,and high sensitivity C-reactive protein in the experimental group were significantly lower than those in the control group(P<0.05).The time for urine volume recovery and intensive care unit treatment in the experimental group was significantly shorter than that in the control group(P<0.05),although there was no statistically significant difference in hospital stays between the two groups.The total incidence of adverse reactions did not differ statistically between the two groups.The 28-d survival rate in the experimental group(80.33%)was significantly higher than that in the control group(66.04%).CONCLUSION PGE combined with CRRT is clinically effective for treating SAKI,and the combination therapy can significantly improve renal function and reduce inflammatory responses.

Cystatin C and serum creatinine in estimating acute kidney injury of shock patients

BACKGROUND： Serum creatinine （SCr） is the most commonly used parameter to estimate renal function impairement, but there are some shortcomings. Many factors including age, gender, drug, diet, muscle mass and metabolic rate can in？ uence SCr, leading to an inaccurate estimation of kidney impairment. Studies have shown that cystatin C （CysC） is not affected by factors such as muscle mass, age, gender, diet, in？ ammation or tumor. The present study was undertaken to compare the sensitivity of CysC and SCr in evaluating renal function impairment at early stage of shock.METHODS： Seventy-one patients aged 38.3±21.4 years, who had been treated at the Emergency Medicine Department of the First Affiliated Hospital, Sun Yat-sen University between February 2006 and June 2007, were studied. They were divided into groups A, B, C, and D according to the shock time. Serum sample was drawn from each patient at 1, 2, 3, 4 hours after shock to determine SCr and CysC. CysC and SCr were determined again at 72 hours and 7 days after shock.RESULTS： CysC increased earlier than SCr in the 71 patients, and CysC decreased slower than SCr when shock was corrected. CysC increased at 1 hour after shock. There was a negative correlationship between CysC, SCr and glomerular filtration rate （GFR）, especially at early stage of shock.CONCLUSIONS： There is renal injury at early stage of shock. CysC is more sensitive than SCr in assessing renal function at the early stage of shock.

Changing picture of renal cortical necrosis in acute kidney injury in developing country

Renal cortical necrosis(RCN) is characterized by patchy or diffuse ischemic destruction of all the elements of renal cortex resulting from significantly diminished renal arterial perfusion due to vascular spasm and microvascular injury. In addition, direct endothelial injury particularly in setting of sepsis, eclampsia, haemolytic uremic syndrome(HUS) and snake bite may lead to endovascular thrombosis with subsequent renal ischemia. Progression to end stage renal disease is a rule in diffuse cortical necrosis. It is a rare cause of acute kidney injury(AKI) in developed countries with frequency of 1.9%-2% of all patients with AKI. In contrast, RCN incidence is higher in developing countries ranging between 6%-7% of all causes of AKI. Obstetric complications(septic abortion, puerperal sepsis, abruptio placentae, postpartum haemorrhage and eclampsia) are the main(60%-70%) causes of RCN in developing countries. The remaining 30%-40% cases of RCN are caused by non-obstetrical causes, mostly due to sepsis and HUS. The incidence of RCN ranges from 10% to 30% of all cases of obstetric AKI compared with only 5% in non-gravid patients. In the developed countries, RCN accounts for 2% of all cases of AKI in adults and more than 20% of AKI during the third trimester of pregnancy. The reported incidence of RCN in obstetrical AKI varies between 18%-42.8% in different Indian studies. However, the overall incidence of RCN in pregnancy related AKI has decreased from 20%-30% to 5% in the past two decades in India. Currently RCN accounts for 3% of all causes of AKI. The incidence of RCN in obstetrical AKI was 1.44% in our recent study. HUS is most common cause of RCN in non-obstetrical group, while puerperal sepsis is leading cause of RCN in obstetric group. Because of the catastrophic sequelae of RCN, its prevention and aggressive management should always be important for the better renal outcome and prognosis of the patients.

Research Progress on Acute Kidney Injury in Patients with Cardiogenic Shock Undergoing Venoarterial Extracorporeal Membrane Oxygenation

Cardiogenic shock(CS)is a life-threatening syndrome characterized by peripheral hypoperfusion and organ dysfunction caused by primary heart disease.Venoarterial extracorporeal membrane oxygenation(VA-ECMO)is a temporary mechanical circulatory support device for CS,used in cases of profound shock,biventricular failure,respiratory failure,and cardiac arrest that require urgent maximal support.While VA-ECMO provides effective tissue perfusion and ensures oxygen supply to organs,it is also associated with severe complications,among which acute kidney injury(AKI)is one of the most common and serious.To date,no comprehensive review has been conducted on the pathophysiology,influencing factors,and treatment of AKI associated with VA-ECMO.This paper aims to elaborate on the pathophysiological mechanisms,influencing factors,and treatment options for AKI in patients with CS undergoing VA-ECMO,providing clinical and nursing references.

Successful treatment of gastrointestinal infection-induced septic shock using the oXiris■ hemofilter: A case report

BACKGROUND Septic shock leads to multiple organ failure,and bacterial endotoxins and endogenous cytokines play essential roles in the pathogenesis.The oXiris■hemofilter can efficiently adsorb endotoxins and cytokines.CASE SUMMARY We admitted a critically ill 59 year-old male patient with gastrointestinal septic shock due to infection by a Gram-negative bacterium and septic acute kidney injury(AKI).Prior to intensive care unit admission,the patient reported intermittent diarrhea and decreased urine output.His blood pressure was 70/40 mmHg,necessitating fluid resuscitation and large doses of noradrenaline.Based on the results of a blood culture and the presence of hypotension,oliguria,and hypoxemia,we diagnosed septic shock,AKI,and multiple organ dysfunction.We administered continuous renal replacement therapy(CRRT)with an oXiris■hemofilter for 72 h with intermittent continuous veno-venous hemodiafiltration(CVVHDF),and changed the filter every 12 h.After his hemodynamic parameters were stable,we used a traditional filter(AN69 hemofilter)with intermittent CVVHDF.The 72 h CRRT with the oXiris■hemofilter led to stabilization of his vital signs,marked reductions in disease severity scores,and decreased levels of procalcitonin,endotoxin,and inflammatory factors.After 8 d of CRRT,his kidney function had completely recovered.CONCLUSION We conclude that the oXiris■hemofilter combined with appropriate antibacterial therapy was an effective treatment for this patient with gastrointestinal septic shock.

连翘苷对感染性休克小鼠急性肺损伤的作用与机制

目的 探讨连翘苷通过腺苷酸活化蛋白激酶(adenosine monophosphate activated protein kinase,AMPK)/哺乳动物雷帕霉素靶蛋白(mammalian target of rapamycin,m TOR)/p70核糖体S6蛋白激酶(p70 S6 kinase,p70S6K)信号通路介导的自噬对感染性休克小鼠急性肺损伤(Acute lung injury,ALI)的影响。方法 随机选择12只小鼠作为对照组,其余小鼠通过腹腔注射20 mg·kg^(-1)脂多糖(Lipopolysaccharide,LPS)构建感染性休克小鼠模型,将感染性休克小鼠随机平分为模型组、低、中、高剂量实验组(5 mg·kg^(-1)、10 mg·kg^(-1)、20 mg·kg^(-1)连翘苷)、高剂量+抑制剂组(20 mg·kg^(-1)连翘苷+20 mg·kg^(-1)AMPK抑制剂compound C),每组均12只小鼠。称量肺干重及湿重,计算W/D比值;ELISA法检测BALF中炎性因子肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)、白细胞介素1β(interleukin-1β,IL-1β)、白细胞介素6(interleukin-6,IL-6)水平、血清内毒素(endotoxin,ET)含量、肺组织髓过氧化物酶(myeloperoxidase,MPO)活性;HE染色检测肺组织病理变化;Western blot检测自噬蛋白微管相关蛋白-轻链3(microtubule-associated protein-light chain 3,LC3)-II/I、Beclin 1、Ras相关GTP结合蛋白7(Rasassociated GTP binding protein 7,Rab7)、溶酶体关联膜蛋白2(lysosomal associated membrane protein 2,LAMP2)、AMPK/m TOR/p70S6K信号通路蛋白表达。结果对照组、模型组、低、中、高剂量实验组和高剂量+抑制剂组小鼠肺组织LC3-II/I比值分别为1.43±0.14、0.73±0.07、0.81±0.07、1.12±0.10、1.39±0.13、0.76±0.08,Beclin1蛋白水平分别为1.05±0.11、0.43±0.05、0.50±0.05、0.76±0.08、0.98±0.10、0.46±0.05,Rab7蛋白水平分别为1.53±0.17、0.67±0.06、0.70±0.07、1.04±0.10、1.41±0.14、0.69±0.06,LAMP2蛋白水平分别为1.47±0.15、0.72±0.07、0.81±0.08、1.09±0.11、1.35±0.13、0.74±0.07,p-AMPK/AMPK蛋白水平分别为0.95±0.05、0.33±0.03、0.39±0.04、0.68±0.07、0.91±0.09、0.36±0.04,p-m TOR/m TOR蛋白水平分别为0.28±0.02、0.94±0.06、0.88±0.07、0.57±0.05、0.30±0.03、0.87±0.09,p70S6K蛋白水平分别为0.32±0.07、0.96±0.04、0.90±0.07、0.69±0.06、0.38±0.04、0.92±0.06。上述指标:模型组与对照组比较,差异均有统计学意义(均P<0.05);中、高剂量实验组与模型组比较,差异均有统计学意义(均P<0.05);高剂量+抑制剂组与高剂量实验组比较,差异均有统计学意义(均P<0.05)。结论连翘苷可能通过调控AMPK/m TOR/p70S6K信号通路介导的自噬对感染性休克小鼠ALI起到改善作用。

脓毒症休克新生儿万古霉素血药浓度水平与急性肾损伤疗效的关系

目的探究脓毒症休克新生儿万古霉素血药浓度变化与疗效、急性肾损伤(AKI)的关系。方法回顾性纳入2020年12月至2023年12月于新乡市中心医院儿科就诊的102例患有脓毒症休克的新生儿为研究对象,收集患者的基本信息及相关指标。当万古霉素血药浓度达稳态时记录其平均血清稳态谷浓度(C_(min)),根据平均C_(min)值将患者分为<10 mg·L^(-1)组、10~15 mg·L^(-1)组、>15 mg·L^(-1)组。探究万古霉素不同C_(min)组患儿的临床疗效及AKI发生率情况。结果102例患儿中共34例患儿发生AKI,发生率为33.33%,3组患儿的AKI发生率对比,差异有统计学意义(χ^(2)=9.280,P=0.010)。102例患儿中治疗有效者75例,无效者27例,临床有效率为73.53%(75/102),3组患儿的临床有效率对比,差异无统计学意义(χ^(2)=0.924,P=0.630)。结论脓毒症休克新生儿万古霉素C_(min)与治疗效果没有明显关系;而C_(min)与AKI发生率存在一定的关系,当平均C_(min)>15 mg·L^(-1)时AKI发生率最高。

oXiris滤器与普通滤器治疗ICU脓毒症休克伴急性肾损伤患者的效果差异

目的探讨oXiris滤器与普通滤器对ICU脓毒症休克伴急性肾损伤患者的影响。方法选取2018年4月—2021年12月河池市人民医院收治的78例ICU脓毒症休克伴急性肾损伤患者,根据使用的滤器不同分为oXiris组、常规组,各39例,其中oXiris组采用oXiris滤器,常规组采用普通滤器。比较两组炎症介质[降钙素原(PCT)、内毒素、白细胞介素-6(IL-6)、干扰素-γ(IFN-γ)、C-反应蛋白(CRP)]、血流动力学和呼吸情况[心率(HR)、血乳酸(Lac)、平均动脉压(MAP)]、肾功能[血肌酐(Cr)、血尿素氮(BUN)]、急性生理与慢性健康(APACHE)Ⅱ评分、序贯器官衰竭评分(SOFA)、康复进程[ICU住院时间、连续性肾脏替代治疗(CRRT)持续时间]、去甲肾上腺素使用量、28 d生存预后。结果①治疗24 h后、治疗48 h后oXiris组PCT、内毒素、IL-6、IFN-γ、CRP、HR、Lac均低于常规组,MAP高于常规组(P<0.05);②治疗24 h后、治疗48 h oXiris组Cr、BUN、APACHEⅡ评分、SOFA评分均低于常规组(P<0.05);③oXiris组ICU住院时间、CRRT持续时间短于常规组,治疗24 h后、治疗48 h后去甲肾上腺素使用量低于常规组(P<0.05);④oXiris组生存率89.74%(35/39)高于常规组的74.36%(29/39)(P>0.05)。结论与普通滤器相比,oXiris滤器更能改善ICU脓毒症休克伴急性肾损伤患者的呼吸功能及肾功能,稳定患者血流动力学,减轻炎症损伤,减少去甲肾上腺素使用量,促进患者病情恢复,并进一步提升生存率。

Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis

AIM: To determine the predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis(SBP).METHODS: Two hundred and eighteen patients admitted to an intensive care unit in a tertiary care hospital between June 2013 and June 2014 with the diagnosis of SBP(during hospitalization) and cirrhosis were retrospectively analysed. SBP was diagnosed by abdominal paracentesis in the presence of polymorphonuclear cell count ≥ 250 cells/mm3 in the peritoneal fluid. Student's t test, multivariate logistic regression, cox proportional hazard ratio(HR), receiver operating characteristics(ROC) curves and Kaplan-Meier survival analysis were utilized for statistical analysis. Predictive abilities of several variables identified by multivariate analysis were compared using the area under ROC curve. P < 0.05 were considered statistical significant. RESULTS: The 50 d in-hospital mortality rate attributable to SBP is 43.11%(n = 94). Median survival duration for those who died was 9 d. In univariate analysis acute kidney injury(AKI), hepatic encephalopathy, septic shock, serum bilirubin, international normalized ratio, aspartate transaminase, and model for end-stage liver disease- sodium(MELD-Na) were significantly associated with in- hospital mortality in patients with SBP(P ≤ 0.001). Multivariate coxproportional regression analysis showed AKI(HR = 2.16, 95%CI: 1.36-3.42, P = 0.001) septic shock(HR = 1.73, 95%CI: 1.05-2.83, P = 0.029) MELD-Na(HR = 1.06, 95%CI: 1.02-1.09, P ≤ 0.001) was significantly associated with 50 d in-hospital mortality. The prognostic accuracy for AKI, MELD-Na and septic shock was 77%, 74% and 71% respectively associated with 50 d inhospital mortality in SBP patients.CONCLUSION: AKI, MELD-Na and septic shock were predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with SBP.

彩色多普勒超声对感染性休克患者急性肾损伤的预测价值

背景感染性休克患者存在肾脏血液灌注异常,严重时可诱发急性肾损伤(AKI),严重威胁患者生命安全;彩色多普勒超声(CDU)可用于评估肾脏血流变化,但有关其在感染性休克患者AKI评估中价值的研究较少。目的通过CDU评价感染性休克患者AKI的发生情况及其血流动力学改变。方法选取2019年6月至2021年7月徐州市中心医院收治的105例确诊为感染性休克的患者并纳入感染组,选取同期健康体检者58例并纳入对照组,收集受试者一般资料。采用CDU检查受试者肾脏血流动力学指标[肾动脉管腔内径(D)、收缩期血流峰值速度(Vs)、舒张末期血流速度(Vd)、阻力指数(RI)、搏动指数(PI)],比较感染组与对照组的一般资料及肾脏血流动力学指标。根据感染组患者入院72 h内发生AKI与否将其分为AKI组及非AKI组,比较AKI组与非AKI组肾脏血流动力学指标。应用受试者工作特征(ROC)曲线分析肾脏血流动力学指标对感染性休克患者发生AKI的预测价值。应用单因素分析及多因素Logistic回归分析探讨感染性休克患者发生AKI的影响因素。以AKI由轻到重的程度将患者分为AKIⅠ组、AKIⅡ组、AKIⅢ组,比较AKIⅠ组、AKIⅡ组、AKIⅢ组的肾脏血流动力学指标,采用Spearman秩相关分析探究肾脏血流动力学指标与AKI分期的相关性。结果确诊为感染性休克后,于72 h内发生AKI的患者共39例,其中AKIⅠ组19例、AKIⅡ组15例、AKIⅢ组5例。感染组D、Vs、Vd小于对照组,RI、PI大于对照组(P<0.05)。AKI组D、Vs、Vd小于非AKI组,RI、PI大于非AKI组(P<0.05)。D、Vs、Vd、RI、PI预测感染性休克患者发生AKI的ROC曲线下面积分别为0.782、0.772、0.708、0.842、0.683,最佳截断值分别为4.91 mm、71.19cm/s、17.19 cm/s、0.71、1.50,灵敏度分别为66.67%、94.87%、58.97%、87.18%、56.41%,特异度分别为80.30%、51.52%、77.27%、66.67%、78.79%。多因素Logistic回归分析结果显示,D≥4.91 mm、Vs≥71.19 cm/s、RI≥0.71为感染性休克患者发生AKI的影响因素(P<0.05)。与AKIⅢ期患者比较,AKIⅡ期患者的D更大,RI更小(P<0.05);与AKIⅢ期患者比较,AKIⅠ期患者的D、Vs、Vd更大,RI更小(P<0.05);与AKIⅡ期患者比较,AKIⅠ期患者的Vd更大(P<0.05)。Spearman秩相关分析结果显示,AKI患者D、Vd与AKI分期呈强负相关,Vs与AKI分期呈弱负相关(rs=-0.421,-0.674,-0.358,P<0.05);RI与AKI分期呈强正相关(rs=0.539,P<0.001);PI与AKI分期无明显相关性(P>0.05)。结论CDU可用于检查感染性休克患者的肾脏血流动力学指标。肾脏血流动力学指标与感染性休克患者AKI的发生及严重程度相关,并对感染性休克患者发生AKI具有预测价值。未来或可通过检测肾脏血流动力学指标来对感染性休克患者AKI发生情况进行诊断和评估。

Prediction of Acute Renal Failure in Dengue Fever Patients

Background: Dengue virus (DENV) infection is caused by an arboviral strain and is transmitted by the mosquito Aedes aegypti which is found in Sudan especially Red Sea and Kassala states in the east. The disease is known to cause renal disturbances and a thorough understanding of that will potentially help in the prediction, diagnosis and treatment of the disease. Methods: This study is a prospective observational cross sectional study conducted in the Eastern Sudan College of Medical Science and Technology and Port Sudan Teaching Hospital. 200 confirmed Dengue virus infected patients along with 200 healthy appearing adults (control) were enrolled for the study. Statistical analysis was carried out after the collection of patients’ demographic, clinical, and investigational data including serum urea and creatinine values. Ethical approval was obtained from the ministry of health, Red Sea state and informed written consent was obtained from each participant. Results: The highest incidence of DENV infection was observed in individuals of the middle age group (29%). Elevated blood urea levels were detected in 10 (5%) patients while elevated creatinine levels were seen in 17 (8.5%) patients. Although fallen within reference ranges found in the literature, mean blood urea and creatinine values differed significantly between patients and controls and between different categories of the disease. Mean blood urea concentration showed a statistically significant difference between the control (22.3 mg/dl) and the test (28.4 mg/dl) (P value Conclusion: We strongly conclude that renal involvement is not uncommon in Dengue fever and that blood urea and creatinine evaluation should be considered in the counseling of DENV infection patients. Patients need to be subjected to necessary laboratory investigations associated with acute kidney injury to decrease the rate of morbidity and mortality associated with the disease.

不同时机连续性肾脏替代治疗用于感染性休克合并急性肾损伤患者的效果

目的:观察不同时机连续性肾脏替代治疗(CRRT)用于感染性休克合并急性肾损伤(AKI)患者的效果。方法:回顾性分析2020年9月至2022年9月该院收治的87例感染性休克合并AKI患者的临床资料,按照CRRT时机不同将其分为对照组43例与观察组44例。对照组于确诊48 h后行CRRT,观察组于确诊12 h内行CRRT,比较两组治疗14 d后生存率、肾功能指标[血尿素氮(BUN)、血肌酐(Scr)、β2微球蛋白(β2-MG)及胱抑素C(Cys C)]水平、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、血清脑钠肽(BNP)水平和血清炎性因子[白细胞介素(IL)-10、IL-6、肿瘤坏死因子-α(TNF-α)、降钙素原(PCT)]水平。结果:治疗14 d后,观察组生存率为90.91%(40/44),明显高于对照组的74.42%(32/43),差异有统计学意义(P<0.05);治疗14 d后,两组存活患者血清BUN、Scr、β2-MG、Cys C、BNP、IL-10、IL-6、TNF-α和PCT水平及APACHEⅡ评分低于治疗前,且观察组低于对照组,差异均有统计学意义(P<0.05)。结论:于确诊12 h内应用CRRT治疗感染性休克合并AKI患者可提高生存率,降低血清肾功能指标、BNP、炎性因子水平和APACHEⅡ评分,效果优于确诊48 h后行CRRT。

氢溴酸山莨菪碱对感染性休克大鼠急性肺损伤的保护作用

目的探讨氢溴酸山莨菪碱(Ani HBr)对感染性休克大鼠急性肺损伤的保护作用及其机制。方法将30只SD大鼠随机分为假手术(Sham)组、模型(LPS)组和Ani HBr治疗(LPS+Ani HBr)组,每组10只。利用气道滴注脂多糖(LPS)构建感染性休克大鼠急性肺损伤模型。建模1 h后,LPS+Ani HBr组大鼠腹腔注射3.6 mg/kg Ani HBr。Sham组和LPS组大鼠分别给予等量0.9%氯化钠溶液。药物干预6 h后,大鼠麻醉处死,取肺组织测定肺系数、肺组织湿/干重比(W/D)和肺组织含水量;同时,苏木精-伊红(HE)染色,观察肺组织的病理结构变化。收集支气管肺泡灌洗液(BALF),用酶联免疫吸附试验(ELISA)检测BALF中促炎细胞因子(IL-1β,IL-6和TNF-α)的表达水平。Western blotting检测肺组织中Bcl2,Bax和Caspase-3等凋亡相关蛋白表达以及NF-κB/NLRP3信号通路的活性。结果与LPS组比较,Ani HBr能够降低感染性休克大鼠的肺系数、肺组织湿/干重比(W/D)和肺组织含水量;改善受损大鼠肺泡结构紊乱,减少炎性细胞浸润;显著降低BALF中促炎细胞因子IL-1β、IL-6及TNF-α含量;减少肺组织中细胞凋亡水平,同时下调NF-κB p65和NLRP3蛋白表达水平。结论Ani HBr能够减轻感染性休克大鼠急性肺损伤,其分子机制与调控NF-κB/NLRP3信号通路相关。

Early prediction of acute kidney injury in children: known biomarkers but novel combination

Acute kidney injury (AKI) is a global public health concern with rapid decline in glomerular filtration rate and signifi-cant increase in serum creatinine and blood urea nitrogen, which is an independent risk factor for short-term and long-term mortality (1, 2)In addition to kidney disease, AKI can occur secondary to a variety of diseases, such as multi-organ dysfunction, respiratory distress syndrome, sepsis, losing of gastrointestinal fluids, cardiac surgery, using of nephrotoxic drugs and tumors. The most common causes for AKI of children include sepsis, ischemia and reperfusion injury and tubulointerstitial lesions (3)Additionally, morbidity and mortality were high in critically ill patients, especially for those who were admitted to pediatric intensive care unit (PICU) and underwent cardiac surgery (2–4)Although renal replacement therapies have greatly improved and can pro-vide relief for most patients, the mortality remained high for critically ill children as high as 10%, about six times higher than non-AKI patients (2)In the past few years, studies have reported that even mild elevation of serum creatinine levels may increase the risk of complications and mortality (5)In a prospective cohort study, 10.3% of survivors from AKI in the PICU eventually progress to chronic kidney disease [6].

脓毒症患者血清IL-1、IL-17的表达水平及其对预后的影响

目的 观察脓毒症患者血清白细胞介素(IL)-1、IL-17的表达水平,并分析二者对预后的影响及预测效能。方法 回顾性分析收治的106例脓毒症患者的临床资料,收集患者基线资料,记录治疗前血清IL-1、IL-17水平,评估患者预后,采用回归分析检验治疗前血清IL-1、IL-17水平对脓毒症患者预后的影响,并分析治疗前血清IL-1、IL-17对脓毒症患者预后不良的预测效能。结果 106例脓毒症患者中,有12例预后不良,有94例预后良好。比较预后不良组与预后良好组基线资料后,经单因素、多因素logistic回归分析检验结果显示,有急性肾损伤、有感染性休克、序贯器官衰竭评分(SOFA)及急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)高评分、IL-1及IL-17高水平是脓毒症患者预后不良的风险因子(OR>1,P<0.05);绘制受试者工作特征(ROC)曲线发现,血清IL-1、IL-17水平单项预测、联合预测及模型预测预后不良的ROC曲线下面积(AUC)均>0.70,均有一定预测价值,且联合预测及模型预测的AUC与单项预测的AUC相近,两指标预测脓毒症预后更简单易行。结论 脓毒症患者预后不良与多种因素有关,其中血清IL-1、IL-17水平可用于预测预后不良风险,可作为临床预测脓毒症患者预后的辅助手段。

阶梯式呼吸管理护理策略在感染性休克合并急性肺损伤患者中的应用效果

目的观察阶梯式呼吸管理策略在改善感染性休克伴急性肺损伤(ALI)患者中的价值。方法纳入我院2019年1月—2020年12月收治的感染性休克伴ALI患者共146例为研究对象,数字表法随机分为观察组(73例)与对照组(73例)。对照组常规护理方案,观察组阶梯式呼吸管理,对比干预前后患者心肺功能的差异。结果观察组平均动脉压、PaCO_(2)水平低于对照组,心脏指数、中心静脉压、血管外肺水指数、PaO_(2)与氧合指数高于对照组(P<0.05);观察组复苏成功率与临床总有效率高于对照组,复苏时间与呼吸平稳时间低于对照组(P<0.05);观察组气管切开率、有创呼吸机使用率及呼吸机相关性肺炎与气道并发症发生率均低于对照组(P<0.05)。结论感染性休克并急性肺损伤患者建立阶梯化呼吸管理策略能够显著改善患者的心肺功能,提高临床复苏效果,降低相关并发症风险。

NLR、IL-6联合肾脏阻力指数对脓毒性休克患者早期急性肾损伤的研究

目的 探究中性粒细胞/淋巴细胞比值(neutrophil/lymphocyte ratio, NLR)、白细胞介素6(interleukin-6,IL-6)联合肾动脉阻力指数(renal artery resistance index, RRI)对脓毒性休克患者早期急性肾损伤(acute kidney injury, AKI)的诊断价值。方法 回顾性分析2021年4月—2022年8月深圳市龙岗区第三人民医院重症医学科收治的96例脓毒性休克患者的病历资料,将患者分为AKI组(n=52)和非AKI组(n=44)。收集、比较两组患者年龄、性别、序贯器官衰竭评分、急性生理与慢性健康评估Ⅱ评分、平均动脉压、C反应蛋白、RRI、IL-6、NLR、ICU住院时间等资料,并采用受试者工作特征曲线(receiver operating characteristic curve, ROC)评估NLR、IL-6、RRI对脓毒性休克患者AKI发生的诊断价值。结果 脓毒性休克患者AKI的发生率为54.17%(52/96)。与非AKI组比较,AKI组患者IL-6水平更高、NLR及RRI值更大,差异有统计学意义(P<0.05)。ROC曲线分析结果显示,NLR≥21.917、IL-6≥22.500 pg/mL、RRI≥0.724可诊断脓毒性休克患者发生AKI,其ROC曲线下面积(area under the curve, AUC)分别为0.775、0.725、0.821。NLR、IL-6、RRI三者联合的诊断价值大于单一指标,其ROC的AUC为0.939,敏感度为82.70%,特异性为97.70%。结论 高水平的NLR、IL-6、RRI是导致脓毒性休克患者发生急性肾损伤的危险因素,三者联合可以用作早期诊断脓毒性休克患者是否会发生急性肾损伤。

持续肾脏替代治疗时机对感染性休克合并急性肾损伤患者预后的影响

目的探讨持续性肾脏替代治疗(CRRT)时机对感染性休克合并急性肾损伤(AKI)患者预后的影响及死亡危险因素。方法选择本院重症监护病房(ICU)感染性休克合并达到RIFLE诊断标准功能衰竭阶段的急性肾损伤(AKI)患者63例,根据治疗开始时机将患者随机分为2组,早期组(n=33)诊断后12 h内开始CRRT,晚期组诊断后48 h后开始CRRT(n=30),比较2组患者生存率,并采用多元回归分析死亡危险因素。结果治疗前,2组患者年龄、手术情况、病史和疾病危重程度等方面差异均无统计学意义(P>0.05)。经Log-Rank检验,2组各时段生存率差异无统计学意义(P=0.574)。Cox回归分析提示,血乳酸和APACHEⅡ评分是影响患者预后的独立危险因素。结论 CRRT治疗开始时机选择对于感染性休克合并急性肾损伤患者短期预后影响不大。

丙酮酸乙酯拮抗内毒素诱导的脓毒症休克犬急性肺损伤

目的:探讨丙酮酸乙酯(EP)对内毒素诱导脓毒症休克犬急性肺损伤的影响。方法:健康雄性杂种犬20只,内毒素的主要活性成分脂多糖(LPS)静脉注射复制脓毒症休克模型,随机分为对照组(n=8)和EP治疗组(n=12)。对照组只接受林格氏液复苏。EP治疗组另外给予丙酮酸乙酯首剂0.05g/kg,然后0.05g.kg-1.h-1持续泵入。休克模型建立前及建立后0h、4h、8h、12h监测血气分析及呼吸力学指标,包括肺动态顺应性(Cdyn)、肺总顺应性(Ctot)、吸气相气道阻力(Rawi)、吸气峰压(PIP)、呼吸功(WOBvt),并用ELISA方法检测血浆肿瘤坏死因子TNF-α、白介素IL-6、白介素IL-10水平。结果:内毒素诱导建立脓毒症休克犬模型后,血气分析及呼吸力学改变符合急性肺损伤。氧合指数(OI)、HCO3-、pH下降,PaCO2上升(与模型前比较,休克后4hP<0.05)。肺动态顺应性和肺总顺应性下降,吸气峰压、气道阻力、呼吸功增加(与模型前比较,休克后8hP<0.05)。与EP治疗组比较,对照组改变更加明显,休克后8h动脉血气各项指标组间比较有显著差异(P<0.05)。丙酮酸乙酯虽未能改善脓毒症休克犬的呼吸力学指标,但能阻止呼吸力学参数的进一步恶化,休克后12h组间差异显著(P<0.05)。丙酮酸乙酯可以降低血浆中TNF-α、IL-6水平,提高IL-10水平,休克8h组间差异显著(P<0.05)。结论:丙酮酸乙酯可以对抗内毒素诱导的脓毒症休克犬的急性肺损伤。

小剂量肠内营养对脓毒性休克伴急性胃肠道损伤病人肠屏障及系统性炎症的改善作用

目的:观察小剂量肠内营养(EN)在脓毒性休克伴急性胃肠道损伤(AGI)病人治疗中的价值。方法:将在我院ICU接受治疗的84例脓毒性休克伴AGIⅢ级病人,依据是否采用EN治疗分为观察组(EN治疗,n=41)和对照组(无EN治疗,n=46)。对比两组病人的病死率、入住ICU时间,检测两组病人治疗前和治疗后1周肠屏障功能、系统性炎症和应激指标。结果:观察组病人EN剂量为836.8~1 715.4 k J(200~410 kcal)/d,中位剂量为1 464.4 k J(350 kcal)/d,未出现严重的EN并发症。两组病人病死率比较无显著性差异(24.4%vs 32.6%,P=0.398),但观察组病人入住ICU时间显著短于对照组,(11.8±3.7 vs 16.2±5.3,P<0.01);治疗后1周后,外周血C反应蛋白(CRP)、白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、外周血二胺氧化酶(DAO)、内毒素(ET)和D-乳酸水平均显著低于对照组(P<0.05)。结论:对合并AGI的脓毒性休克病人,即便给予小剂量EN仍具有改善病人肠屏障功能和系统性炎性反应的作用。