Follow-up study of factors influencing prognosis of cardiac arrest patients after acute myocardial infarction北大核心CSCD

Objective To assess the factors associated with the restoration of spontaneous circulation (ROSC) and 2-year survival prognosis in patients with cardiac arrest (CA) after acute myocardial infarction (AMI), and after ROSC, the effects of various factors on midian survival time and on 2-year survival. Methods In a registry study from January 2005 to January 2015, all consecutive AMI-induced CA patients treated with cardiopulmonary resuscitation (CPR) admitted to our hospital were enrolled. The survivors were followed-up for 2 years. Univariate analysis was applied to evaluate factors associated with rate of ROSC and 2-year survival. Multivariate logistic regression analysis was applied to evaluate statistically significant factors in the univariate analysis. Medians with inter-quartile ranges were used to describe 2-year survival time affected by various factors after ROSC. Kaplan-Meier survival curve analysis was used to evaluate the effect of factors on 2-year survival. Results A total of 254 cases with CA after AMI were enrolled, including 129 cases of ROSC and 71 cases of 2-year survival. Univariate analysis showed age ≥ 70 years, CA occurred during 22:00-8:00, the duration time of CPR > 15 min and adrenaline dosage > 5 mg were unfavorable predictors of ROSC; while, left ventricular ejection fraction (LVEF) > 40% before CA, shockable rhythm and percutaneous coronary intervention (PCI) therapy were favorable predictors. Besides, age ≥ 70 years, intubation during CPR, adrenaline dosage > 5 mg and cardiogenic shock were unfavorable predictors of 2-year survival; While, male, normal daily activity before CA and PCI treatment were favorable predictors. Multivariable analysis showed age, the duration of CPR, adrenaline dosage, LVEF before CA, the rhythm during CPR and PCI therapy were independent predictors of ROSC. Age and PCI therapy were independent predictors of 2-year survival. Among patients, the survival time was affected by various factors after ROSC, and the factors with minimum 25% and small median value were associated with cardiac rupture, cancer, adrenaline dosage > 5 mg and cardiogenic shock. The factor with maximum 25% value was PCI treatment (216 days). Kaplan-Meier survival analysis suggested that age ≥ 70 years was an unfavorable factor of 2-years survival (Log-rank test, P=0.007); while, PCI treatment was a favorable factor (Log-rank test, P<0.01). PCI-related prognosis analysis showed that the effectiveness of PCI was related to the timing of PCI, the number of infarct-related artery and the difference in culprit lesion. Conclusions The age ≥ 70 years was disadvantageous to both ROSC and 2-year survival. PCI treatment was favorable to both ROSC and 2-year survival. © 2018 Chinese Medical Association. All rights reserved.     

持续性肾脏替代治疗在脓毒症诱发多脏器功能失常综合征患者中的应用价值

目的 探讨持续性肾脏替代治疗(continuous renal replacement therapy,CRRT)在脓毒症诱发多脏器功能失常综合征(multiple organ dysfunction syndrome,MODS)患者中的应用价值.方法 天津医科大学第二医院院ICU的62例脓毒症导致MODS患者,按CRRT时间分为非CRRT组、短CRRT组(24～48 h)和长CRRT组(>48 h).观察各组脏器功能、血浆内皮素-1(ET.1)、脓毒症相关器官衰竭(SOFA)评分、生存时间和累计生存率的变化.结果 其中长CRRT组的SOFA评分逐渐下降于第4天处于相对低值,与非CRRT组相比较,差异具有统计学意义(P<0.05);而短CRRT组的SOFA评分逐渐下降于第6天处于相对低值,与非CRRT组相比较差异具有统计学意义(P<0.05).非CRRT、短CRRT和长CRRT的3 d生存率分别为56.3%、83.3%和88.9%,差异具有统计学意义(P<0.05);三组3周生存率分别为53.1%、58.3%和66.7%,差异无统计学意义(P>0.05).生存时间分别为非CRRT组(4.4±2.6)d,短CRRT组(9.5±6.1)d和长CRRT组(10.3±5.4)d,与非CRRT组相比,短CRRT组和长CRRT组患者的生存时间明显长于非CRRT组(P<0.05).患者血浆ET-1在CRRT治疗后明显下降(P<0.05).结论 CRRT能有效改善MODS患者的脏器功能,适当地延长CRRT时间可以明显降低SOFA评分,提高患者短期生存率.

Abstract：

Objective To study the values of continuous renal replacement therapy (CRRT) for the treatment of multiple organ dysfunction syndrome ( MODS) induced by sepsis. Methods A total of 62 patients with MODS were divided into three groups, namely non-CRRT group, short period CRRT group (24 ~ 48 h) and long period CRRT group( >48 h). Relevant factors including organ function, plasma endothelin-1 (ET-1),sepsis-related organ failure assessment(SOFA)score, average length of survival time and accumulative survival rate were analyzed . Results Compared with non-CRRT group, a statistically significant difference in SOFA score was evident on the 4th day after long period CRRT group and on the 6th day after short period CRRT group. The survival rates of three groups on the third day after treatment were 56. 3% 、 83.3% and 88.9%, respectively (P< 0.05). The survival rates of three groups three weeks after treatment were 53. 1% , 58. 3% and 66.7% , respectively (P>0.05). The average lengths of survival time in three groups were(4.4 ±2.6)days, (9.5 ±6. l)days and (10.3 ±5.4)days, respectively. Compared with non-CRRT group, the average lengths of survival time were longer in the other two groups. The levels of serum ET-1 significantly decreased after CRRT treatment (P<0.05). Conclusions The organ function and survival rate could be improved by CRRT. Average lengths of survival time were significantly prolonged in two CRRT groups(P <0.05). More effective therapeutic results including lower SOFA score and longer average length of survival time were observed when the course of CRRT was extended longer properly.     

Risk factors for long-term prognosis of hepatocellular carcinoma patients after anatomic hepatectomy

BACKGROUND The risk factors for patients with major postoperative complications immediately after liver resection have been identified;however,the intermediate and longterm prognoses for these patients have yet to be determined.AIM To evaluate the factors responsible for the long-term recurrence-free survival rate in patients with hepatocellular carcinoma(HCC)following anatomic hepatectomy.METHODS We performed a retrospective analysis of 74 patients with HCC who underwent precise anatomic hepatectomy at our institution from January 2013 to December 2015.The observational endpoints for this study were the tumor recurrence or death of the HCC patients.The overall follow-up duration was three years.The recurrence-free survival curves were plotted by the Kaplan-Meier method and were analyzed by the log-rank test.The value of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis.RESULTS The 1-year and 3-year recurrence-free survival rates of HCC patients were 68.92%and 55.41%,respectively,following anatomic liver resection.The results showed that the 3-year recurrence-free survival rate in HCC patients was closely related to preoperative cirrhosis,jaundice level,tumor stage,maximal tumor diameter,complications of diabetes mellitus,frequency of intraoperative hypotensive episodes,estimated blood loss(EBL),blood transfusion,fluid infusion,and postoperative infection(P<0.1).Based on multivariate analysis,preoperative cirrhosis,tumor stage,intraoperative hypotension,and EBL were identified to be predictors of 3-year recurrence-free survival in HCC patients undergoing anatomic hepatectomy(P<0.05).CONCLUSION Tumor stage and preoperative cirrhosis adversely affect the recurrence-free survival rate in HCC patients following anatomic hepatectomy.The long-term recurrence-free survival rate of patients with HCC is closely related to intraoperative hypotension and EBL.     

Prognostic factors for overall survival in prostate cancer patients with different site-specific visceral metastases: A study of 1358patients

BACKGROUND Distant metastasis,particularly visceral metastasis(VM),represents an important negative prognostic factor for prostate cancer(PCa)patients.However,due to the lower rate of occurrence of VM,studies on these patients are relatively rare.Consequently,studies focusing on prognostic factors associated with PCa patients with VM are highly desirable.AIM To investigate the prognostic factors for overall survival(OS)in PCa patients with lung,brain,and liver metastases,respectively,and evaluate the impact of site-specific and number-specific VM on OS.METHODS Data on PCa patients with VM were extracted from the Surveillance,Epidemiology,and End Results database between 2010 and 2015.Univariate and multivariate Cox regression analyses were used to analyze the association between clinicopathological characteristics and survival of patients with different site-specific VM.Kaplan-Meier analyses and Log-rank tests were performed to analyze the differences among the groups.RESULTS A total of 1358 PCa patients with site-specific VM were identified from 2010 to 2015.Older age(>70 years)(P<0.001),higher stage(T3/T4)(P=0.004),and higher Gleason score(>8)(P<0.001)were found to be significant independent prognostic factors associated with poor OS in PCa patients with lung metastases.Higher stage(T3/T4)(P=0.047)was noted to be the only independent risk factor affecting OS in PCa patients with brain metastases.Older age(>70 years)(P=0.010)and higher Gleason score(>8)(P=0.001)were associated with shorter OS in PCa patients with liver metastases.PCa patients with isolated lung metastases exhibited significantly better survival outcomes compared with PCa patients with other single sites of VM(P<0.001).PCa patients with a single site of VM exhibited a superior OS compared with PCa patients with multiple sites of VM(P<0.001).CONCLUSION This is the first Surveillance,Epidemiology,and End Results-based study to determine prognostic factors affecting OS in PCa patients with different sitespecific VM.Clinical assessments of these crucial prognostic factors become necessary before establishing a treatment strategy for these patients with metastatic PCa.     

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND Sepsis is fatal in patients with gastrointestinal perforation(GIP).However,few studies have focused on this issue.AIM To investigate the risk factors for postoperative sepsis in patients with GIP.METHODS This was a retrospective study performed at the Department of General Surgery in our treatment center.From January 2016 to December 2018,the medical records of patients with GIP who underwent emergency surgery were reviewed.Patients younger than 17 years or who did not undergo surgical treatment were excluded.The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group.Clinical data for both groups were collected and compared,and the risk factors for postoperative sepsis were investigated.The institutional ethical committee of our hospital approved the study.RESULTS Two hundred twenty-six patients were admitted to our department with GIP.Fourteen patients were excluded:Four were under 17 years old,and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members.Two hundred twelve patients were finally enrolled in the study;161 were men,and 51 were women.The average age was 62.98±15.65 years.Postoperative sepsis occurred in 48 cases.The prevalence of postoperative sepsis was 22.6%[95%confidence interval(CI):17.0%-28.3%].Twenty-eight patients(13.21%)died after emergency surgery.Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery[odds ratio(OR)=1.021,95%CI:1.005-1.038,P=0.006],colonic perforation(OR=2.761,CI:1.821–14.776,P=0.007),perforation diameter(OR=1.062,95%CI:1.007-1.121,P=0.027),and incidence of malignant tumorrelated perforation(OR=5.384,95%CI:1.762-32.844,P=0.021)were associated with postoperative sepsis.CONCLUSION The time interval from abdominal pain to surgery,colonic perforation,diameter of perforation,and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.     

换瓣术后急性肾功能衰竭患者无抗凝剂行连续性静脉-静脉血液滤过治疗的护理

目的 探讨换瓣术后急性肾功能衰竭患者无抗凝剂行连续性静脉-静脉血液滤过 (CVVH)治疗的护理.方法 对28例心脏直视换瓣术后并发急性肾功能衰竭(ARF)的患者实施无抗凝剂CVVH治疗138例次,治疗过程中密切观察滤器和管道的血凝情况、采用定时冲洗管路等护理措施.结果 本组治疗138例次,滤器寿命3.5～24 h,多数为10～13 h,连续治疗者每天更换1～2套滤器及管路;1例在连续4次治疗中机械反复出现低压动脉报警,造成滤及管路在3.5～7 h凝血而更换滤器及管路,2例病人出现皮下出血点,1例病人出现血便.结论 对换瓣术后ARF的患者进行CVVH无抗凝剂治疗,结合相应护理措施,能使治疗能顺利完成,减小患者出血并发症.

Abstract：

Objective To study the observation and nursing with continuous veno- venous hemofiltration (CVVH) without anticoagulation therapy in acute renal failure after valve surgery.Methods During the treatment with 138 times of non-anticoagulant CVVH in open heart valve replacement surgery with concurrent acute renal failure (ARF) in 28 cases, the condition variation, filters and piping clotting conditions were closely observed, and regular flushing piping and other nursing measures were taken.Results In the treatment of 138 times, filter life was 3.5 ～ 24 h, 10 ～ 13 h in the majority; continuous treatment replaced 1 to 2 sets of filters and pipes one day; one case of 4 times treatment in a row occurred recurrent mechanical alarm of hypotension, causing coagulation in filters and pipes in 3.5 ～ 7 h and replacement of filters and pipes; 2 patients occurred subcutaneous bleeding, and 1 patient had bloody stools.Conclusions In the patients with ARF after valve surgery, CVVH without anticoagulation therapy, combined with the appropriate care measures, can make the successful completion of treatment and reduce bleeding complications in patients.     

Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND: This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insuffi ciency(CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD).METHODS: Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit(ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group(n=32) and a control group(n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone(150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers ofinfl ammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value 0.05 was considered statistically signifi cant.RESULTS: Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4%. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI(23.8% vs. 8.7%, P0.01). KaplanMeier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group(P0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group(18.2±9.5 vs. 25.8±4.1, P0.05). Treatment with low-dose glucocorticoid obviously decreased the markers ofinfection and inflammation(P0.01), such as C-reactive protein(13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α(26.1±16.2 g/L vs. 17.5±11.7 g/L for the control group; 25.0±14.8 g/L vs. 10.4±7.8 g/L for the treatment group) and procalcitonin(3.88 g/L vs. 2.03 g/L for the control group; 3.77 g/L vs. 1.26 g/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group(P0.01).CONCLUSION: The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers ofinfection and infl ammation.     

Incidence,risk factors,and outcome of BK polyomavirus infection after kidney transplantation

BACKGROUND Polyomavirus-associated nephropathy is a leading cause of kidney allograft failure. Therapeutic options are limited and prompt reduction of the net state of immunosuppression represents the mainstay of treatment. More recent application of aggressive screening and management protocols for BK-virus infection after renal transplantation has shown encouraging results. Nevertheless,long-term outcome for patients with BK-viremia and nephropathy remains obscure. Risk factors for BK-virus infection are also unclear.AIM To investigate incidence, risk factors, and outcome of BK-virus infection after kidney transplantation.METHODS This single-centre observational study with a median follow up of 57(31-80) mo comprises 629 consecutive adult patients who underwent kidney transplantation between 2007 and 2013. Data were prospectively recorded and annually reviewed until 2016. Recipients were periodically screened for BK-virus by plasmaquantitative polymerized chain reaction. Patients with BK viral load ≥ 1000 copies/mL were diagnosed BK-viremia and underwent histological assessment to rule out nephropathy. In case of BK-viremia, immunosuppression was minimized according to a prespecified protocol. The following outcomes were evaluated: patient survival, overall graft survival, graft failure considering death as a competing risk, 30-d-event-censored graft failure, response to treatment,rejection, renal function, urologic complications, opportunistic infections, newonset diabetes after transplantation, and malignancies. We used a multivariable model to analyse risk factors for BK-viremia and nephropathy.RESULTS BK-viremia was detected in 9.5% recipients. Initial viral load was high(≥ 10000 copies/mL) in 66.7% and low(< 10000 copies/mL) in 33.3% of these patients.Polyomavirus-associated nephropathy was diagnosed in 6.5% of the study population. Patients with high initial viral load were more likely to experience sustained viremia(95% vs 25%, P < 0.00001), nephropathy(92.5% vs 15%, P <0.00001), and polyomavirus-related graft loss(27.5% vs 0%, P = 0.0108) than recipients with low initial viral load. Comparison between recipients with or without BK-viremia showed that the proportion of patients with Afro-Caribbean ethnicity(33.3% vs 16.5%, P = 0.0024), panel-reactive antibody ≥ 50%(30% vs14.6%, P = 0.0047), human leukocyte antigen(HLA) mismatching > 4(26.7% vs13.4%, P = 0.0110), and rejection within thirty days of transplant(21.7% vs 9.5%; P= 0.0073) was higher in the viremic group. Five-year patient and overall graft survival rates for patients with or without BK-viremia were similar. However,viremic recipients showed higher 5-year crude cumulative(22.5% vs 12.2%, P =0.0270) and 30-d-event-censored(22.5% vs 7.1%, P = 0.001) incidences of graft failure than control. In the viremic group we also observed higher proportions of recipients with 5-year estimated glomerular filtration rate < 30 mL/min than the group without viremia: 45% vs 27%(P = 0.0064). Urologic complications were comparable between the two groups. Response to treatment was complete in55%, partial in 26.7%, and absent in 18.3% patients. The nephropathy group showed higher 5-year crude cumulative and 30-d-event-censored incidences of graft failure than control: 29.1% vs 12.1%(P = 0.008) and 29.1% vs 7.2%(P <0.001), respectively. Our multivariable model demonstrated that Afro-Caribbean ethnicity, panel-reactive antibody > 50%, HLA mismatching > 4, and rejection were independent risk factors for BK-virus viremia whereas cytomegalovirus prophylaxis was protective.CONCLUSION Current treatment of BK-virus infection offers sub-optimal results. Initial viremia is a valuable parameter to detect patients at increased risk of nephropathy. Panelreactive antibody > 50% and Afro-Caribbean ethnicity are independent predictors of BK-virus infection whereas cytomegalovirus prophylaxis has a protective effect.     

Risk factors of contrast-induced nephropathy in patients with acute myocardial infarction treated with emergent percutaneous coronary intervention北大核心CSCD

Objective To explore the risk factors of contrast-induced nephropathy (CIN) in patients with acute ST-segment elevation myocardial infarction(STEMI)treated with emergent percutaneous coronary intervention(PCI). Methods The clinical data of patients with STEMI treated by emergent PCI from January 2014 to February 2017 in Peking University People's Hospital was reviewed. Exclusion criteria included contrast agent allergy, previous renal diseases, chronic renal failure, heart failure, tumor, acute infection, only one renal function test available during hospitalization and lacking essential medical records. Data of demographics, past medical history, general conditions at admission, laboratory findings, etc, were collected. Patients were divided into CIN group and non-CIN group. The univariate comparison analysis and Logistic regression analysis were performed to obtain the risk factors of CIN. Results A total of 236 patients were enrolled. The incidence of CIN was 10.2% (24/236). Univariable analysis demonstrated that the risk factors of CIN were age, diabetes mellitus, Killip grade ≥ 3 stage, serum uric acid (SUA) level at admission, blood glucose level at admission. Binary logistic regression analysis showed that SUA ≥ 350 μ.mol/L at admission, blood glucos ≥ 11 mmol/L at admission, age 5= 75 years were independent risk factors for CIN. Conclusion SUA ≥ 350 μ mol/L at admission, blood sugar 5= 11 mmol/L at admission, age ≥ 75 years were independent risk factors of CIN in patients with STEMI treated with emergent PCI. © 2018 Chinese Medical Association. All rights reserved.     

估算的肾小球滤过率在冠状动脉旁路移植术预后价值的研究

Objective To evaluate the postoperative prognosis of the modification of diet in renal disease formula (MDRD) in coronary artery bypass graft surgery (CABG) in hospital or 4 years after hospitalization. Methods Two hundred and seventy-two CABG patients were divided into 3 groups according to the levels of estimated glomerular filtration rate (eGFR) including 35 cases in eGFR < 60 ml/min group, 119 cases in 60 ≤ eGFR < 90 mL/min group and 118 cases in eGFR ≥90 ml/min group. The prognostic factors of CABG patients were analyzed by COX proportional hazards models. Kaplan-Meier survival analysis was used to compare survival curves among the three groups stratified by eGFR levels. The Log-rank statistic was used for comparing between groups. Results By multivariate COX regression adjustment for body mass index, smoking, hypertension, hyperlipaemia, diabetes mellitus, previous MI, perioperative PCI and etc. , the relative risk (RR) of the increasing age for cardiac events was 1.077(95% CI 1.002-1.158,P =0.044). RR of left ventricular ejection fraction (LVEF) was 0.005(95% CI 0.000-0.456,P =0.022). RR of eGFR was 0.968(95% CI 0.948-0.988,P =0.002). The survival rate in the first, second, third and fourth year were same in every group. The survival rate of group with eGFR < 60 ml/min, 60 ≤ eGFR < 90 ml/min and eGFR≥ 90 mL/min was 76.4%, 93.1%, and 96.6%. The survival rates among three groups were statistically significant. In the survival curve of 4 year follow-up after CABG, the survival rate of group with eGFR < 60 mL/min was lower than that of 60 ≤ eGFR < 90 ml/min group and eGFR ≥ 90 ml/min group. Conclusions The preoperative eGFR is an independent risk factor in evaluating cardiac events in hospital and after hospitalization. It has a higher prognosis value in patients undergoing CABG.     

连续肾替代抢救重症肾功能衰竭伴多器官衰竭50例探讨

目的：探讨连续肾代疗法（ＣＲＲＴ）地重症肾功能衰竭（肾衰）伴多器官衰竭（ＭＯＦ）抢救效果,以求提高重症肾衰伴ＭＯＦ的存活率。方法：总结我院１９９３年７月￣１、９９９年７月间使用连续动－静脉、静－静脉血液滤过（ＣＡＶＨ｜ＣＶＶＨ组）及连续动－静脉、静－静脉血液透析滤过（ＣＡＶＨＤＦ｜ＣＶＶＨＤＦ组）方法抢救重症肾衰伴ＭＯＦ５０例患者的资料,比较其疗效。结果：ＣＡＶＨ＋ＣＶＶＨ组２２例中存活５例（２２     

连续性静脉-静脉血液滤过在主动脉夹层术后急性肾衰竭中的应用

目的 探讨连续性静脉-静脉血液滤过(CVVH)在主动脉夹层术后急性肾衰竭(ARF)中应用的临床意义.方法 15例术后ARF患者,采用CVVH治疗,比较治疗前后血电解质、尿素氮、肌酐等相关指标的变化,以及全身水肿情况.结果 11例存活,4例死亡.存活患者血液滤过后尿素氮[(37.2±12.1)mmol/L与(22.1±6.8)mmol/L]和血肌酐[(351.4±160.9)μmol/L与(185.7±97.6)μmol/L]均逐渐下降直至恢复正常,尿量分别于滤过后6～40 d恢复正常,肾功能恢复时间为8～60 d.所有患者血液滤过后水肿得到明显改善.结论 CVVH是治疗主动脉夹层术后ARF的一种有效、方便而安全的方法.     

早期持续肾脏替代治疗急性肾功能衰竭

目的回顾性评价在不同的肾功能状态下开始持续肾脏替代治疗(CRRT)对急性肾功能衰竭(ARF)重症患者预后和肾脏功能转归的影响。方法按照RIFLE标准将患者开始CRRT时的肾功能状态由轻到重进行分级,据此将患者分为三组:RIFLE-R(risk of renaldysfunction,R)F组、RIFLE-Ⅰ(Injurytothe kidney,Ⅰ)组和RIFLE-F(failure of kidney function,F)组;统计并比较三组患者的住院存活率以及三组存活者肾脏功能转化为RIFLE-L(loss of kidney function,L)和RIFLE-E(end-stage kidney disease,E)的发生率。结果三组患者的住院存活率依次是81.8%,71.4%和47.8%;RIFLE-F组的存活率明显低于其它两组(P<0.05);RIFLE-F组存活者转化为RIFLE-L RIFLE-E的发生率明显高于其它两组(P<0.05)。结论当ARF发展到RIFLE-F阶段时开始CRRT,其预后和存活者肾脏功能的转归均比较差;早期积极CRRT可以改善ARF重症患者的预后及其存活者肾脏功能的转归。     

135例老年急性肾功能衰竭患者的前瞻性研究

目的 探讨住院患者中老年急性肾功能衰竭(ARF)患者的病因、预后及影响预后的因素.方法 前瞻性研究我院2003年12月至2006年12月老年ARF患者的临床资料,并与同期非老年患者进行比较.结果 观察期间老年ARF患者共135例,占总ARF例数(320例)的42.2%.老年组主要病因为感染、肾后梗阻性疾病.青年组死亡51例(29.7%),60～79岁组死亡31例(32.6%),≥80岁组死亡20例(50.0%).3组病死率比较差异有统计学意义(P<0.05).Logistic回归分析显示少尿、原有肾功能不全以及心力衰竭是与预后相关的危险因素.结论 住院患者中老年ARF的发生率及痛死率高,且随着年龄增长.病死率有升高趋势,及时透析可改善其预后.     

Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score

Objectives: To describe risk factors for the development of acute renal failure (ARF) in a population of intensive care unit (ICU) patients, and the association of ARF with multiple organ failure (MOF) and outcome using the sequential organ failure assessment (SOFA) score. Design: Prospective, multicenter, observational cohort analysis. Setting: Forty ICUs in 16 countries. Patients: All patients admitted to one of the participating ICUs in May 1995, except those who stayed in the ICU for less than 48 h after uncomplicated surgery, were included. After the exclusion of 38 patients with a history of chronic renal failure requiring renal replacement therapy, a total of 1411 patients were studied. Measurements and results: Of the patients, 348 (24.7 %) developed ARF, as diagnosed by a serum creatinine of 300 μmol/l (3.5 mg/dl) or more and/or a urine output of less than 500 ml/day. The most important risk factors for the development of ARF present on admission were acute circulatory or respiratory failure; age more than 65 years, presence of infection, past history of chronic heart failure (CHF), lymphoma or leukemia, or cirrhosis. ARF patients developed MOF earlier than non-ARF patients (median 24 vs 48 h after ICU admission, p < 0.05). ARF patients older than 65 years with a past history of CHF or with any organ failure on admission were most likely to develop MOF. ICU mortality was 3 times higher in ARF than in other patients (42.8 % vs 14.0 %, p < 0.01). Oliguric ARF was an independent risk factor for overall mortality as determined by a multivariate regression analysis (OR = 1.59 [CI 95 %: 1.23–2.06], p < 0.01). Infection increased the risk of death associated with all factors. Factors that increased the ICU mortality of ARF patients were a past history of hematologic malignancy, age more than 65 years, the number of failing organs on admission and the presence of acute cardiovascular failure. Conclusion: In ICU patients, the most important risk factors for ARF or mortality from ARF are often present on admission. During the ICU stay, other organ failures (especially cardiovascular) are important risk factors. Oliguric ARF was an independent risk factor for ICU mortality, and infection increased the contribution to mortality by other factors. The severity of circulatory shock was the most important factor influencing outcome in ARF patients. Received: 9 August 1999/Final revision received: 24 January 2000/Accepted: 6 April 2000     

40例多器官衰竭时急性肾功能衰竭的临床分析

目的：探讨多器官衰竭（ＭＯＦ）时急性肾功能衰竭（ＡＲＦ）的更为有效的防治手段，防止和阻断其进一步发展，改善ＭＯＦ的预后。方法：对４０例ＭＯＦ合并ＡＲＦ的病例资料进行临床分析。结果：ＭＯＦ的主要原发病因是感染（７０．０％），其次是创伤（２２．５％），其它占７．５％；本组患者的病死率６５．０％，且随衰竭器官的数目增多而病死率升高。ＡＲＦ表现为少尿型８７．５％，非少尿型１２．５％。采用血液透析（ＨＤ）治疗２２例中存活１２例，死亡１０例，病死率５４．５％；非ＨＤ治疗１８例中存活２例，死亡１６例，病死率８８．９％，比较此两种治疗方法的疗效ＨＤ组明显高于非ＨＤ组（Ｐ＜０．０１）。结论：对于ＭＯＦ时ＡＲＦ的治疗，首先应针对各器官衰竭的治疗；积极有效地控制感染是抢救成功的关键；早期充分的血液净化是治疗的重要环节；辅助支持疗法，提高免疫功能，改善组织缺氧，禁止应用对肾脏有损害的药物，对改善本病的预后具有重要意义。     

Acute renal failure following cardiopulmonary bypass: a changing picture

Objective: To assess the incidence of acute renal failure (ARF) developing perioperatively in adult patients requiring cardiopulmonary bypass surgery (CPB) and to make comparisons with data from the same institution published earlier. Design: Prospective, observational. Setting: Tertiary referral centre for cardiopulmonary medicine. Patients and participants: All patients admitted to the intensive care unit (ICU) who developed ARF perioperatively necessitating continuous veno-venous haemofiltration (CVVH) during the 24 months January 1997–December 1998. Interventions: None. Measurements and results: Of 2337 adult patients undergoing cardiac surgery, 47 (2.0 %) needed CVVH. Patients were excluded from analysis who underwent cardiac transplantation (n = 4), pericardial surgery (n = 3) or insertion of a left ventricular assist device (n = 1). Of the remaining 39, 21 patients died in ICU (53.8 % mortality). Relatively more non-survivors suffered from diabetes, hypertension and preoperative renal dysfunction. A previous report from our Unit revealed that, in 1989–90, 2.7 % of all patients undergoing CPB required CVVH with an in-hospital mortality of 83 %. The current study population were older (65.3 vs 56.0 years in 1990), and more severely ill as evidenced by a higher percentage of patients requiring redo (30 % vs 8.6 % in 1990) and emergency (50 % vs 25.7 % in 1990) surgery. Conclusions: The need for CVVH following CPB may be diminishing despite increased risk factors. ARF-associated mortality in these circumstances is falling. Received: 10 September 1999 Final revision received: 18 January 2000 Accepted: 15 February 2000     

连续性静脉-静脉血液滤过治疗心脏病术后急性肾功能衰竭的护理

目的:观察连续性静脉-静脉血液滤过(CVVH)治疗心脏病术后急性肾功能衰竭(ARF)的效果,减少护理并发症,提高治疗的安全性和有效性。方法:对53例心脏病术后并发重症ARF患者进行CVVH治疗,观察治疗前后患者MAP,CVP,BUN,Scr,K+等的变化,观察治疗过程中护理并发症发生情况。结果:53例患者经过CVVH治疗后32例存活,15例死亡,6例放弃治疗。存活患者经过CVVH治疗后CVP,Scr,BUN,K+,MAP升高。结论:连续性静脉-静脉血液滤过治疗ARF对于缓解患者临床症状和改善预后是一个有效的治疗手段,治疗过程中科学的护理计划,严密的护理监测和管理是使患者安全及治疗有效的保证。     

Continuous haemofiltration in acute renal failure with prostacyclin as the sole anti-haemostatic agent

OBJECTIVE: To investigate the safety and efficacy of a synthetic prostacyclin analogue (epoprostenol) for circuit maintenance during continuous veno-venous haemofiltration (CVVH) in patients with acute renal failure (ARF). DESIGN: Observational case study. SETTING: University-affiliated six-bed intermediate renal care unit in a nephrology and internal medicine department of a 1300-bed teaching hospital. PATIENTS: A consecutive series of critically ill ARF patients in whom prostacyclin was the sole anti-haemostatic agent used for CVVH. INTERVENTIONS: Bicarbonate-based CVVH in pre-dilution (1.5 l/h); blood flow rate at 200 ml/min; prostacyclin at 4 ng/kg per min infusion in the extracorporeal circuit before the haemofilter. MEASUREMENTS AND MAIN RESULTS: Fifty-one ARF patients (mean APACHE II 27.2, SD 7.8; acute tubular necrosis in 44/51, 83%; mechanical ventilation 14/51, 21%; in-hospital mortality 28/51, 54%) underwent CVVH for a total of 4040 h (230 circuits, median number 4 circuits per patient, range 1-13). Four patients out of 51 (7.8%) experienced major bleeding during CVVH (1.0 episode per 1000 patient-hours of treatment; 95%CI, 0.4-2.6); no death could be attributed to haemorrhage. Therapeutic intervention for hypotension (fluids and/or vasopressors) was required in 15.5% of the CVVH sessions monitored. The median duration of the circuit was 15.0 h (95% CI, 13.0-16.5). CONCLUSIONS: The use of prostacyclin as the sole anti-haemostatic agent for CVVH entails a low risk of haemorrhagic complications, while maintaining the patency of the circuit long enough to allow the delivery of an adequate dose of renal replacement therapy. Further studies are needed to compare this technique to other anti-haemostatic strategies for CVVH.