持续静脉-静脉血液滤过治疗12例婴幼儿先天性心脏病术后急性肾功能衰竭预后的回顾性分析

目的 探讨持续静脉-静脉血液滤过（CVVH）在救治婴幼儿先天性心脏病术后急性肾功能衰竭的疗效和预后。方法 回顾性分析2013年1月至2014年8月于重庆医科大学附属儿童医院经体外循环心脏直视术后发生急性肾功能衰竭进行CVVH治疗的12例婴幼儿临床资料，比较CVVH治疗前后尿量、BUN、SCr、PLT、平均动脉压和血管活性药物使用情况及患儿预后。结果 12例患儿年龄1～24月龄，平均（8.8±6.5）月龄；体重3.5～9.5 kg，平均（6.6±1.9）kg。11例先经腹膜透析治疗，后改为CVVH治疗；1例术后出现腹膜炎，直接行CVVH治疗。①12例行CVVH治疗血流量为15～35 mL·min-1，置换液流量为4～10 mL·min-1。12例均采用肝素抗凝。②经过CVVH治疗后7/12例肾功能和尿量均恢复正常，CVVH治疗前后平均BUN分别为（17.8±8.1）和（5.5±2.2）mmol·L-1（P=0.001），平均SCr分别为（169.6±38.2）和（81.4±25.1）μmol·L-1（P=0.000），正性肌力药物评分分别为（20.3±8.5）和（19.9±12.0）（P＝0.858），平均动脉压分别为（59.0±16.2）和（55.2±12.4）mmHg（P＝0.273）。PLT在CVVH治疗后［35.0(21.2~83.7)×109·L-1］较治疗前［147.8(100.2~214.2)×109·L-1］明显下降（P=0.001），3例在CVVH治疗后因PLT低，出现了消化道或呼吸道出血。③7/12例（58.3％）死亡。死亡患儿正性肌力药物评分明显高于存活患儿，平均动脉压明显低于存活患儿，差异均有统计学意义（P均<0.05）。结论 对于先天性心脏病术后发生急性肾功能衰竭的婴幼儿，可采用CVVH进行肾脏替代治疗以减轻液体过负荷、改善肾功能，CVVH治疗前正性肌力药物使用强度及平均动脉压可能是影响患儿预后的重要因素，CVVH治疗时需警惕PLT降低。

Continuous veno-venous hemofiltration for the treatment of acute renal failure in infants after congenital heart surgery

Objective The aim of this study was to investigate the use of continuous veno-venous hemodiafiltration (CVVH) in infants with acute renal failure after cardiac surgery.MethodsTwelve infants who received CVVH after cardiac surgery for congenital heart disease from Jan. 2013 to Aug. 2014 were retrospectively studied.Results All infants weighed less than 10 kg. Eleven infants were applied CVVH when peritoneal dialysis (PD) was ineffective and one infant had to rely on CVVH because of peritonitis. The mean age at receiving CVVH was 8.8±6.5 months (ranging from 1 month to 24 months) and the mean body weight was 6.6±1.9 kg (ranging from 3.5 to 9.5 kg). The median duration of renal replacement therapy was 25 hours. Serum and urine creatinine concentration were (17.8±8.1) mmol·L-1 and (169.64±38.24) μmol·L-1 before, and (5.5±2.2) mmol·L-1 and (81.4±25.1) μmol·L-1 after CVVH (Ps≤0.001), respectively. The concentration of platelet was decreased after CVVH (P=0.001). The mean artery pressure and vasoactive-inotropic score did not significantly varied before and after CVVH ［mean artery pressure: (59.0±16.2) mmHg vs. (55.2±12.4) mmHg, P=0.273; vasoactive-inotropic score: (20.3±8.5) vs. (19.9±12.0), P=0.878］. Seven infants died in the postoperative period, and the mortality rate was 58.3%. Five infants died from MODS caused by low cardiac output syndrome, one infant died from severe pulmonary infection, and one infant died from MODS caused by peritonitis. Compared with the survivors, vasoactive-inotropic score of non-survivors was significantly higher (median 27.5 vs. 15.0, P=0.017), while the mean arterial pressure was significantly lower ［(48.0±10.2) vs. (65.2±7.2), P=0.009］.Conclusion CVVH is an alternative method of renal support to improve renal function for critically ill infants after cardiac surgery. Vasoactive-inotropic score and mean arterial pressure before CVVH treatment may be the important factors influencing the prognosis of patients. CVVH treatment may lead to thrombocytopenia.