腹膜透析在小儿心脏手术后急性肾功能不全中的应用

目的评价腹膜透析（PD）对小儿心脏术后急性肾功能不全（ARF）的疗效。方法1999年10月至2005年10月行先天性心脏病术后符合ARF诊断的病儿63例，男49例，女14例。年龄0．12—14岁；体重3．5．35．0妇。体外循环下行根治手术52例，姑息手术11例。对术后持续少尿（每小时尿量〈1ml/kg，持续4h以上），经液量限制、利尿剂及正性肌力药物联合治疗无效；或血清肌酐浓度（Or）增高并出现持续代谢性酸中毒，高钾血症（〉5．5mmol／L），容量超负荷，低心排出量综合征（低心排）等任一种情况者予以腹膜透析。记录PD开始时间、持续日程以及尿量恢复时间。动态测定血清肌酐。结果术后均合并多器官功能障碍，共施行腹膜透析58例（92．1％），PD病儿主动脉阻断时间显著延长（P〈0．01）；手术难度分级明显增高（P〈0．05）；血清肌酐下降、恢复时间以及尿量恢复时间明显延后（P〈0．05）。PD〉6d者较PD≤6d者手术复杂程度明显增高，血清肌酐出现峰值、下降、恢复的时间较晚（P〈0．05），尿量恢复时间明显延后（P〈0．05）；低心排持续时间和多器官功能障碍累及的器官数量分别为PD≤6者的1．74倍和1．26倍，插管以及监护室时间显著延长（P〈0．05）。PD后生存者肾功能恢复率100％，恢复值与基础值相比差异无统计学意义（P〉0．05）。死亡原因包括：严重低心排15例（71．4％），多器官功能障碍2例（9．5％），败血症2例（9．5％），呼吸衰竭1例（4．8％），脑损害1例（4．8％）。结论PD治疗小儿心脏术后ARF效果良好，并发症少。PD时间延长与复杂先心病手术，术后较高的血清肌酐浓度及其到达峰值、下降、恢复时间的延后，尿量恢复晚，低心排持续时间长，功能障碍的累及器官多，以及插管、监护时间延长等围术期因素密切相关。     

腹膜透析治疗小儿心脏手术后并发急性肾功能衰竭

目的总结腹膜透析（PD）治疗小儿心脏手术后并发急性肾功能衰竭（ARF）的临床经验。方法27例ARF患者，年龄3个月～12岁（4．20±3．58岁）；体重4．2～30．0kg（12．35±7．65kg）。因心脏手术后发生ARF进行PD。动态监测血气分析、电解质、血清肌酐（Cr）、尿素氮（BUN）、平均动脉压（MAP）和中心静脉压（CVP）的变化。结果PD后5d Cr、BUN与PD前比较明显下降（P〈0．01），血钾、血钠、碳酸氢根（HCO3^-）恢复正常。术后死亡8例（29．6％），死于低心排血量3例，感染并发多器官功能衰竭3例，恶性心律失常1例，肺动脉高压危象1例。发生并发症9例（33．3％），其中管周漏液3例，腹膜炎3例，透析管堵塞3例（其中感染堵塞1例、大网膜堵塞2例）。结论小儿心脏手术后ARF早期行PD疗效肯定、安全，操作方便，可降低死亡率。     

复方大承气汤联合针刺治疗术后早期炎性肠梗阻30例

目的：观察复方大承气汤联合针刺对术后早期炎性肠梗阻疗效的影响。方法：将56例术后早期炎性肠梗阻患者分为西医治疗组26例和中西医结合治疗组30例（西医治疗基础上加用复方大承气及针灸）,观察两组患者疗效。结果：西医治疗组治愈18例,占69.23%,中西医结合治疗组治愈28例,占93.33%。两组比较,统计学有显著性差异（P〈0.05）。结论：复方大承气汤联合针刺治疗术后早期炎性肠梗阻,疗效确切。     

恶性梗阻性黄疸与肾脏损害(附83例临床分析)

1976～1990年间,手术治疗恶性梗阻性黄疸533例,术前检查发现19例(3.6%)有高尿素氮血症表现,19例中术后死亡5例,其中2例直接死亡原因为急性肾功衰竭(ARF)。术后又有68例(12.8%)有高尿素氮血症表现,其中22例(4.1%)直接死亡原因为ARF,术后ARF死亡占全部肾功改变病例总手术病死率的26.5%(22/83)。术前黄疸持续时间在30天以内组中,术后2.2%(4/183)发生ARF而死亡,在黄疸持续时间超过31天组中,术后5.1%(18/350)发生ARF而死亡。术前血胆红素在171μmol/L以内组中,术后1.5%(4/271)发生ARF死亡,而在172μmol/L以上组中,术后6.9%(18/262)发生ARF死亡。上述结果说明肾脏损害与肾功保护是恶性梗阻性黄疸围手术期处理的重要内容。     

腹透患者营养不良-微炎症状态对腹膜炎及死亡风险的影响

目的：探讨腹膜透析（peritoneal dialysis,PD）患者营养不良-炎症复合体综合征（malnutrition inflammation complex syndrome,MICS）对腹膜炎发生率、住院频率及死亡风险的影响。方法：对符合纳入标准的98例PD患者,采用营养不良-炎症评分（malnutrition inflammation score,MIS）评估MICS,按MIS分值分为轻度（1~8分）、中度（9~18）、重度（〉18）;观察患者人体测量学指标、尿素清除率（KT/V）和标化蛋白分解代谢率（nPCR）,检测生化指标、微炎症指标[超敏C反应蛋白（hs-CRP）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）]、24h腹透液中丢失的蛋白量;随访6个月内患者腹膜炎发生率、住院频率及死亡率,运用多元Logistic回归分析、COX比例风险分析MIS对腹膜炎发生率、住院及死亡风险等预后的影响。结果：所纳入的98例PD患者中,MICS患者56例,占57%,其中MIS轻、中、重度平均分值分别为5、12、19.5（各占53.06%、39.80%、7.14%）;MIS分值越高,患者年龄越大,人体测量学指标包括BMI、MAC和TSF下降,与营养相关的生化指标包括Alb、BUN和Scr水平明显降低（P〈0.05）;炎症因子hs-CRP和IL-6水平明显升高（P〈0.05）,但TNF-α水平在各组间差异无统计学意义。各组KT/V、nPCR和24h腹透液蛋白丢失量差异无统计学意义。MIS与腹膜炎发病频次、住院频次、住院总天数显著正相关（P〈0.01）,MIS每增加1分则患腹膜炎的相对风险为1.185（1.036~1.355P〈0.05）,死亡风险为1.242（1.102~1.401,P〈0.01）。结论：57%的维持性腹膜透析患者可并发MICS;MICS患者具有高龄的特点;MICS可增加PD患者患腹膜炎、住院频次以及死亡风险;MIS可预测患者腹膜炎和死亡风险。     

先天性心脏病患儿术后多脏器功能障碍的预后分析

目的 探讨小儿先天性心脏病（先心病）术后多脏器功能障碍（MODS）预后情况及其影响因素，为对此类患儿进行针时性护理提供依据。方法 收集先心病术后并发MODS 77例患儿的临床资料。结果 11例放弃治疗出院，66例中44例救治存活，22例死亡。出现时间最早、累及最多的脏器为心脏；病死率最高的为累及中枢神经系统的患儿（57．69％），其次是累及血液系统的患儿（55．56％）；患儿的病死率与累及脏器的数量呈显著正相关（P〈0.01）。死亡患儿手术体外循环时间和主动脉阻断时间显著长于存活患儿（均P〈0．05），术中意外及术后心肺复苏发生率显著高于存活患儿（均P〈0．05）。结论 心病术后患儿应加强心功能监护，特别是体外循环时间〉120min，主动脉阻断时间〉60min及术中发生过意外情况、术后采取过心肺复苏术的患儿；尽早采取有利措施避免其他脏器功能受损是提高患儿存活率的关键。     

568例基层医院急性肾衰竭患者病因及其危险因素分析

目的：分析基层医院急性肾衰竭（ARF）的病因,寻找影响其预后的危险因素,为降低ARF发病率,提高临床疗效,判断预后提供参考。方法：以2007年6月～2009年6月就诊于温岭市第一人民医院等4个基层医院的ARF患者为研究对象,归纳引起ARF的病因;将其分为治愈组、好转组、无效组和死亡组,首先采用单因素分析方法初步筛查出危险因素,然后将初筛的危险因素进一步使用二分类Logistic回归法做多因素分析,判别各因素对死亡危险度的影响。结果：（1）301224例住院患者中,ARF患者568例（占0.19%）;其中男366例（占64.45%）,女202例（占35.56%）,男女之比1.8∶1。（2）568例ARF患者中,按照肾性、肾前性和肾后性分类方法,以肾性ARF最常见,共282例（占49.65%）,肾前性ARF140例（占24.65%）,肾后性ARF146例（占25.70%）。按照引起ARF的原因分类,肾实质损害和梗阻所占比例最大,分别为22.89%和21.65%,其次是感染和药物因素,分别占11.97%和9.15%。（3）多脏器功能衰竭（MODS）、高血钾及贫血是导致ARF预后差的危险因素。结论：ARF发病率为0.19%,男性多于女性,除肾原性原因外,肾后梗阻、感染和药物性肾损害是最常见原因。MODS、贫血、高血钾是影响预后的危险因素。     

血液透析滤过对急性肾衰竭患者超敏C反应蛋白水平的影响

目的探讨急性肾衰竭（acute rena lfailure,ARF）超敏C反应蛋白（high sensitivity C reactive protein,hs-CRP）水平变化及其与预后的关系。方法回顾性分析97例临床符合ARF诊断标准的患者,收集其病史、治疗经过及治疗过程中所检测的hs-CRP数值;同时取健康的52例患者,检测其hs-CRP数值作为对照。所有入组患者均给予常规血液透析滤过（hemodiafihration,HDF）治疗。结果①老年组治愈3例,好转6例,未愈17例,死亡25例。非老年组治愈8例,好转11例,未愈21例,死亡6例,2组比较差异有统计学意义（P〈0．05）;②Hs-CRP检测值比较,正常健康人群组hs-CRP平均值为（5．1±2．76）mg／L,治疗前老年组、非老年组与正常健康人群组比较,差异有统计学意义（P〈0．05）。老年组与非老年组治疗前、后比较,差异有统计学意义（P〈0．05）;③多因素Lo-gistic回归分析,性别（男）、年龄（老年）、高水平hs-CRP是预后不良的危险因素,一周内HDF为保护性因素。结论高水平hs-CRP检测值为影响ARF患者预后的因素之一。有效降低hs-CRP检测值,减轻机体的炎症反应能增加ARF患者治愈率。     

术前血浆β2-微球蛋白增高与肝移植术后发生急性肾衰竭的关系

目的探讨β2-微球蛋白（β2-microglobulin,β2-MG）水平与肝移植术后急性肾衰竭（acute renal failure,ARF）发生率的关系。方法研究对象为2004年3月至2006年11月在中山大学附属第三医院由同一手术小组进行下腔静脉全阻断改良背驮式肝移植的80例终末期肝病患者,术前血清肌酐（Scr）、血尿素氮（BUN）检测均在正常范围,术中未采用体外静脉-静脉转流术。术前采用散射比浊法测定两组患者桡动脉血β2-MG值。根据术前血β2-MG值正常与否将患者分为两组：术前血β2-MG值异常组（I组）,术前血β2-MG值正常组（Ⅱ组）。术后按有否发生重度ARF分为重度ARF组和非重度ARF组。全部患者术后进行至少随访3年,以随访结束日或死亡为研究终点。记录并比较Ⅰ组与Ⅱ组患者术后ARF的发生率及术后30d、术后1年、2年及3年的生存率;记录并比较重度ARF组和非重度ARF组术后30d、术后1年、2年及3年的生存率。结果根据术前血β2-MG值分组,Ⅰ组32例,Ⅱ组48例,术前血β2-MG值增高异常率为40％。Ⅰ组32例患者中11例（34％）发生轻度ARF,6例（19％）发生重度ARF;Ⅱ组48例患者中12例（25％）发生轻度ARF,1例（2％）重度ARF。两组的轻度和重度ARF发生率比较差异有统计学意义（均为P〈0．05）。Ⅰ组与Ⅱ组相比较,术后30d及术后1年生存率差异无统计学意义（均为P〉0．05）;术后2年及3年生存率比较差异有统计学意义（均为P〈0．05）。重度ARF组的术后30d、术后1年、2年、3年生存率远低于非重度ARF组患者（均为P〈0．01）。结论肝移植患者术前肾功能异常与术后ARF发生率有关,与Scr比较,血浆β2-MG是反映早期肾损害更灵敏的指标,并且具有预测术后ARF的能力。     

介入封堵与外科手术治疗瓣膜置换术后瓣周漏的疗效评价CSCD

目的 对比研究介入封堵与外科手术治疗瓣膜置换术后瓣周漏的临床疗效.方法 自2010年5月至2014年5月采用介入封堵术治疗瓣膜置换术后瓣周漏17例,同期采用外科手术治疗瓣膜置换术后瓣周漏11例.比较两种方法围手术期死亡比例、并发症以及术后残余分流等指标,术后随访1~36个月.结果 介入封堵组全组技术成功比例100%,外科手术组院内死亡2例（18%）.介入封堵组较外科手术组,手术时间较短[（84 ±36）min对（358 ±88）min]（P〈0.01）;住院时间较短[（11.9 ± 12.1）天对（38.1 ±42.2）天]（P〈0.05）;输血量较少[（1029 ±455）ml对（1438 ±908）ml]（P〈0.05）.介入封堵组全组无气管插管呼吸机辅助呼吸,术后无 ICU 停留.介入封堵术后,残余瓣周漏8例（47%）,但残余分流量均减少至小量以内（1.6 ±1.7）ml,较术前明显减少（P〈0.05）,术后心功能明显改善;外科手术组术后残余瓣周漏1例（9%）.随访中两组患者均无死亡,心功能均有不同程度改善.结论 对瓣膜置换术后瓣周漏的治疗,介入封堵术较传统外科手术治疗,具有操作简便安全,创伤小、住院时间短、术后恢复快,治疗费用低等优点.通过改进手术技巧、个性化选择封堵器、早期治疗溶血并发症等方法能够提高介入治疗成功比例及长期效果.     

Peritoneal dialysis after infant open heart surgery: observations in 27 patients.

BACKGROUND: The role of peritoneal dialysis (PD) in the management of infants after heart operation is under discussion. The aim of this study was to investigate the effect of PD on fluid balance and outcome. METHODS: Twenty-seven (33%) of 81 consecutive infants who underwent heart operation required PD. In 22 patients (81%), PD was started prophylactically at the end of the operation. We recorded hemodynamic data and fluid balance. Patients experiencing acute renal failure (ARF) were compared with the remaining infants. RESULTS: Eleven of 81 patients (14%) experienced ARF; 3 of them died (4% of all patients undergoing operation, 27% of those with ARF). Complications of PD, present in 33%, were transitory and of minor significance. Patients with ARF had decreased cardiac function compared with those without ARF but similar fluid balance. CONCLUSIONS: Peritoneal dialysis is an effective and safe method for the treatment of ARF in infants after open heart operation. As PD is helpful in modulating postoperative fluid balance, prophylactic use of PD can be recommended for selected patients who are at risk for low cardiac output syndrome.     

心脏术后低排综合征致急性肾功能衰竭的腹膜透析治疗

目的　探讨腹膜透析对心脏术后低排综合征 (LOS)致急性肾功能衰竭 (ARF)的疗效。方法　 2 4例心脏术后引起LOS合并多脏器功能衰竭 (MSOF)致ARF者 ,因不适合血液透析 (HD) ,于确诊后 2 4小时内进行腹膜透析 (PD)治疗。结果　 12例患者多脏器严重衰竭死亡 ,9例患者PD 3～30天内肾功能恢复 ,3例治疗后病情好转 ,自动出院。结论　心脏术后LOS致MOSF合并有ARF者 ,PD具有较好的治疗效果。     

腹膜透析治疗急性肾衰竭289例临床报道

目的回顾性分析腹膜透析治疗急性肾衰竭的疗效,为探讨腹膜透析治疗急性肾衰竭（ARF）的疗效。方法回顾性分析每例患者的临床资料,并随访3个月～1年。结果289例患者中治愈198例（68．51％）、改血液透析6例（2．1％）、继续腹膜透析8例（2．8％）、自动出院14例（4．8％）、肾移植2例（0．7％）、死亡61例（21％）。结论腹膜透析是治疗ARF的有效方法之一。     

原发性肾病综合征并发急性肾衰竭56例报告

目的分析56例原发性肾病综合征（PNS）并发急性肾衰竭（ARF）患者临床特点、病理改变及疗效。方法回顾性分析56例PNS并发ARF患者临床和病理改变。结果PNS并发ARF发生率约2．9％左右，肾脏病理改变肾小球多以微小病变为主，肾小管上皮细胞浊肿、空泡变性及蛋白管型常见，但肾间质水肿改变并不明显。经及时有效治疗，91．1％患者肾功能可完全恢复正常，其中抗凝治疗和合适透析方式选择起到较为重要的作用。结论PNS并发ARF多发生于肾脏病变轻微患者，其发病机制有待进一步探讨，经及时有效的综合治疗，患者多预后良好。     

Preoperative intravenous hydration confers renoprotection in patients with chronic kidney disease undergoing cardiac surgery

Patients with chronic kidney disease (CKD) are at risk to develop acute renal failure (ARF) after open heart surgery. This complication is associated with high morbidity, mortality, and cost. Because the ability to concentrate urine is lost early in the progression of CKD, renal patients kept on fluid restriction prior to surgery may develop severe dehydration, a situation consistently found to be one of the most critical risk factors for postoperative ARF. Our goal was to investigate whether intravenous hydration for 12 h prior to cardiac surgery could prevent acute renal injury in patients with CKD. This is a prospective study in a tertiary cardiac surgery center. Forty-five patients admitted for elective open heart surgery with moderate-to-severe CKD, as evidenced by a quantified glomerular filtration rate less than 45 mL/min, were assigned using a 2/1 randomization process, to either receive an intravenous infusion of half-isotonic saline (1 mL/kg/h) for 12 h before the operation (hydration group, n = 30, 29 men, 64 + 1.7 years old), or to be simply kept on fluid restriction (control group, n = 15, 14 men, 64.2 + 2.8 years old). Groups were not different in clinical and intraoperative variables associated with postoperative renal injury. ARF developed in 8 of 15 (53%) patients in the control group, but in only 9 of the 30 (30%) patients in the hydration group. Four patients in the control group (27%), but no one in the hydration group, required dialysis after the operation (P < 0.01). Peak creatinine and blood urea nitrogen values were two to three times higher in the control group than in the hydration group. Preoperative intravenous hydration may ameliorate renal damage in patients with moderate-to-severe renal insufficiency undergoing cardiac surgery.     

Peritoneal dialysis in infants and children

Pediatric renal failure patients can be restored to health with peritoneal dialysis more easily, more comfortably, and more safely than with hemodialysis. During the past 3.5 years, we have treated 22 children with either acute (less than 30 days) or chronic (greater than 30 days) peritoneal dialysis (PD) at Henrietta Egleston Hospital for Children. They ranged in age from 2 weeks to 15 1/6 years, mean 5.2 years. The indications for acute dialysis were renal failure following cardiac surgery (4); hemolytic-uremic syndrome (4); and renal failure associated with bromide intoxication (1), congenital urethral stricture (1), or bronchopulmonary dysplasia (1). Chronic dialysis was utilized for end-stage renal disease caused by glomerulonephritis (5), chronic infection (2), hemolytic-uremic syndrome (1), cystinosis (1), congenital renal artery stenosis (1), and unknown etiology (1). Thirty-four adult or pediatric Tenckhoff catheters were utilized to deliver PD for from 6 to 551 days (18 months). Pediatric Tenckhoff catheters must be pre-measured in order to have the Dacron cuffs glued to the appropriate position on the catheter (7-12 cm from the end) to fit the child. There were seven catheter-related infections in four patients; three required catheter revision and four were treated medically. There were eight catheter-related mechanical problems, all of which required re-operation. All of those on chronic PD and seven of those on acute PD survived for an overall survival of 82 per cent. All surviving patients have been restored to health either by recovery of renal function (6 patients), renal transplantation (8 patients), or maintenance of chronic ambulatory peritoneal dialysis (4 patients).     

Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease

The present single-center cohort study was based on a clinical intensive care unit database containing data on 1128 consecutive children undergoing their first operation for congenital heart disease between 1993 and 2002 at Aarhus University Hospital, Skejby, Denmark. A total of 130 (11.5%) children developed postoperative acute renal failure (ARF) managed with peritoneal dialysis (PD). Logistic regression analysis was used to examine risk factors for complications related to PD and to compare mortality between ARF and non-ARF patients controlling for potential confounding factors. A total of 43 complications related to PD were registered in 27 (20.8%) patients. Major complications were seen in eight (6.2%) patients, and only two (1.5%) patients were switched to hemodialysis after peritonitis and hemicolectomy due to bowel perforation. The main risk factors for complications to PD were duration of PD, high RACHS-1 score (Risk Adjusted Classification for Congenital Heart Surgery), and hyperkalemia at initiation of PD. Overall, in-hospital mortality was 6.8% (76/1128). Mortality of ARF patients was 20.0% compared to 5.0% among non-ARF patients (adjusted odds ratio=1.91, 95% confidence interval=1.10-3.36). After stratification, ARF was strongly associated with increased mortality in the subgroups of patients with the lowest overall risk of dying (age> or =1 year, body weight> or =5 kg, RACHS-1 score <3, and no preoperative cyanosis). For patients at high risk of dying (age <1 year, body weight <5 kg, RACHS-1 score> or =3, cardiopulmonary bypass time> or =60 min, and preoperative cyanosis), the association between ARF and mortality was substantially weaker. In conclusion, postoperative ARF was associated with increased mortality in children operated for congenital heart disease. Major complications to PD were few, and our data strongly support that PD is a simple, safe, feasible, and robust dialysis modality for the management of ARF in children.     

Acute renal failure in the pediatric age group - single center prospective study of 180 cases

Acute renal failure (ARF) is one of the common emergencies in pediatric practice. In the Indian subcontinent, its etiology, clinical features and outcome vary from other parts of the world. We decided to perform a prospective study of ARF in 180 pediatric patients admitted to our institute between August 2006 and March 2008. Our study included children, neonates 7.8%, <1 year 16.7%, 1-5 years 30.5% and >5 years comprised 52.8%. The male:female ratio was 2.3:1. Acute tubular necrosis remains the major cause of ARF; other intrinsic renal disease accounted for almost 30% of the patients. In all patients of ARF who required dialysis, peritoneal dialysis was offered as the first-line management. Six patients were offered hemodialysis. Mortality below one year age was higher compared with those who were more than one year of age (40% vs 11.3%). The overall mortality in the present study was 17.7%. ARF in pediatric nephrology is not uncommon. In our setup, peritoneal dialysis (PD) is an effective and safe modality of renal replacement therapy in most of the cases. Delayed referral, malnutrition, infections, age less than one year and multiorgan involvement were bad prognostic features.     

体外膜式氧合支持治疗失败原因的初步分析

目的总结体外膜式氧合（ECMO）支持治疗成人心脏病患者的临床经验,对辅助未成功患者的失败原因进行分析。方法2005年2月至2008年10月,应用ECMO救治58例成人心脏病患者,其中男42例,女16例;年龄44．8±17．6岁。ECMO辅助时间131．9±104．7h。冠心病24例（41．4％）,心肌病11例（19．0％）,心瓣膜病10例（17．20）,先天性心脏病9例（15．5％）。结果院内死亡22例,11例（50％）死于多器官功能衰竭,5例（22．7％）因心功能损害严重,使用ECMO亦无法维持有效循环死亡,其余患者因出血、严重肺动脉高压缺乏后续有效治疗手段等而死亡。ECMO辅助治疗前有心脏停搏和ECMO辅助期间仍出现肾功能不全需同期使用持续肾脏替代治疗（CRRT）,在死亡患者中的比率明显大于生存患者（45．5％vs．19．4％,40．9％vs．5．6％;P=0．043,0．001）。生存患者平均随访15．6个月。随访期间3例因再发心力衰竭而死亡,1例出院后死于神经系统并发症,其余32例心功能分级（NYHA）Ⅰ～Ⅱ级。结论ECMO是救治急重症成人心肺功能衰竭的有效手段。在重要器官出现不可逆损害前及时建立ECMO辅助和积极有效地预防并发症发生,是进一步提高救治成功率的关键。ECMO辅助时仍出现肾功能不全需同期使用CRRT治疗以及在ECMO开始前经历过心脏停搏是提示预后不良的危险因素。