应用连续性肾脏替代治疗抢救重症急性肾衰竭14例的体会

1977年Krammer等首次将连续性动静脉血液滤过(CAVH)应用于临床 ,经过 2 0多年的临床实践 ,在此基础上发展起来的连续性肾脏替代治疗 (CRRT)技术已日趋成熟。CRRT在治疗重症急性肾衰竭 (ARF) ,特别是那些无法应用传统透析方法者 ,如ARF伴有心血管功能衰竭 (心衰、低血压 ) ,ARF伴有脑水肿 ,创伤后ARF ,ARF伴有高分解代谢需用静脉营养 ,更有其独特优点 ,非其他方法能比拟。我院 2 0 0 0年 1月引进德国FreseniusADM 0 8/ABM床边机开展连续性静脉静脉血液滤过 (CVVH)抢救重症ARF ,至目前已治疗患者 14例 ,取得较好临床疗效 ,现…     

无肝素连续性肾脏替代治疗抢救脑出血并发肾衰竭的护理

为了提高脑出血并发肾衰竭患者的抢救成功率，对８例患者进行无肝素连续肾脏替代治疗（ＣＲＲＴ），同时严密监测生命体征，保持血管通路畅通、出入量平衡，严格无菌操作，注意保暖等，结果２７例次ＣＲＲＴ中２４例次顺利完全治疗，３例次因血滤器凝血，中途更换后完成ＣＲＲＴ，未发生凝血、堵管、感染等并发症。５例治愈出院，２例自动出院，１例死亡，死亡原因为多脏器功能衰竭，提示ＣＲＲＴ及高质量护理能提高脑出血并发肾衰竭患者的抢救成功率。     

连续性肾脏替代治疗重症急性肾衰竭进展

连续性肾脏替代治疗（continuous renal replacement thera-py,CRRT）已广泛用于急性肾衰竭（ARF）,特别是重危患者的救治,提高了患者生存率及肾功能恢复率。但在治疗模式、时机及治疗剂量等方面还存在争议。本文主要是对连续性肾脏替代治疗重症ARF的进展进行综述。     

连续性肾脏替代治疗在脓毒症治疗中的作用

连续性肾脏替代治疗能够清除炎症介质、改善机体内环境,调节免疫功能。在脓毒症的治疗中发挥着重要的作用。对于治疗时机,治疗方式,剂量选择和终止时机,都需要结合临床情况仔细判断。     

连续性肾脏替代治疗在非肾脏疾病中应用

CRRT可应用于危重急性肾衰竭(ARF)患者,而在其他一些非肾脏疾病,如严重SIRS,MODS ,ARDS ,心肺旁路(CPB)中应用也逐渐增加,其可能机制是通过血液滤过清除炎性介质,改善血流动力学状态来改善预后。ARDS、顽固性充血性心力衰竭、脑水肿以及CPB后患者应用CRRT可连续而平稳地排除过多体液来改善脏器功能状态。持续清除毒素加上间歇性血液透析对于先天性代谢异常、严重酸中毒或肿瘤细胞溶解综合征、药物中毒、肝性脑病可能有益。     

连续性肾脏替代治疗在危重病中的应用

近年来，连续性肾脏替代治疗（CRRT）技术日趋成熟，在复杂性急性肾功能衰竭（ARF）中的应用已达成共识。而其临床应用范围已远远超过肾脏替代治疗领域，拓展至非肾脏病邻域已成为重症监护病房（ICU）各种危重病救治中多器官功能支持（MOST）的重要手段之一。     

连续性肾脏替代治疗在尿毒症患者中的临床应用

我院自2001年以来，将连续性肾脏替代治疗(CRRT)用于尿毒症患者，取得了较好的临床效果，报告如下。     

连续性肾脏替代治疗剂量对急性肾衰竭患者预后影响的荟萃分析

目的 通过荟萃分析评价连续性肾脏替代治疗（CRRT）剂量对急性肾衰竭（ARF）患者预后的影响。 方法 制定原始文献的纳入标准和检索策略,在Medline、EMBASE及Cochrane 图书馆内进行相关的检索。比较标准剂量和低剂量CRRT对ARF患者预后影响的随机对照试验（RCT）纳入分析。应用随机或固定效应模型处理预后指标的相对危险度（RR）。 结果 6项研究符合纳入标准。与低剂量比较,标准剂量CRRT未能降低病死率（RR 0.87,95%CI 0.70~1.07,P = 0.19）和联合终点事件（死亡和依赖透析）的发生率（RR 0.87,95%CI 0.69~1.09,P = 0.21）,但有增加依赖透析率的趋势（RR 1.43,95%CI 0.94~2.18,P = 0.09）。由于研究间存在异质性,亚组分析显示,实际治疗剂量达标（标准剂量>35 ml&#8226;kg-1&#8226;min-1）、治疗模式以连续性静脉-静脉血液滤过（CVVH）为主（置换液量大于透析液量）、非脓毒症为ARF主要原因（脓毒血症发病率<50%）的研究中,经标准剂量CRRT后病死率显著下降（P < 0.01）。 结论 尽管标准剂量CRRT未能降低ARF患者的病死率、依赖透析率和联合终点事件的发生率,但可改善实际治疗剂量达标、治疗模式以CVVH为主及非脓毒症ARF患者的存活率。     

连续性肾脏替代治疗临床应用的现状况

本文就目前对连续性肾脏替代治疗在重症急性肾衰及非肾脏疾病中的应用现状有关文献作一阐述。     

连续性肾脏替代治疗新理念

1997年Peter Kramer等提出边疆性动静肪血液滤过(CAVH)并应用于临闲,1982年美国FDA批准CAVH在重症监护病记(ICU)中应用.1998年Tetta等证明边疆性血浆滤过吸附(CPFA)可提高对细胞因子和炎症介质的清除率.     

A Simple and Early Prognostic Index for Acute Renal Failure Patients Requiring Renal Replacement Therapy

Recent advances in technology have not substantially changed the high mortality rate associated with acute renal failure (ARF). To obtain a simple, valid prognostic index, we retrospectively evaluated the relative importance of demographic data, causes (acute insults) of renal failure, and comorbid clinical conditions for the outcome in 102 ARF patients who received renal replacement therapy with an overall mortality rate of 65% (66 of 102). There were no significant differences between survivors and nonsurvivors in age and gender. Mortality according to acute insults was similar to that of the whole population studied. Of the 10 clinical conditions at the time of the first renal replacement therapy, mechanical ventilation (p = 0.0002), cardiac failure (p = 0.0006), hepatic failure (p = 0.003), central nervous system dysfunction (p = 0.005), and oliguria (p = 0.04) were found to be significantly related to mortality by univariate analysis. Furthermore, multivariate analysis demonstrated that only mechanical ventilation, cardiac failure, and hepatic failure were significant risk factors. Survival was directly related to the number of significant variables in univariate analysis: zero, 89% (8 of 9); one, 62% (21 of 34); two, 19% (5 of 27); three, 10% (2 of 20); four, 0% (0 of 8); five, 0% (0 of 4). This simple and early prognostic index, derived from the assessment of clinical conditions which were easily de-termined at the patient's bedside, could be useful for outcome prediction in ARF patients requiring renal replacement therapy.     

急性肾衰竭三种治疗方法的疗效对比观察

目的 :回顾性探讨治疗急性肾衰竭较理想的透析方法。方法 :对 2 3例HD患者和 2 0例PD患者及 17例CRRT患者进行比较 ,观察其治愈率、死亡率及透析后的主要并发症。结果 :HD组、PD组、CRRT组的治愈率分别为 82 .6 %、85 %、76 .5 % ;死亡率分别为 8.7%、0、17.6 %。腹膜透析并发症少。结论 :急性肾衰竭在缺少CRRT条件 ,病情允许情况下可首选腹膜透析治疗 ,严重病例、多器官衰竭还是选择CRRT为宜     

持续性肾脏替代治疗难治性心衰疗效的影响因素分析

目的：探讨持续性肾脏替代（CRRT）治疗难治性心衰疗效的影响因素。方法：回顾性分析住院诊断为难治性心力衰竭、接受CRRT治疗的患者45例。按治疗效果分为治疗有效组25例,无效组20例,比较两组患者间疾病构成比例、血压、心脏射血分数以及电解质、肾肝功能。结果：（1）本组资料中CRRT治疗难治性心衰的有效率为55．6％;（2）扩张型心肌病和缺血性心肌病总比例,无效组明显高于治疗有效组（80％vs32％,P〈0．01）;（3）与治疗有效组比较,无效组患者的收缩压、舒张压和心脏射血分数明显低下[（145．5±30．5VS126．5±23．5）mmHg,（85．4±23．6VS68．5±20．6）mmHg,（33．0±5．33）％VS（29．6±4．26）％];各项指标比较均P〈0．05。结论：CRRT可用于治疗难治性心力衰竭,但对于扩张型心肌病和缺血性心肌病引起的心肌收缩力下降导致血压偏低、心脏射血分数明显低下者,疗效不佳。     

急性肾损伤患者行连续性床旁血液净化治疗时机的临床研究

目的：探讨连续性床旁血液净化（continuous renal replacement therapy,CRRT）治疗时机对急性肾损伤（acute kidney injury, AKI）患者临床预后的影响.方法：选取符合AKI诊断标准并行CRRT治疗的患者83例,以BUN 22 mmol/L为界值,分为早期透析组50例,晚期透析组33例.记录一般临床资料,观察透析开始后28 d、90 d死亡率、肾功能恢复率.结果：（1）早期透析组、晚期透析组28 d、90 d死亡率分别为50.0% vs 72.7%、56.0% vs 78.8%,P＜0.05.Kaplan-Meier生存曲线提示早期透析组生存时间显著高于晚期透析组（P＜0.05）.晚期透析患者28 d、90 d死亡危险分别是早期透析患者的2.667倍、2.918倍（P＜0.05）.（2）早期透析组、晚期透析组28 d、90 d肾功能恢复率分别为44% vs 15.2%、46% vs 15.2%,P＜0.01.晚期透析患者28 d、90 d不能脱离透析的危险性是早期透析患者的4.563倍、4.954倍（P＜0.01）.结论：早期CRRT治疗可改善AKI患者的肾功能,降低死亡风险.     

Acute Renal Failure in Patients with Kidney Transplant: Continuous Versus Intermittent Renal Replacement Therapy

Mortality from acute renal failure in critically ill patients remains in excess of 50% despite decades of improvement in supportive care. It is not known whether replacement of other failing organs by non-renal organ transplantation affects mortality in acute renal failure. We retrospectively reviewed the course of 169 patients with acute renal failure managed at a single university medical center over a 1-year period. Measures of disease severity (need for renal replacement therapy, mechanical ventilation or parenteral nutrition, presence of oliguria and APACHE II scores) and final outcome were compared in 97 patients with acute renal failure who did not receive transplants and 72 patients with acute renal failure who underwent non-renal solid organ transplants. Overall mortality was 50.3% and directly correlated with APACHE II score. Compared to nontransplant patients, transplant recipients were younger, more frequently male, and less often oliguric; but the groups were similar in mean APACHE II scores and need for renal replacement therapy, prolonged mechanical ventilation, and parenteral nutrition. Overall, mortality was significantly lower for transplant patients compared to nontransplant patients (34.7% vs. 61.9%, p < 0.05). In nonoliguric acute renal failure and renal failure not requiring renal replacement therapy, mortality was low and similar in both transplant and nontransplant patients. Compared to nontransplant patients with similar risk factors and similar APACHE II scores, mortality was significantly lower for transplant patients who were oliguric, or who required renal replacement therapy, mechanical ventilation, or parenteral nutrition. Organ transplantation is associated with a survival advantage in acute renal failure when compared to the outcome of critically ill nontransplant patients. The relation between APACHE II scores and survival is altered by transplantation.     

连续性静脉-静脉血液滤过对尿毒症脑病的疗效观察

目的:探讨连续性静脉-静脉血液滤过(CVVH)对慢性肾衰竭(CRF)合并尿毒症脑病(UE)患者的血液动力学、电解质、溶质清除方面的影响,并评价其治疗效果。方法:30例次CRF并发UE的患者,接受CVVH治疗。观察治疗前和治疗中、治疗后患者的心率、平均动脉压(MAP)以及意识情况和患者的APACHEⅡ评分、Glasgow评分;测定治疗前、后的肾功能、电解质及血浆渗透压。结果:(1)CVVH治疗前后MAP、心率及渗透压变化无统计学差异(P>0.05);(2)CVVH治疗后意识明显改善,尿毒症症状明显缓解;(3)CVVH治疗后患者APACHEⅡ评分较治疗前有明显降低的趋势,Glasgow评分明显好转(P<0.05);(4)CVVH治疗后BUN、Scr清除好,电解质、酸碱紊乱得以纠正(P<0.05)。结论:CVVH具有稳定的血流动力学,缓慢、持续、稳定清除尿毒症毒素和纠正电解质和酸碱失衡,对心血管系统和血脑屏障的干扰小,病人的耐受性好,有助于尿毒症脑病的治疗。     

Palliative Medicine Referral in Patients Undergoing Continuous Renal Replacement Therapy for Acute Kidney Injury

Abstract

Background: Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied. Methods: We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury. Results: Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15–25) days compared with 12.5 days (95% CI = 9–17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9–15) days vs. 7.0 (95% CI = 6–9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4–8) vs. 3.0 (95% CI = 3–4) days; p < 0.01]. Conclusions: PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, “triggered” referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.