连续性肾脏替代疗法治疗心肾综合征临床研究

目的：研究连续性肾脏替代疗法（CRRT）治疗心肾综合征（CRS）的临床疗效。方法：选取CRS患者72例,将患者按随机数字表法分至观察组和对照组,各36例,对照组予以常规抗心衰治疗,观察组在对照组患者治疗基础上加用CRRT,治疗1个月后比较两组患者的临床治疗总有效率、左室内径（LVD）、射血分数（LVEF）、心胸比率、CRP及肾功能。结果：观察组治疗总有效率为83.33%,远高于对照组的61.11%,组间差异存在统计学意义（P〈0.05）。观察组患者LED、心胸比率、BNP、CRP水平明显低于对照组,LVEF明显高于对照组,两组间以上各项指标均差异存在统计学意义（P〈0.05）。观察组肌酐、尿素氮、尿酸分别为（112.48±25.64）μmol/L、（0.94±0.33）mmol/L、（373.58±156.45）μmol/L,对照组为（140.54±136.46）μmol/L、（1.00±0.21）mmol/L、（419.54±170.65）μmol/L。观察组肌酐、尿素氮及尿酸水平均明显低于对照组,组间差异存在统计学意义（P〈0.05）。结论：CRRT可提高CRS患者治疗的临床疗效,明显改善心肾功能,有利于疾病的治疗。     

连续性肾脏替代疗法在治疗多器官功能障碍综合征中的应用

病史摘要 患者,男性,４１岁,因腹部外伤ｌｈ后入院。查体：体温３６．２℃,脉搏１２８次／ｍｉｎ,呼吸２０次／ｍｉｎ,ＢＰ ８０／６０ｍｍＨｇ。胸廓无畸形及压痛,两肺呼吸音清。心率１２８次／ｍｉｎ,律齐,无杂音。腹稍饱满,剑突下、左上腹明显压痛,伴肌紧张;肝区无叩痛,肝肋下未及;脾肋下未及,左季肋部无压痛,但有叩痛。肛指检查阴性。辅助检查：血常规：Ｈｂ ８０ｇ／Ｌ,ＷＢＣ １０．４ × １０~９／Ｌ,Ｎ ０．７６,Ｌ ０．２４;Ｐｌｔ１０~３ × １０~９／Ｌ。肝功能：正常。肾功能：ＢＵＮ１４．２ ｍｍｏｌ／Ｌ…     

早期应用连续性血液净化治疗危重型肾病综合征出血热的临床分析

目的探讨连续性血液净化（continuous blood purification,CBP）在危重型肾病综合征出血热（hemorrhagic fever with renal syndrome,HFRS）的临床治疗效果。方法回顾分析解放军第三医院肾脏内科近2年收治的24例危重型HFRS患者在治疗原发病的基础上,均给予CBP治疗,采用连续性静脉一静脉血液滤过（continuous veno-venous hemofiltration,CVVH）或连续性静脉一静脉血液透析滤过（continuous veno-venous hemodiafiltration,CVVHDF）,持续治疗时间不少于24h。比较患者治疗前后血白细胞（WBC）、血小板（PLT）,动脉血气分析、二氧化碳结合力（C02CP）,C反应蛋白（CRP）,血尿素氮（BUN）、血肌酐（SCr）、血清丙氨酸氨基转氨酶（ALT）、天冬氨酸氨基转氨酶（AST）、部分活化凝血活酶时间（APTT）的变化。结果24例危重型HFRS患者经CBP治疗后12～48h的PLT、动脉血气pH值、C02CP显著提高（P〈0．05）,WBC、CRP、BUN、SCr、ALT、AST、部分活化凝血活酶时间降低（P〈0．01）。结论对于危重型HFRS患者给予早期积极CBP干预治疗可稳定血流动力学、迅速改善内皮细胞功能紊乱的全身炎症状态,为补液、营养支持及后续的药物治疗创造条件,能获得满意疗效。     

连续性肾脏替代疗法治疗肿瘤溶解综合征一例

急性肿瘤溶解综合征（ATLS）是由于肿瘤细胞大量溶解，快速释放胞内物质，超过肝脏代谢和肾脏排泄能力，引起以高尿酸血症、高钾血症、高磷血症和肾功能不全为主要表现的症候群。现报道连续性肾脏替代疗法（CRRT）治疗肿瘤溶解综合征1例。     

病毒唑及阿昔洛韦治疗肾综合征出血热对照观察

本文将病程５天内的８１例肾综合征出血热随机分成２且，分别用病毒唑和阿昔洛韦治疗。结果发现病唑的血白细胞、血小板复常、异形淋巴细胞消失的平均时间、尿蛋白转阴时间及多尿期持续时间显著短于阿洛韦组（Ｐ〈０．０５或０．０１）；病毒唑越过低血压期和少尿期者占７５．６％，优于阿昔洛韦组（４５．０％）Ｐ〈０．０５。     

连续性血液净化在肾综合征出血热患者中的治疗时机及预后分析

目的：探讨连续性血液净化（CBP）在肾综合征出血热（HFRS）患者中的治疗时机及预后。方法：回顾性分析我院近10年以来行连续性血液净化治疗的322例肾综合征出血热患者，按RIFLE标准分为AKIⅠ期、Ⅱ期和Ⅲ期，并对不同AKI分期患者行连续性静-静脉血液滤过（CVVH）治疗前和治疗24h后的APACHE Ⅱ评分、SOFA评分、平均动脉压、氧合指数指标、患者死亡率进行比较。结果：AKI Ⅱ期和AKI Ⅲ期较AKIⅠ期患者的机械通气率、缩血管药物使用率、肝脏衰竭率、ARDS发生率，全身炎症反应和中枢神经系统症状发生率都显著提高（P〈0.05）。与CVVH治疗前相比，CVVH治疗24h后平均动脉压和氧合指数均明显升高（P〈0.05），APACHE Ⅱ评分和SOFA评分在AKIⅠ期和Ⅱ期患者显著降低（P〈0.05），在AKI Ⅲ期患者中变化则差异无统计学意义（P〉0.05）。AKI Ⅲ期患者的医院死亡率显著高于AKIⅠ期和AKI Ⅱ期患者（P〈0.05），AKI Ⅰ期和AKI Ⅱ期患者死亡率则差异无统计学意义（P〉0.05）。结论：对合并AKI、MODS的HFRS患者早期行CBP治疗可以改善患者预后。     

人血白蛋白治疗肾综合征出血热低血压休克患疗效观察

目的：观察人血白蛋白对肾综合征出血热低血压休克期的治疗效果。方法：采用回顾性对照的比较方法，治疗组在应用晶体液的同时，尽早应用人血白蛋白。对照组按“先晶后胶，晶3胶1”的补液原则治疗，胶体液用低分子右旋糖酐。结果：治疗组在血红蛋白降至正常时间，血压升至正常时间，少尿持续时间、尿蛋白阳性时间及血肌酐恢复正常时间均较对照组明显缩短，P＜0．01。治疗组在住院时间上与对照组相比 也明显缩短，P＜0．05。结论：尽早应用人血白蛋白治疗优于以往的“先晶后胶，晶3胶1”的液体疗法，它可减轻外渗，使休克尽快得以纠正，从而减轻低血压休克对肾脏的损害，缩短少尿期，使肾功能损害尽快恢复。     

连续性肾替代疗法在特重度烧伤中的应用前景

连续性肾替代疗法（continuous renal replacement therapy，CRRT）是每天连续24h（或接近24h）进行的一种替代受损肾脏功能的血液净化疗法。它通过血泵在患大动脉与静脉或静脉与静脉之间建立连续血液循环，利用超滤、对流、弥散和吸附原理，使血液中病原成分、炎症介质和机体内过多的液体等在通过血滤器过程中被连续清除，同时通过输液泵补充大量置换液和机体所需的能量、电解质和营养成分，实现机体内环境的稳定和平衡。目前，CRRT包括连续动脉-静脉血液滤过（CAVH）、连续静脉-静脉血液滤过（CVVH）、连续静脉-静脉血液透析滤过（CVVHDF）和高透性血液滤过（high permeability haemofihration，HP—HF）等方法，随着CRRT技术的成熟和对疾病认识的逐渐深入，CRRT在重症监护病房（ICU）以及治疗重症急性肾功能衰竭（ARF）、全身炎症反应综合征（SIRS）和多器官功能障碍综合征（MODS）等方面的应用越来越广泛，被认为是近年来急救医学治疗中最重要的进展之一。现结合烧伤的病理生理特点和病理演变过程，对CRRT在特重度烧伤治疗中的应用作一展望。     

连续性肾脏替代疗法对溶质清除的影响

连续性肾脏替代疗法(CRRT)是在常规血液透析基础上发展形成的一项新技术，已广泛用于重症急性肾功衰竭、多脏器失常综合征(MODS)、败血症、全身炎性反应综合征(SIRS)等疾病的救治，可有效地清除各种尿毒症毒素、内毒素和炎性介质。本文详细介绍了CRRT中不同操作方式对溶质清除的影响，临床医生可根据实际需要采用不同的治疗方式，使其成为一种既安全又高效的血液净化形式。     

Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy

BACKGROUND: Critical illness leading to multi-organ dysfunction syndrome (MODS) and associated acute renal failure (ARF) is less common in children compared to adult patients. As a result, many issues plague the pediatric ARF outcome literature, including a relative lack of prospective study, a lack of modality stratification in subject populations and inconsistent controls for patient illness severity in outcome analysis. METHODS: We now report data from the first multicenter study to assess the outcome of pediatric patients with MODS receiving continuous renal replacement therapy (CRRT). One hundred twenty of 157 Registry patients (63 male/57 female) experienced MODS during their course. RESULTS: One hundred sixteen patients had complete data available for analysis. The most common causes leading to CRRT were sepsis (N= 47; 39.2%) and cardiogenic shock (N= 24; 20%). Overall survival was 51.7%. Pediatric Risk of Mortality (PRISM 2) score, central venous pressure (CVP), and% fluid overload (%FO) at CRRT initiation were significantly lower for survivors versus nonsurvivors. Multivariate analysis controlling for severity of illness using PRISM 2 at CRRT initiation revealed that%FO was still significantly lower for survivors versus nonsurvivors (P < 0.05) even for patients receiving both mechanical ventilation and vasoactive pressors. We speculate that increased fluid administration from PICU admission to CRRT initiation is an independent risk factor for mortality in pediatric patients with MODS receiving CRRT. CONCLUSION: We suggest that after initial resuscitative efforts, an increased emphasis should be placed on early initiation of CRRT and inotropic agent use over fluid administration to maintain acceptable blood pressure.     

Veno-venous continuous renal replacement therapy for burned patients with acute renal failure

From 1995 to 1998, 12 burned patients with acute renal failure (ARF) were treated by veno-venous continuous renal replacement therapy (CRRT) at the Burn Unit of H?tel-Dieu de Montréal. Their mean (+/-SD) age was 51+/-12 years, and the mean burned surface covered 48.6+/-15.8% of total body surface area. All patients were mechanically ventilated and presented evidence of sepsis. The mean delay before occurrence of ARF was 15+/-6 days and ARF was mainly related to sepsis and hypotension. Main reasons for CRRT initiation were azotemia and fluid overload. A total of 15 CRRT modalities were applied (12 continuous veno-venous hemodiafiltration, CVVHDF; two continuous veno-venous hemofiltration, CVVH; and one continuous veno-venous hemodialysis, CVVHD) over 14+/-13 days. For CRRT, nine patients received heparin and three were not anticoagulated. Mean values for dialysate and reinjection flow rates were 1134+/-250 ml/h and 635+/-327 ml/h, respectively. Admission weight was 78.8+/-12.7 kg with a mean weight gain before CRRT initiation of 10.0+/-5.8 kg and a mean weight loss during CRRT of 8.9+/-5.5 kg. Nine patients received enteral plus parenteral nutrition, and three, parenteral nutrition only; the total caloric intake was 31.5+/-7.0 kcal/kg/day and protein intake, 1.8+/-0.4 g/kg/day. The normalized protein catabolic rate (nPCR) was evaluated at 2.28+/-0.78 g/kg/day during CRRT. The mortality rate was 50%. The six survivors all recovered normal renal function with four of them requiring intermittent hemodialysis for short periods. In conclusion, veno-venous CRRT is particularly well suited for this selected population allowing smooth fluid removal and aggressive nutritional support.     

Electrolyte excretion in patients with a history of hemorrhagic fever with renal syndrome

Renal transportation of sodium and potassium was studied in 85 patients who sustained hemorrhagic fever complicated with renal syndrome (HFRS). The examinees were given routine diet No. 7 recommended by Pevzner. The conclusions were made on the analysis of circadian excretion and clearance of electrolytes studied and the levels of their water-load-induced tubular transportation: distal and proximal reabsorption and distal excretion of sodium, the correlation between potassium secretion and reabsorption in the distal part of the nephron. It was revealed that within the first year after the disease onset, 37.5 per cent of patients had increased levels of sodium excretion as part of the salt-loss syndrome developed due to decreased sodium reabsorption in the distal part of the nephron. Later the status was featured by moderately pronounced disorders of distal sodium reabsorption in 6.25 per cent of the patients only, mostly in those with HFRS-induced pyelonephritis. Increased excretion of potassium noted in the first months after HFRS only was the result of an increase in sodium excretion. The aforementioned disorders could be easily compensated by a routine diet and therefore a decrease in the levels of sodium or potassium avoided.     

连续性肾脏替代治疗应用于重症急性胰腺炎的临床疗效分析

目的 研究连续性肾脏替代治疗(CRRT)应用于重症急性胰腺炎(SAP)的临床疗效.方法 2010年3月至2012年12月收治的58例SAP患者,分为2组,CRRT组(40例)患者入院后即在常规治疗的同时给予CRRT;常规治疗组(18例)患者则给予常规抗胰腺炎治疗.结果 治疗3 d后,APACHEⅡ评分CRRT组优于常规治疗组(P＜0.01);血生化指标中CRRT组氧合指数、血钙水平高于常规治疗组,而血肌酐水平、白细胞计数低于常规治疗组,差异有统计学意义(P＜0.05或P＜0.01).CRRT组并发症发生率(6.2%)低于常规治疗组(13.7%),而治愈率(88.3%)高于常规治疗组(67.1%),差异有统计学意义(P＜0.05或P＜0.01).结论 SAP发病早期,无急诊手术指征的患者在常规治疗的基础上实施CRRT可有效缓解病情,减少并发症发生率,提高治愈率.     

Spontaneous rupture of the kidneys in hemorrhagic fever with renal syndrome

During the recent 5 years we had 29 patients with hemorrhagic fever and renal syndrome complicated by a spontaneous kidney rupture. This complication occurred during an anuric period in 18 patients and within the first 24 hours of restored diuresis in 11 patients. Major clinical presentations of the kidney rupture were deterioration of lumbar and abdominal pains, meteorism and symptoms of an internal bleeding. Palpation revealed hematoma at the site of the ruptured kidney, tension of the anterior abdominal wall and symptomatic peritoneal irritation. Diagnosis of spontaneous kidney rupture in hemorrhagic fever with the renal syndrome (HFRS) relies on clinical, laboratory and ultrasound studies. Additional studies are plain urography and retroperitoneal diagnostic puncture of the affected site. Conservative therapy was given to 11 patients with erythrocyte counts of 3 x 10(12)/l or higher. The treatment was operative in 18 patients. Indications for surgery were progressive anemia, a palpable retroperitoneal hematoma and symptomatic peritoneal irritation. All patients underwent evacuation of blood clots and ligation of the renal ruptures. In the authors' opinion, renal decapsulation and pyelostomy are useful in this condition. Bilateral involvement and severe renal failure are contraindications for nephrectomy in HFRS. It may be used only as a last resort in life-threatening bleeding.     

连续性肾脏替代治疗与间歇性血液透析治疗多器官功能障碍综合征的疗效比较

目的比较连续性肾脏替代治疗(CRRT)与间歇性血液透析(IHD)治疗伴急性肾功能衰竭(ARF)的多器官功能障碍综合征(MODS)患者的疗效.方法49例伴ARF的MODS患者,23例接受CRRT,26例接受每周3次或隔日1次的IHD.所有患者血液净化治疗前及治疗后记录液体摄人量,每日晨检查血肌酐、尿素氮、血钾、血碳酸氢根浓度,动脉血pH值.结果CRRT组和IHD组每日液体摄入量分别为(5128±103)ml、(2207±97)ml(P＜0.05).IHD组21例次出现透析相关低血压、17例次透析间期发生容量依赖性心功能衰竭,高于CRRT组的3例次及2例次(P＜0.05).IHD组每日晨血尿素氮、血肌酐、碳酸氢根、pH值组内比较差异有显著性意义(P＜0.05),而CRRT组组内比较差异没有显著性意义(P＞0.05);IHD组每日晨平均血肌酐、尿素氮高于CRRT组(P＜0.05);IHD组和CRRT组存活率分别为65.4%(17/26)、34.8%(8/23),但在APACHEⅡ评分27以上、衰竭器官数在3个以上的患者中,CRRT组和IHD组存活率分别为26.7%、14.3%(P＞005).结论CRRT控制伴ARF的MODS患者酸碱平衡、液体平衡及氮质血症优于IHD.