Community-acquired acute renal failure

Acute renal failure usually occurs during hospitalization, but may also be present on admission to the hospital. To define the causes and outcomes of community-acquired acute renal failure, we undertook a prospective study of patients admitted to the hospital with acute elevations in serum creatinine concentrations. Over a 17-month period, all admission serum creatinine determinations were screened for patients with values greater than 177 mumol/L (2 mg/dL). These values were compared with baseline creatinines to select patients with an acute elevation in serum creatinine occurring outside the hospital. One hundred patients were entered into the study, with an overall incidence of 1% of hospital admissions. Seventy percent of the patients had prerenal azotemia, 11% had intrinsic acute renal failure, 17% had obstruction, and 2% could not be classified. Mean peak serum creatinine (318 +/- 18 mumol/L [3.6 +/- 0.2 mg/dL]) and mortality (7%) was lowest in the group with prerenal azotemia. In this group, volume contraction due to vomiting, decreased fluid intake, diarrhea, fever, glucosuria, or diuretics was the most common underlying cause. The group with intrinsic acute renal failure had the most severe renal failure and the highest mortality (55%). Although ischemic acute tubular necrosis is the most common cause of hospital-acquired intrinsic acute renal failure, this etiology was seen in only one patient. Drug-induced nephrotoxicity and infection-related causes were the most common underlying etiologies of intrinsic acute renal failure. Obstructive renal failure had a mortality of 24% and was most commonly due to benign prostatic hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Decreased fractional excretion of urate as an indicator of prerenal azotemia

Although the fractional excretion of uric acid (FEUA) is known to reflect extracellular fluid volume changes, the diagnostic significance of decreased FEUA in dehydration has not been previously reported. We studied the possible association between low FEUA and acute prerenal azotemia, and its diagnostic value, compared with other traditional indices, in discriminating prerenal azotemia from renal parenchymal causes of acute renal failure. In 65 chronic renal disease patients, 174 FEUA measurements were obtained from 24-hour urine collections. FEUA levels increased as reciprocal serum creatinine levels decreased. All 8 patients with prerenal azotemia showed significantly decreased FEUA values compared with chronic renal disease patients with a comparable degree of serum creatinine elevation, whereas all 7 patients with acute renal failure had FEUA values higher than those of chronic renal disease patients with comparable creatinine levels. FEUA values in prerenal azotemia were distinctly lower than those in acute renal failure (p less than 0.001). Patients with prerenal azotemia showed a lower fractional excretion of sodium, a lower fractional excretion of chloride and renal failure index, and a higher urine-to-plasma creatinine ratio than those with acute renal failure (p less than 0.05). However, these traditional indices were not useful in discriminating between the two conditions. The urine-to-plasma urea nitrogen ratio and the ratio of plasma urea nitrogen to creatinine showed no statistical difference between prerenal azotemia and acute renal failure. We conclude that, in acute azotemia, a decreased FEUA value may represent a reliable indicator of prerenal azotemia in the differential diagnosis of acute renal failure.     

Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure

BACKGROUND: Fractional excretion of sodium (FENa) has been used in the diagnosis of acute renal failure (ARF) to distinguish between the two main causes of ARF, prerenal state and acute tubular necrosis (ATN). However, many patients with prerenal disorders receive diuretics, which decrease sodium reabsorption and thus increase FENa. In contrast, the fractional excretion of urea nitrogen (FEUN) is primarily dependent on passive forces and is therefore less influenced by diuretic therapy. METHODS: To test the hypothesis that FEUN might be more useful in evaluating ARF, we prospectively compared FEUN with FENa during 102 episodes of ARF due to either prerenal azotemia or ATN. RESULTS: Patients were divided into three groups: those with prerenal azotemia (N = 50), those with prerenal azotemia treated with diuretics (N = 27), and those with ATN (N = 25). FENa was low only in the patients with untreated plain prerenal azotemia while it was high in both the prerenal with diuretics and the ATN groups. FEUN was essentially identical in the two pre-renal groups (27.9 +/- 2.4% vs. 24.5 +/- 2.3%), and very different from the FEUN found in ATN (58.6 +/- 3.6%, P < 0.0001). While 92% of the patients with prerenal azotemia had a FENa <1%, only 48% of those patients with prerenal and diuretic therapy had such a low FENa. By contrast 89% of this latter group had a FEUN <35%. CONCLUSIONS: Low FEUN (相似文献   

Synergistic effect of acute renal failure and respiratory failure in the surgical intensive care unit

A retrospective evaluation of the effect of renal and respiratory failure on mortality in our surgical intensive care unit was undertaken. The coexistence of combined renal and respiratory failure had a synergistic adverse effect on survival. Combined pulmonary and kidney failure appeared to develop simultaneously. A subset of patients with severe prerenal azotemia but without uremia had the highest mortality. These results are not consistent with the simple combination of single systems failure but rather suggest that renal and respiratory failure are markers of a generalized underlying defect.     

A comparison of continuous renal replacement therapy to intermittent dialysis in the management of renal insufficiency in the acutely III surgical patient

Acute renal failure (ARF) occurs in 10 per cent to 23 per cent of intensive care unit patients with mortality ranging from 50 per cent to 90 per cent. ARF is characterized by an acute decline in renal function as measured by urine output (UOP), serum creatinine, and blood urea nitrogen (BUN). Causes may be prerenal, intrarenal, or postrenal. Treatment consists of renal replacement therapy (RRT), either intermittent (ID) or continuous (CRRT). Indications for initiation of dialysis include oliguria, acidemia, azotemia, hyperkalemia, uremic complications, or significant edema. Overall, the literature comparing CRRT to ID is poor. No studies of only surgical/trauma patients have been published. We hypothesize that renal function and hemodynamic stability in trauma/ surgical critical care patients are better preserved by CRRT than by ID. We performed a retrospective review of trauma/surgical critical care patients requiring renal supportive therapy. Thirty patients received CRRT and 27 patients received ID. The study was controlled for severity of illness and demographics. Outcomes assessed were survival, renal function, acid-base balance, hemodynamic stability, and oxygenation/ventilation parameters. Populations were similar across demographics and severity of illness. Renal function, measured by creatinine clearance, was statistically greater with CRRT (P = 0.035). There was better control of azotemia with CRRT: BUN was lower (P = 0.000) and creatinine was lower (P = 0.000). Mean arterial blood pressure was greater (P = 0.021) with CRRT. No difference in oxygenation/ventilation parameters or pH was found between groups. CRRT results in an enhancement of renal function with improved creatinine clearance at the time of dialysis discontinuation. CRRT provides better control of azotemia while preserving hemodynamic stability in patients undergoing renal replacement therapy. Prospective randomized controlled studies and larger sample sizes are needed to further evaluate these modalities.     

Haemodynamics in leptospirosis: effects of plasmapheresis and continuous venovenous haemofiltration

BACKGROUND: Haemodynamics in leptospirosis may differ from that of sepsis because of frequently obeserved myocarditis and severe cholestatic jaundice. A haemodynamic study was therefore made in 10 patients with severe leptospirosis. METHODS AND RESULTS: All patients had pulmonary complications with a chest X-ray showing either pulmonary oedema or infiltration. Renal failure was present in nine patients. Three patterns of haemodynamics were revealed. The first pattern was observed in six patients who showed increased cardiac index, decreased systemic vascular resistance, normal pulmonary capillary wedge pressure, normal pulmonary vascular resistance and hypotension. The pattern resembled that of sepsis. The second pattern shown in two patients with haemoptysis consisted of a normal cardiac index, normal systemic vascular resistance, normal blood pressure, normal pulmonary capillary wedge pressure and increased pulmonary vascular resistance. The third pattern was observed in two patients with severe jaundice who had hypotension, a relatively low cardiac index, increased systemic vascular resistance and normal pulmonary capillary wedge pressure, and pulmonary vascular resistance. Plasmapheresis performed in two patients and continuous venovenous haemofiltration performed in two patients improved systemic haemodynamics and normalized blood pressure with a resolution of lung signs.     

Elevated serum creatinine and a normal urinalysis: a short differential diagnosis in the etiology of renal failure

OBJECTIVE: The diagnosis of renal failure with a normal urinalysis represents a short differential diagnosis that has not been characterized in the literature. This study was designed to identify the specific disease states that encompass this interesting renal condition. MATERIAL: The Regenstrief database, which is an electronic medical record containing inpatient laboratory and other clinical data for patients admitted to Wishard Memorial Hospital, was utilized to provide data for this study. METHODS: The database was culled to provide data for hospitalized patients admitted between March 1, 1992, and March 1, 2001, with the concurrent findings of a serum creatinine greater than or equal to 2 mg/dL, a normal urinalysis, and diagnoses of obstructive uropathy, multiple myeloma, prerenal azotemia, hypertensive nephrosclerosis, interstitial nephritis, renal vascular disease, hypokalemic nephropathy, and hypercalcemia, as identified by their corresponding ICD-9 codes. RESULTS: A search of the Regenstrief database yielded a total of 190,343 patient admissions. There were 515 patient admissions with renal failure and a concurrent normal urinalysis. The largest specific diagnostic categories within this group were hypertension and prerenal azotemia. CONCLUSIONS: An elevated serum creatinine and normal urinalysis present a short differential for the etiologies of renal failure and include such entities as hypertensive nephrosclerosis, prerenal azotemia, obstructive nephropathy, interstitial nephritis, renal vascular disease, and various electrolyte abnormalities. An awareness of these specific disease states may lead to an earlier diagnosis and more effective treatment of renal failure.     

Elevated Serum Creatinine and a Normal Urinalysis: A Short Differential Diagnosis in the Etiology of Renal Failure

Objective. The diagnosis of renal failure with a normal urinalysis represents a short differential diagnosis that has not been characterized in the literature. This study was designed to identify the specific disease states that encompass this interesting renal condition. Material. The Regenstrief database, which is an electronic medical record containing inpatient laboratory and other clinical data for patients admitted to Wishard Memorial Hospital, was utilized to provide data for this study. Methods. The database was culled to provide data for hospitalized patients admitted between March 1, 1992, and March 1, 2001, with the concurrent findings of a serum creatinine greater than or equal to 2 mg/dL, a normal urinalysis, and diagnoses of obstructive uropathy, multiple myeloma, prerenal azotemia, hypertensive nephrosclerosis, interstitial nephritis, renal vascular disease, hypokalemic nephropathy, and hypercalcemia, as identified by their corresponding ICD-9 codes. Results. A search of the Regenstrief database yielded a total of 190,343 patient admissions. There were 515 patient admissions with renal failure and a concurrent normal urinalysis. The largest specific diagnostic categories within this group were hypertension and prerenal azotemia. Conclusions. An elevated serum creatinine and normal urinalysis present a short differential for the etiologies of renal failure and include such entities as hypertensive nephrosclerosis, prerenal azotemia, obstructive nephropathy, interstitial nephritis, renal vascular disease, and various electrolyte abnormalities. An awareness of these specific disease states may lead to an earlier diagnosis and more effective treatment of renal failure.     

Renal magnesium wasting and tubular dysfunction in leptospirosis.

BACKGROUND: Tubulo-interstitial nephritis is the main cause of acute renal injury in leptospirosis. The aim of this study was to evaluate renal tubular function and excretion of solutes in leptospirosis patients during a recent outbreak of leptospirosis in Nan province, Thailand. METHODS: Clinical manifestations were recorded and routine laboratory tests were performed upon admission. Renal tubular functions including tubular reabsorption of phosphate (TRP), fractional excretion of magnesium (FE(Mg)), urinary calcium to creatinine ratio (Uca/cr), urine N-acetyl-beta-D glucosaminidase (NAG) and urine beta(2)-microglobulin were serially monitored during 2 weeks after admission. RESULTS: A total of 20 leptospirosis patients were recruited. Nine (45%) patients had acute renal failure (ARF). Increased urine NAG and beta(2)-microglobulin, which indicate proximal tubular dysfunction, were demonstrated in all 20 (100%) patients. Fifteen (75%) patients had hypermagnesuria, whereas 10 (50%) patients had decreased TRP. Renal magnesium (Mg) and phosphate (P) wasting caused hypomagnesaemia and hypophosphataemia in nine and three patients with ARF, respectively. These abnormal findings significantly improved within 2 weeks after admission. CONCLUSIONS: We conclude that renal Mg and P wasting commonly occur in patients with leptospirosis. The measurement of Mg and P levels in both serum and urine of leptospirosis patients, especially those with ARF, is therefore highly recommended.     

Leptospiral nephropathy

Renal involvement is common in leptospirosis. Clinical manifestations vary from urinary sediment changes to acute renal failure. Renal failure is observed in 44% to 67% of patients. Hypokalemia frequently occurs. Severe hypotension is an important warning sign for the later development of renal and pulmonary complications. Prognosis of the disease is generally good except for its association with pulmonary complications, especially pulmonary hemorrhage and acute respiratory distress syndrome. Interstitial nephritis is the basic renal lesion. Vasculitis is observed in the acute phase of the disease. Tubular necrosis and interstitial nephritis are responsible for renal failure. Glomerular changes usually are not remarkable. Hemodynamic alterations, immune response, and direct nephrotoxicity are responsible for the development of renal lesions. As in many infectious diseases, decreased renal blood flow and glomerular filtration rate play a basic role. Bacterial invasion and toxicity of outer membrane with generation of cytokines, chemokines, and cellular infiltration are important in cellular injury.     

Urinary doubly refractile lipid bodies in nonglomerular renal diseases

Urinary doubly refractile lipid bodies (DRLB) are a characteristic finding in patients with glomerular renal diseases causing heavy proteinuria. DRLB are felt to be an uncommon finding in glomerular diseases without heavy proteinuria, and a rare finding in nonglomerular renal diseases. In order to determine whether DRLB are found in nonglomerular renal diseases, we reviewed the medical records of all patients who had urinalyses performed in our laboratory from February 1975 to June 1983. Three hundred sixty one patients demonstrated less than or equal to +2 proteinuria, and at least two DRLB. Of these, 290 were identified as having a single renal diagnosis. One hundred forty eight patients (51%) had a variety of acute and chronic glomerular diseases, and 125 patients (43.2%) had nonglomerular renal diseases, including acute tubular necrosis (ATN), prerenal azotemia, chronic interstitial nephritis, polycystic kidney disease, acute interstitial nephritis, renal neoplasia, and acute myeloma kidney. Ten patients had transient proteinuria associated with acute illness, and seven patients had no renal disease at all. Only two patients with nonglomerular renal disease had more than five DRLB per 20 high power microscopic fields. The frequency of DRLB in patients with nonglomerular renal diseases was: chronic interstitial nephritis, 26%; polycystic kidney disease, 38%; prerenal azotemia, 20%; ATN, 15%; and acute interstitial nephritis, 33%. These data suggest that at lower levels of proteinuria, DRLB are found frequently in nonglomerular renal diseases, and that DRLB do not differentiate glomerular from nonglomerular renal diseases unless more than five DRLB are found on urinary sediment examination.     

Elevated plasma renin activity associated with renal dysfunction

Elevated plasma renin activity (PRA) has been documented in patients with established acute renal failure. To study the association of PRA and renal dysfunction, 53 patients who were at risk of developing acute renal failure had serial measurements of PRA, renal function, and urinary beta 2-microglobulin. Those entered for study had pneumonia, septicaemia, volume loss with hypotension, or major surgical procedures with complications. Patients were divided into groups of abnormal or normal renal function. Abnormal renal function was defined by an elevated plasma urea and/or creatinine level with a submaximal urine urea to plasma urea ratio. The mean values of PRA for the abnormal and normal renal function groups, respectively, were 29 and 5.2 ng/ml/h (p less than 0.0001) and for beta 2-microglobulin 16.2 and 6.4 micrograms/l X 10(3) (p less than 0.0005). A linear regression of the logs of PRA to beta 2-microglobulin for the total group of patients gave an r value of 0.526 (p less than 0.001). These data show an association of PRA to renal dysfunction and tubular injury/dysfunction in the prerenal phase of renal failure, suggesting an effect of the renin-angiotensin system at this phase. It is not possible, however, to conclude from our study that the renin-angiotensin system has a direct role in the development of established acute tubular necrosis, since only 3 patients fell within this category.     

Identification of admission values predictive of complicated acute alcoholic pancreatitis

BACKGROUND: Hospital admission indexes (serum urea nitrogen level, serum glucose level, heart rate, and white blood cell count) have been previously identified as useful predictors for the development of both severe systemic complications and death in patients with gallstone pancreatitis. HYPOTHESIS: We hypothesized that (1) these same 4 indexes would predict complications and/or death in first-time acute alcoholic pancreatitis and (2) these indexes would compare favorably with an admission Ranson score. DESIGN: Retrospective cohort study. SETTING: A university-affiliated, urban, public teaching hospital. PATIENTS: One hundred five patients who experienced first episodes of alcoholic pancreatitis treated between January 1, 1992, and June 30, 2003. MAIN OUTCOME MEASURES: Major systemic complications (pulmonary, cardiac, renal, infectious) requiring intensive care unit admission and/or death. RESULTS: A total of 105 patients were identified. Twenty-six patients (25%) (95% confidence interval [CI], 17%-34%) had a major systemic complication, and 6 patients (6%) (95% CI, 2%-12%) died. A serum glucose level of 160 mg/dL (8.9 mmol/L) or higher combined with a white blood cell count of 17 x 10(3)/ micro L or more had a positive predictive value of 80% (95% CI, 44%-98%), and an admission Ranson score of 3 or higher had a positive predictive value of 100% (95% CI, 48%-100%) for determining the likelihood of a systemic complication. Both an admission Ranson score of 1 or more and a white blood cell count of 17 x 10(3)/ micro L or more, independent of each other, had equally high negative predictive values (100% [95% CI, 94%-100%] and 99% [95% CI, 94%-100%], respectively) with respect to mortality. CONCLUSIONS: Two simple admission laboratory values--white blood cell count and serum glucose level--are useful predictors for development of major systemic complications and/or mortality in patients with first-time alcoholic pancreatitis. The predictive values of leukocytosis and hyperglycemia compare favorably with those of the admission Ranson score.     

Acute renal failure: a common manifestation of leptospirosis

Leptospirosis is an infectious disease caused by pathogenic leptospires and may vary in degree from an asymptomatic infection to severe and fatal illness. Sixteen patients (all males; aged 40+/-17 years) with leptospirosis were admitted to Si?li Etfal Training and Research Hospital between July 1998 and August 2003 and were retrospectively reviewed. Age, gender, occupation, clinical presentation, laboratory features, seasonal distribution of the disease, diagnostical approach, and prognostic factors were evaluated. Eleven patients were cured with no complication; four patients died of hepatic and/or renal failure. Eight patients presented with acute renal failure; seven of them needed dialytic support. One patient developed chronic renal failure and had to undergo regular hemodialysis. All deceased patients (aged 61+/-7 years) were anuric at admission and their serum bilirubin changed between 39-44 mg/dL (mean 41.3+/-2.2 mg/dL). Cured patients ranged in age from 14-62 years (34+/-14 years) and their serum bilirubin levels ranged from 9-35 mg/dL (23.1+/-11.4 mg/dL). Crystalline penicillin G 12 million U/day was administered to all patients. Six patients also received hepatic coma treatment. This study emphasizes that leptospirosis presenting with renal failure is a severe disease, and mortality is frequently related to delays in diagnosis due to lack of clinical understanding. The association of acute renal failure and jaundice should lead the clinician to suspect leptospirosis. We concluded that old age, oliguria/anuria, high serum bilirubin levels (>36 mg/dL), and high serum potassium levels might be risk factors that increase mortality in leptospirosis.     

Acute renal failure after a holiday in the tropics

A 20-year-old, previously healthy woman, presented with high fever, headache and myalgia 3 days after her return from a holiday in Southeast Asia. Laboratory data on admission demonstrated a pronounced increase in plasma creatinine, marked thrombocytopenia and moderately elevated liver aminotransferases. After having ruled out malaria, dengue fever was primarily suspected and supportive intravenous fluid therapy was initiated. Still, 1 day after admission, platelet counts dropped even further and she became anuric although she did not appear hypovolemic. On day 2 after admission, urine production commenced spontaneously and the patient slowly recovered. All laboratory test results had returned to normal approximately 2 months later. Serological analysis for dengue fever was negative. It turned out that the patient had been trekking in the jungle while in Thailand and we, therefore, analyzed serology for Leptospira spirochetes which was clearly positive. The patient was diagnosed with leptospirosis which is a serious condition associated with a high mortality when complicated by acute renal failure. Differential diagnoses in patients with acute renal failure and tropical infections are reviewed. The importance of early recognition of leptospirosis, and prompt treatment with antibiotics in suspected cases, is emphasized.     

腹主动脉瘤患者术后近期死亡和严重并发症

目的了解肾动脉下腹主动脉瘤患者术后近期病死率和并发症发生率,并分析其原因. 方法选择自1988年1月～200 0年12月,在我院行手术治疗的肾动脉下腹主动脉瘤186例,统计术后近期病死率和并发症发生率,分析术前心、肺、肾功能,年龄和手术因素与严重并发症和死亡的关系. 结果择期手术术后近期病死率5.0%,动脉瘤破裂急诊手术57.1 %.择期手术术后近期严重并发症发生率18.4%,其中心血管并发症10.6%,呼吸道并发症1 1.2%,急性肾功能衰竭2.8%,脑血管意外1.1%,肝功能损害1.1%.心血管并发症与术前冠心病明显相关(χ2=19.737,P＜0.01)而与高血压无关(χ2=1.870,P ＞0.05).术前肺功能异常、吸烟史和血氧分压＜80 mmHg与肺部感染有关(χ2=4. 051、5.885和5.162,P＜0.05)而与成人呼吸窘迫综合征无关(χ2=0.127、0 .916和1.067,P＞0.05).术前肾功能状况与急性肾功能衰竭无关(χ2=0.404 ,P＞0.05).70岁以上或手术时间超过5 h,术后严重并发症(χ2=16.119和10 .163,P＜0.01)和死亡(χ2=7.045和12.145,P＜0.01)的发生率明显增加. 结论多系统器官功能衰竭是导致腹主动脉瘤术后近期死亡的主要原因.术后严重并发症以心肺疾病居多.术前心、肺功能,年龄和手术因素与术后严重并发症和死亡密切相关.     

微创治疗上尿路结石所致急性肾功能衰竭

目的探讨微创治疗上尿路结石所致急性肾功能衰竭的临床效果。方法2012年12月～2013年8月,对30例上尿路结石致急性梗阻性肾功能衰竭先行输尿管置管或经皮肾穿刺造瘘,根据病情行输尿管镜取石术或微通道经皮肾镜取石术。结果均成功解除尿路梗阻,输尿管镜气压弹道取石术18例,结石取净率94．4％（17／18）;微通道经皮肾镜气压弹道取石术12例,结石取净率91．7％（11／12）,无严重并发症发生。术后3～14d血cr由285～1162μmol／L降至58～343μmol／L。术后随访1～6个月,平均3个月,肾功能恢复正常25例,5例仍有氮质血症,但肾功能明显改善。结论输尿管镜取石术或微通道经皮肾镜取石术治疗上尿路结石所致急性肾功能衰竭具有微创、安全、效果好等优点。     

Epstein-Barr virus-associated acute renal failure: diagnosis,treatment, and follow-up

We retrospectively reviewed our experience of Epstein-Barr virus (EBV)-associated acute renal failure. Of 165 previously healthy children hospitalized with serologically proven primary EBV infection, 8 had acute renal failure, of whom 5 (group A) did not have virus-associated hemophagocytic syndrome (VAHS), while 3 (group B) did have VAHS. All had complications in four or more organ systems. Two patients in group A had renal biopsies showing acute tubulointerstitial nephritis, and the clinical and laboratory findings in the other 3 group A patients were consistent with acute tubulointerstitial nephritis. Acyclovir was used in 1 patient, but she died of hepatic failure and pulmonary hemorrhage. The other 4 spontaneously recovered renal function after supportive care, including hemodialysis in 1 patient. Our experience does not support the routine use of corticosteroids or antiviral agents in these patients. Children in group B had a relatively normal urinalysis. Renal biopsies were not performed, but their presentations were compatible with acute tubular necrosis. We conclude that EBV should be considered as a possible etiological agent in all children presenting with acute renal failure of unknown cause. The diagnosis depends on a high index of suspicion and careful serological evaluation in atypical cases.     

The lack of clinical value of laboratory parameters in predicting outcome in acute renal failure

In 55 patients with either the oliguric and nonoliguric form of acute renal failure, some laboratory parameters for the analysis of prerenal and intrinsic types of acute renal failure were examined. The parameters were analyzed within 7 days of the clinically known beginning of the illness. The parameters were analyzed as follows: sodium in urine, creatinine urine/plasma ratio, urine osmolality, osmolality urine/plasma ratio, renal failure index, and fractional excretion of filtered sodium. Hemodialysis was performed in 29 of the 55 patients. The oliguric form of acute renal failure was present in 49 of the 55 patients. In relation to renal failure index, prerenal acute renal failure was present in 7 patients and intrinsic acute renal failure in 48. It appears that in patients with a clinical diagnosis of prerenal acute renal failure, the urinary parameters do not separate them from those with acute tubular necrosis. It also appears that in patients with laboratory diagnosis of prerenal acute renal failure (i.e., a RFT less than 1.0), the response to treatment is unpredictable and in fact may have a worse prognosis than in those with a RFI greater than 1.0 (5/7 deaths vs 10/48 deaths).     

高风险腹主动脉瘤开放和腔内治疗术后严重并发症的分析及防治

目的了解高风险腹主动脉瘤患者行开放和腔内治疗术后严重并发症的发生率,分析其原因并总结防治经验。方法回顾性分析2009年1月至2011年9月期间我院收治的57例高风险腹主动脉瘤患者的临床资料(高风险定义为年龄≥60岁、美国麻醉医师协会分级3或4级、且至少有一个心脏或肺或肾方面的合并症)。统计手术后严重并发症发生率,分析术前合并症、手术方式、麻醉方式与术后严重并发症的关系。结果 57例高风险腹主动脉瘤患者中,行腹主动脉瘤腔内修复术(即腔内治疗)41例,行腹主动脉瘤切除人造血管移植术(即开放手术)16例。术后近期(30 d内)病死率为1.8%(1/57),术后严重并发症发生率为19.3%(11/57)。其中心血管并发症发生率为8.8%(5/57),呼吸道并发症发生率为8.8%(5/57),急性肾功能衰竭发生率为1.8%(1/57)。术前有冠心病者心血管并发症发生率高〔19.0%(4/21)比2.8%(1/36),χ2=4.387,P<0.05〕,而心血管并发症发生率与有或无高血压无关〔10.3%(4/39)比5.6%(1/18),χ2=0.340,P>0.05〕。术前有肺功能异常者术后呼吸道并发症发生率高〔20.0%(4/20)比5.6%(1/18),χ2=4.387,P<0.05〕,有或无慢性阻塞性肺病病史与术后呼吸道并发症发生率无关〔13.2%(5/38)比0(0/19),χ2=2.740,P>0.05〕。术前有或无肾功能损伤与急性肾功能衰竭无关〔0(0/4)比1.9%(1/53),χ2=0.077,P>0.05〕。腔内治疗术后并发症发生率低于传统开放手术〔12.2%(5/41)比37.5%(6/16),χ2=3.980,P<0.05〕。在术后呼吸道并发症的发生率上,监护麻醉的患者较全身麻醉的患者低〔0(0/20)比19.0%(4/21),χ2=4.221,P<0.05〕。结论高风险腹主动脉瘤患者术后严重并发症以心、肺疾病居多。术前心肺功能、麻醉及手术方式的选择与术后严重并发症有关。术前对各个系统进行充分的评估,选择合理的麻醉及手术方式,术后积极、有效的对症、支持治疗是降低术后并发症发生率的关键。