连续性静脉-静脉血液滤过在腹部肿瘤术后急性肾功能衰竭中的应用

目的 探讨连续性静脉-静脉血液滤过在腹部肿瘤手术后急性肾功能衰竭中应用的临床意义.方法 对31例腹部肿瘤术后急性肾功能衰竭患者采用连续性静脉-静脉血液滤过治疗,比较治疗前、后电解质、血肌酐、尿素氮以及动脉血气分析的变化.结果 31例患者中30例存活,1例死亡.存活患者经连续性静脉-静脉血液滤过后血尿素氨和肌酐均逐渐下降直至恢复正常;经连续性静脉.静脉血液滤过后4～5 h血钾可降至正常范围;酸中毒得到纠正、动脉血氧分压明显升高,尿量分别于连续性静脉-静脉血液滤过后5～20 d恢复正常,所有患者经连续性静脉-静脉血液滤过后水肿得到明显改善.结论 连续性静脉-静脉血液滤过是治疗腹部肿瘤术后急性肾功能衰竭的一种有教、方便而安全的方法.     

连续性静脉-静脉血液滤过在腹部肿瘤术后急性肾功能衰竭中的应用

目的 探讨连续性静脉-静脉血液滤过在腹部肿瘤手术后急性肾功能衰竭中应用的临床意义.方法 对31例腹部肿瘤术后急性肾功能衰竭患者采用连续性静脉-静脉血液滤过治疗,比较治疗前、后电解质、血肌酐、尿素氮以及动脉血气分析的变化.结果 31例患者中30例存活,1例死亡.存活患者经连续性静脉-静脉血液滤过后血尿素氨和肌酐均逐渐下降直至恢复正常;经连续性静脉.静脉血液滤过后4～5 h血钾可降至正常范围;酸中毒得到纠正、动脉血氧分压明显升高,尿量分别于连续性静脉-静脉血液滤过后5～20 d恢复正常,所有患者经连续性静脉-静脉血液滤过后水肿得到明显改善.结论 连续性静脉-静脉血液滤过是治疗腹部肿瘤术后急性肾功能衰竭的一种有教、方便而安全的方法.     

连续性静脉-静脉血液滤过治疗妊娠合并急性肾衰竭临床分析

目的观察连续性静脉－静脉血液滤过（CVVH）治疗妊娠合并急性肾衰竭的临床疗效。方法回顾性分析26例妊娠合并急性肾衰竭患者采用CVVH治疗的资料,每例患者治疗30～89h,平均48h,滤过器采用AN69,AV600S,血流量100～150ml／min,置换液流量1500－2500ml／h,采用前稀释法。结果26例患者中,23例存活,3例转为慢性肾衰竭,治疗后血尿素氮、肌酐、尿酸明显下降,死亡3例。人工流产术4例,22例均适时终止妊娠,16例剖宫产,6例阴道分娩;胎儿存活18例。结论CVVH治疗妊娠合并急性肾衰竭安全、有效,值得推广。     

CVVH治疗急性肾功能衰竭的应用与护理

目的:为探讨连续性静脉-静脉血液滤过治疗急性肾功能衰竭患者治疗中的监测和护理.方法:取12例实施CVVH治疗的急性肾功能衰竭的患者,做好血滤前的充分准备,血滤过程中的监测,护理及并发症的预防,监测患者治疗前后肾功能,电解质,动脉血气,中心静脉压的变化.结果:所有患者治疗后生命体征趋于平稳,肾功能改善率为66.7%,从而纠正了水电解质、酸碱平衡紊乱,稳定血液动力学,未见明显并发症.结论:CVVH对治疗急性肾功能衰竭患者有显著疗效!     

连续性静脉—静脉血液透析治疗体外循环心脏直视术后急性肾损伤

目的：探讨连续性静脉-静脉血液透析（CVVHD）治疗体外循环心脏直视术后急性肾损伤（acute kidney injury,AKI）的治疗作用。方法：回顾性分析2007年01月～2011年01月15例体外循环心内直视术后AKI的患者采用CVVHD治疗的临床资料。结果：13例存活,2例死亡。存活患者的心率、平均动脉压、动脉氧分压、中心静脉压在CVVHD过程中波动于正常范围,血肌酐、尿素氮、血钾水平在治疗后显著下降,肾功能恢复正常。结论：CVVHD是救治体外循环心脏直视术后AKI患者的有效手段,仍需病例的积累进一步研究。     

大黄甘草汤联合间断短时静脉-静脉血液滤过对重症急性胰腺炎患者细胞因子的影响

目的 探讨大黄甘草汤联合间断短时静脉-静脉血液滤过对重症急性胰腺炎治疗作用及机制.方法 103例患者按随机数字表法分为3组.大黄甘草汤灌胃组(A组,25例),间断短时静脉-静脉血液滤过组(B组,35例)和间断短时静脉-静脉血液滤过联合大黄甘草汤组(C组,43例).在常规治疗的基础上,A组加用大黄甘草汤灌胃;B组加用间断短时静脉-静脉血液滤过;C组加用间断短时静脉-静脉血液滤过联合大黄甘草汤灌胃.观察3组患者的心率、呼吸、血压、肝、肾功能,氧合指数,血氧饱和度,血常规,血浆电解质,葡萄糖及C反应蛋白并行A-PACHE Ⅱ评分;所有患者入院时分别于治疗后24、48、96 h取血测苗肿瘤坏死因子α,白细胞介素10水平.结果 治疗后24、48、96 h时,3组患者APACHE Ⅱ评分、肿瘤坏死因子α、白细胞介素10水平比较筹异均有统计学意义(P均 < 0.05);C组患者经治疗后急性肺损伤、胸/腹腔积液、肠麻痹/梗阻、败血症等并发症与A、B组患者比较差异也有统计学意义(P < 0.05).结论 间断短时静脉-静脉血液滤过能大量清除血浆炎症介质,大黄甘草汤能较好地改善胃肠功能,减少并发症,两者早期联合应用能提高其临床疗效.     

不同剂量血液滤过对脓毒性休克并急性肾功能衰竭患者血管活性药物应用的影响

目的 探讨脓毒性休克合并急性肾功能衰竭患者行不同剂量连续性静-静脉血液滤过对血管活性药物应用的影响.方法 20例脓毒性休克合并急性肾功能衰竭患者,按置换液剂量随机分为低剂量组(35 ml·kg-1 ·h-1)和高剂量组(55ml·kg-1·h-1)行连续性静-静脉血液滤过治疗,所有患者治疗前调整血管活性药物(去甲肾上腺素)剂量,使平均动脉压＞ 65 mm Hg(1 mmHg=0.133kPa).比较两组患者0、6、12、24h时去甲肾上腺素用量和平均动脉压水平;比较两组患者连续性静-静脉血液滤过前和治疗24h后氧合指数、乳酸、尿素氮、肌酐、超敏C反应蛋白、降钙素原、急性生理功能和慢性健康状况评分系统Ⅱ评分等指标;并比较两组患者72 h和24h尿量.结果 两组患者年龄、液体输入量、连续性静-静脉血液滤过平均治疗时间、治疗前平均动脉压、去甲肾上腺素用量、氧合指数、乳酸、尿素氮、肌酐、超敏C反应蛋白、降钙素原、急性生理功能和慢性健康状况评分系统Ⅱ评分、尿量比较差异无统计学意义(P＞0.05);治疗开始后两组患者去甲肾上腺素用量均逐渐减少,但差异无统计学意义(P＞0.05).高剂量组患者去甲肾上腺素用量较低剂量组患者减少更迅速,连续性静-静脉血液滤过治疗24h时高剂量组患者去甲肾上腺素总量与低剂量组患者比较差异有统计学意义(P＜0.05).两组患者治疗24h后氧合指数、乳酸、尿素氮、肌酐、超敏C反应蛋白、降钙素原、急性生理功能和慢性健康状况评分系统Ⅱ评分等指标比较差异均有统计学意义(P＜0.05).高剂量组患者超敏C反应蛋白、降钙素原、急性生理功能和慢性健康状况评分系统Ⅱ评分等指标与低剂量组患者比较差异有统计学意义(P＜0.05).低剂量组患者72、24h尿量与高剂量组患者比较略多,但差异无统计学意义(P＞0.05).结论 高剂量组患者经连续性静-静脉血液滤过治疗后,脓毒性休克合并急性肾功能衰竭患者的血管活性药物用量减少,超敏C反应蛋白、降钙素原、急性生理功能和慢性健康状况评分系统Ⅱ评分等指标下降更明显,有助于此类患者早期病情的缓解.     

连续性血液净化治疗在多脏器功能障碍综合征患者中的应用

目的：探讨连续性血液净化(CBP)治疗在多脏器功能障碍综合征(MODS)惠中的疗效。方法：9例伴急性肾衰竭(ARF)的MOD6患，共进行43例次的连续性血液净化治疗，以连续性静脉一静脉血液滤过(CVVH)和连续性静脉—静脉血液透析(CVVHD)为主，根据病情需要加做血浆置换(PE)或血液灌流(HP)。连续性血液净化治疗期间随时监测血压、心率、中心静脉压等生命体征，根据需要检测肾功能、电解质、动脉血气、肝功能等。结果：9例患在连续性血液净化治疗期间，生命体征稳定，血尿素氮、肌酐、血钾等的清除较满意，脱水量均可迭预期目标。连续性血液净化治疗未发生严重副作用。9例患经治疗后2例治愈，1例好转出院，自动出院2例，死亡4例。结论：连续性血液净化是较好的治疗多脏器功能障碍综合征的血液净化方法，在多脏器功能障碍综合征患的抢救中取得了一定的疗效。     

前列地尔联合持续性血液净化对急性肾功能衰竭的疗效影响

目的 探讨前列地尔联合连续性血液净化对急性肾功能衰竭患者肾功能的影响.方法 急性肾功能衰竭患者60例,按随机数字表法分为前列地尔组(30例)和对照组(30例),两组均予以连续性血液净化治疗7d,前列地尔组在此基础上联合前列地尔治疗.记录治疗3、7d后患者的血肌酐、血尿素氮,血尿酸、肌酐清除率、尿量、APACHEⅡ评分....     

连续性静脉-静脉血液滤过在老年多器官功能障碍中的应用

目的观察连续性静脉-静脉血液滤过（continuous venc-venous blood hemofihrition，CVVH）治疗老年多器官功能障碍的疗效，探讨其应用价值。方法回顾性分析2005年5月至2007年11月期间在我院住院发生多器官功能障碍并接受CVVH治疗的危重患者32例。观察治疗过程中血压、血气分析、毒素清除、电解质的波动及APACHEⅡ评分的变化情况。结果治疗开始时APACHEⅡ评分为（20．7±4．30），存活时间超过2周者16例，临床痊愈12例。死亡组患者APACHEⅡ评分为（27．0±4．37），存活组评分为（13．8±3．86）。存活的患者，治疗过程中血压、血气分析等指标逐渐好转，治疗前后比较差异具有统计学意义。8例治疗前休克需要升压药维持血压者，治疗后5例升压药物逐渐减量、停药；合并心衰者治疗过程中心功能稳定；合并急性肾衰竭者17例，其中13例为肺部感染诱发多器官功能障碍综合征（MODS），治疗过程中内环境稳定，治疗后尿量均有不同程度好转，最终因病原菌耐药8例死亡、1例肾功能未恢复转变为慢性肾功能不全；治疗过程中未发生血液净化治疗相关的严重并发症。结论连续性静脉-静脉血液滤过是老年多器官障碍治疗中有效的辅助手段，可明显改善患者预后。     

双侧上尿路结石并发肾功能不全术后急性肾衰的处理

目的：探讨治疗双侧上尿路结石并发肾功能不全术后急性肾衰的方法。方法：对54例双侧上尿路结石并发肾功能不全术后急性肾功能衰竭（ARF）患者的治疗方法进行回顾性分析,根据不同病情分别行急诊输尿管镜碎石（URL）和输尿管逆行插管或经皮肾造瘘（PCN）后二期碎石。所有病例监测血肌酐（Cr）和尿素氮（BUN）。结果：术后全部患者血Cr和BUN进行性下降,恢复到正常43例,氮质血症6例,尿毒症4例,死亡1例。结论：双侧上尿路结石并发肾功能不全应早期诊断,选择恰当的外科治疗时机和方法,一旦术后出现ARF,要立即明确原因,进行治疗。     

Prevention of tumor lysis syndrome using continuous veno-venous hemofiltration

Tumor lysis syndrome (TLS) and renal failure remain significant causes of morbidity and mortality in children with newly diagnosed Burkitt's lymphoma and high white blood cell count acute lymphocytic leukemia (ALL) despite conventional management with aggressive hydration, alkalinization, allopurinol, and the slow introduction of chemotherapy. A subgroup of patients at very high risk for TLS and renal failure can be identified based on the level of serum lactate dehydrogenase (LDH) and urine output. We evaluated the prospective use of continous veno-venous hemofiltration (CVVH), in addition to conventional management to prevent renal failure from tumor lysis, in three children with advanced abdominal Burkitt's lymphoma and in two children with high white blood cell count T-cel ALL who were at very high risk based on LDH and urine output. In this cohort of very highrisk patients, the LDH ratio (value at diagnosis/upper limit of normal) ranged from 0.88 to 10.3 and urine output from 0.13 to 4.7 ml/kg per hour. CVVH was begun at a mean time of 10.5 h before chemotherapy was initiated. Full-dose induction chemotherapy was begun within 24 h of diagnosis. After beginning CVVH, the uric acid levels decreased 46% prior to beginning chemotherapy and decreased to a mean of 4.2 mg/dl 24 h after chemotherapy was initiated. Four of the five patients had either no change or a drop in the serum creatinine. In patient one, blood urea nitrogen peaked at 58 mg/dl, and the creatinine at 4.7 mg/dl 6 days after beginning chemotherapy with a subsequent return to normal. Asymptomatic hypokalemia developed in all patients. After beginning chemotherapy, CVVH was continued for a mean of 85 h (range 70–91 h). No patient had complications secondary to CVVH. In summary, CVVH prevented renal failure secondary to TLS in 80% of these very high-risk patients. In the fifth patient, CVVH allowed full-dose chemotherapy to continue. The prospective use of CVVH could potentially decrease the morbidity and mortality associated with induction chemotherapy in very high-risk patients with a large tumor burden.     

Adequacy Indices for Dialysis in Acute Renal Failure: Kinetic Modeling

Many aspects of the management of renal replacement therapy in acute renal failure (ARF), including the appropriate assessment of dialysis adequacy, remain unresolved, because ARF patients often are not in a metabolic steady state. The aim of this study was to evaluate a system of adequacy indices for dialysis in ARF patients using urea and creatinine kinetic modeling. Kinetic modeling was performed for two different fictitious patients (A and B) with characteristics described by the average parameters for two patient groups and for two blood purification treatments: sustained low efficiency daily dialysis (SLEDD) in Patient A and continuous venovenous hemofiltration (CVVH) in Patient B, based on data from a clinical report. Urea and creatinine generation rates were estimated according to the clinical data on the solute concentrations in blood. Then, using estimated generation rates, two hypothetical treatments were simulated, CVVH in Patient A and SLEDD in Patient B. KT/V, fractional solute removal (FSR) and equivalent renal clearance (EKR) were calculated according to the definitions developed for metabolically unstable patients. CVVH appeared as being more effective than SLEDD because KT/V, FSR, and EKR were higher for CVVH than SLEDD in Patients A and B. Creatinine KT/V, FSR, and EKR were lower and well correlated to the respective indices for urea. Urea and creatinine generation rates were overestimated more than twice in Patient A and by 30–40% in Patient B if calculated assuming the metabolically stable state than if estimated by kinetic modeling. Adequacy indices and solute generation rates for ARF patients should be estimated using the definition for unsteady metabolic state. EKR and FSR were higher for urea and creatinine with CVVH than with SLEDD, because of higher K·T and minimized compartmental effects for CVVH.     

肝移植术患者术后早期并发急性肾功能衰竭的危险因素

目的 分析肝移植术患者术后早期并发急性肾功能衰竭(ARF)的危险因素.方法 择期行肝移植术的终末期肝病患者60例,年龄28～64岁,术前血清肌酐和尿素未见异常.根据术后24h内是否发生ARF,分为2组:ABF组与非ARF组(NARF组).可能的危险因素进行组间比较后,将差异有统计学意义的因素进行logistic回归分析,筛选发生ARF的危险因素.结果 logistic回归分析结果显示,术前血β1-微球蛋白高于正常值、术中持续性低血压与术后早期并发ABF有关(P＜0.05).结论 肝移植术患者术前血β2-微球蛋白高于正常值和术中发生持续性低血压是术后早期并发ABF的危险因素.     

Etiology, incidence, and prognosis of renal failure following cardiac operations. Results of a prospective analysis of 500 consecutive patients.

A prospective study of 500 consecutive patients surviving the first 24 hours following cardiac surgical procedures was undertaken to determine the prevalence, etiology and results of therapy for postoperative acute renal failure (ARF). Thirty-five patients developed either moderate or severe ARF and an additional 102 developed mild preprenal azotemia. Positive risk factors noted inthe development of postoperative renal failure included age, elevated preoperative concentrations of blood urea nitrogen (BUN), serum creatinine, and decreased 24 hour urine creatinine clearance. The duration of cardiopulmonary bypass (CPB), aortic cross-clamping, and the total duration of the operation also closely correlated with the incidence of ARF. In the early postoperative period, clinical assessment of hemodynamic change was most helpful in predicting postoperative ARF. Significant negative risk factors included type of operation performed, New York Heart Association classification, the use of preoperative diuretic therapy, and associated other chronic illnesses. During the operation itself, the lowest and mean blood pressures, flow rates on CPB and the presence of hemoglobinuria failed to correlate with subsequent ARF. The mortality rate for established ARF was extremely poor (88.8 per cent), and there were no survivors among those requiring dialysis. ARF following cardiac surgery is a highly lethal complication which arises in a setting of inadequate cardiac function and is associated with a multiple organ system failure. Therapy of this postoperative complication, therefore, appears to be better directed toward its prevention rather than treatment once established.     

Continuous renal replacement therapy: does technique influence azotemic control?

BACKGROUND AND OBJECTIVES: Different techniques of continuous renal replacement therapy (CRRT) might have different effects on azotemic control. Accordingly, we tested whether continuous veno-venous hemodiafiltration (CVVHDF) or continuous veno-venous hemofiltration (CVVH) would achieve better control of serum creatinine and plasma urea levels. DESIGN: Retrospective controlled study. SETTING: Two tertiary Intensive Care Units. PATIENTS: Critically ill patients with acute renal failure (ARF) treated with CVVHDF (n = 49) or CVVH (n = 50). Interventions: Retrieval of daily morning urea and creatinine values before and after the initiation of CRRT for up to 2 weeks of treatment. MEASUREMENTS AND RESULTS: Before treatment, serum urea and creatinine concentrations were significantly lower in the CVVH group than in CVVHDF group (urea: 31.0 +/- 15.0 mmol/L for CVVHDF and 24.7 +/- 16.1 mmol/L for CVVH, p = 0.01, creatinine: 547 +/- 308 micromol/L vs. 326 +/- 250 micromol/L, p < 0.0001). These differences were still significant after 48 h of treatment (urea: 20.1 +/- 8.3 mmol/L vs. 14.1 +/- 6.1 mmol/L; p = 0.0003, creatinine: 360 +/- 189pmol/L vs. 215 +/- 118 micromol/L; p < 0.0001). Throughout the duration of therapy, mean urea levels (22.3 +/- 9.0 mmol/L for CVVHDF vs. 16.7 +/- 7.8 mmol/L for CVVH, p < 0.0001) and mean creatinine levels (302 +/- 167 vs. 211 +/- 103 micromol/L, p < 0.0001) were better controlled in the CVVH group. CONCLUSIONS: CRRT strategies based on different techniques might have a significantly different impact on azotemic control.     

Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure.

OBJECTIVE: The application and timing of hemofiltration (continuous veno-venous hemofiltration, CVVH) in patients with acute renal failure (ARF) post cardiac surgery has been called into question because of uncertain short-term outcome. The aim of the present study was to identify how the timing of introduction of hemofiltration affects the morbidity and mortality in patients with ARF after cardiac surgery. METHODS: 1264 consecutive patients who underwent adult cardiac surgical procedures performed between January 2002 and January 2003 were audited. Out of these, case notes of 64 patients who required renal supportive intervention were reviewed. Statistical significance was accepted at a level of P<0.05. RESULTS: Of the 64 (5%) patients, who developed ARF and required CVVH, there were 48 males and 16 females. Mean age was 70+/-6.8 years. The hospital mortality was 43% (12 patients) in Group-I and 22% (8) in Group-II (P<0.05), giving an overall 1.5% mortality associated with ARF. The mean time between the operation and the initiation of CVVH was 2.55+/-2.2 days in Group-I and 0.78+/-0.2 days in Group-II (P<0.001). The mean duration of CVVH was 4.57+/-11.4 days in Group-I and 4.61+/-2.0 days in Group-II (P=NS). Older age (P=0.013), elevated preoperative creatinine (P=0.002), postoperative pulmonary oedema (P=0.01), sepsis (P=0.001), multiple organ failure (P=0.031), hypotension (P=0.031) and preoperative renal failure (P<0.05) were the independent factors influencing the poor postoperative outcome and cardiac instability. CONCLUSION: Early and aggressive use of CVVH is associated with better than expected survival in severe ARF after cardiac operations.     

肝移植术后腹内高压与急性肾功能衰竭的关系

目的探讨肝移植术后腹内高压（IAH）与急性肾功能衰竭（ARF）的关系。方法回顾分析62例肝移植患者的临床相关资料，确定ARF的诊断标准；采用膀胱内压检测法间接测量腹内压，术后前3d内每天腹内压超过20mmHg者为IAH，比较IAH组与非IAH组在术后3d的腹内压值和血清肌酐、尿素氮水平及肾小球滤过梯度、每小时尿量以及平均动脉压的变化。采用多元相关性分析、Logistic回归方法分析肝移植术后ARF发生的相关危险因素。结果IAH组24例患者中，11例（45．800）发生ARF，术后前3d肾小球滤过梯度显著降低．血清肌酐和尿素氮的水平显著升高，每小时尿量显著减少；非1AH组38例患者中，仅有3例（7．9％）发生ARF，两组比较，差异有统计学意义（P〈0．05）。多元相关性分析提示，患者年龄≥60岁、术中输血量≥3000ml、术中MAP降低、术后IAH、感染、急性肺损伤等与肝移植术后ARF的发生明显相关；回归分析提示，术中输血量≥3000ml、术中MAP降低、术后IAH是ARF发生的独立危险因素；多元逐步回归分析显示，术中输血量≥3000ml、术中MAP降低及术后IAH是ARF发生的高度危险因素。结论IAH是ARF发生的独立高度危险因素；严密监测术后腹内压的变化，对预防与减轻ARF具有较重要的临床意义。