连续性血液净化治疗糖尿病肾病酮症酸中毒合并急性肾损伤临床分析

目的观察连续性血液净化(continuous blood purification,CBP)治疗糖尿病肾病酮症酸中毒合并急性肾损伤(acute kidney injury,AKI)的临床疗效。方法回顾性分析四川大学华西医院2008～2011年期间收治的16例2型糖尿病肾病(diabetic nephropathy,DN)合并酮症酸中毒(diabetic ketoacidosis,DKA)的AKI患者。患者一经确诊在常规治疗的基础上均采用持续性静-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)的干预方式,治疗时间不少于48h,观察患者治疗前后各项临床及生化指标的变化及AKI的临床转归。结果 16例AKI患者中1例入院10h后经抢救无效死亡,其余15例患者经CVVH治疗12h后二氧化碳结合力(carbondioxide combining power,CO2CP)显著提高(P<0.01),动脉血pH值改善;治疗48h后不仅降低了血尿素氮(BUN)(P<0.05)、血肌酐(SCr)(P<0.05)、血糖(Glu)(P<0.01)、血钾(K+)(P<0.01),还改善了血液高渗透压状态(P<0.05),从而有效纠正患者的酮症酸中毒;16例AKI患者中有11例均在入院(12±5)d后进入多尿期,(18±12)d后肾功能恢复。结论糖尿病肾病酮症酸中毒合并AKI属临床危重症,早期积极的CVVH干预治疗可稳定血流动力学、迅速改善内环境、为补液及营养支持及后续的药物治疗创造条件,能获得满意疗效。

Continuous blood purification therapy on 16 patients with diabetic ketoacidosis and acute kidney injury

Objective To determine the effectiveness of Continuous blood purification(CBP) therapy on diabetic ketoacidosis(DKA) and acute kidney injury(AKI) in diabetic nephropathy(DN) patients.Methods Sixteen DN patients who developed severe DKA and AKI between 2008 and 2011 in the West China Hospital were recruited.All of the recruited patients presented with severe metabolic acidosis,electrolyte disturbance and dehydration.In addition to routine treatments,continuous venovenous hemofiltration(CVVH) was performed for at least 48 h with Baxter Accura or B.Braun Diapact CRRT machine and B.Braun Diacap Acute M hemofilter.Hemofiltration was accomplished using predilution bicarbonate replacement fluid at the rate of 3 000 mL/h and citrate or low-molecular weight heparin(LMWH) for anticoagulation,with blood flow rates of 180 to 250 mL/min.Results One patient died unexpectedly 10 h after admission to hospital.The other fifteen patients had significant improvements in metabolic acidosis index after 12 hours of CVVH therapy,such as an average increase of 7.21±0.07 carbon dioxide combining power(CO2CP)and improvement of arterial PH.The blood urea nitrogen(BUN),serum creatinine(SCr),serum glucose(Glu),serum potassium(K+) and bloodosmotic pressure of the 15 patients decreased significantly after 48 hours of CVVH therapy.Eleven cases entered into diuretic phase and had renal functions recovered(12±5) d and(18±12) d after admission to the hospital,respectively.Conclusion CVVH therapy as an early intervention can bring significant benefits to DN patients with DKA and AKI.Early institution of CVVH therapy may be considered not only for treating uremia and fluid retention but also for correcting metabolic abnormalities like metabolic acidosis.