连续性静静脉血液滤过治疗的置换液剂量对危重急性肾损伤患者预后的影响

目的探讨连续性静脉静脉血液滤过(continuous veno-venous hemofiltration,CVVHF)治疗中置换液剂量对危重急性肾损伤患者预后的影响。方法所有患者资料均来源于上海市医学发展基金重点研究课题《急性肾衰竭的早期发现与防治》数据库。选取数据库中发生急性肾损伤,并进行CVVHF治疗且置换液量30ml/(kg·h)的患者74例,其中男性48例,女性26例,年龄(55.8±17.7)岁(19～87岁)。将患者分成两组:①CVVHF-A组(37例):置换液剂量为30～40ml/(kg·h);②CVVHF-B组(37例):置换液剂量40ml/(kg·h)。观察两组患者透析前后生命体征及血生化指标的变化,同时在治疗前、治疗第4d和治疗结束后用急性生理学与慢性健康状况评分(acute physiology and chronic health evaluation,APACHE)Ⅱ评估疾病严重性,评估两组患者在30d和60d时的患者生存率和肾存活率,观察不同置换液剂量对急性肾损伤患者预后的影响。结果两组患者的基础情况包括性别、年龄、一周内手术史、慢性肾脏疾病史、糖尿病史和肾功能以及治疗前的血气分析、肾功能、心率、平均动脉压(mean arterial pressure,MAP)、尿量、多器官功能障碍综合征和全身炎症反应综合征发生率、APACHEⅡ评分均相匹配(P0.05)。CVVHF-A组患者的平均置换液量为(33.4±3.3)ml/(kg·h),CVVHF-B组患者的平均置换液剂量为(53.2±8.5)ml/(kg·h),两组相比差异有统计学意义(P0.001)。单次CVVHF治疗后患者的血PH、HCO3-、K+、尿素氮和肌酐均较治疗前显著改善(P0.05),而心率、MAP和Na+在治疗前后差异均无统计学意义(P0.05)。Kaplan-Meier生存曲线分析结果显示CVVHF-A组患者30d和60d的生存率分别为48.7%和40.5%;CVVHF-B组患者30d和60d的生存率分别为56.8%和48.6%,Log-Rank检验显示两组生存率差异均无统计学意义(P=0.724)。肾存活与患者存活结果相似。结论在危重急性肾损伤患者中应用CVVHF治疗时,30ml/(kg·h)以上的置换液剂量可以显著纠正代谢性酸中毒,改善肾功能,而对血液动力学影响不大。40ml/(kg·h)以上的置换液剂量与30～40ml/(kg·h)的剂量相比并未显示出更多的优势。

The effect of substitution fluid rate on the prognosis of critical acute kidney injury patients treated with continuous veno-venous hemorfltration therapy

Objective To investigate the effect of substitution fluid rate on the prognosis of critical acute kidney injury （AKI） patients treated with continuous vend-venous hemofiltration therapy （CVVHF）. Method Patients＇ data were obtained from the Early Detection and Prevention of Acute Renal Failure Database funded by Shanghai Medical Development Foundation. A total of 74 patients （48 males and 26 females） treated with CVVHF using fluid substitution rate 〉30ml/kg/hr were collected. They were 19-87 years old with the mean age of 55.8 ± 17.7years old. Patients were divided based the on substitution fluid rate into two groups, group CVVHF-A （substitution fluid rate 30-40ml/kg/hr, n=37） and group CVVHF-B （substitution fluid rate 〉40ml/kg/hr, n=37）. Their vital signs, biochemical parameters, and APACHE II score at pre-treatment, the fourth day during the treatment and post-treatment were also recorded. We then compared patient survival rate and renal survival rate after 30 days and 60 days between the two groups. Result Before the treatment, the two groups were similar in sex, age, renal function, blood gas parameters, heart rate, mean arterial blood pressure, urinary output, APACHE II score, and the incidences of surgery in a week, chronic kidney disease, multiple organ dysfunction and systemic inflammatory response syndrome （SIRS） （≥0.05）. The substitution fluid rate was significantly higher in CVVH-B group （53.2 ±8.5ml/kg/hr） than in CVVHF-A group （33.4 ± 3.3ml/kg/hr, P〈0.001）. In patients after one session of CVVHF, serum K＋, BUN and Scr decreased （P〈0.05）, and pH and HCO3- increased （P〈0.05）, but without significant changes in hear rate, mean blood pressure and serum Na~ （P〈0.05）. Kaplan-Meier sur- vival analysis showed that the patient survival rate in group CVVHF-A and CVVHF-B was 48.7% and 56.8%, respectively, after 30 days, and was 40.5% and 48.6%, respectively, after 60 days （P=0.724）. Therefore, no significant difference in patient survival rate was found between the two groups. Renal survival rate was also similar in the two groups. Conclusion CVVHF using substitution fluid rate 〉30ml/kg/hr was suitable for the improvement of metabolic acidosis, renal function and hemodynamic stability in critical AKI patients. CVVHF using substitution fluid rate 〉40ml/kg/hr may not further improve their prognosis.