连续性血液净化治疗心血管术后急性肾功能衰竭的时机探讨

目的 探讨连续性血液净化(CBP)治疗心血管术后急性肾功能衰竭(ARF)的疗效.方法 将入选病人按CBP实施前的病情严重程度分为全身炎症反应综合征(SIRS)组13例,多器官功能障碍(MODS)组12例;进行APACHEⅢ评分及常规检测血尿素氮(BUN)和血肌酐(Scr)水平,同时采用放射免疫分析法检测病人血浆中炎症介质白细胞介素(IL)6、肿瘤坏死因子8、(TNF-α)水平.结果 CBP实施24 h后APACHEⅢ评分、血BUN、血Scr,IL-6、8、TNF-α,均较CBP实施前显著降低(分别为(61±15)vs(81±20),(19±5)mml/L vs(26±5)mmoVL,(312±87)/μmol/L vs(458±107)μmol/L,(544±154)ng/L vs(842±132)ng/L,(18±7)ng/L vs(25±8)ng/L,(43±15)ng/L vs(59±17)ng/L].SIRS、MODS组病人的存活率分别为84.62%、41.67%(P<0.05);CBP实施前和实施24 h后MODS组ARF病人的APACHEⅢ评分、血BUN、血Scr,血清IL6、IL-8均显著高于SIRS组.结论 APACHEⅢ评分为60～90分时可能是心血管术后发生ARF实施CBP治疗的较理想时机.

Opportunity for treatment of acute renal failure after cardiac vascular operation using continuous blood purification

Objective To evaluate the effect and timing of continuous blood purification (CBP) in treatment of acute renal failure (ARF) following cardiac-vascular surgery. Methods Twenty-five patients with ARF following cardiac-vascular surgery were divided into systematic inflammatory response syndrome (SIRS) Group (n = 13) and multiple organ dysfunction syndrome (MODS) Group (n = 12) according to the illness state prior to CBP and were divided into Group A (n = 5, with the APACHE Ⅲ score prior to CBP≤60), Group B (n = 9, with the APACHE Ⅲ score 61 - 90), and Group C (n = 11, with the APACHE Ⅲ score 90 ) . All of the 25 patients underwent continuous veno-venous hemofiltration (CVVH). Before and 24h after the CVVH APACHEⅢ score was calculated and peripheral; blood samples were collected to detect the levels of blood urea nitrogen (BUN) and serum creatinine (Scr) and the plasma levels of interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-or (TNF-α). Results The APACHEⅢ score, BUN, Scr, IL-6, IL-8, and TNFα 24 h after the CBP of the 25 patients were 61±15 retool/L, (19±5) mmol/L, (312±87) μmol/L, (544±154) ng/L, (18±7) ng/L, and( 43±15 )ng/ L respectively, all significantly lower than those before CBP (81±20, 26± mmol/L, 458 ± 107 μmol/L, ( 842 ± 132) ng/L, (25 ± 8) ng/L, and (59 ± 17 ) ng/L respectively, all P =0.000). The survival rate of SIRS Group was 84.62%, significantly higher than that of MODS Group (41.67%, P < 0.05 ). The APACHEⅢ score, and the levels of BUN, Ser, IL-6, IL-8, and TNF-α of Group MODS were significantly higher than those of Group SIRS. The higher the level of Scr, IL-6, IL-8, and TNF-α and the APACHEⅢ score the lower the survival rate. Conclusion CBP has a positive effect on ARF following cardiac-vascular surgery. The APACHEⅢ score 60 to 90 reflects an opportunity to treat the ARF following cardiac-vascular surgery using CBP.