[摘要] 目的 觀察日間連續(xù)性靜脈-靜脈血液濾過(CVVH)用于高齡老年重癥急性腎功能衰竭(ARF)伴多器官功能衰竭(MOF)患者中的臨床療效以及治療并發(fā)癥的情況。方法 回顧性分析我院接受日間CVVH治療的46例ARF患者的臨床資料，年齡80~101(85.6±5.5)歲，觀察CVVH的療效及治療過程中血壓、心率等生命體征，監(jiān)測治療前后血尿素氮、肌酐、電解質(zhì)、動(dòng)脈血?dú)庾兓瑫r(shí)觀察CVVH治療中并發(fā)癥情況。結(jié)果 所有患者對(duì)CVVH治療均耐受良好，治療過程中血壓、心率平穩(wěn)，血流動(dòng)力學(xué)穩(wěn)定。與治療前相比較，血尿素氮、肌酐顯著下降(P<0.05)，電解質(zhì)紊亂、酸中毒得到糾正。46例患者中存活時(shí)間超過2周者34例(73.9%)，3例腎功能恢復(fù)正常。治療中技術(shù)相關(guān)并發(fā)癥發(fā)生率低，其中4例出現(xiàn)導(dǎo)管相關(guān)性感染，10例并發(fā)出血，經(jīng)積極處理后好轉(zhuǎn)。結(jié)論 高齡老年人應(yīng)用日間CVVH救治ARF伴MOF是安全有效的，良好的內(nèi)環(huán)境、穩(wěn)定的血流動(dòng)力學(xué)有助腎功能的恢復(fù)。CVVH并發(fā)癥少，是救治高齡ARF的首選治療手段。
[關(guān)鍵詞] 連續(xù)性靜脈-靜脈血液濾過；急性腎衰竭；老年人
Daytime continuous venovenous hemofiltration treatment of acute renal failure complicated with multiple organ failure in 46 very elderly patients
YAN Zhenwen,SUN Jianshe,YE Zhibin，et al.
Department of Nephrology，Huadong Hospital，Shanghai 200040，China
[Abstract] Objective To observe the efficacy of daytime continuous venovenous hemofiltration ( CVVH) in the treatment of elderly patients with severely acute renal failure.The complications during CVVH were also recorded.Methods The clinical data including blood pressure，heart rate，BUN,Scr，electrolyte，arterial blood gas of fortysix elderly patients aged 80~101 years ( average age was 85.6±5.5 years) with ARF and MOF treated with CVVH were analyzed.The complications were observed during CVVH. Results CVVH was well tolerated in all of the patients.During the period of treatment，the blood pressure，heart rate and haemodynamic were maintained in a steady state.Both blood urea nitrogen and serum creatinine were significantly decreased，compared with those before treatment (P<0.05).Electrolyte disorder and acidosis were improved.Of these 46 patients，34 patients(73.9% )survived over two weeks after CVVH，and renal function recovered finally in 3 patients.The main complications included bleeding in 10 and catheter related infection in 4 cases.Conclusion CVVH is safe and effective to the highelderly patients with ARF complicated with MOF.The complication rate was low.CVVH might be the method of choice for these old patients.
[Key words] continuous venovenous hemofiltration；acute renal failure；the elderly
隨著社會(huì)老齡化，老年急性腎衰竭(ARF)的發(fā)病率逐漸增高，70歲以上患者占全部ARF的72%[1]。老年重癥ARF的合并癥多、病死率高、治療難度大。連續(xù)性血液凈化治療以其不同于傳統(tǒng)間斷性血液透析的優(yōu)勢，越來越多地應(yīng)用于重癥ARF、MOF、SIRS等危重患者的救治。但國內(nèi)外有關(guān)該技術(shù)在超高齡ARF伴MOF患者中應(yīng)用的研究甚為罕見。現(xiàn)就我院2000年3月以來應(yīng)用日間CVVH治療46例老年重癥ARF做一回顧性分析。
1 資料與方法
1.1 一般資料
46例老年重癥ARF患者，男41例，女5例；年齡80~101歲，平均(85.6±5.5)歲，80~89歲33例，90歲以上12例，100歲以上1例。所有患者均為重癥ARF：(1)無腎臟病疾患者，SCr≤310 μmol/L和(或)BUN≥36 mmol/L;(2)原有腎功能不全者，SCr和(或)BUN水平在原來基礎(chǔ)上增加100%。46例患者最終均合并多臟器功能衰竭(MOF)，器官衰竭數(shù)目均在3個(gè)以上，其中心衰發(fā)生率84.8%，呼吸衰竭發(fā)生率56.5%。呼吸機(jī)輔助通氣26例，30例使用升壓藥物。其原發(fā)病及治療前并發(fā)癥見表1。CVVH前24 h尿量<100 ml 10例，<400 ml 21例，>400 ml 15例，平均血尿素氮(34.3±16.4)mmol/L，血肌酐(532.0±131.9)μmol/L。表1 原發(fā)病及治療前合并癥(略
1.2 治療方法
全部患者經(jīng)股靜脈或頸內(nèi)靜脈留置雙腔導(dǎo)管建立臨時(shí)血管通路，采用Fresenius ADM08TM /ABMTM CRRT機(jī)行日間CVVH，血流量150~200 ml/min。血濾器采用Fresenius AV600或F60，聚砜膜，膜面積1.3 m2。置換液：血液濾過置換液(上海長征富民藥業(yè)有限公司)，各種離子成分分別為：Na+135 mmol/L，K+2.0 mmol/L，Cl108.5 mmol/L，Ca2+1.875 mmol/L，Mg2+0.75 mmol/L，乳酸33.75 mmol/L，pH 5.0~7.0。置換液2.5~3.0 L/h，每天用量12~ 40 L，采用后稀釋法輸入，有出血傾向患者采用前稀釋法輸入。5%碳酸氫鈉從外周靜脈同步輸入。每日治療時(shí)間5~14 h，治療頻率每周2~7次，總治療時(shí)間2周~19個(gè)月。采用低分子肝素鈉(法安明)抗凝，5000~10000 u/次，有嚴(yán)重出血傾向者:濾器和管路在使用前以肝素鈉12500 u加入生理鹽水500 ml預(yù)充后，生理鹽水再次沖洗管路，采用無肝素法，前置法每30~60 min用置換液100~200 ml沖洗濾器。
1.3 觀測指標(biāo)
(1)CVVH治療前后臨床癥狀。(2)血液生化指標(biāo)：腎功能，電解質(zhì)和動(dòng)脈血?dú)狻?3)心電監(jiān)護(hù)心律、心率、血壓。(4)治療相關(guān)并發(fā)癥。
1.4 統(tǒng)計(jì)學(xué)方法
數(shù)值采用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示。以P<0.05為差異有顯著性。治療前后比較采用配對(duì)t檢驗(yàn)。
2 結(jié)果
2.1 治療效果 見表2。
2.1.1 溶質(zhì)清除
46例患者接受CVVH治療前后72 h，死亡前，溶質(zhì)(BUN，SCr)對(duì)比顯示其有很好的清除效果。對(duì)血鉀清除明顯(P<0.05)，pH和HCO3-改變差異有顯著性(P<0.05)，酸中毒治療后皆有不同程度改善。
[關(guān)鍵詞] 連續(xù)性靜脈-靜脈血液濾過；急性腎衰竭；老年人
Daytime continuous venovenous hemofiltration treatment of acute renal failure complicated with multiple organ failure in 46 very elderly patients
YAN Zhenwen,SUN Jianshe,YE Zhibin，et al.
Department of Nephrology，Huadong Hospital，Shanghai 200040，China
[Abstract] Objective To observe the efficacy of daytime continuous venovenous hemofiltration ( CVVH) in the treatment of elderly patients with severely acute renal failure.The complications during CVVH were also recorded.Methods The clinical data including blood pressure，heart rate，BUN,Scr，electrolyte，arterial blood gas of fortysix elderly patients aged 80~101 years ( average age was 85.6±5.5 years) with ARF and MOF treated with CVVH were analyzed.The complications were observed during CVVH. Results CVVH was well tolerated in all of the patients.During the period of treatment，the blood pressure，heart rate and haemodynamic were maintained in a steady state.Both blood urea nitrogen and serum creatinine were significantly decreased，compared with those before treatment (P<0.05).Electrolyte disorder and acidosis were improved.Of these 46 patients，34 patients(73.9% )survived over two weeks after CVVH，and renal function recovered finally in 3 patients.The main complications included bleeding in 10 and catheter related infection in 4 cases.Conclusion CVVH is safe and effective to the highelderly patients with ARF complicated with MOF.The complication rate was low.CVVH might be the method of choice for these old patients.
[Key words] continuous venovenous hemofiltration；acute renal failure；the elderly
隨著社會(huì)老齡化，老年急性腎衰竭(ARF)的發(fā)病率逐漸增高，70歲以上患者占全部ARF的72%[1]。老年重癥ARF的合并癥多、病死率高、治療難度大。連續(xù)性血液凈化治療以其不同于傳統(tǒng)間斷性血液透析的優(yōu)勢，越來越多地應(yīng)用于重癥ARF、MOF、SIRS等危重患者的救治。但國內(nèi)外有關(guān)該技術(shù)在超高齡ARF伴MOF患者中應(yīng)用的研究甚為罕見。現(xiàn)就我院2000年3月以來應(yīng)用日間CVVH治療46例老年重癥ARF做一回顧性分析。
1 資料與方法
1.1 一般資料
46例老年重癥ARF患者，男41例，女5例；年齡80~101歲，平均(85.6±5.5)歲，80~89歲33例，90歲以上12例，100歲以上1例。所有患者均為重癥ARF：(1)無腎臟病疾患者，SCr≤310 μmol/L和(或)BUN≥36 mmol/L;(2)原有腎功能不全者，SCr和(或)BUN水平在原來基礎(chǔ)上增加100%。46例患者最終均合并多臟器功能衰竭(MOF)，器官衰竭數(shù)目均在3個(gè)以上，其中心衰發(fā)生率84.8%，呼吸衰竭發(fā)生率56.5%。呼吸機(jī)輔助通氣26例，30例使用升壓藥物。其原發(fā)病及治療前并發(fā)癥見表1。CVVH前24 h尿量<100 ml 10例，<400 ml 21例，>400 ml 15例，平均血尿素氮(34.3±16.4)mmol/L，血肌酐(532.0±131.9)μmol/L。表1 原發(fā)病及治療前合并癥(略
1.2 治療方法
全部患者經(jīng)股靜脈或頸內(nèi)靜脈留置雙腔導(dǎo)管建立臨時(shí)血管通路，采用Fresenius ADM08TM /ABMTM CRRT機(jī)行日間CVVH，血流量150~200 ml/min。血濾器采用Fresenius AV600或F60，聚砜膜，膜面積1.3 m2。置換液：血液濾過置換液(上海長征富民藥業(yè)有限公司)，各種離子成分分別為：Na+135 mmol/L，K+2.0 mmol/L，Cl108.5 mmol/L，Ca2+1.875 mmol/L，Mg2+0.75 mmol/L，乳酸33.75 mmol/L，pH 5.0~7.0。置換液2.5~3.0 L/h，每天用量12~ 40 L，采用后稀釋法輸入，有出血傾向患者采用前稀釋法輸入。5%碳酸氫鈉從外周靜脈同步輸入。每日治療時(shí)間5~14 h，治療頻率每周2~7次，總治療時(shí)間2周~19個(gè)月。采用低分子肝素鈉(法安明)抗凝，5000~10000 u/次，有嚴(yán)重出血傾向者:濾器和管路在使用前以肝素鈉12500 u加入生理鹽水500 ml預(yù)充后，生理鹽水再次沖洗管路，采用無肝素法，前置法每30~60 min用置換液100~200 ml沖洗濾器。
1.3 觀測指標(biāo)
(1)CVVH治療前后臨床癥狀。(2)血液生化指標(biāo)：腎功能，電解質(zhì)和動(dòng)脈血?dú)狻?3)心電監(jiān)護(hù)心律、心率、血壓。(4)治療相關(guān)并發(fā)癥。
1.4 統(tǒng)計(jì)學(xué)方法
數(shù)值采用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示。以P<0.05為差異有顯著性。治療前后比較采用配對(duì)t檢驗(yàn)。
2 結(jié)果
2.1 治療效果 見表2。
2.1.1 溶質(zhì)清除
46例患者接受CVVH治療前后72 h，死亡前，溶質(zhì)(BUN，SCr)對(duì)比顯示其有很好的清除效果。對(duì)血鉀清除明顯(P<0.05)，pH和HCO3-改變差異有顯著性(P<0.05)，酸中毒治療后皆有不同程度改善。