不同连续性肾脏替代治疗模式及其剂量对脓毒症合并急性肾损伤患者溶质清除效果的研究

摘要

目的：观察不同连续性肾脏替代治疗（CRRT）模式及其剂量对脓毒症合并急性肾损伤（ AKI）患者的溶质清除效果。方法选取2013年12月—2014年12月河北医科大学第四医院重症医学科（ICU）收治的符合纳入与排除标准的脓毒症合并 AKI 患者23例为研究对象。采用随机数字表法将患者分为连续性静脉-静脉血液滤过（CVVH）组（14例）和连续性静脉-静脉血液透析滤过（CVVHDF）组（9例）。两组均使用100%前稀释，处方废液剂量（Kp）设置为40.00 ml·kg -1·h -1，其中 CVVHDF 组置换液流速与透析液流速相同。抗凝方案的选择依据患者凝血功能由临床医师决定。收集患者一般资料，计算 CRRT 剂量〔包括 Kp、校正剂量（Kpc）、交付剂量（Kd）、实际溶质清除剂量（K）〕。记录患者处方 CRRT 时间、实际 CRRT 时间、机械通气时间、住 ICU 时间、总住院时间、28 d病死率。结果两组患者 Kp 比较，差异无统计学意义（P >0.05）；CVVHDF 组患者 Kpc、Kd、KCr大于 CVVH 组（P<0.05）。CVVH 组、CVVHDF 组患者 Kpc、Kd、KCr小于 Kp，Kd、KCr小于 Kpc，KCr小于 Kd（P <0.05）。CVVHDF 组患者 Kβ2- M、KIL-6、KIL-8小于 CVVH 组（P <0.05）。两组患者处方 CRRT 时间、实际 CRRT 时间、机械通气时间、住ICU 时间、总住院时间、28 d 病死率比较，差异无统计学意义（P >0.05）。结论不同 CRRT 模式下 CRRT 剂量均被高估；Kp 相同的情况下，不同 CRRT 模式均能有效清除炎性因子，且患者预后无差异，但 CVVHDF 对小分子溶质的清除率优于 CVVH，而 CVVH 对中大分子溶质的清除率优于 CVVHDF。%Objective To observe the effect of different modes of continuous renal replacement therapy(CRRT)on the solute clearance of patients with sepsis - induced acute kidney injurt(AKI). Methods We enrolled 23 patients with sepsis- induced AKI who were hospitalized in the intensive - care unit of the Fourth Hospital of Hebei Medical University from December 2013 to December 2014. The patients were randomly divided into continuous venous - venous hemofiltration(CVVH) group with 14 patients and continuous venovenous hemodiafiltration(CVVHDF)group with 9 patients by random number table method. Both groups used 100 % pre - dilution,and Kp was prepared as 40. 00 ml·kg - 1 ·h - 1. The fluid displacement velocity and dialyzate velocity of CVVHDF group were the same. Clinicians decided anticoagulation therapies according to coagulation function. The general data of the patients were collected,and CRRT dosages( Kp,Kpc,Kd and K) were calculated. Prescribed CRRT time,actual CRRT time,mechanical ventilation time,ICU time,total hospitalization time and 28 d mortality of the patients were recorded. Results The two groups were not significantly different in Kp(P > 0. 05);CVVHDF group was higher than CVVH group in Kpc,Kd and KCr (P < 0. 05). In patients of CVVH group and CVVHDF group,Kpc,Kd and KCr were lower than Kp,Kd and KCr were lower than Kpc,KCr was lower than Kd(P < 0. 05). CVVHDF group was lower than CVVH group in Kβ2 - M ,KIL-6 and KIL-8 (P < 0. 05). The two groups were not significantly different in prescribed CRRT time, actual CRRT time,mechanical ventilation time,ICU time,total hospitalization time and 28 d mortality ( P > 0. 05 ). Conclusion In different CRRT modes,the dosage of CRRT is highly estimated. With same Kp,different CRRT modes can effectively eliminate inflammatory mediators,and there is no different in the prognosis of patients. However,CVVHDF is superior to CVVH in the clearance rate of small solute, and CVVH is superior to CVVHDF in the clearance rate of macromolecular solute.