杂合肾脏替代治疗在蜂蜇伤致急性肺水肿合并急性肾损伤中的应用

摘要

目的 本研究旨在分析杂合肾脏替代治疗(hybrid renal replacement therapy,HRRT)在蜂蜇伤致APE合并AKI中的应用.方法 前瞻性分析四川大学华西医院2007年至2010年收治的9例蜂蜇伤致急性肺水肿(acute pulmonary edema,APE)合并急性肾损伤(acute kidney injury,AKI)的患者,HRRT采用持续静静脉血液滤过(continuous veno-venous hemofiltration,CVVH)联合血浆置换(plasma exchange,PE)及持续缓慢低效血液透析(sustained low-efficiency dialysiS,SLED)的方式.CVVH机型为百特Accura、贝朗Diapact,滤器选择贝朗Diacap Acute M,血流量180～250 ml/min,置换液速度3000 ml/h,应用枸橼酸或低分子肝素抗凝,碳酸氧盐置换液采用前稀释方法输入,治疗时间至少72 h;入院第1 d及第2 d给予PE治疗(置换量:新鲜冰冻血浆2000～2500 ml/次);患者病情稳定后使用SLED隔日治疗8～12 h,透析量150 ml/min.于此同时,给予局部生理盐水冲洗湿敷伤口,给予糖皮质激素、保护肝功能、营养支持,必要时给予红细胞生成素、输血及输注人血白蛋白.结果 1例患者入院2 h后猝死,8 h后行尸体解剖提示死亡原因为蜂毒致多器官急性严重中毒性损伤及功能衰竭而死亡.余8例患者经HRRT后,氧合指数均显著改善,(5.3±2.6)d后复查胸部CT发现肺水肿显著改善,机械通气的5例患者均在2～7 d后成功脱离呼吸机.8例患者的B型尿钠肽(B-type natriuretic peptide,BNP)、肌酸激酶(creatine kinase,CK)、肌红蛋白(myoglobin,Myo)、乳酸脱氢酶(lactate dehydrogenase,LDH)经治疗后显著下降,均在入院(18±7)d后进入多尿期,(29±12)d后肾功能均完全恢复,(37±21)d后血红蛋白水平恢复至正常水平.随访(92±68)d未发现器官功能损伤.结论 APE合并AKI是蜂蜇伤严重并发症,早期积极的HRRT(CVVH+PE+SLED)干预能获得满意疗效.%Objective The aim of this study is to investigate the effect of hybrid renal replacement therapy (HRRT) on acute pulmonary edema (APE) with acute kidney injury (AKI) following multiple wasp stings. Methods We designed a prospective study which enrolled nine patients who developed APE with AKI after multiple wasp stings between 2007 and 2010 in West China Hospital. HRRT included continuous venous-venous hemofiltration (CVVH), plasmapheresis (PE) and sustained low-efficiency dialysis (SLED). CVVH was performed for at least 72h 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 3000ml/h and citrate or low-molecular- weight heparin (LMWH) for anticoagulation, with blood flow rates of 180 to 250 ml/min. PE was performed on the 1st and 2nd day after admission to hospital respectively (dose: fresh frozen plasma 2000 to 2500ml each time), then was replaced with SLED as patients in stable condition (dose: 150ml/min, for 10 to 12 hours every other day). Meanwhile, other therapeutic measures, such as regional wash and wet compress with normal saline around wounds, glucocorticoids therapy, hepatic function protection and nutritional support, were applied. Erythropoietin injection, as well as albumin and blood transfusion, were also carried out when necessary. Results One patient died unexpectedly 2h after admission to hospital. Autopsy, done 8h after sudden death, showed that the main cause of death was multiple organ failure due to the massive wasp envenomation. The other eight patients had a sharp improvement in oxygenation index after HRRT therapy, with obvious amelioration of APE as CT scan showed after an average span of 5.3±2.6 days. Among them, five ventilator dependent patients successfully weaned from mechanical ventilation 2 to 7 days after that. All the patients had distinct decrease in BNP, CK, myoglobin (Myo) and LDH after initiation of HRRT. They progressed to the commence of diuretic phase, renal function recovery and Myo decreasing to normal at 18±7d, 29±l 2d and 37±21 d after admission to hospital, respectively. No organ dysfunction was found after an average follow-up span of 92±68 days. Conclusion We conclude that the coalition of APE and AKI is a severe complication of multiple wasp stings, and active HRRT therapy (CVVH+PE+SLED) as early intervention can bring significant benefits.