连续性肾脏替代治疗在慢性肾衰竭并发急性心肌梗死中的应用

目的:总结日间连续性肾脏替代治疗(CRRT)救治慢性肾衰竭并发急性心肌梗死的经验.方法:对9例慢性肾衰竭常规透析时发生急性心肌梗死的患者改行CRRT,观察临床效果,监测血生化、肾功能.结果:所有患者经CRRT治疗,心前区疼痛、胸闷、憋气均有不同程度缓解,7例患者度过急性期,平均治疗时间90～146 h,转为常规血透,目前仍存活;2例患者因并发症死亡.结论:CRRT操作简便,对血流动力学影响小,日间CRRT同样能有效救治病人,使其度过急性期,降低急性心肌梗死的病死率.     

无肝素连续性肾脏替代治疗抢救脑出血并发肾衰竭的护理

为了提高脑出血并发肾衰竭患者的抢救成功率，对８例患者进行无肝素连续肾脏替代治疗（ＣＲＲＴ），同时严密监测生命体征，保持血管通路畅通、出入量平衡，严格无菌操作，注意保暖等，结果２７例次ＣＲＲＴ中２４例次顺利完全治疗，３例次因血滤器凝血，中途更换后完成ＣＲＲＴ，未发生凝血、堵管、感染等并发症。５例治愈出院，２例自动出院，１例死亡，死亡原因为多脏器功能衰竭，提示ＣＲＲＴ及高质量护理能提高脑出血并发肾衰竭患者的抢救成功率。     

急性肾功能衰竭与肾脏替代治疗

肾脏替代治疗是抢救急性肾功能衰竭的有效措施,可以有效的控制症状,降低死亡率和病程.本文将对ARF透析时机和透析方式的选择、透析液和透析膜的选择、透析充分性的判定等问题作一简单综述.     

应用连续性肾脏替代治疗抢救重症急性肾衰竭14例的体会

1977年Krammer等首次将连续性动静脉血液滤过(CAVH)应用于临床 ,经过 2 0多年的临床实践 ,在此基础上发展起来的连续性肾脏替代治疗 (CRRT)技术已日趋成熟。CRRT在治疗重症急性肾衰竭 (ARF) ,特别是那些无法应用传统透析方法者 ,如ARF伴有心血管功能衰竭 (心衰、低血压 ) ,ARF伴有脑水肿 ,创伤后ARF ,ARF伴有高分解代谢需用静脉营养 ,更有其独特优点 ,非其他方法能比拟。我院 2 0 0 0年 1月引进德国FreseniusADM 0 8/ABM床边机开展连续性静脉静脉血液滤过 (CVVH)抢救重症ARF ,至目前已治疗患者 14例 ,取得较好临床疗效 ,现…     

腹膜透析治疗小儿急性肾衰竭

腹膜透析(peritoneal dialysis,PD)是治疗急性肾衰竭(acute renal failure,ARF)的重要手段之一,国内开展较普遍,但儿科开展尚不多见.我院自1988年以来,采用腹膜透析治疗小儿ARF 40例,现报告如下.     

连续性肾脏替代治疗剂量对急性肾衰竭患者预后影响的荟萃分析

目的 通过荟萃分析评价连续性肾脏替代治疗（CRRT）剂量对急性肾衰竭（ARF）患者预后的影响。 方法 制定原始文献的纳入标准和检索策略,在Medline、EMBASE及Cochrane 图书馆内进行相关的检索。比较标准剂量和低剂量CRRT对ARF患者预后影响的随机对照试验（RCT）纳入分析。应用随机或固定效应模型处理预后指标的相对危险度（RR）。 结果 6项研究符合纳入标准。与低剂量比较,标准剂量CRRT未能降低病死率（RR 0.87,95%CI 0.70~1.07,P = 0.19）和联合终点事件（死亡和依赖透析）的发生率（RR 0.87,95%CI 0.69~1.09,P = 0.21）,但有增加依赖透析率的趋势（RR 1.43,95%CI 0.94~2.18,P = 0.09）。由于研究间存在异质性,亚组分析显示,实际治疗剂量达标（标准剂量>35 ml&#8226;kg-1&#8226;min-1）、治疗模式以连续性静脉-静脉血液滤过（CVVH）为主（置换液量大于透析液量）、非脓毒症为ARF主要原因（脓毒血症发病率<50%）的研究中,经标准剂量CRRT后病死率显著下降（P < 0.01）。 结论 尽管标准剂量CRRT未能降低ARF患者的病死率、依赖透析率和联合终点事件的发生率,但可改善实际治疗剂量达标、治疗模式以CVVH为主及非脓毒症ARF患者的存活率。     

急性肾功能衰竭与肾脏替代治疗

肾脏替代治疗是抢救急性肾功能衰竭的有效措施,可以有效的控制症状,降低死 亡率和病程。本文将对ARF透析时机和透析方式的选择、透析液和透析膜的选择、透析充分性的判 定等问题作一简单综述。     

血液透析治疗鱼胆中毒致急性肾衰竭13例疗效观察

近十年来,我们采取血液透析治疗13例重症鱼胆中毒并急性肾衰竭的患者,报道如下。     

急性心肌梗死合并急性肾衰竭的腹膜透析治疗

我科自1993年以来采用腹膜透析治疗16例急性心肌梗死合并急性肾衰竭患者,取得较好疗效,现报道如下。     

急性心肌梗死并发急性肺水肿联合CRRT治疗的临床疗效观察

目的：探讨连续性肾脏替代治疗（continuous renal replacement treatment,CRRT）治疗急性心肌梗死后并发急性肺水肿患者的疗效和安全性。方法：回顾性分析我院2010年8月～2011年7月期间,12例因急性心肌梗死后并发急性肺水肿经心内科常规治疗无效者联合CRRT治疗患者,观察其治疗前后临床症状、体征等变化和治疗的疗效和安全性。结果：9例患者显效,2例有效,1例无效,总有效率91.67%,未见严重的并发症。结论：CRRT治疗急性心肌梗死后肺水肿的疗效显著,值得临床应用推广。     

Acute Renal Failure in Severe Hypothermia

A patient who developed acute renal failure associated with severe hypothermia is reported. Warm peritoneal dialysis was initiated for core rewarming followed by intermittent hemodialysis till he entered the diuretic phase. The factors which led to acute renal failure in this patient included hypovolemia, hypotension, and acute pancreatitis.     

A Simple and Early Prognostic Index for Acute Renal Failure Patients Requiring Renal Replacement Therapy

Recent advances in technology have not substantially changed the high mortality rate associated with acute renal failure (ARF). To obtain a simple, valid prognostic index, we retrospectively evaluated the relative importance of demographic data, causes (acute insults) of renal failure, and comorbid clinical conditions for the outcome in 102 ARF patients who received renal replacement therapy with an overall mortality rate of 65% (66 of 102). There were no significant differences between survivors and nonsurvivors in age and gender. Mortality according to acute insults was similar to that of the whole population studied. Of the 10 clinical conditions at the time of the first renal replacement therapy, mechanical ventilation (p = 0.0002), cardiac failure (p = 0.0006), hepatic failure (p = 0.003), central nervous system dysfunction (p = 0.005), and oliguria (p = 0.04) were found to be significantly related to mortality by univariate analysis. Furthermore, multivariate analysis demonstrated that only mechanical ventilation, cardiac failure, and hepatic failure were significant risk factors. Survival was directly related to the number of significant variables in univariate analysis: zero, 89% (8 of 9); one, 62% (21 of 34); two, 19% (5 of 27); three, 10% (2 of 20); four, 0% (0 of 8); five, 0% (0 of 4). This simple and early prognostic index, derived from the assessment of clinical conditions which were easily de-termined at the patient's bedside, could be useful for outcome prediction in ARF patients requiring renal replacement therapy.     

Hemodynamics and Survival of Patients with Acute Renal Failure Treated by Continuous Dialysis with Two Synthetic Membranes

Synthetic membranes are not identical and have specific interactions that may be harmful or beneficial. We have investigated the incidence of hypotension and the outcome of acute renal failure (ARF) in ventilated patients treated by continuous venovenous dialysis with 2 different synthetic membranes. In Study 1, the mean arterial pressure (MAP) and systemic vascular resistance (SVR) were monitored during the first 12 min of dialysis with polyacrylonitrile (PAN). In Study 2, the MAP and survival rates were compared in patients randomly assigned to either PAN or polysulfone. No subjects were receiving angiotensin converting enzyme inhibitors. In Study 1, the MAP decreased due to a reduction in the SVR during the first 6 min of dialysis but returned to the baseline value by 12 min in 22 patients during 27 dialysis treatments. In Study 2, the MAP was lower than the baseline value at 6 min during 233 dialysis treatments in 133 patients randomly assigned to PAN or polysulfone membranes (PAN group, 81.5 ± 15 to 78.7 ± 15.6 mm Hg, p =0.001; and polysulfone group, 81.3 ± 15.4 to 80.0 ± 15.7 mm Hg, p =0.06). Severe reductions in the MAP were seen during 13.2% of the PAN and 7.2% of the polysulfone treatments (χ², p =NS). The age, APACHE II score, MAP, inotrope requirement, and primary diagnosis did not differ according to membrane material in a total of 197 consecutive patients (PAN, n =97; polysulfone, n =100). Patient survival was 29% (PAN) and 27% (polysulfone). In multivariate analysis, APACHE II score, inotrope requirement, and liver failure were significant determinants of survival. In conclusion, PAN and polysulfone membranes were not different with respect to hypotensive reactions or survival in critically ill patients undergoing continuous venovenous hemodialysis.     

Acute Renal Failure Complicating Severe Acute Pancreatitis

The records of 563 patients admitted to the hospital with diagnosis of acute pancreatitis have been studied retrospectively. The aim of the study was to investigate the prevalence of acute renal failure (ARF) in these patients, and to evaluate the most important risk factors for ARF development and mortality. The prevalence of ARF in studied population was 14%, but only 3.8% of ARF patients with acute pancreatitis had isolated renal failure. Other patients had additional failure of other organ systems, 68.4% of whom had multiorgan failure (MOF) before the onset of ARF. In only 8.9% of ARF patients was the renal system the first organ system to fail. Patients with ARF were significantly older, had more preexisting chronic diseases (including chronic renal failure), usually had MOF, and local pancreatic complications relative to these in the group with normal renal function. The development of ARF was directly influenced by severity of acute pancreatitis. The mortality rate in ARF patients was 74.7%, compared to an 7.4% mortality of patients with acute pancreatitis and normal renal function. Preexisting chronic disease, the presence of MOF and their number, local pancreatic complications, and older age of the patients increased mortality in ARF patients. The prognosis of patients with oliguric ARF requiring renal replacement therapy was extremely poor, indicating the importance of prevention of ARF in the patients with acute pancreatitis.     

Mortality in Elderly Patients with Acute Renal Failure

In a retrospective study, we identified 55 elderly patients with acute renal failure (ARF) admitted to our hospital during an 8-year period from 1985 to 1993. Information about the etiology, complications, laboratory data, and treatment course were obtained from the clinical history. Of the 200 patients with ARF admitted to the hospital during this period, 28% were patients more than 60 years old (41 male and 14 female) with an average age of 68.5 ± 7 years. The main causes of ARF were sepsis, volume depletion, low cardiac output, arterial hypotension, nephrotoxicity by antibiotics, and obstructive uropathy. The global mortality of elderly patients with ARF was 53%. The mortality rate of the different types of the ARF were: prerenal 35%, intrinsic 64% (oliguric 76%, nonoliguric 50%), and postrenal 40%. Mortality as a result of sepsis occurred in 18 patients (62%), by cardiovascular disease in 4 patients (13%), by acute respiratory failure in 2 patients (7%), and by other causes in 5 patients (18%). In the cases of sepsis, Pseudomonas was detected in 7 cases (39%), Escherichia coli in 2 cases (11%), Gram-negative nonspecific in 3 cases (17%), Klebsiella in 1 case (5%), and in 5 cases (16%), the hemoculture was negative. The patient survival rate was 47% (26 of 55 patients). Of these patients, 19 recovered their normal renal function (73%), but 7 patients remained with renal failure (27%). In conclusion, the global mortality in the elderly patients without considering the types of ARF was 53%. The oliguric form had the highest mortality rate with 76%. The main causes for mortality were sepsis with 62%, cardiovascular disease with 13%, and other causes 18%.     

Strategies for the Treatment of Acute Renal Failure in Intensive Care Units: The Aspect of Dosing

Despite all the medical progress, the mortality rate in intensive care units for patients with acute renal failure (ARF) remains high, among specific patient populations, up to 88% [Letourneau I, Dorval M, Belanger R, Legare M, Fortier L, Leblanc M. Acute renal failure in bone marrow transplant patients admitted to the intensive care unit. Nephron Apr 2002; 90(4), 408–12.]. Recent trial results indicate that patient survival may be improved by adequate renal replacement therapy. In particular, the dose of intermittent and continuous renal replacement therapies has proved to be a significant factor affecting patient survival. Daily intermittent hemodialysis, e.g., is superior to alternate‐day intermittent hemodialysis, and with continuous therapies, survival is related to the filtration rate. Further relevant factors include early initiation of renal replacement therapy, choice of biocompatible membranes and the application of bicarbonate‐buffered replacement solutions for defined patient groups. The advantages offered by continuous techniques could be demonstrated for individual patient groups; in meta‐analyses, advantages were shown for the total population of patients with ARF. Other than for patients with chronic renal failure (NKF—DOQI. Clinical practice guidelines for hemodialysis adequacy. Am J Kid Dis 1997; Vol. 30, 515–566.), there are no current clinical guidelines for a standard treatment of intensive care patients with ARF. Therefore, such a treatment standard still needs to be determined.     

急性肾损伤患者行连续性床旁血液净化治疗时机的临床研究

目的：探讨连续性床旁血液净化（continuous renal replacement therapy,CRRT）治疗时机对急性肾损伤（acute kidney injury, AKI）患者临床预后的影响.方法：选取符合AKI诊断标准并行CRRT治疗的患者83例,以BUN 22 mmol/L为界值,分为早期透析组50例,晚期透析组33例.记录一般临床资料,观察透析开始后28 d、90 d死亡率、肾功能恢复率.结果：（1）早期透析组、晚期透析组28 d、90 d死亡率分别为50.0% vs 72.7%、56.0% vs 78.8%,P＜0.05.Kaplan-Meier生存曲线提示早期透析组生存时间显著高于晚期透析组（P＜0.05）.晚期透析患者28 d、90 d死亡危险分别是早期透析患者的2.667倍、2.918倍（P＜0.05）.（2）早期透析组、晚期透析组28 d、90 d肾功能恢复率分别为44% vs 15.2%、46% vs 15.2%,P＜0.01.晚期透析患者28 d、90 d不能脱离透析的危险性是早期透析患者的4.563倍、4.954倍（P＜0.01）.结论：早期CRRT治疗可改善AKI患者的肾功能,降低死亡风险.     

终末期肾病并发急性左心衰应用序贯透析联合BiPAP治疗的临床研究

目的:观察序贯透析(SD)联合双水平气道正压通气(Bi PAP)治疗终末期肾病(ESRD)并发急性左心衰的可行性,以期为ESRD并发急性左心衰的患者提供新的、经济的、安全的治疗思路和方法。方法:选择2013年1月~2014年10月在东莞市清溪医院住院的ESRD并发急性左心衰患者60例为研究对象,随机分成:SD联合Bi PAP治疗观察组和连续肾脏替代疗法(CRRT)对照组,每组30例。比较两组肾功能相关临床指标、血气分析指标以及临床疗效。结果:治疗后两组血尿素氮(BUN)、血肌酐(Scr)肾功能指标,钾(K+)、钙(Ca2+)、磷(P3-)均出现显著减低(P<0.05和P<0.01),两组对上述指标的减低作用差异无统计学意义(P>0.05)。治疗后两组氧分压(Pa O2)、二氧化碳分压(Pa CO2)均得到显著改善(P<0.05和P<0.01),但观察组的改善作用优于对照组(P<0.05)。对照组透析时间为(64.32±12.96)h,显著高于观察组的(51.36±7.92)h,P<0.05。观察组的临床治疗有效率为96.7%(29/30),对照组为93.3%(28/30),两组之间差异无统计学意义(P>0.05)。对照组所用费用约为(9 274.5±814.6)元,显著高于观察组的(7 116.2±658.4)元,P<0.01。结论:SD联合Bi PAP治疗ESRD并发急性左心衰临床疗效与CRRT治疗差异无统计学意义,但联合治疗对于患者缺氧的纠正作用优于CRRT治疗,而且联合治疗操作简单,费用大幅减低,有利于基层医院的推广使用。     

Peritoneal Dialysis for Acute Renal Failure in Infants: A Comparison of Three Types of Peritoneal Access

Peritoneal access for peritoneal dialysis (PD) poses a significant problem in infants due to their small size and can result in considerable morbidity and occasional mortality. This study was carried out to compare the complications associated with three different types of PD catheters for intermittent PD. A total of 79 sessions of PD were given to 51 infants with acute renal failure. Twenty-nine infants received 1, 18 received 2 and 2 infants received 3 and 4 sessions of PD, respectively. For PD access an intravenous cannula was used in 36, stylet catheter in 18, and guide wire inserted femoral vein catheter in 25 procedures. Percentage reduction of serum creatinine per PD session was comparable in infants being dialysed with different types of PD access. Local puncture site and intraperitoneal bleed were associated with the use of a stylet catheter during 4 procedures each (22.2%). Catheter blockade was commonest with the intravenous cannula (22.2%), followed by guide wire inserted femoral vein catheter (16%), and was least with the stylet catheter (5.5%). Total mechanical complications were lower with guide wire inserted femoral vein catheter (16%) as compared to intravenous cannula (25%) and stylet catheter (66%) (p < 0.05). There were 4 episodes of peritonitis (5.0%), 3 bacterial and 1 fungal. Although peritonitis was more common with intravenous cannula (8.3%) than guide wire inserted catheter (4%) and stylet catheter (nil), the difference was not statistically significant. Total complications including mechanical and infective were least with guide wire inserted femoral vein catheter (20%), followed by intravenous cannula (33%) and stylet catheter (66%) (p < 0.05). Of 51 infants, 20 died (39.0%). The PD procedure per se resulted in mortality in 2 cases, 1 because of massive intraperitoneal bleed due to stylet induced injury of an intra abdominal blood vessel and the other due to fungal peritonitis. To conclude, of the three types of access for intermittent PD, complications related to the PD procedure are the least with guide wire inserted femoral vein catheter.