目标导向的肾替代治疗对1型心肾综合征预后的影响
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摘要
目的比较目标导向的连续性肾脏替代治疗(goal-directed continuousrenal replacement therapy,GD-CRRT)与常规的连续性肾脏替代治疗(continuousrenal replacement therapy,CRRT)对1型心肾综合征(cardiorenal syndrome,CRS)患者预后的影响。方法对北京安贞医院肾内科在2015年1月～2017年12月收治的33例1型CRS患者采取GD-CRRT,再匹配选取2010年1月～2017年12月北京安贞医院33例接受常规CRRT的1型CRS患者,比较2组患者的预后(死亡、脱离或依赖透析)。结果 GD-CRRT组的启动时机在诊断CRS后为15.0(10.0,22.5)h;低血压的发生率为27.3%(9/33);血管活性药的应用为21.2%(7/33);住院死亡率为18.2%(6/33)、脱离透析率为63.6%(21/33)、依赖透析率为18.2%(6/33)。常规CRRT组的启动时机在诊断CRS后为94.0(43.5,183.5)h;低血压的发生率为57.6%(19/33);血管活性药的应用为54.5%(18/33);住院死亡率为45.4%(15/33)、脱离透析率为27.3%(9/33)、依赖透析率为27.3%(9/33)。2组患者的CRRT启动时机(Z=-6.989, P<0.001)、低血压的发生率(F=6.203,P=0.013)、血管活性药的应用(F=7.791,P=0.013)、住院死亡率(F=5.657,P=0.017)和脱离透析率(F=8.800,P=0.003)有统计学差异(P<0.05)。多因素Logistic逐步回归分析显示,CRRT的启动时机(OR=15.15;95%CI:1.15～200.00;P=0.039)、单位时间除水量(OR=47.13;95%CI:2.48～893.90;P=0.010)和低血压的发生(OR=83.61;95%CI:5.47～1278.40;P=0.001)是死亡及依赖透析的独立危险因素。结论 1型CRS的患者早期启动CRRT并进行精确的容量评估及动态监控,可有效维持血液流力学稳定,挽救心肾功能,降低死亡率。
Objectives To evaluate the effect of goal-directed continuous renal replacement therapy(GD-CRRT) and continuous renal replacement therapy(CRRT) on the prognosis of patient with type 1 cardiorenal syndrome(CRS). Methods A total of 33 cases with type 1 CRS admitted to Beijing Anzhen Hospital from January 2015 to December 2017 and treated with GD-CRRT were enrolled in the present study. Thirtythree type 1 CRS cases admitted from January 2010 to December 2017 receiving regular CRRT were selected as matched control. Prognosis including mortality rate and hemodialysis withdrawal or hemodialysis dependence was analyzed and compared between the two groups. Results In GD-CRRT group, the initiation of GD-CRRT was 15.0 h(10.0, 22.5 h) after diagnosis of CRS; the incidence of hypotension was 27.3%(9/33);the application of vasoactive drugs was 21.2%(7/33); the in-hospital mortality, rate of hemodialysis withdrawal and rate of hemodialysis dependence were 18.2%(6/33), 63.6%(21/33) and 18.2%(6/33), respectively. In matched control of CRRT group, the initiation of CRRT was 94.0h(43.5, 183.5 h) after diagnosis of CRS; the incidence of hypotension was 57.6%(19/33); the application of vasoactive drugs was 54.5%(18/33); the inhospital mortality, rate of hemodialysis withdrawal and rate of hemodialysis dependence were 45.4%(15/33),27.3%(9/33) and 27.3%(9/33), respectively. There were significant differences in time interval between CRS diagnosis and treatment(Z=-6.989, P<0.001), incidence of hypotension(F=6.203, P=0.013), use of vasoactive agents(F=7.791, P=0.013), in-hospital mortality(F=5.657, P=0.017) and rate of hemodialysis withdrawal(F=8.800, P=0.003) between GD-CRRT group and CRRT group(P<0.05). Multivariate logistic stepwise regression analyses showed that the time interval between CRS diagnosis and treatment(OR=15.15, 95% CI1.15～200.00, P=0.039), ultrafiltration per unit time(OR=47.13, 95% CI 2.48～893.90, P=0.010) and incidence of hypotension(OR=83.16, 95% CI 5.47～1278.40, P=0.001) were the independent risk factors for death and hemodialysis dependence. Conclusions Patients with type 1 CRS who were treated with early CRRT, accurate volume assessment and dynamic monitoring can effectively maintain the stability of hemodynamics, improve cardiorenal functions and reduce mortality.
Objectives To evaluate the effect of goal-directed continuous renal replacement therapy(GD-CRRT) and continuous renal replacement therapy(CRRT) on the prognosis of patient with type 1 cardiorenal syndrome(CRS). Methods A total of 33 cases with type 1 CRS admitted to Beijing Anzhen Hospital from January 2015 to December 2017 and treated with GD-CRRT were enrolled in the present study. Thirtythree type 1 CRS cases admitted from January 2010 to December 2017 receiving regular CRRT were selected as matched control. Prognosis including mortality rate and hemodialysis withdrawal or hemodialysis dependence was analyzed and compared between the two groups. Results In GD-CRRT group, the initiation of GD-CRRT was 15.0 h(10.0, 22.5 h) after diagnosis of CRS; the incidence of hypotension was 27.3%(9/33);the application of vasoactive drugs was 21.2%(7/33); the in-hospital mortality, rate of hemodialysis withdrawal and rate of hemodialysis dependence were 18.2%(6/33), 63.6%(21/33) and 18.2%(6/33), respectively. In matched control of CRRT group, the initiation of CRRT was 94.0h(43.5, 183.5 h) after diagnosis of CRS; the incidence of hypotension was 57.6%(19/33); the application of vasoactive drugs was 54.5%(18/33); the inhospital mortality, rate of hemodialysis withdrawal and rate of hemodialysis dependence were 45.4%(15/33),27.3%(9/33) and 27.3%(9/33), respectively. There were significant differences in time interval between CRS diagnosis and treatment(Z=-6.989, P<0.001), incidence of hypotension(F=6.203, P=0.013), use of vasoactive agents(F=7.791, P=0.013), in-hospital mortality(F=5.657, P=0.017) and rate of hemodialysis withdrawal(F=8.800, P=0.003) between GD-CRRT group and CRRT group(P<0.05). Multivariate logistic stepwise regression analyses showed that the time interval between CRS diagnosis and treatment(OR=15.15, 95% CI1.15～200.00, P=0.039), ultrafiltration per unit time(OR=47.13, 95% CI 2.48～893.90, P=0.010) and incidence of hypotension(OR=83.16, 95% CI 5.47～1278.40, P=0.001) were the independent risk factors for death and hemodialysis dependence. Conclusions Patients with type 1 CRS who were treated with early CRRT, accurate volume assessment and dynamic monitoring can effectively maintain the stability of hemodynamics, improve cardiorenal functions and reduce mortality.
引文
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[17]Koratala A,Kazory A.Extracorporeal Ultrafiltration for Acute Heart Failure:Lost Battle or Lasting Opportunity?[J].Blood Purif,2017,43(1-3):1-10.
[18]Dupont M,Mullens W,Finucan M,et al.Determinants of dynamic changes in serum creatinine in acute decompensated heart failure:the importance of blood pressure reduction during treatment[J].Eur J Heart Fail,2013,15(4):433-440.
[19]Marenzi G,Muratori M,Cosentino ER,et al.Continuous ultrafiltration for congestive heart failure:the CUORE trial[J].J Card Fail,2014,20(5):378 e1-9.
[20]Douvris A,Malhi G,Hiremath S,et al.Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients:a systematic review[J].Crit Care,2018,22(1):41.
[2]Verbrugge FH,Mullens W,Tang WH.Management of CardioRenal Syndrome and Diuretic Resistance[J].Curr Treat Options Cardiovasc Med,2016,18(2):11.
[3]Wierstra BT,Kadri S,Alomar S,et al.The impact of“early”versus“late”initiation of renal replacement therapy in critical care patients with acute kidney injury:a systematic review and evidence synthesis[J].Critical Care,2016,20(1):122.
[4]Wang YN,Cheng H,Yue T,et al.Derivation and validation of a prediction score for acute kidney injury in patients hospitalized with acute heart failure in a Chinese cohort[J].Nephrology(Carlton),2013,18(7):489-496.
[5]Ronco C,McCullough P,Anker SD,et al.Cardio-renal syndromes:report from the consensus conference of the acute dialysis quality initiative[J].Eur Heart J,2010,31(6):703-711.
[6]Kidney Disease:Improving Global Outcomes(KDIGO)Acute Kidney Injury Work Group.KDIGO Clinical practice guideline for acute kidney injury[J].Kidney Int Suppl,2012,2:1-138.
[7]陈孝平.外科学[M].人民卫生出版社,2007:88.
[8]Yancy CW,Jessup M,Bozkurt B,et al.2017ACC/AHA/HFSA Focused update of the 2013ACCF/AHA Guideline for the Management of Heart Failure:A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America[J].J Am Coll Cardiol,2017,70(6):776-803.
[9]王海燕.肾脏病学.第三版[M].北京:人民卫生出版社,2008:847-887.
[10]Mullens W,Abrahams Z,Francis GS,et al.Importance of venous congestion for worsening of renal function in advanced decompensated heart failure[J].J Am Coll Cardiol,2009,53(7):589-596.
[11]Ronco C,Brendolan A,Bellomo R.On-line monitoring in continuous renal replacement therapies[J].Kidney Int,1999,72(Suppl):S8-S14.
[12]Ponikowski P,Voors AA,Anker SD,et al.2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure:The Task Force for the diagnosisand treatment of acute and chronic heart failure of the European Society of Cardiology(ESC)developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J].EurHeart J,2016,37(27):2129-2200.
[13]Vodovar N,Mebazaa A,Januzzi Jr J L.Evolution of natriuretic peptide biomarkers in heart failure:Implicationsfor clinical care and clinical trials[J].Int JCardiol,2018,254:215-221.
[14]Agar JW.Personal viewpoint:Limiting maximum ultrafiltration rate as a potential new measure of dialysis adequacy[J].Hemodial Int,2016,20(1):15-21.
[15]Fox CS,Muntner P,Chen AY,et al.Short-term outcomes of acute myocardial infarction in patients with acute kidney injury:a report from the national cardiovascular data registry[J].Circulation,2012,125(3):497-504.
[16]ShakarSF1,LindenfeldJ.Treatment Approaches to Congestion Reliefin Acute Decompensated HF:Insights After DOSE-AHF and CARRESS-HF[J].Curr Treat Options Cardiovasc Med,2014,16(8):330.
[17]Koratala A,Kazory A.Extracorporeal Ultrafiltration for Acute Heart Failure:Lost Battle or Lasting Opportunity?[J].Blood Purif,2017,43(1-3):1-10.
[18]Dupont M,Mullens W,Finucan M,et al.Determinants of dynamic changes in serum creatinine in acute decompensated heart failure:the importance of blood pressure reduction during treatment[J].Eur J Heart Fail,2013,15(4):433-440.
[19]Marenzi G,Muratori M,Cosentino ER,et al.Continuous ultrafiltration for congestive heart failure:the CUORE trial[J].J Card Fail,2014,20(5):378 e1-9.
[20]Douvris A,Malhi G,Hiremath S,et al.Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients:a systematic review[J].Crit Care,2018,22(1):41.