日间CRRT和IHD的治疗重症患者的临床观察比较
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摘要
[目的]连续肾脏替代治疗(CRRT)作为一种治疗模式，和间歇性血液透析(IHD)相比有着血流动力学更稳定、溶质清除率高、清除炎症介质等优点，但其价格昂贵。本研究采用相对价廉的日间CRRT这一肾脏替代治疗方法，观察其与IHD在治疗效果上的差异。
[方法]本研究收集了危重症患者37例，前瞻性将其分成日间CRRT组(n=17)和IHD组(n=20)。两组患者的病情危重程度没有差异(APACHEII评分)。记录分析治疗中的血压、心率、体温、多巴胺用量和血肌酐尿素氮变化以及患者的病死率和生存时间。
[结果]IHD组患者治疗第1小时起心率较日间CRRT组明显升高(8+11比-1±7，P＜0.05)和收缩压明显下降(-13±30比-2±11，P＜0.05)；日间CRRT组患者在治疗后可以明显减少多巴胺用量(5.8±9.8比17.5+5.6，P＜0.05)；日间CRRT组与IHD组相比可见体温明显降低(-0.7+2.8比0.1+0.5，P＜0.05)；血肌酐的反弹尤以IHD明显，较日间CRRT组明显升高(62+73比22±52，P＜0.05)；日间CRRT组病死率58％，IHD组病死率75％。
[结论]日间CRRT较IHD治疗重症患者时可能血压更平稳，可减慢心率，清除血浆肌酐、尿素氮更平稳。日间CRRT控制体温更好。日间CRRT治疗可能可降低危重症患者的病死率。
Background: Improved cardiovascular stability, superior metabolic control, remove inflammatory substance during continuous renal replacement therapy(CRRT) in comparison to intermittent hemodialysis (IHD),but it may be more costly than IHD. In a prospective, comparative, clinical study, we investigated whether daytime continuous renal replacement therapy that is cheaper than CRRT, is superior to IHD in critically ill patients.
Methods: Thirty seven critically ill patients were divided into two groups of patients, daytime continuous renal replacement therapy (n=17) and IHD(n=20)group. Patients characteristics on baseline were not different in term of severity of illness. We analyzed parameter during therapy, such as blood pressure, heart rate, dosage of dopamine, serum creatinine and urea nitrogen, and mortality rate and survival time.
Results: In contrast to daytime continuous renal replacement therapy, IHD caused a increase in heart rate(8 11 vs. -1 + 7, P<0.05)and decrease in systolic blood pressure(-13 30 vs. -2+11, P<0.05)after 1 hour; Daytime daytime continuous renal replacement therapy can decreased dosage of dopamine (5.8 9.8 vs. 17.5 5.6, P<0.05 ) during
therapy; And the decreasing of temperature in daytime continuous renal replacement therapy was more significant than in IHD(-0.7 2.8 vs. 0.1 0.5, p<0.05) after therapy; Rebounding of serum creatinine was more significant in IHD than in daytime continuous renal replacement therapy (62+73 vs. 22 + 52, P<0.05) ; The mortality of daytime continuous renal replacement therapy and IHD were 58 percent and 75 percent respectively.
Conclusion. In contrast to IHD, improved blood pressure stability and decreased heart rate, superior serum creatinine and urea nitrogen control, superior temperature control during daytime continuous renal replacement therapy in critically ill patients. Daytime continuous renal replacement therapy maybe decrease in-hospital mortality rate.
[方法]本研究收集了危重症患者37例，前瞻性将其分成日间CRRT组(n=17)和IHD组(n=20)。两组患者的病情危重程度没有差异(APACHEII评分)。记录分析治疗中的血压、心率、体温、多巴胺用量和血肌酐尿素氮变化以及患者的病死率和生存时间。
[结果]IHD组患者治疗第1小时起心率较日间CRRT组明显升高(8+11比-1±7，P＜0.05)和收缩压明显下降(-13±30比-2±11，P＜0.05)；日间CRRT组患者在治疗后可以明显减少多巴胺用量(5.8±9.8比17.5+5.6，P＜0.05)；日间CRRT组与IHD组相比可见体温明显降低(-0.7+2.8比0.1+0.5，P＜0.05)；血肌酐的反弹尤以IHD明显，较日间CRRT组明显升高(62+73比22±52，P＜0.05)；日间CRRT组病死率58％，IHD组病死率75％。
[结论]日间CRRT较IHD治疗重症患者时可能血压更平稳，可减慢心率，清除血浆肌酐、尿素氮更平稳。日间CRRT控制体温更好。日间CRRT治疗可能可降低危重症患者的病死率。
Background: Improved cardiovascular stability, superior metabolic control, remove inflammatory substance during continuous renal replacement therapy(CRRT) in comparison to intermittent hemodialysis (IHD),but it may be more costly than IHD. In a prospective, comparative, clinical study, we investigated whether daytime continuous renal replacement therapy that is cheaper than CRRT, is superior to IHD in critically ill patients.
Methods: Thirty seven critically ill patients were divided into two groups of patients, daytime continuous renal replacement therapy (n=17) and IHD(n=20)group. Patients characteristics on baseline were not different in term of severity of illness. We analyzed parameter during therapy, such as blood pressure, heart rate, dosage of dopamine, serum creatinine and urea nitrogen, and mortality rate and survival time.
Results: In contrast to daytime continuous renal replacement therapy, IHD caused a increase in heart rate(8 11 vs. -1 + 7, P<0.05)and decrease in systolic blood pressure(-13 30 vs. -2+11, P<0.05)after 1 hour; Daytime daytime continuous renal replacement therapy can decreased dosage of dopamine (5.8 9.8 vs. 17.5 5.6, P<0.05 ) during
therapy; And the decreasing of temperature in daytime continuous renal replacement therapy was more significant than in IHD(-0.7 2.8 vs. 0.1 0.5, p<0.05) after therapy; Rebounding of serum creatinine was more significant in IHD than in daytime continuous renal replacement therapy (62+73 vs. 22 + 52, P<0.05) ; The mortality of daytime continuous renal replacement therapy and IHD were 58 percent and 75 percent respectively.
Conclusion. In contrast to IHD, improved blood pressure stability and decreased heart rate, superior serum creatinine and urea nitrogen control, superior temperature control during daytime continuous renal replacement therapy in critically ill patients. Daytime continuous renal replacement therapy maybe decrease in-hospital mortality rate.
引文
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2. Nerlich S,Sefton E. Prevention and management of acute renal failure.Aust Nurs J, 1998,1:1-5
3. Kramer P, Wigger W, Rieger J,Matthaei D,Scheler F. Arteriovenous haemofiltration :A new and simple method for treatment of overhydrated patients resistant to diuretics. Klin Wachenschr, 1977,55: 1121-1122
4. Clark WR,Mueller BJ,Alaka KJ,Macias WL.A comparison of metabolic control by continuous and intermittent therapies in acute renal failure. J Am Soc Nephrol, 1994,4:1412-1420
5. Davenport A,Will EJ, Davison AM. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med, 1993,21:328-338
6. Ilvester W. Prospective study of renal replacement therapy for acute renal failure in 21 hospitals in state of Victoria Australian。Blood Purif,1997, 15:147
7. Warady BA,Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol,2000, 15:11-13
8. Michael Dunham. Clinical impact of continuous renal replacement
therapy on multiple organ failure. World J surg, 2001,25:669-676
9. Van Bommel EFH,Ponssen HH. Advantage of CRRT vs. IHD Remains difficult to demonstrate intermittent versus continuous treatment for acute renal failure: where do we stand? Am J Kidney Dis,1997, 30:s72-79
10．汤天清，吴华，毛永辉，裕东洁，贺承松，徐中武．连续肾脏替代疗法在急性肾功能衰竭及多脏器功能衰竭中的临床应用．中国实用内科杂志，2002，22：297-299．
11. Bansal VK, Beto JA ,Comparison of intermittent hemodialysis and continuous renal replacement therapy in acute renal failure: meta-analysis of published data.J Am Soc Nephrol, 1999, 10:167A
12. Liano F, Pasacual J. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group. Kidney Int,1996, 50:1811-1818
13. Claude Gu (?) rin,Raphaele Girard,Jean Marc Selli,Louis Ayzac. Intermittent versus continuous renal replacement therapy for acute renal failure in intensive care units: results from a multicenter prospective epidemiological survey.Intensive Care Med,2002,28:1411-1418
14. Van der Schueren, M Diltoer, M Laurey, L Huyghens. Intermittent hemodialysis in critically ill patients with multiple organ dysfunction syndrome is associated with intestinal intramucosal acidosis. Intensive
Care Med, 1996,22:747-751
15. Stenfan John, Daniela Griesbach, Mathias Baumg(?)rtel, Weihprecht H,Schmieder RE, Geiger H. Effects of continuous haemofiltration vs.intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial.Nephrol Dial Transplant, 2001, 16:320-327
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