连续性肾脏替代疗法对多器官功能障碍综合征患者的疗效分析

doi:10.3877/cma.j.issn.2095-9133.2018.06.002

目的

探讨连续性肾脏替代疗法(continuous renal replacement therapy，CRRT)对多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS)患者的疗效。

方法

将194例多器官功能障碍综合征患者分为两组，89例未使用连续性肾脏替代疗法治疗，作为常规治疗组，采用常规治疗方案，包括病因治疗、抗炎、器官功能支持等对症支持治疗。105例在常规治疗基础上加用连续性肾脏替代疗法治疗作为CRRT组。比较两组患者治疗24 h前后急性生理功能和慢性健康状况评分系统Ⅱ(acute Physiology and chronic health evaluation Ⅱ，APACHEⅡ)评分、Marshall评分、序贯器官衰竭评分(Sequential Organ Failure Assessment, SOFA)、降钙素原、平均动脉压、肌酐、氧合指数等指标的变化及7 d生存率。

结果

CRRT组治疗前后APACHEⅡ评分(24.1±7.9)&(19.8±7.6)、治疗前后Marshall评分(7.3±2.7)&(6.8±2.9)及治疗前后SOFA评分(11.9±2.7)&(10.8±3.2)均显著降低，P均<0.05，而常规治疗组治疗前后APACHEⅡ评分(23.2±8.4)&(23.1±8.6)、治疗前后Marshall评分(7.1±3.1)&(7.3±3.1)，治疗前后SOFA评分(11.1±3.3)&(11.2±3.5)均无显著差异。CRRT组治疗前后降钙素原10.6(7.1，16.1)& 4.7(2.5，6.9)、治疗前后平均动脉压(76.3±19.7)&(83.2±15.6)、治疗前后肌酐199(147.5, 328.5)& 149(95.5，232.5)及治疗前后氧合指数(228.9±105.1)&(269.1±111.5)均显著改善，P均<0.05，而常规治疗组治疗前后降钙素原13.7(10.1，19.6)& 13.4(10.1，21.6)、治疗前后平均动脉压(83.0±17.9)&(80.0±15.9)、治疗前后肌酐180(119.5, 281.0)& 195(113.5, 313.5)及治疗前后氧合指数(286.3±139.3)&(283.2±126.6)均无显著差异。CRRT组7 d生存率显著提高，P<0.05。

结论

多器官功能障碍综合征患者早期行连续性肾脏替代疗法治疗APACHEⅡ评分、Marshall评分、SOFA评分显著降低，炎症明显消退，心血管系统功能、肾功能、呼吸系统功能得到明显改善，可显著提高患者短期生存率。

关键词: 连续性肾脏替代疗法, 多器官功能障碍综合征, 短期生存率

Objective

To investigate the curative effect of continuous renal replacement therapy(CRRT) in patients with multiple organ dysfunction syndrome(MODS).

Methods

194 patients with multiple organ dysfunction syndrome were divided into two groups. 89 patients without using CRRT treatment for various reasons, as a routine treatment group, were treated by the conventional treatment, including etiological treatment, anti-inflammatory, organ function support and other symptomatic supportive treatment.The other 105 patients were treated with continuous renal replacement therapy on the basis of conventional therapy as the CRRT group. analysis of two groups of Patients before and after treatment for 24 hours The acute Physiology and chronic health evaluation Ⅱ score, Marshall score, Sequential Organ Failure Assessment (SOFA) score, the changes of calcitonin original, mean arterial Pressure, creatinine, oxygenation index and 7 days survival rate of two groups of patients before and after treatment for 24 hours were compared, and the efficacy of treatment was analyzed.

Results

Before and after treatment in the CRRT group, APSCHE Ⅱ scores were (24.1±7.9) and (19.8±7.6), Marshall scores were (7.3±2.7) and (6.8±2.9), and SOFA scores were (11.9±2.7) and (10.8±3.2) with significant differences (P<0.05). Before and after treatment in the conventional group, the APACHE Ⅱ score were (23.2 ± 8.4) and (23.1 ± 8.6), Marshall score were (7.1 ± 3.1) and (7.3 ± 3.1), SOFA score were (11.1±3.3) and (11.2±3.5) with no significant differences. Before and after treatment in the CRRT group, procalcitonin were 10.6 (7.1, 16.1) & 4.7 (2.5, 6.9), mean arterial pressure were (76.3±19.7) and (83.2±15.6), creatinine were 199 (147.5, 328.5) & 149, and oxygenation index were (228.9±105.1) and (269.1±111.5) with significant differences (P<0.05). Before and after treatment in the conventional treatment group, procalcitonin were 13.7 (10.1, 19.6) & 13.4. 10.1, 21.6), mean arterial pressure were (83.0±17.9) and (80.0±15.9), creatinine were 180 (119.5, 281.0) & 195 (113.5, 313.5), and oxygenation index were (286.3±139.3) and(283.2±126.6)with no significant differences. The 7-day survival rate of the CRRT group was significantly improved (P<0.05).

Conclusions

in Patients with multiple organ dysfunction syndrome were treated early with continuous renal replacement therapy. APACHE Ⅱ grade, Marshall, SOFA score were significantly reduced. Inflammation, cardiovascular system function, renal function, and respiratory function were improved significantly. Sothe short-term survival rate can be significantly improved.

Key words: continuous renal replacement therapy, multiple organ dysfunction syndrome, Short-term survival rate

表1 两组患者一般情况比较

组别	性别		年龄 (岁，±s)	基础病[例(%)]			评分(±s)
组别	男	女	年龄 (岁，±s)	高血压	糖尿病	冠心病	SOFA	APACHEⅡ	Marshall评分
CRRT组	65(61.9%)	40(38.1%)	60.9±16.2	11(10.48%)	4(3.81%)	2(1.9%)	11.9±2.7	24.1±7.9	7.3±2.7
常规治疗组	50(56.2%)	39(43.8%)	63.2±18.4	16(17.98%)	6(6.74%)	6(6.7%)	11.1±3.3	23.2±8.4	7.1±3.1
χ²/t值	0.65		0.21	2.27	0.65	2.85	－1.70	－0.78	－0.56
P值	>0.05		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表1 两组患者一般情况比较

组别	性别		年龄 (岁，±s)	基础病[例(%)]			评分(±s)
组别	男	女	年龄 (岁，±s)	高血压	糖尿病	冠心病	SOFA	APACHEⅡ	Marshall评分
CRRT组	65(61.9%)	40(38.1%)	60.9±16.2	11(10.48%)	4(3.81%)	2(1.9%)	11.9±2.7	24.1±7.9	7.3±2.7
常规治疗组	50(56.2%)	39(43.8%)	63.2±18.4	16(17.98%)	6(6.74%)	6(6.7%)	11.1±3.3	23.2±8.4	7.1±3.1
χ²/t值	0.65		0.21	2.27	0.65	2.85	－1.70	－0.78	－0.56
P值	>0.05		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表2 两组治疗24 h前后降钙素原和白细胞比较[QM(Q₁～Q₃)]

组别		降钙素原(ng/mL)	WBC(×10⁹/L)
CRRT组		?	?
?	治疗前	10.6(7.1，16.1)	13.56(8.60, 19.83)
?	治疗后	4.7^a(2.5，6.9)	13.15(8.70, 20.40)
常规治疗组		?	?
?	治疗前	13.7(10.1，19.6)	12.57(7.35, 19.50)
?	治疗后	13.4(10.1，21.6)	12.58(7.61, 18.78)
?	χ²值	－5.97	－0.49
?	P值	<0.05	>0.05

表2 两组治疗24 h前后降钙素原和白细胞比较[QM(Q₁～Q₃)]

组别		降钙素原(ng/mL)	WBC(×10⁹/L)
CRRT组		?	?
?	治疗前	10.6(7.1，16.1)	13.56(8.60, 19.83)
?	治疗后	4.7^a(2.5，6.9)	13.15(8.70, 20.40)
常规治疗组		?	?
?	治疗前	13.7(10.1，19.6)	12.57(7.35, 19.50)
?	治疗后	13.4(10.1，21.6)	12.58(7.61, 18.78)
?	χ²值	－5.97	－0.49
?	P值	<0.05	>0.05

表3 两组治疗前后评分比较(±s)

组别		Marshall评分	APACHEⅡ评分	SOFA评分
治疗组		?	?	?
?	治疗前	7.3±2.7	24.1±7.9	11.9±2.7
?	治疗后	6.8±2.9^a	19.8±7.6^a	10.8±3.2^a
对照组		?	?	?
?	治疗前	7.1±3.1	23.2±8.4	11.1±3.3
?	治疗后	7.3±3.1	23.1±8.6	11.2±3.5
?	t值	－3.16	－5.59	－4.49
?	P值	<0.05	<0.05	<0.05

表3 两组治疗前后评分比较(±s)

组别		Marshall评分	APACHEⅡ评分	SOFA评分
治疗组		?	?	?
?	治疗前	7.3±2.7	24.1±7.9	11.9±2.7
?	治疗后	6.8±2.9^a	19.8±7.6^a	10.8±3.2^a
对照组		?	?	?
?	治疗前	7.1±3.1	23.2±8.4	11.1±3.3
?	治疗后	7.3±3.1	23.1±8.6	11.2±3.5
?	t值	－3.16	－5.59	－4.49
?	P值	<0.05	<0.05	<0.05

表4 表4　两组治疗24 h前后MAP、HR、Lac比较(±s)

组别		MAP(mmHg)	HR(次/min)	Lac(mmol/L)
CRRT组		?	?	?
?	治疗前	76.3±19.7	112.6±21.7	3.6±0.8
?	治疗后	83.2±15.6^a	99.8±20.7^a	1.9±0.5^a
常规治疗组		?	?	?
?	治疗前	83.0±17.9	111.1±25.4	3.3±0.9
?	治疗后	80.0±15.9	112.3±25.5	3.4±0.8
?	t值	－3.41	－5.07	－12.03
?	P值	<0.05	<0.05	<0.05

表4 表4　两组治疗24 h前后MAP、HR、Lac比较(±s)

组别		MAP(mmHg)	HR(次/min)	Lac(mmol/L)
CRRT组		?	?	?
?	治疗前	76.3±19.7	112.6±21.7	3.6±0.8
?	治疗后	83.2±15.6^a	99.8±20.7^a	1.9±0.5^a
常规治疗组		?	?	?
?	治疗前	83.0±17.9	111.1±25.4	3.3±0.9
?	治疗后	80.0±15.9	112.3±25.5	3.4±0.8
?	t值	－3.41	－5.07	－12.03
?	P值	<0.05	<0.05	<0.05

表5 两组各自治疗24h前后尿量、肌酐、尿素氮比较[QM(Q₁～Q₃)]

组别		尿量(mL/24 h)	Scr(μmol/L)	BUN(mmol/L)
CRRT组		?	?	?
?	治疗前	530(200, 1475)	199(147.5, 328.5)	17.5(11.2, 26.9)
?	治疗后	858^a(350, 2070)	149^a(95.5, 232.5)	12.0^a(8.3, 21.7)
常规治疗组		?	?	?
?	治疗前	1 100(650, 1713)	180(119.5, 281.0)	14.9(10.2, 20.9)
?	治疗后	850(420, 2615)	195(113.5, 313.5)	16.4(10.9, 23.9)
?	Z值	－3.17	－6.23	－6.65
?	P值	<0.05	<0.05	<0.05

表5 两组各自治疗24h前后尿量、肌酐、尿素氮比较[QM(Q₁～Q₃)]

组别		尿量(mL/24 h)	Scr(μmol/L)	BUN(mmol/L)
CRRT组		?	?	?
?	治疗前	530(200, 1475)	199(147.5, 328.5)	17.5(11.2, 26.9)
?	治疗后	858^a(350, 2070)	149^a(95.5, 232.5)	12.0^a(8.3, 21.7)
常规治疗组		?	?	?
?	治疗前	1 100(650, 1713)	180(119.5, 281.0)	14.9(10.2, 20.9)
?	治疗后	850(420, 2615)	195(113.5, 313.5)	16.4(10.9, 23.9)
?	Z值	－3.17	－6.23	－6.65
?	P值	<0.05	<0.05	<0.05

表6 两组治疗24 h前后pH值、HCO₃^－、氧合指数和呼吸频率比较(±s)

组别		pH值	HCO₃^－(mmol/L)	PaO₂/FiO₂(mmHg)	呼吸(次/min)
CRRT组		?	?	?	?
?	治疗前	7.32±0.10	19.6±7.2	228.9±105.1	22.5±6.3
?	治疗后	7.38±0.08^a	23.4±4.9^a	269.1±111.5^a	20.5±5.2^a
常规治疗组		?	?	?	?
?	治疗前	7.35±0.10	19.7±6.9	286.3±139.3	22.9±6.6
?	治疗后	7.34±0.10	20.3±6.7	283.2±126.6	22.4±6.7
t值		－4.47	－4.23	－3.77	－1.75
P值		<0.05	<0.05	<0.05	<0.05

表6 两组治疗24 h前后pH值、HCO₃^－、氧合指数和呼吸频率比较(±s)

组别		pH值	HCO₃^－(mmol/L)	PaO₂/FiO₂(mmHg)	呼吸(次/min)
CRRT组		?	?	?	?
?	治疗前	7.32±0.10	19.6±7.2	228.9±105.1	22.5±6.3
?	治疗后	7.38±0.08^a	23.4±4.9^a	269.1±111.5^a	20.5±5.2^a
常规治疗组		?	?	?	?
?	治疗前	7.35±0.10	19.7±6.9	286.3±139.3	22.9±6.6
?	治疗后	7.34±0.10	20.3±6.7	283.2±126.6	22.4±6.7
t值		－4.47	－4.23	－3.77	－1.75
P值		<0.05	<0.05	<0.05	<0.05

图1 两组患者生存曲线图(7 d)　的比较

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Curative effect analysis of continuous renal replacement therapy in patients with multiple organ dysfunction syndrome

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Curative effect analysis of continuous renal replacement therapy in patients with multiple organ dysfunction syndrome