摘要
目的:探讨顽固性心力衰竭(心衰)合并心肾综合征(CRS)的患者早期应用连续性血液净化治疗的有效性和安全性。方法:选择2013年6月至2018年5月天津泰达国际心血管病医院心脏重症监护室(CCU)住院的纽约心脏协会(NYHA)心功能分级Ⅳ级的顽固性心衰合并1型CRS,即符合全球肾脏病预后组织(KDIGO)提出急性肾损伤(AKI)分级1级诊断标准的患者,启动连续性血液净化(CBP)治疗,采用连续性静脉-静脉血液透析滤过(CVVHDF)方式。记录治疗前、治疗后24h、48h及结束时的生命体征,动脉血气指标,血生化指标,B型利钠肽(BNP)以及平均肺毛细血管楔压(mPCWP)、平均肺动脉压(mPAP)及心输出量(CO)等血流动力学指标,并于治疗结束后7天再次评估NYHA心功能分级,定义治疗结束后7天时心功能分级Ⅱ级或Ⅰ级为显效,心功能Ⅲ级为有效,心功能仍为Ⅳ级为无效,计算总有效率(%)=[(显效+有效)/总治疗人数]*100。结果:共纳入89例患者,男性48例(占53.9%),年龄为(66±13)岁。CVVHDF治疗后24h、48h及治疗结束后,患者的心率、呼吸频率、体质量、外周血氧饱和度、动脉血气氧分压、血肌酐及血尿素氮等指标与治疗前比较均有改善,差异均有统计学意义(P均<0.05);与治疗前比较,BNP和24h尿量在治疗24h后差异无统计学意义(P均>0.05),但治疗48h及治疗结束后差异有统计学意义(P均<0.05);治疗后24h、48h和治疗结束后患者的mPCWP及mPAP水平均较治疗前下降,CO水平较治疗前升高,差异均有统计学意义(P均<0.05);酸碱度(pH)及血钾、血钠、血氯离子等电解质水平在治疗24 h后恢复正常(与治疗前比较,P均<0.05),并且在以后的治疗中均维持在正常范围。治疗结束后7天时NYHA心功能分级Ⅳ级有6例,Ⅲ级有37例,Ⅱ级有42例,Ⅰ级有4例。因此,显效46例,有效37例,无效6例,总有效率93%(83/89)。治疗过程中出现低血压7例。心律失常和感染在治疗过程中、治疗结束后均无恶化,无CVVHDF治疗相关感染发生。未出现出血、栓塞、死亡事件。结论:CVVHDF在顽固性心衰合并CRS的早期应用(AKI 1级),可以有效、快速地改善心衰症状、血流动力学障碍和肾脏功能,而且安全性良好。
Objective:To investigate the efficacy and safety of early continuous blood purification(CBP)therapy in patients with refractory heart failure(RHF)complicated by cardiorenal syndrome(CRS).Method Patients hospitalized in cardiac care unit(CCU)of TEDA International Cardiovascular Hospital from June 2013 to May 2018 with clinical diagnosis of RHF and New York Heart Association(NYHA)functional class IV complicated by CRS type 1,that is acute kidney injury(AKI)stage 1 defined by the guideline from the Kidney Disease Improving Global Outcomes(KDIGO)2012,were selected and initiated CBP therapy using the mode of continuous veno-venous hemodialysis-filtration(CVVHDF).Vital signs,hemodynamic indexes such as mean pulmonary capillary wedge pressure(mPCWP),mean pulmonary artery pressure(mPAP)and cardiac output(CO)were recorded before and 24 hours,48 hours after and at the end of treatment of CBP.NYHA functional class were reevaluated 7 days after the end of treatment and significantly effective was defined as functional classⅡorⅠ,effective defined as functional classⅢ,ineffective defined as functional class IV.The total effective rate(%)was calculated as the number with significantly effective and effective divided by the total number of patients treated with CBP and subsequently multiplied by 100.Result A total of 89 patients were enrolled with 48 males(53.9%)and age of(66±13)years.Compared with those before treatment,the heart rate,respiratory rate,body weight,SpO_(2),PO_(2),serum creatinine and blood urea nitrogen were significantly improved at 24h,48h and end of treatment with CVVHDF(all P<0.05).There were no significantly differences in plasma brain natriuretic peptide(BNP)and 24h-urine output at 24h after treatment in comparison with those before treatment(both P>0.05).However,both of the BNP and 24h-urine output significantly improved at 48h and end of treatment(all P<0.05).There were significantly decrease in mPCWP and mPAP,and increase in CO at 24h,48h and end of treatment compared to those before treatment(all P<0.05).Moreover,levels of potential of hydrogen(pH)and serum electrolytes such as potassium,sodium and chloride returned to normal at 24h after treatment(all P<0.05 compared with before treatment)and remained within the normal range during the subsequent treatment.At 7 days after the end of treatment,there were 6 patients with NYHA functional class IV,37 with classⅢ,42 with classⅡ,and 4 with classⅠ.Therefore,there were 46 patients with significantly effective,37 with effective,other 6 with ineffective,with a total effective rate of 93%(83/89).Hypotension(blood pressure<90/60 mmHg)occurred in 7 cases during CVVHDF.Arrhythmia and infection did not deteriorate during and after treatment.There was no infection associated with CVVHDF as well as hemorrhage,embolization or death.Conclusion Early application of CVVHDF can improve symptoms of heart failure,hemodynamic indexes and renal function effectively and rapidly in patients with RHF complicated by CRS type 1(AKI level 1)with acceptable safety.
作者
王钊
梁海青
宋昱
Wang Zhao;Liang Haiqing;Song Yu(Cardiac Care Unit,Tianjin Medical University Cardiovascular Institute,TEDA International Cardiovascular Hospital,Tianjin 300457,China)
基金
天津市医药卫生科技基金项目 (2013KZ006)
关键词
难治性心力衰竭
心肾综合征
急性肾损伤
连续性血液净化
Refractory heart failure
Cardiorenal syndrome
Acute kidney injury
Continuous blood purification
