连续性肾脏替代治疗在蜂蜇伤致横纹肌溶解合并急性肾损伤中的应用
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摘要
目的分析连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)在蜂蜇伤致横纹肌溶解症合并急性肾损伤(acute kidney injury,AKI)中的应用。方法前瞻性分析简阳市人民医院、四川大学华西医院及安岳县人民医院2013年1月—2016年12月收治的132例蜂蜇伤致横纹肌溶解症患者,其中62例合并AKI,均接受CRRT治疗,采用连续性静脉-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)的模式。CVVH机型为金宝Prismaflex,滤器选择M100-AN69,血流量180~200 m L/min,置换液速度2 000~2 500 m L/h[30~35 m L/(kg·h)],应用普通肝素或低分子肝素抗凝,碳酸氢盐置换液采用前稀释方法输入,治疗时间至少48 h;患者病情稳定后使用间断血液透析。对比患者治疗前后生化指标变化、住院时间、生存率及肾功能恢复情况,使用SPSS 19.0软件进行统计学分析。结果 51例患者符合入选标准,其中4例(7.8%)在住院期间死亡,其余47例完成治疗及随访。经治疗3、7、14 d后患者肌酸激酶、肌红蛋白、乳酸脱氢酶均明显下降,并逐渐恢复至正常水平。45例(95.7%)患者肾脏功能在3个月内恢复,2例患者发展为慢性肾脏病。患者血红蛋白于(30.5±11.3)d后恢复至正常水平。结论蜂蜇伤致横纹肌溶解合并AKI是蜂蜇伤的严重并发症,早期积极的CRRT干预能获得满意疗效。
Objective To investigate the effect of continuous renal replacement therapy(CRRT) on rhabdomyolysis with acute kidney injury(AKI) following multiple wasp stings. Methods We designed a prospective study which enrolled 132 patients who developed rhabdomyolysis after multiple wasp stings between January 2013 and December 2016 in Jianyang People's Hospital, West China Hospital of Sichuan University and Anyue People's Hospital.Among these, 62 patients with AKI were treated with CRRT. The modality of CRRT was continuous veno-venous hemofiltration(CVVH). CVVH was performed for at least 48 hours by using Prismaflex and M100-AN69 hemofilter.Hemofiltration was accomplished using predilution bicarbonate with the replacement fluid rate of 2 000–2 500 m L/h[30–35 m L/(kg·h)]. Heparin or low-molecular-weight heparin was used for anticoagulation, with blood flow rate of180–200 m L/min. Then intermittent hemodialysis was performed when patients' condition became stable. Mortality,kidney recovery, biochemical indicators and length of stay were collected. Results Fifty-one patients met the inclusion criteria finally, and four(7.8%) of them died during hospitalization, and the remaining 47 patients survived with completed treatment and follow-up. At 3, 7, and 14 days after treatment, the creatine kinase, myoglobin and lactate dehydrogenase of the patients all decreased significantly and gradually, and returned to normal level finally. Kidney function was recovered in 45(95.7%) patients within 3 months, and 2 patients suffered chronic kidney disease. The patients' hemoglobin recovered to normal level at(30.5±11.3) days. Conclusion Rhabdomyolysis and AKI were severe complications following multiple wasp stings, and early CRRT may bring significant benefits to such patients.
Objective To investigate the effect of continuous renal replacement therapy(CRRT) on rhabdomyolysis with acute kidney injury(AKI) following multiple wasp stings. Methods We designed a prospective study which enrolled 132 patients who developed rhabdomyolysis after multiple wasp stings between January 2013 and December 2016 in Jianyang People's Hospital, West China Hospital of Sichuan University and Anyue People's Hospital.Among these, 62 patients with AKI were treated with CRRT. The modality of CRRT was continuous veno-venous hemofiltration(CVVH). CVVH was performed for at least 48 hours by using Prismaflex and M100-AN69 hemofilter.Hemofiltration was accomplished using predilution bicarbonate with the replacement fluid rate of 2 000–2 500 m L/h[30–35 m L/(kg·h)]. Heparin or low-molecular-weight heparin was used for anticoagulation, with blood flow rate of180–200 m L/min. Then intermittent hemodialysis was performed when patients' condition became stable. Mortality,kidney recovery, biochemical indicators and length of stay were collected. Results Fifty-one patients met the inclusion criteria finally, and four(7.8%) of them died during hospitalization, and the remaining 47 patients survived with completed treatment and follow-up. At 3, 7, and 14 days after treatment, the creatine kinase, myoglobin and lactate dehydrogenase of the patients all decreased significantly and gradually, and returned to normal level finally. Kidney function was recovered in 45(95.7%) patients within 3 months, and 2 patients suffered chronic kidney disease. The patients' hemoglobin recovered to normal level at(30.5±11.3) days. Conclusion Rhabdomyolysis and AKI were severe complications following multiple wasp stings, and early CRRT may bring significant benefits to such patients.
引文
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11 Scharman EJ,Troutman WG.Prevention of kidney injury following rhabdomyolysis:a systematic review.Ann Pharmacother,2013,47(1):90-105.
12丁盛,张渝华,张近宝,等.RIFLE标准对蜂蛰伤并发多器官功能障碍患者行连续性静脉-静脉血液滤过治疗时机选择的价值.第二军医大学学报,2011,32(4):417-421.
13 Oh HJ,Shin DH,Lee MJ,et al.Early initiation of continuous renal replacement therapy improves patient survival in severe progressive septic acute kidney injury.J Crit Care,2012,27(6):743.e9-743.el8.
14 Zarbock A,Kellum JA,Schmidt C,et al.Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury:the EL AIN randomized clinical trial.JAMA,2016,315(20):2190-2199.
15 Gaudry S,Hajage D,Schortgen F,et al.Initiation strategies for renal-replacement therapy in the intensive care unit.N Engl J Med,2016,375(2):122-133.
16 Naka T,Jones D,Baldwin I,et al.Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis:a case report.Crit Care,2005,9(2):R90-R95.
2 Kim YO,Yoon SA,Kim KJ,et al.Severe rhabdomyolysis and acute renal failure due to multiple wasp stings.Nephrol Dial Transplant,2003,18(6):1235.
3 Zhang R,Meleg-Smith S,Batuman V.Acute tubulointerstitial nephritis after wasp stings.Am J Kidney Dis,2001,38(6):e33.
4 Kidney Disease:Improving Global Outcomes(KDIGO)Acute Kidney Injury Work Group.KDIGO clinical practice guideline for acute kidney injury.Kidney Int Suppl,2012,2(1):1-138.
5 Moreno M,Giralt E.Three valuable peptides from bee and wasp venoms for therapeutic and biotechnological use:melittin,apamin and mastoparan.Toxins(Basel),2015,7(4):1126-1150.
6 Zhang L,Kang Y,Fu P,et al.Myoglobin clearance by continuous venous-venous haemofiltration in rhabdomyolysis with acute kidney injury:a case series.Injury,2012,43(5):619-623.
7 Dongol Y,Shrestha RK,Aryal G,et al.Hymenoptera stings and the acute kidney injury.EMJ Neph,2013,1:68-75.
8 Lima RS,da Silva Junior GB,Liborio AB,et al.Acute kidney injury due to rhabdomyolysis.Saudi J Kidney Dis Transpl,2008,19:721-729.
9 Huerta-Alardin AL,Varon J,Marik PE.Bench-to-bedside review:rhabdomyolysis--an overview for clinicians.Crit Care,2005,9(2):158-169.
10 Parekh R,Care DA,Tainter CR.Rhabdomyolysis:advances in diagnosis and treatment.Emerg Med Pract,2012,14(3):1-15.
11 Scharman EJ,Troutman WG.Prevention of kidney injury following rhabdomyolysis:a systematic review.Ann Pharmacother,2013,47(1):90-105.
12丁盛,张渝华,张近宝,等.RIFLE标准对蜂蛰伤并发多器官功能障碍患者行连续性静脉-静脉血液滤过治疗时机选择的价值.第二军医大学学报,2011,32(4):417-421.
13 Oh HJ,Shin DH,Lee MJ,et al.Early initiation of continuous renal replacement therapy improves patient survival in severe progressive septic acute kidney injury.J Crit Care,2012,27(6):743.e9-743.el8.
14 Zarbock A,Kellum JA,Schmidt C,et al.Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury:the EL AIN randomized clinical trial.JAMA,2016,315(20):2190-2199.
15 Gaudry S,Hajage D,Schortgen F,et al.Initiation strategies for renal-replacement therapy in the intensive care unit.N Engl J Med,2016,375(2):122-133.
16 Naka T,Jones D,Baldwin I,et al.Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis:a case report.Crit Care,2005,9(2):R90-R95.