连续性血液滤过剂量的选择对危重型横纹肌溶解症预后的影响  

Therapeutic dose of continuous hemofiltration contributes to the favorable prognosis of critical rhabdomyolysis

作　　者：孟建中[1] 李丹丹[1] 贾凤玉[1] 周春华[2] 刘文渊[1] 王素霞[1] 葛彦明[1] 景颖[1] 岳冀[1] 

机构地区：[1]济南军区总医院血液净化科,济南250013 [2]海军总医院肾内科,北京100037

出　　处：《中国血液净化》2011年第10期552-555,共4页Chinese Journal of Blood Purification

基　　金：全军"十一五"重点计划项目体外血液净化疗法救治"生物活性化合物伤害综合征"的研究"编号:CJN08L033

摘　　要：目的探讨连续性血液滤过治疗剂量对危重型横纹肌溶解症预后的影响。方法将47例横纹肌溶解症(Rhabdomyolysis,RM)患者随机分为:①A组26例,采用连续性静脉-静脉血液滤过(continuous venovenous hemofiltration,CVVH);②B组21例,应用高容量血液滤过(high volume hemofiltration,HVHF)治疗。观察2组治疗24h后血Mb、生化指标、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)、白介素-6(interleukin,IL-6)水平,以及对急性生理学及慢性健康状况(APACHEⅡ)评分值变化;分析2组患者治疗24、48、72、96、120h的TNF-α水平动态变化趋势对预后的影响。结果①发病24～48h,2组患者低血压、急性肾损伤(acute kidney injury,AKI)、高钾血症和急性呼吸窘迫综合征(ARDS)等危险事件的发生率无差异(P>0.05)。②治疗后2组患者APACHEⅡ评分值均明显好转(P<0.05);29例(61.70%)患者经(9.3±3.7)d治疗进入多尿期。18例患者(38.29%)发生肾功能延迟恢复,其中A组肾功能延迟恢复的发生率(50%)明显高于B组(23.81%),P<0.05。③肾功能延迟恢复者中12例(66.66%)经(24.2±4.2)d渡过少尿期,6例死亡(33.33%),死亡原因为急性肝衰竭、弥散性血管内凝血(DIC)、严重颅脑损伤和二重感染。④肾功能恢复者在治疗24h后,TNF-α水平明显低于治疗前(P<0.05);而死亡患者TNF-α水平下降不明显,甚至出现增高的现象;其中B组降低TNF-α水平的时间较A组提前24h;治疗120h后,B组对TNF-α浓度的清除量亦多于A组,而病死率则低于A组(P<0.05)。结论肾功能延迟恢复是导致本组患者死亡的重要病理基础;HVHF有利于阻遏DIC、多器官功能衰竭的发展,为危重型RM患者肾功能的重建争取时间。Objective To investigate the therapeutic dose of continuous hemofiltration in relation to the prognosis of critical rhabdomyolysis （RM）. Methods A total of 47 RM patients were randomized into 2 groups： group A （n=26） treated with continuous venovenous hemofiltration （CVVH）, and group B （n=21） treated with high volume hemofiltration （HVHF）. Serum myoglobin （Mb）, biochemistry parameters, tumor necrosis factor-？（TNF-？ and IL-6, and acute physiology and chronic health evaluation Ⅱ （APACHEⅡ） score were measured after the treatment for 24 hours. Changes of serum TNF-？after the treatment for 24, 48, 72, 96 and 120 hours were analyzed in association with the prognosis in the 2 groups. Results （a） After the presence of RM for 24～48h, the incidence of critical signs such as hypotension, acute kidney injury （AKI）, hyperkalemia and acute respiratory distress syndrome （ARDS） were similar between the 2 groups （P0.05）. （b） After treatment, APACHEⅡ score improved remarkably in the 2 groups （P0.05）. Twenty-nine patients （61.70%） progressed into diuresis stage after treatment for 9.3±3.7 days. Eighteen patients （38.29%） showed delayed recovery of renal function, of which the incidence was 50% and 23.81% in group A and B （P0.05）, respectively. （c） In the patients with delayed recovery of renal function, 12 patients （66.66%） passed through the oliguria stage after 24.2±4.2 days, while the remaining 6 patients （33.33%） died of acute hepatic failure, disseminated intravascular coagulation （DIC）, severe craniocerebral injury or superinfection. （d） In patients showing recovery of renal function after the treatment for 24-48 hours, serum TNF-？was significantly lower than that before treatment （P0.05）. In the dead patient, however, serum TNF-？decreased insignificantly or even increased. The decrease of serum TNF-？occurred earlier for 24 hours in group B than in group A. After the treatment for 120 hours, the clearance of TNF-�

关 键 词：危重型 横纹肌溶解症 高容量血液滤过 剂量 

分 类 号：R459.5[医药卫生—治疗学]