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肾功能损伤分级在心脏术后肾脏替代治疗中的应用

摘要： 目的 探讨肾功能损伤分级(AKIN分级)在心脏术后肾脏替代治疗时机选择中的作用。 方法 2006年9月至2007年10月在我院首次行冠状动脉旁路移植术和/或心瓣膜手术100例患者中，根据AKIN分级，选取最高分级在2级、3级的患者，并结合是否接受肾脏替代治疗(RRT)将患者分为4组：A组：2级接受RRT治疗；B组：2级未接受RRT治疗；C组：3级接受RRT治疗；D组：3级未接受RRT治疗，记录4组患者临床资料和临床转归等。结果 4组患者术后肾功能均出现不同程度的损伤，血肌酐最高值分别为197.8±32.1 μmol/L，154.1±40.1 μmol/L，330.9±78.2 μmol/L和339.1±107.7 μmol/L，明显高于术前。4组患者住院病死率分别为16.7%、14.3%、52.2%和56.3%，C组患者住院病死率高于A组（χ2=5.487，P=0.019）和B组（χ2=11.036，P=0.001），D组患者住院病死率明显高于A组（χ2=5.812，P=0.016）和B组（χ2=11.003，P=0.001），其中以D组患者的病死率最高。结论 心脏术后患者肾功能损伤分级进入AKIN分级2级时接受RRT有可能改善其临床预后。

体外循环心脏手术后急性肾功能衰竭的肾脏替代治疗

目的 探讨体外循环（CPB）心脏手术后急性肾功能衰竭(ARF)的发生原因及肾脏替代治疗的方法，总结其治疗经验。 方法 回顾性分析我院2004年2月至2008年2月14例体外循环心脏手术后发生急性肾功能衰竭患者的临床资料，所有患者除常规治疗外，分别给予持续血液滤过1例、血液透析5例、腹膜透析7例。 结果 14例患者中死亡7例，其中5例死于多器官功能衰竭，1例死于低心排血量综合征，1例死于腹膜透析并发败血症。余7例经肾脏替代治疗8～39 d肾功能恢复，治愈出院。生存的7例患者随访1～48个月，肾功能无明显异常，尿素氮4.16±3.19 mmol/L(2.96±8.18 mmol/L)，肌酐56±16 μmol/L(55~89 μmol/L)。 结论 急性肾功能衰竭是体外循环心脏手术后严重并发症之一，死亡率较高。采取适当的预防措施可减少该并发症的发生，血液滤过、血液透析及腹膜透析是有效的肾脏替代治疗方法。

Application of Continuous Renal Replacement Therapy in Patients with Acute Renal Insufficiency after Heart Transplantation

Objective To summarize and analyze the clinical outcomes and experiences of continuous renal replacement therapy(CRRT) in patients with acute renal insufficiency after heart transplantation. Methods There were 39 patients received orthotopic heart transplantation from September 2007 to September 2008 in Fu Wai hospital. Seven cases required the use of PRISMA CRRT machine (Gambro Healthcare,Inc.) because of acute renal insufficiency after heart transplantation, and received continuous venovenous hemodiafiltration(CVVHDF) treatment via M100 blood filter (hemofilters). Activated coagulation time (ACT) was maintained in 160200 s. Results Six survivals with New York Heart Association (NYHA)Ⅰdischarged ，1 case died of multiple system organ failure (MSOF) and severe infection. The time of CRRT was 48658 h, with an average of 252 h. Seven patients were oliguric or anuric during CRRT, but hemodynamics and internal environment were stable. After stopping CRRT, the creatinine level rose to 267.1±68.5 μmol/L， then the creatinine level decreased to normal range with urine increasing gradually. Postoperative glomerular filtration rate (GFR) was 56.5±19.0 ml/min， and there was no statistical significance compared with preoperative GFR（Pgt;0.05）. Six survivals were followed up for 513(9.7±3.8)months，and their creatinine level was in normal range(90.6±26.7 μmol/L). There was no statistical significance compared with the creatinine level at discharge (83.2±26.5 μmol/L, Pgt;0.05）. Conclusion The prognostic outcomes of patients with acute renal insufficiency after heart ransplantation are excellent after using CRRT. No significant renal dysfunction is found.

i-STAT便携式血气分析仪在连续性肾脏替代治疗中的应用

目的　讨论i-STAT便携式血气分析仪在连续性肾脏替代治疗（CRRT）中的应用。 方法　2012年2月－5月，对92例行CRRT治疗患者采用i-STAT便携式血气分析仪监测分析治疗中各参数变化并及时予以调整。 结果　92例患者治疗中酸碱及电解质的失衡得到及时调整，无意外情况发生。 结论　i-STAT便携式血气分析仪在CRRT治疗中能较好的监测患者的血气及电解质，确保CRRT的安全完成。

Nursing Experience of Continuous Renal Replacement Therapy for Senile Patients with Diabetic Nephropathy

目的　总结老年糖尿病肾病（DN）连续性肾脏替代治疗（CRRT）临床护理措施。 方法　2010年2月－2012年3月对15例老年DN患者CRRT治疗中，采取相应的通路与抗凝、饮食、并发症及心理护理。 结果　患者经CRRT 治疗82 h后水肿明显消退，治疗中发生5例低血糖，3例低血压，3例高血压，各种并发症在相应的对症处置和护理后很快缓解，且无感染病例。 结论　老年DN患者行CRRT治疗中容易出现各种并发症，护理人员需要采取相应的护理措施，确保治疗顺利进行及安全。

连续性肾脏替代治疗专科护士培训方式及效果

目的　总结连续性肾脏替代治疗（CRRT）专科护士的培训方式及效果，为进一步完善专科护士培训提供依据。 方法　针对CRRT专科护士所应具备的知识和技能，对我基地2010年－2012年5期培训班招收的28名CRRT学员进行为期3个月理论学习及临床实践培训。 结果　经培训，CRRT学员全部顺利通过各项考核，培训合格，取得由四川省护理学会颁发的“血液净化专业护士证书”。 结论　理论与实践相结合的培训方式，使学员系统掌握了血液净化方面的理论知识，规范了专科护理操作技能，提高了职业综合能力，取得满意效果，为进一步完善CRRT专科护士培训积累了经验。

连续性肾脏替代治疗护士交接班特点与方法

【摘要】　目的　总结连续性肾脏替代治疗（continuous renal replacement therapy，CRRT）专业护士交接班的特点及重要性，以规范交接班制度，完善交接班内容。　方法　针对CRRT治疗地点的分散性、治疗时间及患者人数不确定性等因素，建立起符合CRRT专业护士的交接班内容与方法。　结果　交接班方法推行以来，从未发生过因交接班不规范而导致治疗事故和护理差错，有效的保证了CRRT的护理质量及工作连续性。　结论　严谨细致的CRRT专业护士交接班方法是患者治疗安全的可靠保证。

连续性肾脏替代治疗急性重型肾盂肾炎一例

Effect of Continuous Renal Replacement Therapy on Serum Phosphate Level in Patients after Cardiac Surgery

ObjectiveTo observe the effect of continuous renal replacement therapy (CRRT) on serum phosphate level in patients after cardiac surgery. MethodA single-center retrospective observational study was conducted on 30 patients received CRRT after cardiac surgery. There were 14 males and 16 females with mean age of 57.0±10.8 years (ranged 37-79 years). A total of 16 patients underwent CRRT with continuous veno-venous hemofiltration (CVVH), and 14 patients with continuous veno-venous hemodiafiltration (CVVHDF). The serum phosphate level was measured before treatment, at 24 h, and 48 h during therapy and 24 h after phosphate salt supplementation. ResultsThe level of serum phosphate at 24 h and 48 h during CRRT was decreased (0.6±0.4 mmol/L vs. 0.4±0.2 mmol/L vs. 1.1±0.3 mmol/L, P<0.01). After intravenous phosphate salt supplementation, serum phosphate level got increased (0.6±0.3 mmol/L, P<0.01). There was no statistical difference in serum phosphate level between CVVH and CVVHDF (P>0.05). ConclusionHypophosphatemia occurs frequently during CRRT, particularly with long treatment time. Phosphate salt supplementation is necessary. The dosage of the supplementation should be adjusted personally based on the regularly monitoring results of serum phosphate tests.

Effectiveness of Continuous Renal Replacement Therapy of Acute Kidney Injury after Type A Aortic Dissection Surgery: A Case Control Study

ObjectiveTo evaluate the efficacy of the continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) after the surgery of type A aortic dissection. MethodsWe retrospectively analyzed 58 hemodialysis patients with AKI after type A aortic dissection surgery in our hospital between January 2003 and January 2014.The 58 patients were divided into two groups including a bedside intermittent hemodialysis (IHD) group and a CRRT group based on the methods of hemodialysis. There were 38 patients with 29 males and 9 females at average age of 49.8± 13.7 years in the CRRT group. There were 20 patients in the IHD group with 14 males and 6 females at average age of 52.6± 11.0 years. ResultsCompared with IHD, CRRT had significantly greater effect on reducing the simplified acute physiology scoring system (SAPS)Ⅱscore (Ftime=60.964, P=0.000; Ftime * group=3.178, P=0.041). However, there was no significant difference in reducing the acute tubular necrosis individual illness severity index (ATN-ISI) score between the two groups (Ftime=13.803, P=0.000; Ftime * group=0.222, P=0.951). Lower incidences of dialysis-related complications including hypotension (P=0.027) and acute congestive heart failure (P=0.011) were found in the CRRT group. There was no statistical difference in operation time (P=0.367) between the two groups. While statistical differences in duration of hospitalization in intensive care unit (P=0.006), in hospital time (P=0.047), frequency of dialysis (P=0.001), and dialysis time (P=0.039) were found between the two groups. However there were no significant differences in mortality during hospital (P=0.544)and incidences of recovery (P=0.056) between the two groups. ConclusionCompared with IHD, CRRT had significantly positive effect on patients who suffered from AKI after type A aortic dissection surgery, which can help reduce incidences of dialysis-related complications, duration and cost of hospitalization in ICU.