危重症患者连续肾脏替代治疗的适应证 和治疗时机研究进展

2019-11-22 14:21李季陈小兰张效铭李洋平马峰柏明
中国当代医药 2019年27期
关键词:急性肾损伤危重症

李季 陈小兰 张效铭 李洋平 马峰 柏明

[摘要]急性肾损伤(AKI)是危重症患者的常见并发症之一。近年来需要肾脏替代治疗(RRT)的AKI患者发病率显著升高。对于血液动力学不稳定的患者,连续肾脏替代治疗(CRRT)是最常用的RRT模式。目前,虽有一些临床研究对CRRT治疗的适应证、开始和停止治疗的时机进行了深入探讨,但在一些结果上仍存在较大争议。本文就危重症患者使用CRRT治疗的适应证、开始和停止治疗的时机等方面的研究进展作一综述,以期为CRRT相关的临床工作和临床研究提供重要信息。

[关键词]急性肾损伤;连续肾脏替代治疗;适应证;危重症

[中图分类号] R692.5          [文献标识码] A          [文章编号] 1674-4721(2019)9(c)-0022-04

[Abstract] Acute kidney injury (AKI) is one of the common complications of critically ill patients. The incidence rate of AKI patients requiring renal replacement therapy (RRT) has increased significantly in recent years. For patients with hemodynamic instability, continuous renal replacement therapy (CRRT) is the most commonly used RRT mode. At present, although some clinical studies have conducted in-depth discussions on the treatment indications and timing of initiation and discontinuation for CRRT, there are still some controversies on some results. This article reviews the research advances of treatment indications timing of initiation and discontinuation for CRRT in critically ill patients, so as to provide important information for clinical work and clinical research related to CRRT.

[Key words] Acute kidney injury; Continuous renal replacement therapy; Indications; Critically ill

急性肾损伤(acute kidney injury,AKI)是危重患者常见的并发症,5%~10%的AKI患者在ICU期间需要接受肾脏替代治疗(renal replacement therapy,RRT)[1],接受RRT的重症AKI患者住院期间死亡率可达30%~70%[2]。在过去的20年中,需要RRT的AKI发病率每年增加约10%[3]。常用的RRT模式包括连续肾脏替代治疗(continuous renal replacement therapy,CRRT)、常规间歇性血液透析(conventional intermittent hemodialysis,IHD)和延长的间歇性肾替代疗法。RRT应用的许多方面仍然存在争议,包括其适应证、开始和停止的最佳时机等。重症患者多合并血液动力学不稳定,CRRT是首选模式。本文就危重症患者使用CRRT治疗的适应证、开始和停止治疗的时机等方面的研究进展作一综述,以期为CRRT相关的临床工作和临床研究提供参考依据。

1 CRRT适应证

CRRT适应证与常规RRT的适应证类似,包括容量超负荷、严重的代酸和电解质紊乱(高钾、低钠、高钠、高磷血症)、尿毒症(尿毒症脑病、心包炎等)以及持续/进展型AKI[1]。每个适应证均包含较广泛的内容和范围,应当作半客观指标。

1.1容量超负荷

由于AKI患者肾脏调节容量平衡的能力受损,且常需使用较多的静脉液体、血液制品,较易出现容量超负荷。临床上,容量超负荷导致器官功能受损且利尿剂无效时,需开始RRT治疗。虽然,儿童和成人开始RRT时容量负荷的严重程度与死亡风险之间存在很强的相关性,但其因果关系仍未明确。患者基础疾病的严重程度、容量负荷发展速度与患者预后之间存在复杂的相互作用[4-5]。目前,还无前瞻性数据明确在何种容量负荷阈值时采用RRT进行超滤能降低患者死亡率。

1.2酸碱失衡

肾衰竭患者常伴随肾脏泌酸能力的受损,因此常常出现进行性代谢性酸中毒[6]。对于某些严重酸中毒且难以接受常规纠酸治疗的患者,间歇性或连续性RRT均能给患者带来显著收益[7]。通常当pH<7.1~7.2或血碳酸氢盐水平<12~15 mmol/L时开始RRT治疗。代谢和呼吸性酸中毒同时出现时常易导致严重酸中毒,危及患者生命。对于接受机械通气的急性肺损伤患者,可能需要更早开始RRT。尽管RRT能有效清除乳酸,但很少有证据证实通过RRT增加乳酸清除后能显著改善药物中毒(如二甲双胍)之外的乳酸酸中毒患者的臨床预后。

1.3严重电解质紊乱

多种电解质紊乱与AKI密切相关。严重的高钾血症最易危及患者生命,需及时纠正以预防心脏毒性和心律失常。当高钾血症经药物治疗无效或在缓解后快速复发时需进行RRT治疗。血钾水平<6 mmol/L时,很少仅为了治疗高钾血症而开始RRT。如经保守治疗且血钾仍>6.5 mmol/L则需开始RRT。一方面,IHD可以更快地纠正高钾血症,可作为首选治疗模式;另一方面,虽然CRRT降低血钾的速率相对缓慢,但可以较好将血钾维持在相对稳定的水平。其他AKI可能伴随的电解质异常,如严重低钠血症、高钠血症和高磷血症,也应作为启动RRT的一个重要因素进行考虑[6]。在伴有严重低钠或高钠血症的AKI患者中,与IHD相比,CRRT可以缓慢、可控地升高或降低血钠浓度,这对于防止患者出现渗透性脱髓鞘相关的神经系统后遗症非常重要[6,8]。

4 RRT治疗与否的伦理问题

在AKI患者中,由于AKI患者死亡率很高,开始或停止RRT也会面临一些临床和伦理之间的矛盾。在与患者和/或其家人/监护人探讨开始和停止RRT治疗时,应综合考虑患者的整体预后、治疗目标以及其他生命支持治疗的情况[25],并及早開始姑息治疗。另一方面,患者预后不确定时或患者及家属/监护人未最终决定开始/停止RRT及其他生命支持治疗时,限制治疗时间原则是一种有效的应对策略[26]。

5小结

CRRT已成为重症AKI患者治疗的主要手段。对于无RRT急诊适应证的患者,开始RRT的最佳时机仍存在争议,需进一步研究进行探讨,以实现对患者的个体化指导。在决定开始和停止CRRT时,应综合考虑患者的整体预后、总体治疗目标以及其他生命支持治疗的使用情况。

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(收稿日期:2019-04-08  本文編辑:任秀兰)

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