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目的比较延长每日血液透析(EDD)和延长每日血液滤过(EDHF)治疗原位心脏移植术后急性肾损伤(AKI)的有效性和安全性。方法回顾性分析原位心脏移植术后发生AKI行肾脏替代治疗的20例患者,其中行EDD治疗9例,EDHF治疗11例。所有患者均采用临时深静脉置管作为血液透析通路,应用床旁血透机治疗,血流量为200～250 mL/min。EDD组应用1.4 m2聚醚砜膜透析器,治疗时间≥8 h/d。EDHF组应用1.7 m2高通量聚醚砜膜透析器,置换总量>48 L/d,治疗剂量约为25 mL.kg-1.h-1,治疗时间≥8 h/d。动态随访两组肾脏替代治疗前和开始治疗后24、72 h的血尿素氮、血肌酐、心率、平均动脉压、急性生理功能和慢性健康状况评分系统Ⅱ(APACHEⅡ)评分,并比较两组患者的住院病死率、肾脏替代治疗天数、重症监护病房停留时间及肾脏替代治疗直接费用。结果肾脏替代治疗前,EDD组与EDHF组间年龄、性别、体重、血肌酐、尿素氮、心率、中心静脉压、APACHEⅡ评分等基线资料的差异均无统计学意义(P值均>0.05),但EDD组的平均动脉压为(81.9±7.1)mmHg(1 mmHg=0.133 kPa),显著高于EDHF组的(73.9±9.1)mmHg(P<0.05)。EDD组治疗24 h后的中心静脉压为(16.6±3.1)cmH2O(1 cmH2O=0.098 kPa),显著低于治疗前的(19.6±4.2)cmH2O(P<0.05)。EDHF组治疗24 h后的中心静脉压、APACHEⅡ评分分别为(16.5±3.3)cmH2O、15.5±4.2,均显著低于治疗前的(20.8±5.0)cmH2O和16.9±4.6(P值均<0.05)。治疗72 h后,EDD、EDHF组的中心静脉压分别为(14.7±2.4)、(14.5±3.3)cmH2O,均较同组治疗24 h时显著下降(P值均<0.05),EDHF组治疗72 h时的APACHEⅡ评分为14.1±4.6,亦较同组治疗24 h时显著降低(P<0.05)。此外,两组肾脏替代治疗前、治疗后24、72 h时的血尿素氮、血肌酐水平均保持稳定,两组间差异也均无统计学意义(P值均>0.05)。两组间肾脏替代治疗天数、重症监护病房停留时间、住院期间病死率的差异均无统计学意义(P值均>0.05),但EDD组的肾脏替代治疗直接费用为(9 600±2 700)元,显著低于EDHF组的(15 300±4 800)元(P<0.01)。结论EDD和EDHF治疗原位心脏移植术后非脓毒症相关性AKI的疗效相当,但EDD治疗费用较低。
Objective To compare the efficacy and safety of extended daily hemodialysis (EDD) and extended daily hemofiltration (EDHF) for acute kidney injury (AKI) after orthotopic heart transplantation. Methods A retrospective analysis of 20 patients with AKI who underwent renal replacement therapy after orthotopic heart transplantation was performed, including 9 EDD and 11 EDHF. All patients were treated with temporary deep venous catheterization as hemodialysis accessorial, with a bedside hemodialysis machine with blood flow of 200-250 mL / min. EDD group using 1.4 m2 polyethersulfone membrane dialyzer, treatment time ≥ 8 h / d. EDHF group using 1.7 m2 high-throughput polyethersulfone membrane dialyzer, the total replacement volume> 48 L / d, the treatment dose of about 25 mL.kg-1.h-1, treatment time ≥ 8 h / d. The blood urea nitrogen, serum creatinine, heart rate, mean arterial pressure, acute physiology and chronic physiology score system Ⅱ (APACHEⅡ) scores of 24 kidney and 72 h after renal replacement therapy were compared dynamically between the two groups In-hospital mortality, number of days of kidney replacement therapy, length of stay in ICU, and direct costs of renal replacement therapy. Results There was no significant difference in baseline data between EDD group and EDHF group before and after renal replacement therapy (P> 0.05), such as age, sex, body weight, serum creatinine, blood urea nitrogen, heart rate, central venous pressure, APACHEⅡscore, However, the mean arterial pressure in EDD group was (81.9 ± 7.1) mmHg (1 mmHg = 0.133 kPa), which was significantly higher than that in EDHF group (73.9 ± 9.1 mmHg) (P <0.05). The central venous pressure in EDD group was (16.6 ± 3.1) cmH2O (1 cmH2O = 0.098 kPa) after 24 h treatment, which was significantly lower than that before treatment (19.6 ± 4.2) cmH2O (P <0.05). The central venous pressure and APACHEⅡscores in EDHF group after 24 h treatment were (16.5 ± 3.3) cmH2O and 15.5 ± 4.2, respectively, which were significantly lower than those before treatment (20.8 ± 5.0) cmH2O and 16.9 ± 4.6 (P <0.05) . After 72 hours of treatment, the central venous pressure in EDD and EDHF groups were (14.7 ± 2.4) and (14.5 ± 3.3) cmH2O, respectively, which were significantly lower than those in the same group at 24 hours (all P <0.05) h, APACHEⅡ score was 14.1 ± 4.6, which was significantly lower than that of the same group at 24 h (P <0.05). In addition, blood urea nitrogen and serum creatinine remained unchanged at 24 and 72 h after treatment, and no significant difference was found between the two groups (P> 0.05). There was no significant difference in the number of days of renal replacement therapy, the length of stay in intensive care unit, and the mortality during hospitalization between the two groups (P> 0.05), but the direct cost of renal replacement therapy in EDD group was (9 600 ± 2 700) Yuan, significantly lower than that of EDHF group (15 300 ± 4 800) yuan (P <0.01). Conclusions The efficacy of EDD and EDHF in treating non-sepsis-associated AKI after orthotopic heart transplantation is comparable, but EDD is less costly to treat.