在急性肾衰竭危重症患者中使用前列环素进行持续低效透析（SLED）。

Sustained low-efficiency dialysis (SLED) with prostacyclin in critically ill patients with acute renal failure.

作者信息

Fiaccadori Enrico, Maggiore Umberto, Parenti Elisabetta, Giacosa Roberto, Picetti Edoardo, Rotelli Carlo, Tagliavini Dante, Cabassi Aderville

机构信息

Dipartimento di Clinica Medica, Nefrologia & Scienze della Prevenzione Universitá degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy.

出版信息

Nephrol Dial Transplant. 2007 Feb;22(2):529-37. doi: 10.1093/ndt/gfl627. Epub 2006 Oct 28.

DOI:10.1093/ndt/gfl627

PMID:17071958

Abstract

BACKGROUND

Prostacyclin is an easy-to-use and safe antihaemostatic drug for continuous renal replacement therapies (RRTs). No study has been performed so far about its use in critically ill patients with acute renal failure (ARF) treated with sustained low-efficiency dialysis (SLED), a hybrid modality between conventional intermittent and continuous RRTs.

METHODS

We studied 35 consecutive ICU patients with ARF, in whom data on safety and efficacy were prospectively collected in a single-centre experience over 15 months since August 2001. There were 25 males and 10 females; mean age, 72.1 (SD 11.4); mean APACHE II score at ICU admission, 24 (range 14-43); at RRT start, 27.4 (20-43); 28 patients (80%) were on mechanical ventilation and 17 (48.6%) had sepsis. SLED was performed using a conventional dialysis machine, with blood flow at 200 ml/min, bicarbonate-based ultrapure dialysate running at 100 ml/min, dialysate temperature 35 degrees C and low-flux polysulfone filters. Prostacyclin, under the form of its synthetic analogue epoprostenol, was infused at 6 ng/kg/min before the filter.

RESULTS

Out of 185 daily sessions performed (8-10 h, median 4 per patient, range 1-19), 19 (in 11 patients) were prematurely interrupted (10.3%; 95% CI: 5.4-18.6), after an average 58.5% of the prescribed treatment time (nine sessions in six patients for circuit clotting). This finding compared favourably with the experience we had at our unit using SLED with saline flushes. With the use of prostacyclin, two episodes of upper gastrointestinal bleeding were observed in 2/35 patients during SLED (5.7%; 95% CI: 0.7-19.2), corresponding to 1.1 episodes per 100 person-day on SLED. Therapeutic intervention for hypotension (fluids and/or vasopressor increase) was required in 45/185 (in 20 patients) of the sessions monitored (24.3%; 95% CI: 17.4-32.9); two sessions had to be interrupted because of refractory hypotension. Urea reduction ratio was 0.50 (SD 0.12); mean prescribed and obtained net ultrafiltration were 1.96 l (range 0.5-5.0) and 1.99 l (0.5-5.0), respectively. In-hospital mortality was 46%; mortality predicted by the APACHE II model at ICU admission was 42%; at SLED start, 51%.

CONCLUSIONS

Prostacyclin is a safe and effective antihaemostatic agent for SLED.

摘要

背景

前列环素是一种用于连续性肾脏替代治疗（RRT）的易用且安全的抗凝血药物。目前尚未有关于其在接受持续低效透析（SLED，一种介于传统间歇性和连续性RRT之间的混合模式）治疗的急性肾衰竭（ARF）重症患者中应用的研究。

方法

我们研究了35例连续入住重症监护病房（ICU）的ARF患者，自2001年8月起在单中心进行了为期15个月的前瞻性安全性和有效性数据收集。其中男性25例，女性10例；平均年龄72.1岁（标准差11.4）；入住ICU时的平均急性生理与慢性健康状况评分系统（APACHE II）评分为24分（范围14 - 43）；开始RRT时为27.4分（20 - 43）；28例患者（80%）接受机械通气，17例（48.6%）患有脓毒症。使用传统透析机进行SLED，血流速度为200 ml/分钟，以碳酸氢盐为基础的超纯透析液流速为100 ml/分钟，透析液温度35摄氏度，采用低通量聚砜膜过滤器。前列环素以其合成类似物依前列醇的形式，在滤器前以6 ng/kg/分钟的速度输注。

结果

在进行的185次每日治疗（8 - 10小时，每位患者中位数为4次，范围1 - 19次）中，19次（涉及11例患者）提前中断（10.3%；95%置信区间：5.4 - 18.6），平均为规定治疗时间的58.5%（6例患者中的9次因体外循环凝血）。这一结果优于我们科室使用生理盐水冲洗进行SLED的经验。使用前列环素时，在SLED期间，35例患者中有2例出现上消化道出血（5.7%；95%置信区间：0.7 - 19.2），相当于SLED期间每100人日1.1次。在监测的185次治疗中有45次（涉及20例患者）需要针对低血压进行治疗干预（增加液体和/或血管升压药）（24.3%；95%置信区间：17.4 - 32.9）；2次治疗因难治性低血压而中断。尿素清除率为0.50（标准差0.12）；平均规定和实际获得的净超滤量分别为1.96升（范围0.5 - 5.0）和1.99升（0.5 - 5.0）。住院死亡率为46%；ICU入院时APACHE II模型预测的死亡率为42%；开始SLED时为51%。