华西医学

华西医学

连续性肾脏替代治疗在蜂蜇伤致横纹肌溶解合并急性肾损伤中的应用

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目的 分析连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)在蜂蜇伤致横纹肌溶解症合并急性肾损伤(acute kidney injury,AKI)中的应用。 方法 前瞻性分析简阳市人民医院、四川大学华西医院及安岳县人民医院 2013 年 1 月—2016 年 12 月收治的 132 例蜂蜇伤致横纹肌溶解症患者,其中 62 例合并 AKI,均接受 CRRT 治疗,采用连续性静脉-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)的模式。CVVH 机型为金宝 Prismaflex,滤器选择 M100-AN69,血流量 180~200 mL/min,置换液速度 2 000~2 500 mL/h[30~35 mL/(kg·h)],应用普通肝素或低分子肝素抗凝,碳酸氢盐置换液采用前稀释方法输入,治疗时间至少 48 h;患者病情稳定后使用间断血液透析。对比患者治疗前后生化指标变化、住院时间、生存率及肾功能恢复情况,使用 SPSS 19.0 软件进行统计学分析。 结果 51 例患者符合入选标准,其中 4 例(7.8%)在住院期间死亡,其余 47 例完成治疗及随访。经治疗 3、7、14 d 后患者肌酸激酶、肌红蛋白、乳酸脱氢酶均明显下降,并逐渐恢复至正常水平。45 例(95.7%)患者肾脏功能在 3 个月内恢复,2 例患者发展为慢性肾脏病。患者血红蛋白于(30.5±11.3) d 后恢复至正常水平。 结论 蜂蜇伤致横纹肌溶解合并 AKI 是蜂蜇伤的严重并发症,早期积极的 CRRT 干预能获得满意疗效。

Objective To investigate the effect of continuous renal replacement therapy (CRRT) on rhabdomyolysis with acute kidney injury (AKI) following multiple wasp stings. Methods We designed a prospective study which enrolled 132 patients who developed rhabdomyolysis after multiple wasp stings between January 2013 and December 2016 in Jianyang People’s Hospital, West China Hospital of Sichuan University and Anyue People’s Hospital. Among these, 62 patients with AKI were treated with CRRT. The modality of CRRT was continuous veno-venous hemofiltration (CVVH). CVVH was performed for at least 48 hours by using Prismaflex and M100-AN69 hemofilter. Hemofiltration was accomplished using predilution bicarbonate with the replacement fluid rate of 2 000–2 500 mL/h [30–35 mL/(kg·h)]. Heparin or low-molecular-weight heparin was used for anticoagulation, with blood flow rate of 180–200 mL/min. Then intermittent hemodialysis was performed when patients’ condition became stable. Mortality, kidney recovery, biochemical indicators and length of stay were collected. Results Fifty-one patients met the inclusion criteria finally, and four (7.8%) of them died during hospitalization, and the remaining 47 patients survived with completed treatment and follow-up. At 3, 7, and 14 days after treatment, the creatine kinase, myoglobin and lactate dehydrogenase of the patients all decreased significantly and gradually, and returned to normal level finally. Kidney function was recovered in 45 (95.7%) patients within 3 months, and 2 patients suffered chronic kidney disease. The patients’ hemoglobin recovered to normal level at (30.5±11.3) days. Conclusion Rhabdomyolysis and AKI were severe complications following multiple wasp stings, and early CRRT may bring significant benefits to such patients.

关键词: 蜂蜇伤; 横纹肌溶解; 急性肾损伤; 连续性肾脏替代治疗

Key words: Wasp stings; Rhabdomyolysis; Acute kidney injury; Continuous renal replacement therapy

引用本文: 陈德政, 张凌, 李明鹏, 张勇, 方宏, 徐伟钧, 王明莉, 杨建兵, 唐小琰, 付平. 连续性肾脏替代治疗在蜂蜇伤致横纹肌溶解合并急性肾损伤中的应用. 华西医学, 2018, 33(7): 848-851. doi: 10.7507/1002-0179.201806117 复制

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1. Temizoz O, Celik Y, Asil T, et al. Stroke due to bee sting. Neurologist, 2009, 15(1): 42-43.
2. Kim YO, Yoon SA, Kim KJ, et al. Severe rhabdomyolysis and acute renal failure due to multiple wasp stings. Nephrol Dial Transplant, 2003, 18(6): 1235.
3. Zhang R, Meleg-Smith S, Batuman V. Acute tubulointerstitial nephritis after wasp stings. Am J Kidney Dis, 2001, 38(6): e33.
4. Kidney Disease: Improving Global Outcomes (KDIGO) AcuteKidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl, 2012, 2(1): 1-138.
5. Moreno M, Giralt E. Three valuable peptides from bee and wasp venoms for therapeutic and biotechnological use: melittin, apamin and mastoparan. Toxins (Basel), 2015, 7(4): 1126-1150.
6. Zhang L, Kang Y, Fu P, et al. Myoglobin clearance by continuous venous-venous haemofiltration in rhabdomyolysis with acute kidney injury: a case series. Injury, 2012, 43(5): 619-623.
7. Dongol Y, Shrestha RK, Aryal G, et al. Hymenoptera stings and the acute kidney injury. EMJ Neph, 2013, 1: 68-75.
8. Lima RS, da Silva Junior GB, Liborio AB, et al. Acute kidney injury due to rhabdomyolysis. Saudi J Kidney Dis Transpl, 2008, 19: 721-729.
9. Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: rhabdomyolysis -- an overview for clinicians. Crit Care, 2005, 9(2): 158-169.
10. Parekh R, Care DA, Tainter CR. Rhabdomyolysis: advances in diagnosis and treatment. Emerg Med Pract, 2012, 14(3): 1-15; quiz 15.
11. Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: a systematic review. Ann Pharmacother, 2013, 47(1): 90-105.
12. 丁盛, 张渝华, 张近宝, 等. RIFLE标准对蜂蛰伤并发多器官功能障碍患者行连续性静脉-静脉血液滤过治疗时机选择的价值. 第二军医大学学报, 2011, 32(4): 417-421.
13. Oh HJ, Shin DH, Lee MJ, et al. Early initiation of continuous renal replacement therapy improves patient survival in severe progressive septic acute kidney injury. J Crit Care, 2012, 27(6): 743.e9-743.e18.
14. Zarbock A, Kellum JA, Schmidt C et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA, 2016, 315(20): 2190-2199.
15. Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med, 2016, 375(2): 122-133.
16. Naka T, Jones D, Baldwin I, et al. Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report. Crit Care, 2005, 9(2): R90-R95.