The Comparative Application Study Of Continuous Blood Purification And Peritoneal Dialysis For Severe Acute Renal Failure After Cardiac Surgery

Objective:Acute renal failure (ARF) is a common and serious complication after cardiac surgery using cardiopulmonary bypass (CPB), a variety of reasons could induce ARF, such as pre-operative chronic kidney damage caused by cardiac dysfunction, CPB in the surgery, postoperative serious low cardiac output, hypoxemia, as well as drug side effects, and so on. In recent years,with CPB-related technology advanced, surgical handle and perioperative management improved, the incidence of ARF has been reduced, but if patients in the event of the ARF, the mortality rate is still high. Therefore, how to properly handle ARF after cardiopulmonary bypass still has a great significance.The main measures to ARF are hemodialysis and peritoneal dialysis and continuous blood purification (CBP). Because of its unique advantage, CBP is still the most important treatment of ARF, the effect of which has been confirmed by a large number of clinical trials. But how to know the best time to use CBP when occurrence of ARF after cardiopulmonary bypass still has no uniform conclusion, its impact on the body and the specific mechanism need further study.In this paper, the clinical use of the CBP and PD during ARF in cardiac surgery and the optimal time of clinical application of CBP treatment were investigated. We further analyzed the effects of CBP and PD treatment and specific mechanism involved. Methods:36patients with ARF after heart surgery from August2005to May2010in Qilu Hospital of Shandong University receiving continuous blood purification,while21patients with ARF receiving PD. All patients have no abnormal renal function before surgery. By percutaneous femoral vein indwelling double lumen catheter vascular access, All patients were divided into survival group (n=24) and death group (n=12)in CBP according to the prognosis,while13&8in PD ones. Clinical data were retrospectively analyzed, including ARF-occurence time after cardiac surgery, the number of days, the initiation of dialysis time, total duration times of hemodialysis, intensive care unit stay times and the APACHE III scores. And some important indicators including renal function (BUN, Cr), cardiac enzymes (AST, CPK and LDH), left ventricular ejection factor (LVEF), cardiac output (CO), cardiac index (CI), mean arterial pressure (MAP), heart rate (HR), oxygenation index (PaO2/FiO2), blood lactate (Lac), WBC (white blood cell) and PLt (platelet), were observed in all patients before and after12h,24h,48h and72h treatment. Changes of inflammatory factors including interleukin-6(IL-6), interleukin10(IL-10), tumor necrosis factor alpha (TNF-a) were also observed during hemodialysis.Results:1, A total of13patients after CBP treatment discharged, with utter recovery of renal function and normal urine output.8cases still died after CBP treatment during hospitalization (12cases in survival group and8cases in death group at48h;11cases in survival group and6cases in death group at72h), of which5cases died of multiple organ failure,2cases died of heart failure and1case died of infection.2, Before using CBP, compared with the survival group, the indicators including CO, LDH (P<0.05), CI, BUN, Cr, AST and CPK (P<0.01) has statistically significance in death group. LVEF, CO and CI form two groups of patients with ARF at48and72h after CBP were significantly improved after hemodialysis.72h later after hemodialysis, LVEF values in survival group significantly increased (P<0.01) and it was also in death group (P<0.05). Indicators of CO, CI in two groups at72hours after hemodialysis were both significantly increased (P<0.01), BUN and Cr were gradually decreased with the using of hemodialysis, compared to preoperative value, the measured value at24h,48h, and72h were significantly decreased after hemodialysis (P<0.01).3, Before treatment of hemodialysis, difference of indicator Lac (P<0.05) has statistically significance in the death group v.s. survival group, but the other has no significant differences.72h after hemodialysis, the MAP, HR was significantly improved in two groups (P<0.05), the level of Lac was remarkably reduced compared with the preoperation (P<0.01), respiratory function was also improved significantly, Pa02/Fi02was significantly increased (P<0.05) at24h after hemodialysis, and continue to increase at48h,72h after hemodialysis (P<0.01). Hemodialysis had no significant effect (P>0.05) on WBC and PLT. PLT in death group at72h treatment was decreased significantly compared with that of before hemodialysis (P<0.05) and it was also decreased significantly compared with that of in survival group at12h after treatment (P<0.05).4, The concentrations of IL-6, IL-8, TNF-alpha in blood have no significant difference before hemodialysis between two groups (P>0.05), but at72h after hemodialysis, IL-6, IL-8, TNF-alpha concentrations in death group were significantly higher than that of in survival group (P<0.05). And IL-6, IL-8and TNF-a concentrations were significantly decreased after hemodialysis in each group (P<0.05).Conclusion:CBP is an effective treatment for ARF following cardiac surgery. The earlier diagnosis of ARF after cardiac surgery and faster treatment measures to be implemented will greatly reducing the incidence of other complication, such as multiple organ dysfunction syndrome and mortality in patients.