急性脑卒中患者并发急性肾功能衰竭的临床特点回顾性分析

  本文关键词：急性脑卒中患者并发急性肾功能衰竭的临床特点回顾性分析，由笔耕文化传播整理发布。

        目的急性脑卒中以高发病率、高致死率和高致残率,与心脏病、恶性肿瘤共同构成了人类的三大疾病死因。急性脑卒中患者多为老年患者,有高血压、糖尿病、冠心病等病史,发病后意识障碍、进食量不足、应用大量脱水剂等因素均可导致急性肾衰竭(ARF)的发生,ARF已成为急性脑卒中的严重并发症之一。然而ARF的预后并不理想,尽管监护手段和肾脏替代治疗有了长足进步,但ARF的预后仍然不尽人意。ARF的发生增加了脑卒中的治疗难度和病死率,但若提早预防,及时纠正,合理治疗,则对疾病的良性转归起很大作用。本文旨在探究急性脑卒中住院患者并发ARF的发病原因,临床特点,治疗及预后情况等,为预防和治疗急性脑卒中患者并发ARF提供临床参考资料。方法1.选取2005年1月至2012年6月山东大学附属省立医院神经内科收治住院的确诊为脑卒中患者为统计对象,包括缺血性脑卒中和出血性脑卒中，共5218例。2.依据急性肾功能衰竭(ARF)诊断标准,从以上脑卒中患者中,筛选符合标准者207例,从剩余5011例非急性肾功能衰竭患者中筛选2012年1月至2012年5月期间219例作为对照组。3.收集整理纳入本研究的所有病例的临床资料,包括：(1)一般资料、(2)现病史、(3)既往史、(4)并发症、(5)肾功能衰竭危险因索及肾功能衰竭临床症状和体征、(6)影像学检查及辅助检查结果、(7)治疗措施、转归等;进行回顾性研究,分析其临床特点。4.所有数据统计分析均采用SPSS18.0版统计软件包进行,两组间计量资料采用1检验；两组间计数资料采用卡方检验；P<0.05有统计学意义。结果1.本研究ARF患者中,平均年龄为(72.3±10.3)岁,其中65-75岁和80-85岁是发病的两个高峰。卒中后患ARF与未患ARF者在年龄上有显著差异性(P<0.05)。2.本研究中脑卒中患者病例总数为5218例,符合ARF诊断标准者为207例。其中卒中后患ARF者中男92例(44.44%),女115例(55.56%)；卒中后未患ARF者中男2509例(50.07%),女2502例(49.93%)。脑卒中患者是否发生卒中后ARF与其性别无显著差异性(P>0.05)。3.缺血性脑卒中病例数为4514例,出血性脑卒中病例为704例。其中缺血性脑卒中发生卒中后ARF患者171例,出血性脑卒中发生卒中后ARF患者36例。不同类型的脑卒中患者所致卒中后ARF的发病率具有显著性差异(P<0.05)。4.不同卒中类型的卒中后ARF患者,其卒中部位无显著性差异。不同类型的脑卒中后ARF患者病变部位与皮层的关系有显著性差异(P<0.05)。不同卒中类型ARF患者与其血供出现障碍部位无显著相关性(P>0.05)。腔隙性脑梗塞后并发ARF患者为26例(12.56%)；动脉粥样硬化性脑梗塞并发ARF患者为55(26.57%)。5.ARF患者既往史有高血压病者为131例(63.29%),ARF患者既往有糖尿病患者有57例(27.54%),卒中后ARF患者与对照组患者有显著差异性。不同卒中类型患者有显著差异性(P<0.05)。ARF患者既往出现TIA、脑卒中病史者17例(8.21%),冠心病病史者有58例(28.02%),ARF患者既往有心房纤颤者为53(25.60%),卒中后ARF患者与对照组患者无显著差异性。不同卒中类型患者无显著性差异(P>0.05)。ARF患者既往吸烟者为57例(27.54%),ARF患者既往饮酒为33例(15.95%),卒中后ARF患者与对照组患者无显著差异性(P>0.05)。不同卒中类型吸烟比率有显著性差异(P<0.05)。不同卒中类型患者饮酒比率无显著性差异(P>0.05)。6.卒中后ARF患者多为意识清醒者,意识障碍发生率为40.58%,缺血性脑卒中患者较易出现嗜睡。出血性脑卒中患者意识障碍程度较为严重,较易出现昏睡、昏迷。7.出血性脑卒中患者血压(SBP.DBP)明显高于缺血性脑卒中患者(P<0.05)。脑卒中后ARF患者甘油三酯平均值为(1.47±0.53)mmol/L,脑卒中后ARF患者总胆固醇平均值为(5.66±2.35)mmol/L,卒中后ARF患者与对照组患者无明显差异性,出血性脑卒中患者与缺血性脑卒中患者无明显差异性(P>0.05)。脑卒中后ARF患者血糖平均值为(8.34±3.24)mg/dl,缺血性脑卒中患者血糖平均水平明显高于出血性脑卒中患者(P<0.05)。脑卒中后ARF患者BUN变化范围为(13.85±5.33)mmol/L,脑卒中后ARF患者SCr平均值为(163.3±28.91)umol/L,脑卒中后ARF患者BUN/Cr平均值为(113.5±38.64),脑卒中后ARF患者尿比重平均值为(1.02±0.005),脑卒中后ARF患者尿蛋白平均值为(0.54±0.22)g,出血性脑卒中患者与缺血性脑卒中患者无明显差异性(P>0.05)。脑卒中后ARF患者渗透压平均值为(298.2±20.41)mOsm/L,出血性脑卒中患者渗透压明显高于缺血性脑卒中患者(P<0.05)。脑卒中后ARF患者血钙平均值为(2.23±0.62)mmol/L,脑卒中后ARF患者血钾平均值为(3.89±0.81)mmol/L,脑卒中后ARF患者血钠平均值为(142.1±5.92)mmol/L,脑卒中后ARF患者血氯平均值为(101.4±2.71)mmol/L。不同卒中类型其电解质水平的改变有明显差异性(P<0.05)。8.从发病第1天到出现ARF患者应用20%甘露醇的总量为(358.5±72.36)g,出血.性脑卒中患者甘露醇用量明显高于缺血性脑卒中患者(P<0.05)。住院期间卒中后肾功能衰竭患者导尿总人数为39例(18.85%),ARF出现后前5天每日液体入、出总量为(3288±725.4)ml/d、(2924±691.1)ml/d,缺血性和出血性患者无明显差异性(P>0.05)。9.脑卒中并发ARF患者发病后30天内死亡人数为75例(36.23%),明显高于脑卒中对照组患者(P<0.05)。脑卒中并发ARF患者发病后好转人数为111例(53.62%),明显低于对照组患者好转比率(P<0.05)。缺血性和出血性患者30天内死亡率无明显差异性(P>0.05)。结论：目前研究发现急性脑卒中患者并发ARF的主要因素及临床特点如下：1)年龄因素。2)高血压病、糖尿病是ARF发展的危险因素之一。3)出血性脑卒中较缺血性脑卒中更容易发生ARF。4)出血性脑卒中皮层下病变容易诱发肾脏损伤。5)意识障碍的患者容易出现肾脏灌注不足,诱发ARF。6)甘露醇的过度使用以促使ARF的发生,出现水电解质平衡紊乱。7)ARF的发生增加脑卒中的死亡风险。

    Objective:Stroke is a common disease in neurology department,morbidity, mortality and disability rate are high, as cerebrovascular disease and heart disease, malignant tumor form the top three leading causes of death in humans. Acute stroke patients, mostly consisting of elderly patients with a history of hypertension, diabetes, coronary heart disease.After onset,suffer from a large number of complications,such as disturbance of consciousness, lack of food intake, the application of dehydration,etc, all of which lead to the occurrence of acute renal failure (ARF), while ARF has become one of the most serious complications of acute stroke. However, the prognosis of ARF is not ideal.Though guardianship means and renal replacement therapy have made great progress, the prognosis of ARF is still far from satisfactory. The occurrence of ARF adds to the difficulty of treatment and mortality of stroke, but early prevention,prompt correction,and proper treatment can play a significant role in the positive outcome of the disease. My article aims at exploring the causes of hospitalized acute stroke patients with ARF, clinical features, treatment and prognosis, offering clinical reference for the treatment and prevention of acute stroke patients with ARF.Methods and materials:1.We selected stroke patients diagnosed in the Department of Neurology of Shandong Provincial Hospital from January2005to June2012as subjects for the survey, a total of5218cases including ischemic stroke and hemorrhagic stroke,2.207cases of the above mentioned stroke patients screened met the standard, according to diagnostic criteria for ARF.3.We collected the clinical data of all cases included in the study, including: general information, history of present illness, past history, imaging studies, complications, renal failure risk factors, renal failure clinical symptoms and signs, laboratory test results, treatment measures, outcome. The retrospective study was used to analyze and summarize the clinical features. 4. All data were statistically analyzed using the statistical package SPSS18.0version, the measurement data between the two groups using t test; data calculating between the two groups using chi-square test; P<0.05being statistically significant.Results:1.Among the ARF patients as subjects in this study, with an average age of (72.3±10.3) years old, subjects of65-75years old and80-85years old were two peaks of incidence. Trouble with ARF or without ARF after Stroke made a significant difference in the age of patients(P <0.05).2. Among the total of5218cases of stroke patients in this study.,the male with ARF were92cases (44.44%), female with ARF being115cases (55.56%); while men cover2509cases (50.07%), with women without ARF2502cases (49.93%). Which indicated no significant difference in their gender whether patients suffer from ARF or not after stroke (P>0.05).3.Cases of ischemic stroke number is4514,cases of hemorrhagic stroke cases is704among whom171cases had occurrence of ischemic stroke with ARF,36cases of hemorrhagic stroke with ARF. Different types of stroke patients after stroke showed a significant difference in incidence of ARF (P<0.05).4.Stroke section made no significant difference in different types of patients with ARF after stroke.Different types of stroke in patients with ARF has much to do with cortex lesions area (P <0.05).Different types of stroke in patients with ARF has no significant correlation with their blood supply obstacles site (P>0.05). Lacunar infarction patients with ARF were26cases (12.56%); atherosclerotic cerebral infarction were complicated with ARF patients,55(26.57%).5.ARF in patients with previous history of hypertension patients were131cases (63.29%), ARF patients with a history of diabetes57cases (27.54%), indicating that the post-stroke patients with ARF and non-ARF patients were significantly different. Different type of stroke in patients had significant differences (P<0.05). patients of ARF with previous history of coronary heart disease were58cases (28.02%), patients of ARF with a history of atrial fibrillation53(25.60%), among whom, no significant difference was shown in post-stroke patients with ARF and non-ARF patients. Namely,different type of stroke in patients had no significant difference (P>0.05). Among patients with ARF there were57cases of former smokers (27.54%),33cases previously drinking (15.95%), Therefore there was no significant difference in post-stroke patients with ARF and non-ARF patients (P>0.05). Smoking rates made a significant difference in different types of stroke (P<0.05), while alcohol ratio was of no significant difference.in different types of stroke in patients (P>0.05).6.Patients with ARF after stroke are more conscious persons,the rate of disturbance of consciousness was40.58%.Ischemic stroke patients are prone to lethargy.Level of consciousness in hemorrhagic stroke patients is more serious,and prone to coma.7. Blood pressure (SBP, DBP) in patients with hemorrhagic stroke was significantly higher than that in patients with ischemic stroke (P<0.05).The average of triglycerides in post-stroke patients with ARF was (1.47±0.53) mmol/L, the average of total cholesterol in stroke patients with ARF being (5.66±2.35) mmol/L, indicating no significant difference in stroke patients with ARF and non-ARF,and no significant difference in patients with hemorrhagic stroke and ischemic stroke patients.(P>0.05) The avarage level of blood glucose in patients with ARF after stroke was (8.34±3.24) mg/dl, indicating the average blood glucose levels of patients with ischemic stroke were significantly higher that in patients with hemorrhagic stroke (P<0.05). BUN of stroke patients with ARF ranged from (13.85±5.33) mmol/L, with an average SCr of (163.3±28.91) umol/L, in ARF patients after stroke.The average BUN/Cr was (113.5±38.64) in stroke patients with ARF while stroke patients with ARF had a urine specific gravity average (1.02±0.005). The average of urinary protein in patients with ARF after stroke was (0.54±0.22)g, indicating no significant difference in patients with hemorrhagic stroke compared with patients with ischemic stroke(P>0.05).ARF patients after stroke had the osmotic average (298.2±20.41) mOsm/L. Namely, the osmotic pressure of patients with hemorrhagic stroke was significantly higher than that in patients with ischemic stroke (P<0.05).The calcium average is of (2.23±0.62) mmol/L in ARF post-stroke patients,patients with ARF after stroke averaging (3.89±0.81) mmol/L in serum potassium. The average serum sodium of post-stroke patients with ARF being (142.1±5.92) mmol/L, serum chloride average was (101.4±2.71) mmol/L ARF in patients after stroke. Electrolyte levels change significantly in different type of stroke (P<0.05).8.From the first day to the onset of ARF the total amount of20%mannitol had been applied to patients is (358.5±72.36) g, while patients with hemorrhagic stroke had a much higher dosage of mannitol than patients with ischemic stroke (P<0.05). For patients hospitalised after stroke, a total of39cases (18.85%) patients with ARF, had urine catheterization.The first5days of daily fluid when ARF occurred, there was a total of (3288±725.4)g/d、(2924±691.1)g/d in and out, indicating no significant difference to patients with ischemic and hemorrhagic states (P>0.05).9. A total of75cases (36.23%) of stroke patients with ARF died within30days after onset, which was significantly higher than stroke patients without ARF (P<0.05).111cases (53.62%) of ARF patients after onset of stroke had their state improved,which was significantly lower than with non-ARF patients (P<0.05). Namely,there was no significant difference between ischemic and hemorrhagic patients who died within in30days (P>0.05).Conclusion:The main factors and clinical features of acute stroke patients with ARF found in the current study are as follows:1) age factor.2) Hypertension, DM are risk factors for the development of ARF.3) Hemorrhagic stroke is more prone to have the occurrence of ARF compared with ischemic stroke.4) Hemorrhagic stroke which belonged to subcortical lesions is likely to cause ARF.5) Consciousness impairment in patients is prone to renal hypofusion inducing ARF.6) Excessive use of mannitol will promote the occurrence of ARF, balance disorders of water and electrolyte.7) ARF incidence adds to the risk of death with stroke.

急性脑卒中患者并发急性肾功能衰竭的临床特点回顾性分析

中文摘要6-10英文摘要10-13符号说明14-15前言15-18临床资料和研究方法18-20结果20-28讨论28-41结论41-43附图表43-52参考文献52-55综述55-61    参考文献59-61致谢61-62学位论文评阅及答辩情况表62

  本文关键词：急性脑卒中患者并发急性肾功能衰竭的临床特点回顾性分析，由笔耕文化传播整理发布。