新活素在心外科术后心肾综合征的应用

发布时间：2018-09-18 19:20

【摘要】：目的:心肾综合征(CRS)是指在病理状态下,心脏或肾脏中任何其一发生急性或慢性功能损害,而导致另一器官发生急性或慢性功能损害。心衰不能纠正,心输出量减少导致肾灌注减少,造成肾功能损害;肾功能受损,肾小球滤过率降低,尿量减少,心脏前负荷增加,加重心功能衰竭。目前尚缺乏针对CRS的确定治疗方案,但治疗重点已从单纯改善患者的血流动力学转到阻断患者过度激活的神经体液及细胞因子上来。重组人脑钠肽(商品名:新活素)可抑制肾素-血管紧张素-醛固酮(RAAS)和交感神经系统激活,已有大量文献报导新活素在充血性心衰的应用,但多见于心内科患者,关于新活素在心外科术后心肾综合征患者中的应用罕见。本文对新活素在心外科术后CRS患者中的应用进行疗效观察,并对其可能机制做进一步研究。方法:选取我院心外科2013年1月至2014年7月行心脏手术术后发生CRS的患者为治疗组入选病例,入选标准:(1)心功能不全(中心静脉压CVP持续升高、动脉压ABP示血压进行性下降,心超测左室射血分数LVEF≤45%,胸片示肺门影增粗、肺水肿、心影增大,血浆脑钠肽BNP水平400pg/m L);(2)肾功能损害(血肌酐Scr增高≥26.5μmol/L,肾小球滤过率e GFR降低,尿量0.5 m L/kg/h)。排除标准:心源性休克、既往有肾脏病史、严重肝肾功能不全。全部病例共50例,男29例、女21例、年龄47~83(66.7±8.6)岁,其中冠脉搭桥26例、瓣膜置换14例、冠脉搭桥+瓣膜置换3例,升主动脉手术5例,左房粘液瘤切除1例,房缺+迷宫射频消融1例,所有患者均在体外循环辅助下手术。所有患者术后均予心电监护,颈部深静脉测CVP,桡动脉测ABP,记每小时尿量、24 h出入量。在用药(新活素)24 h、48 h后分别抽血测BNP、BUN、Scr,采用改良的简化MDRD方程估算GFR:GFR(m L/min/1.73 m2)=186×(Scr)-1.154×(age)-0.203×0.742(女性)×1.233(中国人群)。其中Scr以μmol/L为单位;年龄以岁为单位。用药48 h和7 d后行心脏超声检查,由专人应用Philips Intelli Vue mp50多普勒心脏超声诊断仪进行检查,测LVEF,并进行比较。结果:加用新活素治疗24 h后,患者CVP降低、收缩压(SBP)和舒张压(DBP)升高,7天后LVEF升高(除舒张压的P值0.05,余P值均0.01)。与用药前相比,24 h后血浆BNP水平升高(P0.01),48 h后开始下降(P0.05)。治疗前后心率差异无统计学意义(P0.05)。加用新活素治疗24 h后,患者Scr、BUN降低,e GFR增高,尿量明显增多(P值均0.01)。48 h后尿量增多、BUN降低、e GFR增高,与用药前相比仍具统计学差异(P值0.01),但Scr降低无统计学意义(P0.05)。结论:我们观察到在常规抗心衰药物治疗疗效欠佳时,加用小剂量新活素,患者的心、肾功能改善,尤以肾功能改善为主。新活素应用24h后尿量明显增加,Scr、BUN降低,e GFR增高,CVP降低,ABP升高,48h后血浆BNP水平下降,7天后LVEF升高。
[Abstract]:Objective: cardiorenal syndrome (CRS) refers to the acute or chronic impairment of the heart or kidney, which leads to the acute or chronic impairment of the other organ. Heart failure can not be corrected, the decrease of cardiac output leads to the decrease of renal perfusion and renal function damage, glomerular filtration rate decreased, urine volume decreased, cardiac preload increased, aggravated heart failure. At present, there is no definite treatment for CRS, but the focus of treatment has shifted from simply improving the hemodynamics of patients to blocking the excessive activation of neurohumoral and cytokines in patients. Recombinant human brain natriuretic peptide (trade name: neovasin) can inhibit the activation of renin-angiotensin-aldosterone (RAAS) and sympathetic nervous system. The application of neovasin in patients with cardiorenal syndrome after cardiac surgery is rare. The therapeutic effect of neovasin in patients with CRS after cardiac surgery was observed and the possible mechanism was further studied. Methods: patients with CRS after cardiac surgery in our hospital from January 2013 to July 2014 were selected as the treatment group. The inclusion criteria were as follows: (1) Cardiac insufficiency (central venous pressure (CVP) continued to increase, arterial pressure (ABP) showed a progressive decrease in blood pressure; Left ventricular ejection fraction (LVEF 鈮，

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