Evaluation Of Indicators On Time To Initiate Continuous Renal Replacement Treatment

PartⅠAdjunctive continuous high-volume hemofiltration in acute severe pancreatitis patients:a prospective non-randomized studyObjectives:Continuous high-volume hemofiltration (HVHF) technique is an important support treatment for severe acute pancreatitis (SAP) patients. The aim of this study was to evaluate the efficacy of HVHF in severe acute pancreatitis and the optimal time to initiate HVHF treatment.Methods:75 patients admitted to the Intensive Care Unit (ICU) for severe acute pancreatitis from July 2006 to May 2009 were given informed consent and were followed prospectively. Whether to accept adjunctive HVHF treatment was decided in 24 hour of admission. Patients were divided into 4 groups according to whether they accepted continuous HVHF (42 vs.33) and if they showed signs of acute kidney injury (AKI). The patient's vital signs, biochemical parameters, and APACHEⅡscore were observed.Results:Patients of the 4 groups were comparable at baseline. After 72 hours therapy, the patients who accepted HVHF has significantly better of APACHEⅡscores (16.8±4.37 vs.13.77±3.19; p<0.05), body temperature (38.2±1.01 vs.37.73±0.95; p<0.05), urine volume (1186±841 vs.2381±2462; p<0.05), and base excess (-6.3±4.5 vs. 0.64±3.4; p<0.05). However, the improvement in patients who didn't accept HVHF was not so obviously. The 28-day survival rate was higher in patients who accepted HVHF (81% vs.57.6%, p=0.026), especially in those without AKI (95% vs.66.7, p=0.026).Conclusion:Adjunctive HVHF was associated with improved clinical outcome in acute severe pancreatitis patients, HVHF should be initiated before kidney injury appearance.PartⅡCorrelation between parameters at initiation of continuous renal replacement treatment and outcome in critically ill patientsObjective:Continuous renal replacement treatment (CRRT) is an important support therapy in critically ill patients, especially in whose with acute kidney injury (AKI). In order to analyze the epidemiological characteristics of critically ill patients receiving CRRT and investigate the correlation between physiological and biochemical parameters at initiation of CRRT and the outcome, we conducted this retrospectively study.Methods:Patients receiving CRRT after admitted the Intensive Care Unit of First Affiliated Hospital, College of Medicine, Zhejiang University from January 2004 to December 2008 were collected. Those who received CRRT more than 24 hours were included. Those who were younger than 16 years and who had received hemofiltration before admission were excluded. Patients who had previous chronic renal disease or cancer were also excluded, as well as organ transplant recipients.382 cases were eventually analyzed. Patient's general characteristics, vital signs, biochemical parameters were recorded, APACHEⅡscore and AKI classification were evaluated. Results:The patients'average age was 57.7±17.8, APACHEⅡscore was 22.9±7.11, mean serum creatinine before CRRT was 268±201 umol/L. The etiology was complex. Infection was the major cause (83 cases,21.7%), followed by surgery (77 cases,20.9%) and digestive diseases (75 cases,19.6%).285 cases (74.6%) received mechanical ventilation during ICU state.205 cases (53.7%) used vasopressors.245 patients had confirmed diagnosis of sepsis. Compared with dead patients, survival patients showed a relatively younger age, lower APACHEⅡscore and smaller proportion of use of mechanical ventilation and vasopressors.78.8% patients suffering AKI before CRRT began. Multivariate regression analysis showed that APCHEⅡscore, serum albumin, and mean arterial pressure when CRRT initiated had a significant influence on the prognosis.Conclusion:Infection is the main cause in critically ill patients receiving CRRT. Factors that affect prognosis of patients included APCHEⅡscore, serum albumin, and mean arterial pressure when CRRT initiated and those parameters could be used to guide the determination of timing to initiate CRRT.PartⅢSerum neutrophil gelatinase-associated lipocalin (NGAL), high-mobility group box 1 (HMGB-1) and Netrin-1 predict outcomes at inception of renal replacement therapy in sepsis patientsObjective:Sepsis a common complication in critically ill patients, and affects the outcomes. The sensitivity and specificity of traditional acute kidney injury indicators including creatinine and urine volume were not enough. In order to find suitable biomarkers, the present study investigated the concentrations of serum neutrophil gelatinase-associated lipocalin (NGAL), high-mobility group box-1 (HMGB-1) and Netrin-1 at inception of renal replacement therapy treatment(CRRT), and explored the relationship between their concentrations and outcomes. The concentration change of these three biomarkers during CRRT was also observed.Methods:43 patients receiving CRRT after admitted the Intensive Care Unit (ICU) of First Affiliated Hospital, College of Medicine, Zhejiang University for Sepsis from January 2007 to December 2008 were studied. Blood samples were collected before CRRT and 2 hours,6 hours,12 hours,24 hours,36 hours,48 hours,60 hours and 72 hours after CRRT initiation in all patients. Serum NGAL, HMGB-1, and Netrin-1 were measured by ELIS A method.Results:Patients'average age was 52.9±15.4. The APACHEⅡscore was 20.1±6.6, and serum creatinine was 219.8±167umol/L at inception of CRRT.78.8% patients had AKI before CRRT began. Serum NGAL were 582.8±265.1 ug/ml in non-survival patients and 291.8±143.4ug/ml in survival, p<0.01. Serum HMGB-1 were 6.76±3.61ng/ml in non-survival and 3.34±1.56ng/ml in survival, p<0.01. Serum Netrin-1 was 715.9±362.7pg/ml in non-survival and 439.7±196.7pg/ml in survival, p<0.01. The ROC curve of NGAL, HMGB-1 and Netrin-1 for prognosis showed a significantly large area of 0.890,0.874 and 0.787, respectively. Serum NGAL, HMGB-1 decreased gradually during CRRT; however Netrin-1 not changed so much. Netrin-1 showed an increased trend in survival patients and a downward trend in non-survival.Conclusion:Serum NGAL and HMGB-1 concentrations at inception of CRRT were sensitive biomarks for AKI diagnosis and prognosis, Serum Netrin-1 could only be used for predicting outcomes. Netrin-1 concentration increased in survival patients suggesting that Netrin-1 may be protective proteins during AKI.