新生児敗血症関連急性腎障害治療における持続的腎代替療法の臨床効果と安全性

Clinical effect and safety of continuous renal replacement therapy in the treatment of neonatal sepsis-related acute kidney injury.

• Cheng Cai
• Gang Qiu
• Wenchao Hong
• Yunlin Shen
• Xiaohui Gong

抄録

背景:

敗血症は新生児集中治療室（NICU）における急性腎障害（AKI）の主な原因である。本研究の目的は、新生児の敗血症関連AKIの治療における持続的腎代替療法（CRRT）の有効性と安全性を探ることである。

BACKGROUND: Sepsis is the leading cause of acute kidney injury (AKI) in the neonatal intensive care unit (NICU). The aim of the study is to explore the efficacy and security of continuous renal replacement therapy (CRRT) in the treatment of neonatal sepsis-related AKI.

方法:

CRRTで治療を受けた敗血症関連AKIの新生児全12例を、2012年11月から2019年11月までの間に上海小児病院のNICUに入院させ、この12例の臨床データをレトロスペクティブに分析した。腎機能、酸塩基バランス、電解質、血圧、血行動態指標をCRRT開始前、CRRT開始後12/24/48h、CRRT終了時にそれぞれ記録した。これら12例の敗血症関連AKI新生児を対象にCRRTの有効性を評価し，臨床転帰を観察した．統計解析には反復測定分散分析を用いた。

METHOD: Totally12 sepsis-related AKI neonates treated with CRRT were hospitalized in the NICU of Shanghai Children's Hospital between November 2012 and November 2019, and the clinical data of these 12 cases were retrospectively analyzed. Renal function, acid-base balance, electrolytes, blood pressure and hemodynamics indexes were recorded before CRRT initiation, 12/24/48 h after CRRT initiation and at the end of CRRT respectively. The efficacy of CRRT was evaluated and the clinical outcome was observed in these 12 sepsis-related AKI neonates. Repeated measurement analysis of variance was used for statistical analysis of the data.

結果:

(1) 敗血症関連AKI新生児12例に持続的静脈血液透析濾過（CVVHDF）を行った。乏尿6例、体液過多（FO）3例、敗血症性ショック3例であった。(2)敗血症関連AKIの新生児12例の血圧はCRRT開始12時間後に正常値（40～60mmHg）に達し、CRRT治療中も正常値を維持できた。CRRT12時間後、血液pH値は正常範囲（7.35~7.45）に上昇した。12時間CRRT治療後、12セプシス関連AKI新生児の酸素化指数は200mmHgに達した。24h CRRT治療後には300mmHg以上に上昇した。血清カリウム、血清尿素窒素、血清クレアチニンはCRRT開始12時間後に有意に減少し、CRRT開始24時間後には正常範囲に達した。尿量はCRRT開始24時間後に有意に増加した。(3) 敗血症に関連したAKI新生児に対して静脈カテーテル検査を実施したところ，すべての新生児で成功した．CRRTの経過では血小板減少が2例、閉塞が1例、低血圧が1例認められた。低体温，出血，血栓症，感染症などの合併症は認められなかった．新生児1例はCRRT治療を受けてAKIの乏尿期を通過したが，両親が治療を断念して死亡した。

RESULT: (1) Continuous veno-venous hemodialysis filtration (CVVHDF) was used in 12 cases of sepsis-related AKI neonates. There were 6 cases with oliguria, 3 cases with fluid overload (FO), 3 cases with septic shock. The duration of CRRT was 49 ~ 110 h, average (76.2 ± 23.5) h. (2) The blood pressure (BP) of 12 sepsis -related AKI neonates could reach the normal level (40-60 mmHg) 12 h after CRRT initiation, and the normal BP level could be maintained during the CRRT treatment. After 12 h CRRT, the blood pH value increased to the normal range (7.35 ~ 7.45). After 12 h CRRT treatment, the oxygenation index of 12sepsis-related AKI neonates could reach 200 mmHg. After 24 h CRRT treatment, it could rise to more than 300 mmHg. Serum potassium, serum urea nitrogen and serum creatinine levels decreased significantly 12 h after CRRT initiation, and reached the normal range 24 h after CRRT initiation. The urine volume significantly increased 24 h after CRRT initiation. (3) Venous catheterization was performed successfully in all sepsis-related AKI neonates. We observed 2 cases of thrombocytopenia, 1 case of obstruction and 1 case of hypotension in the course of CRRT. There were no complications such as hypothermia, hemorrhage, thrombosis and infection.11 neonates were cured and discharged. One neonate was treated with CRRT and passed through the oliguria stage of AKI, but died after the parents gave up the treatment.

結論:

CRRTによる新生児の敗血症関連AKIの治療は安全かつ効果的であり、敗血症関連AKIの新生児の治療に有効な対策となるはずである。

CONCLUSIONS: It is safe and effective to treat neonatal sepsis-related AKI with CRRT, which should be an effective measure for the treatment of sepsis-related AKI neonates.