【摘要】：目的:心腎綜合征(CRS)是指在病理狀態(tài)下,心臟或腎臟中任何其一發(fā)生急性或慢性功能損害,而導(dǎo)致另一器官發(fā)生急性或慢性功能損害。心衰不能糾正,心輸出量減少導(dǎo)致腎灌注減少,造成腎功能損害;腎功能受損,腎小球?yàn)V過率降低,尿量減少,心臟前負(fù)荷增加,加重心功能衰竭。目前尚缺乏針對(duì)CRS的確定治療方案,但治療重點(diǎn)已從單純改善患者的血流動(dòng)力學(xué)轉(zhuǎn)到阻斷患者過度激活的神經(jīng)體液及細(xì)胞因子上來。重組人腦鈉肽(商品名:新活素)可抑制腎素-血管緊張素-醛固酮(RAAS)和交感神經(jīng)系統(tǒng)激活,已有大量文獻(xiàn)報(bào)導(dǎo)新活素在充血性心衰的應(yīng)用,但多見于心內(nèi)科患者,關(guān)于新活素在心外科術(shù)后心腎綜合征患者中的應(yīng)用罕見。本文對(duì)新活素在心外科術(shù)后CRS患者中的應(yīng)用進(jìn)行療效觀察,并對(duì)其可能機(jī)制做進(jìn)一步研究。方法:選取我院心外科2013年1月至2014年7月行心臟手術(shù)術(shù)后發(fā)生CRS的患者為治療組入選病例,入選標(biāo)準(zhǔn):(1)心功能不全(中心靜脈壓CVP持續(xù)升高、動(dòng)脈壓ABP示血壓進(jìn)行性下降,心超測(cè)左室射血分?jǐn)?shù)LVEF≤45%,胸片示肺門影增粗、肺水腫、心影增大,血漿腦鈉肽BNP水平400pg/m L);(2)腎功能損害(血肌酐Scr增高≥26.5μmol/L,腎小球?yàn)V過率e GFR降低,尿量0.5 m L/kg/h)。排除標(biāo)準(zhǔn):心源性休克、既往有腎臟病史、嚴(yán)重肝腎功能不全。全部病例共50例,男29例、女21例、年齡47~83(66.7±8.6)歲,其中冠脈搭橋26例、瓣膜置換14例、冠脈搭橋+瓣膜置換3例,升主動(dòng)脈手術(shù)5例,左房粘液瘤切除1例,房缺+迷宮射頻消融1例,所有患者均在體外循環(huán)輔助下手術(shù)。所有患者術(shù)后均予心電監(jiān)護(hù),頸部深靜脈測(cè)CVP,橈動(dòng)脈測(cè)ABP,記每小時(shí)尿量、24 h出入量。在用藥(新活素)24 h、48 h后分別抽血測(cè)BNP、BUN、Scr,采用改良的簡(jiǎn)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(中國(guó)人群)。其中Scr以μmol/L為單位;年齡以歲為單位。用藥48 h和7 d后行心臟超聲檢查,由專人應(yīng)用Philips Intelli Vue mp50多普勒心臟超聲診斷儀進(jìn)行檢查,測(cè)LVEF,并進(jìn)行比較。結(jié)果:加用新活素治療24 h后,患者CVP降低、收縮壓(SBP)和舒張壓(DBP)升高,7天后LVEF升高(除舒張壓的P值0.05,余P值均0.01)。與用藥前相比,24 h后血漿BNP水平升高(P0.01),48 h后開始下降(P0.05)。治療前后心率差異無統(tǒng)計(jì)學(xué)意義(P0.05)。加用新活素治療24 h后,患者Scr、BUN降低,e GFR增高,尿量明顯增多(P值均0.01)。48 h后尿量增多、BUN降低、e GFR增高,與用藥前相比仍具統(tǒng)計(jì)學(xué)差異(P值0.01),但Scr降低無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:我們觀察到在常規(guī)抗心衰藥物治療療效欠佳時(shí),加用小劑量新活素,患者的心、腎功能改善,尤以腎功能改善為主。新活素應(yīng)用24h后尿量明顯增加,Scr、BUN降低,e GFR增高,CVP降低,ABP升高,48h后血漿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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