【作者】 陈燕；

【导师】 杨立明；

【作者基本信息】 吉林大学 ， 内科学， 2004， 硕士

【摘要】 肾综合征出血热（HFRS）是由汉坦病毒引起的一种自然疫源性疾病。临床上常表现为发热期、低血压休克期、少尿期、多尿期、恢复期典型五期经过。广泛流行于亚欧等国，我国是本病的高发区。由于没有特效疗法，虽然随着医疗措施不断改进，人们对该病的认识逐渐提高，但其病死率仍达3%～5%，尤其是合并ARF时，大多病情危重，病死率极高，占HFRS死亡原因的50%～80%，单纯内科保守治疗难以奏效。因此，适时的血液净化治疗成为救治HFRS-ARF的关键，而其中的血液透析治疗又被大家广泛接受。目前国内外文献对血液透析治疗HFRS-ARF虽有多方面报道，但少有对自行收治病例的多样本全面分析。本文收录了11年来我院肾病科血液透析治疗的HFRS-ARF46例，通过系统的回顾性分析，力求对血液透析治疗HFRS-ARF有较全面的认识。文章着重探讨了血液透析治疗HFRS-ARF的机理、血透时机、肝素应用、血管通路的选择、血透个体化原则、并发症的处理、加强各期护理及血透与内科综合治疗的关系。本组46例患者，青壮年农民为主（65.2%），多有鼠类接触史，具有典型五期经过者40例（87.5%），多为重型（30.4%）、危重型（58.7%）HFRS，ARF以少尿型为主（91.3%），中、重度肾衰占97.8%。血BUN、CRE升高显著（100%），肾<WP=58>超声多有肾脏明显增大，肾脏摄取、排泄功能障碍，以排泄障碍为主。血小板降低者26例（56.5%）、便潜血阳性者21例（45.7%）、肝功能异常者28例（60.9%），心电及胸片异常者分别为21例及17例。并发症有腔道出血21例，心脏损害20例，继发感染17例，腹水13例，高血容量综合征12例、胸腔积液6例，脑出血1例。入院后积极给予规律血液透析，根据病情给予抗炎、止血、对症、支持治疗。经过上述治疗，46例患者中31例尿量恢复正常，恶心、呕吐等症状消失，查体无阳性体征，复查肾功能正常，治愈出院；12例经治疗后临床症状好转，进入多尿期，电解质紊乱纠正、肝功能好转，血BUN、CRE明显回降后因经济原因自动出院；1例因合并肾结核（一侧肾已切除）转为CRF，维持规律HD7年后死于脑出血；2例死亡，死因分别是大咯血、脑出血。治疗时间7～59天，平均22.9天。探讨血液透析的作用如下：1、清除因ARF而滞留在体内的各种代谢性废物，减轻它们对机体各个器官、组织细胞，尤其是肾脏的毒性作用。2、将原发病引起的感染性炎症介质,如肿瘤坏死因子、白细胞介素2等排出体外，重新建立可控的、有效的炎症反应，避免全身炎症反应综合征，多器官功能障碍综合征及多器官功能衰竭的发生。3、通过调节透析液电解质的浓度，迅速纠正电解质平衡失调，通过超滤水排除体内多余的水分，减轻循环负荷，从而达到纠正机体内环境紊乱的目的。4、血液透析可以部分调节免疫细胞平衡，消除<WP=59>细胞免疫功能紊乱。把握好血液透析的时机：具体透析指征如下：1、尿量<500 ml/d或无尿12～24ｈ以上，经大剂量速尿治疗无效者(除外肾前因素)；2、BUN>14mmol/L,CRE>365umol/L；3、血钾>6.0mmol /L,或每日增加≥1mmol/L，或心电图显示高血钾者；4、高血容量综合征；5、急性肺水肿；6、有尿毒症症状和水潴留表现或体重增加>2kg/d或出现心衰先兆者；7、严重代谢性酸中毒；8、有ARDS者；9、既往有慢性肾炎史；10、高分解代谢状态，CRE或BUN每日增加分别≥100umol/L或≥7.14mmol/L；11、有严重精神、神经症状，特别是昏迷伴有大抽搐，保守治疗无效者；12、发热期用肾毒性药物者，BUN>14mmol/L；13、病情进展迅速者。上述指标中具有1项情况即应进行血液透析治疗。下列情况应慎重考虑：1、休克纠正48小时之内，血压130/90mmHg以下者；2、心肌损害特别严重者；3、老年人心、肺功能差者。应该指出的是重型及危重型HFRS合并ARF患者大多伴有严重的出血倾向或临床活动性出血，但不应列为血液透析的禁忌症，如有透析指征，应在止血对症治疗基础上进行透析。血液透析治疗应个体化：血透应依据病人具体病情操作。即根据血压、有效循环血量情况，是否合并高血容量综合征、心衰、肺水肿及水肿情况决定超滤量的多少；根据水电解质平衡失调程度，调配透析液电解质浓度；根据出血倾向严重<WP=60>程度，决定肝素用量等。注意肝素应用与出血问题：血透能降低血中胍类、酚类及其它小分子有害物质水平,恢复血小板第Ⅲ因子的功能,血小板粘附性降低在血透中可获纠正,纤维蛋白降解产物的各种小碎片也减少,同时血透过程中应用肝素阻断了DIC的继续发展,此外还通过输入新鲜血或血小板,补充凝血因子,这样可使出血现象减轻。因此，透析中肝素是可以应用的，但要用量个体化，根据病情，可分别采用全身肝素化、边缘肝素化，有条件者可选用低分子肝素。血管通路的选择：应根据各医院医疗条件、患者血管情况、病情、透析时间及患者疾病转归等情况选择血管通路。患者血管条件好，透析时间短，又需紧急血透者可采用直接动静脉穿刺；直接穿刺有困难及透析次数多者可根据医疗条件选择行动-静脉外瘘及股静脉插管；转变为CRF者可行动静脉内瘘手术。如需手术建立血管通路时应注意避免手术切口感染，一旦发现有感染应积极应用抗生素。针对血透中不良反应及时处理：由于HD是在体更多还原

【Abstract】 Hameorrhagic fever with renal syndrome (HFRS) is an acute inflammatory disease caused by Hantavirus (HV). The syndrome evolves through five phases: febrile, hypotensive, oliguric, diuretic, and convalescent. It’s prevalent throughout most of Asia and Europe. China is a high emiting area of HFRS. Because of no particular therapeusis, its fatality still reach 3%～5% though recognization of people have been raised gradually and medicial measure have been improved unceasing. Especially when it accompanies acute renal failure(ARF), most of patient’s conditions are dangerous and the fatality is high, it takes 50%～80% of death cause of HFRS and only conservative therapy is hard to have the intended effect. So blood purification becomes the key point of saving and curing HFRS-ARF at the right moment and hemodialysis (HD) has been acceptted by people extensively. Now, though many literatures home and abroad have reported treatment on HFRS -ARF by HD in many ways, large-samples analysis is rare. In this article, there are forty-six cases of treatment on HFRS-ARF by HD in recent eleven years. By systematic reviewing analysis, we manage to get a throughout conception to the treatment on <WP=63>HFRS-ARF by HD. We emphatically probe into the mechanism of treatment on HFRS-ARF by HD, occasio of HD, application of heparin, selection of blood vessel way, individualizatic doctrine of HD, treatment of complication, enforcing care in all periods and the relations between HD and comprehensive therapy.In the forty-six patients, young and strong farmers were the major part (65.2%). Most of them had the history of contacting rats. Forty patients(87.5%) had typical five phases. Most of them were serious form (30.4%) and critical form (58.7%) HFRS. The acute renal failure type was mostly oliguria (91.3%). moderate and severe renal failure took 97.8%. The values of BUN and CRE increased notably (100%). The injury of kidney was mainly in renal tubule and interstitium. Most of them had a large kidney in ultrasound. The renal intake and excretion function were injured, and the injury of excretion function was the major. Thrombocytopenia was observed in 26 (56.5%) patients. Twenty-one patients’ (45.7%) occult blood was positive. There were liver disfunctions in twenty-eight patients (60.9%). Abnormalities of electrocardio and X-ray were twenty-one and seventeen cases respectively. The complications were twenty-one cavity pathway bleeding, twenty heart injuries, seventeen secondary infection, thirteen <WP=64>ascites, twelve hypervolemia syndrome, six pleural effusion and one cerebral hemorrhage. Early regular hemodialysis was given to get rid of the poision. All the cases were done with antibiotic, hemostasis, supportting and symptomatic therapy according to the patient’s conditions. After the above-mentioned treatment, among the forty-six patients the uric amounts of thirty-one patients recovered to the normal level. Symptom, such as nausea, vomiting, lumbag, etc were all disappeared，body-examing showed nothing abnormal, reviewing renal function were normal and the thirty-one patients discharged with healing. Twelve patients’ clinical symptoms took a turn for better. They all entered polyuria stage, redressed electrolyte disturbance, improved liver function, the values of BUN and CRE decreased transparently. They left hospital because of difficulty in economy. One case turned into chronic renal failure (CRF) for complicating tuberculosis of kidney (one kidney had been resected), died of cerebral hemorrhage after seven years regular hemodialysis. Two patients died. One died of hemoptysis, the other died of cerebral hemorrhage. The cure duration was 7～59 days, the mean one was 22.9 days.Discussing the action of hemodialysis are following. 1. It can Clean retentived various kinds of metabolic refuse induced <WP=65>by acute renal failure, relieve their toxic effect on all kinds of organs and histocytes of the body, especially the kidney. 2. It can output infective inflammation medium induced by primary disease, such as TNF,更多还原