Гемофильтрация и гемодиализ в профилактике и лечении острой почечной недостаточности после операций на сердце с искусственным кровообращением

Objective: to analyze the efficiency of hemofiltration (HF) in the stage of extracorporeal circulation (EC) during cardiac surgery in order to prevent acute renal function lowering and the development of acute renal failure (ARF). Materials and methods. The risk of postoperative ARF requiring renal replacement therapy (RRT) was preoperatively assessed by the summed Cleveland risk score and percentage (2005). HF during EC was used in patients at high risk for ARF. The procedure was performed, by combining 2 extracorporeal circuits: EC and a Diapact®CRRT apparatus. With evolving ARF, Stage 3 after Risk, Injury, Failure, Loss of Kidney Function, End-stage Renal Disease (RIFLE), 2004, and Acute Kidney Injury Network (AKIN), 2007, continuous venovenous hemofiltration (CVVHF) and continuous high-flow hemodialysis (CHFHD) were done in the dialysate recirculation mode after surgery under EC. The Mann-Whitney non-parametric test was used to estimate the significance of intergroup differences. The results are presented: median (lower quartile; upper quartile), the differences considered to be significant atpResults. HF during EC; 6 patients were aged 65.5 (range 57—70) years with chronic kidney disease, preoperative glomerular filtration rate (GFR) was 50 (range 41.5—65) ml/min/1.73 m2 using the Cockroft-Gault formula. The maximum GFR decrease by 2.9 (range 0.7—7) ml/min/1.73 m2 was seen after EC. A control group comprised 12 patients aged 73 (range 63—75) years. There was a postoperative GFR reduction by 17 (range 13.7—22) ml/min/1.73 m2. One patient from the control group developed ARF and multiple organ dysfunction, which required CVVHF and CHFHD. Conclusion. The use of intraoperative HF in patients at high risk for renal function lowering is likely to prevent a considerable GFR reduction and ARF after surgery under EC.Цель исследования — анализ эффективности гемофильтрации (ГФ) на этапе искусственного кровообращения (ИК) при операциях на сердце, для профилактики острого снижения функции почек и развития острой почечной недостаточности (ОПН). Материал и методы. Риск развития после операции ОПН, требующей применения заместительной почечной терапии (ЗПТ), оценивали до операции согласно сумме баллов и процентов риска по Cleveland score (2005). ГФ на этапе ИК применяли у больных высокого риска развития ОПН. Процедуру проводили посредством совмещения 2-х экстракорпоральных контуров: ИК и аппарата Diapact®CRRT. В случае развития ОПН, 3 стадия по Risk, Injury, Failure, Loss of kidney function, End-stage Renal Disease (RIFLE) 2004 и Acute Kidney Injury Network (AKIN) 2007, после операции с ИК проводили продолжительную вено-венозную гемофильтрацию (ПВВГФ) и продолжительный высокопоточный гемодиализ (ПВГД) в режиме рециркуляции диализата. Для оценки достоверности межгрупповых различий применяли непараметрический метод анализа по Манна—Уитни. Результаты представлены: медиана (нижний квартиль; верхний квартиль), различия считались достоверными приp<0,05. Результаты. ГФ на этапе ИК. Шесть больных, возраст 65,5 (57; 70) лет, с хронической болезнью почек (ХБП), скорость клубочковой фильтрации (СКФ) по Кокрофту-Гаулту до операции 50 (41,5; 65) мл/мин/1,73 м2. Максимальное снижение СКФ после ИК на 2,9 (0,7; 7) мл/мин/1,73 м2. Контрольная группа — 12 больных, возраст 73 (63; 75) лет. Наблюдали снижение СКФ после операции на 17 (13,7; 22) мл/мин/1,73 м2. У одного пациента контрольной группы развилась ОПН и полиорганная недостаточность (ПОН), потребовалось проведение ПВВГФ и ПВГД. Заключение. Использование интраоперационной гемофильтрации у больных с высоким риском снижения функции почек, вероятно, позволит предотвратить значительное снижение СКФ и развитие ОПН после операций с ИК. Ключевые слова: операции на сердце с искусственным кровообращением, острая почечная недостаточность, гемофильтрация, гемодиализ

Renal replacement therapy in the treatment and prevention of contrastinduced nephropathy after cardiovascular surgery

Aim. To analyse the effectiveness of hemofiltration and high-volume hemodialysis for acute renal failure (ARF) prevention and treatment after cardiovascular surgery and contrast media (CM) use. Material and methods. The patients cardiovascular jurgery. For cardiovascular visualisation, low-osmolar or isoosmolar CM were used (ultravist, optiray and visipack, respectively). The risk of contrast-induced nephropathy (CIN) was assessed, according to the guidelines by Barrett ВJ, Parfrey PS (2006). Hemofiltration and high-volume hemodialysis (recirculating dialysate regimen) were performed with the Diapact®CRRT device, using the Duosol® solution. Heparin anticoagulation was monitored by activated coagulation time. Every 2-3 hours, the levels of hematocrit, potassium, sodium, glucose, pH, bicarbonate, and lactate in venous blood were measured. Results. Renal replacement therapy (RRT) procedures were performed in 5 patients after Stage III ARF development. In two cases, ARF was combined with multi-organ failure (MOF). In one case, ARF resulted in death, and in four other cases, ARF regressed with renal function normalisation. In one case of MOF, hyperbilirubinemia, and hyperenzymemia, hemofiltration was combined with plasmapheresis. In two patients with a very high ARF risk, hemofiltration and high-volume hemodialysis were performed preventatively, after cardiac surgery. Preventive RRT was not associated with a significant reduction in glomerular filtration rate (GFR) or with ARF development.Conclusion. In patients with CIN and ARF after CM use during angioplasty and hybrid cardiac surgery, RRT effectively reduces life-threatening metabolic complications of ARF. Among individuals with a very high ARF risk, RRT immediately after CM-using cardiovascular surgery can prevent a significant GFR reduction and ARF development

β1-adrenoreceptor antibody measurement and antibody removal effects on left ventricular contractility in dilated cardiomyopathy patients

Aim. To develop a test system measuring β1-adrenoreceptor antibody (anti- β1-AR) level. To study the effects of autoantibody removal on left ventricular (LV) contractility. Material and methods. Peptides, according to second human extracellular β1-AR loop fragments (197-222 amino acid fragments), were synthesized by modified hard-phase method and then lyophilized. Molecular mass control was performed by laser desorption mass spectrometry. In total, 47 patients were examined, with the aim of anti- β1-AR detection. Dilated cardiomyopathy (DCMP) was diagnosed in 22 patients, ischemic CMP – in 8, post-infarction cardiosclerosis – in 6, myocarditis – in 3, alcohol CMP – in 1, and post-transplantation CMP – in 7 participants. Anti- β1-AR were removed in 4 DCMP patients, by plasmapheresis (PF; n=3) or immunoadsorption (IA; n=1). Results. A new immune-enzyme test system for autoantibody detection has been developed, using the second extracellular β1-AR loop 26 amino acid peptide as the antigen. Anti- β1-AR removal by IA or PF methods resulted in improved LV contractility among DCMP patients. Conclusion. It is important to determine whether LV contractility improvement is explained by anti-β1-AR removal exclusively. More advanced methods for anti- β1-AR and other anti-myocardial antibody detection should be developed, and auto-antibodies’ role in impaired myocardial contractility should be studied