新生儿和婴儿的体外肾脏支持：多器官功能障碍综合征中的治疗前景与结局——一项结构化叙述性综述。
完整摘要 · 中文译文
背景：多器官功能障碍综合征（MODS）在新生儿和婴儿的重症监护中仍然是一个重大挑战，并且与显著的发病率和死亡率相关，尤其是在存在脓毒症和急性肾损伤时。由于技术和生理上的限制，常规的肾脏替代和解毒策略可能难以在新生儿和低体重婴儿中实施。血液透析滤过（HDF）结合了对流和弥散清除机制，已成为一种潜在的体外支持方式，用于代谢和炎症控制，同时维持血流动力学稳定。 目的：对关于新生儿和婴儿多器官功能障碍综合征中血液透析滤过的临床应用、潜在获益、安全性考虑及技术方面的现有文献进行结构化叙述性综述。 方法：本研究为一项具有系统性检索要素的结构化叙述性综述。检索了PubMed、Scopus、Web of Science和Cochrane Library中2018年1月至2025年10月期间发表的文献。通过参考文献列表筛查确定的早期里程碑式出版物也被纳入，以提供历史和技术背景。采用结构化检索和描述性筛选过程来识别与新生儿和婴儿体外血液净化相关的出版物。符合条件的群体包括患有MODS、脓毒症的体重≤8 kg的新生儿（出生后<28天）以及超过新生儿期（出生后28天至<12个月）的婴儿。 高氨血症，或急性肾损伤。涉及血液透析滤过（HDF）或连续性肾脏替代治疗（CKRT）的观察性研究、病例系列、注册报告和综述文章被考虑。涉及更广泛儿科人群的研究仅在符合条件的新生儿或婴儿亚组的有关数据可单独获得时才被纳入。缺乏临床相关信息的文献被排除在描述性综合之外。由于研究设计、患者人群和报告结局存在显著异质性，研究结果以描述性方式综合。 结果：综述的文献提示，HDF可能与经选择的新生儿和婴儿的代谢稳定、酸碱紊乱纠正及电解质平衡改善相关。有限的基于病例的证据还描述了体外治疗后血流动力学稳定和血管升压药支持减少；然而，这些观察仍不足以确立因果治疗效应。由于患者特征、临床指征和治疗方案的差异，各研究间的临床结局差异很大。报告的并发症包括低血压、管路凝血和凝血异常，尽管其发生频率和临床意义在不同文献间差异相当大。 结论：当前证据提示，血液透析滤过可能代表一种有前景的体外支持策略，适用于经选择患有MODS的新生儿和婴儿，特别是在代谢稳定和器官支持方面。然而， 现有证据仍然有限、异质性较高，且主要基于观察性研究和病例系列。需要进一步开展多中心前瞻性研究，以明确最佳适应证、治疗方案及长期预后。
完整摘要 · 英文原文
BACKGROUND: Multiple organ dysfunction syndrome (MODS) remains a major challenge in the intensive care of neonates and infants and is associated with substantial morbidity and mortality, particularly in the presence of sepsis and acute kidney injury. Conventional kidney replacement and detoxification strategies may be difficult to implement in neonates and low-weight infants because of technical and physiological limitations. Hemodiafiltration (HDF), which combines convective and diffusive clearance mechanisms, has emerged as a potential extracorporeal support modality for metabolic and inflammatory control while maintaining hemodynamic stability. OBJECTIVE: To provide a structured narrative review of the available literature on the clinical applications, potential benefits, safety considerations, and technical aspects of hemodiafiltration in neonates and infants with multiple organ dysfunction syndrome. METHODS: This study was conducted as a structured narrative review with systematic search elements. PubMed, Scopus, Web of Science, and the Cochrane Library were searched for publications from January 2018 to October 2025. Earlier landmark publications identified through reference-list screening were additionally included to provide historical and technical context. A structured search and descriptive selection process was used to identify publications relevant to extracorporeal blood purification in neonates and infants. Eligible populations included neonates (<28 days of life) and infants beyond the neonatal period (28 days to <12 months) weighing ≤8 kg with MODS, sepsis, hyperammonemia, or acute kidney injury. Observational studies, case series, registry reports, and review articles addressing HDF or continuous kidney replacement therapy (CKRT) were considered. Studies involving broader pediatric populations were included only when relevant data for eligible neonatal or infant subgroups were separately available. Publications lacking clinically relevant information were excluded from the descriptive synthesis. Owing to substantial heterogeneity in study designs, patient populations, and reported outcomes, findings were synthesized descriptively. RESULTS: The reviewed literature suggests that HDF may be associated with metabolic stabilization, correction of acid-base disturbances, and improvement in electrolyte balance in selected neonates and infants. Limited case-based evidence has also described hemodynamic stabilization and reduced vasopressor support following extracorporeal therapy; however, these observations remain insufficient to establish a causal treatment effect. Clinical outcomes varied substantially across studies because of differences in patient characteristics, clinical indications, and treatment protocols. Reported complications included hypotension, circuit clotting, and coagulation abnormalities, although their frequency and clinical significance differed considerably among publications. CONCLUSIONS: Current evidence suggests that hemodiafiltration may represent a promising extracorporeal support strategy for selected neonates and infants with MODS, particularly for metabolic stabilization and organ support. However, the available evidence remains limited, heterogeneous, and predominantly based on observational studies and case series. Further multicenter prospective studies are required to clarify optimal indications, treatment protocols, and long-term outcomes.