中国血液净化

中国血液净化 ›› 2016, Vol. 15 ›› Issue (09): 470-474.doi: 10.3969/j.issn.1671-4091.2016.09.007

• 临床研究 • 上一篇    下一篇

日间高容量血液滤过治疗感染性休克伴急性肾损伤疗效观察

柳彩侠1,程书立2   

  1. 1. 徐州市中心医院
    2. 徐州医学院附属医院
  • 收稿日期:2016-02-22 修回日期:2016-07-10 出版日期:2016-09-12 发布日期:2016-09-12
  • 通讯作者: 程书立 shulicheng008@163.com E-mail:liucaixiaxz@163.com

The effect of daytime high-volume hemofiltration for the treatment of septic shock patients complicated with acute kidney injury

  • Received:2016-02-22 Revised:2016-07-10 Online:2016-09-12 Published:2016-09-12

RichHTML

0

PDF

243

摘要： 目的观察日间高容量血液滤过(high volume hemofiltration,HVHF)治疗感染性休克伴急性肾损伤(acute kideny injury,AKI)、多脏器功能不全(multiple organ dysfunction syndrome,MODS)患者的临床疗效。方法50 例患者分为对照组和治疗组，每组25 例患者。采集患者炎症介质：肿瘤坏死因子-α(Tumor necrosis factor-α,TNF-α)、白细胞介素-10(Interleukin-10,IL-10)的浓度；中心静脉压力、维持患者平均动脉压(mean arterial pressure, MAP)在65～70mmHg(1mmHg= 0.133kpa)时的去甲肾上腺(noradrenaline,NE)的剂量及动脉血乳酸浓度，氧和指数；血肌酐、尿素氮水平，急性生理与慢性健康评分(acute physiology and chronic health evaluationⅡ,APACHEⅡ)；并记录2 组患者住院期间机械通气时间、2 组实验结束后需要继续血液透析患者人数、ICU 住院时间、总住院时间、住院病死率、28 天病死率。结果?血液净化治疗后，2 组患者血液中TNF-α,IL-10 浓度均下降，治疗组下降更加明显：IL-10 在48h 和72h 与对照组相比，差异有统计学意义(t 分别为2.425、2.893；P 分别为0.019、0.006)，TNF-a 在72h 差异有统计学意义(t=2.646，P= 0.011)。②治疗后2 组患者呼吸、循环、肾功能指标及APACHEⅡ评分均改善，治疗组改善显著：在维持患者MAP 在65～70mmHg 所需NE 剂量治疗组在24h、48h、72h 较对照组降低更显著，差异有统计学意义(t 为2.228、2.490、3.674；P 分别为0.031、0.016、0.001)；在治疗后48h 和72h，治疗组氧合指数升高程度较对照组更显著，差异有统计学意义(t 为-2.343、-2.225, P 为0.023 及0.031)。治疗组平均机械通气时间显著少于对照组，差异有统计学意义(t=6.363,P＜0.001)；治疗组在24h、48h、72h 的APACHEⅡ评分分低于对照组，差异有统计学意义(t 为3.732、2.502、2.771；P 为0.001、0.016、0.008)；治疗组机械通气时间(t=6.363，P＜0.001)、ICU 住院时间(t=2.409,P=0.020)、总住院时间(t=2.527,P=0.015)均显著少于对照组。结论日间高容量血液滤过可以改善患者的呼吸循环指标，降低APACHEⅡ评分，减少ICU 及总住院时间，减少住院及28 天病死人数。

关键词: 急性肾损伤, 高容量血液透析, 炎症因子

Abstract: Objective To assess the therapeutic effect of daytime high-volume hemofiltration (HVHF) on septic shock patients combined with acute kidney injury (AKI). Methods A total of 50 septic shock cases complicated with AKI and treated in the ICU during the period from Oct. 2013 to Jun. 2015 were enrolled in this study. They were randomly divided into treatment group (treated with daytime HVHF, n=25) or control group (treated with CVVH, n=25). Serum tumor necrosis factor alpha (TNFα), interleukin-10 (IL-10), lactic acid (Lac), BUN and creatinine were measured. Central venous pressure (CVP) was monitored. The norepinephrine dose needed to maintain average arterial pressure at 65-70 mmHg and the normal oxygenation indices were recorded. APACHE II score, mechanical ventilation duration, days in ICU, hospitalization days, and mortality in hospital were also collected. Results After the treatment, serum TNF-α and IL-10 levels decreased in both groups. The decrease of TNF-α and IL-10 levels was more in treatment group than in control group. Serum IL-10 levels were 62.32±11.39 μg/l and 70.82 ± 13.31 μg/l (t=2.425, P=0.019) in treatment group and control group respectively at the 48th hour after the treatment, and were 57.36±13.83 μg/l and 68.23 ±12.73 μg/l (t=2.893; P=0.006) in treatment group and control group respectively at the 72nd hour after the treatment. Serum TNF-α levels were 94.16±15.11 μg/l and 104.81±13.30 μg/l (t=2.646, P=0.011) in treatment group and control group respectively at the 72nd hour after the treatment. Hemodynamics, respiration, renal function and APACHE II score improved after the treatment in both groups, and improved more in treatment group than in control group. Norepinephrine doses used were 0.67±0.14 μg/kg/min and 0.75±0.10 μg/kg/min (t=2.228, P=0.031) in treatment group and control group respectively at the 24th hour after the treatment, and APACHE II scores were 24.20±2.83 and 27.44±3.30 (t= 3.732, P=0.001) in treatment group and control group respectively at the 24th hour after the treatment. The oxygenation indices were 270.40 ± 37.72 mmHg and 244.76±39.66 mmHg (t=-2.343; P=0.023) in treatment group and control group respectively at the 48th hour after the treatment. Mechanical ventilation duration, days in ICU, and hospitalization days were 63.2±12.8 hours, 81.8±7.2 hours, and 6.3±2.1 days respectively in treatment group, and were 7.8±2.3 days, 12.8±4.1 days, and 15.6±3.9 days respectively in control group (t=6.363, P＜0.001 for mechanical ventilation duration; t=2.409, P=0.020 for days in ICU; t=2.527, P=0.015 for hospitalization days). Conclusion Daytime HVHF can significantly improve the prognosis of severe septic shock patients, clinically showing recovery of respiration/ circulation failure, alleviation of systemic inflammation, and decrease of APACHEII score.

Key words: acute kidney injure, daytime high-volume hemofiltration(HVHF), inflammatory factor