中国血液净化

中国血液净化 ›› 2015, Vol. 14 ›› Issue (11): 662-666.doi: 10.3969/j.issn.1671-4091.2015.11.006

• 临床研究 • 上一篇    下一篇

连续性血液透析滤过改善顽固性心l力衰竭患者心功能的机制探讨

李旭,刘加明,李玉琴,金鑫,阿丽娅   

  1. 新疆石河子市人民医院肾病内科
  • 收稿日期:2015-07-23 修回日期:2015-09-11 出版日期:2015-11-12 发布日期:2015-11-12
  • 通讯作者: 刘加明 ljm680805@sohu.com E-mail:lixudr@163.com
  • 基金资助:

    新疆生产建设兵团第八师石河子市科技计划项目(项目编号：2013YL09)

Study on the improvement of cardiac function by continuous hemodiafiltration in patients with refractory heart failure

  • Received:2015-07-23 Revised:2015-09-11 Online:2015-11-12 Published:2015-11-12

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摘要： 目的探讨连续性血液透析滤过改善顽固性心力衰竭患者心功能的机制。方法选择2013 年3 月～2015 年2 月收住石河子市人民医院的顽固性心力衰竭患者40 例，根据患者意愿，分为连续性静-静脉血液透析滤过联合常规药物治疗组(试验组)与常规药物治疗组(对照组)各20 例。记录治疗前后尿量；测量治疗48h 前后体质量(BW，用于评价患者液体潴留程度)，血浆C-反应蛋白(CRP)、白细胞介素6(IL-6)、白细胞介素8(IL-8)、肿瘤坏死因子α(TNF-α)水平，以及左心室射血分数(LVEF)，计算上述指标的改变量(ΔCRP、ΔIL-6、ΔIL-8、ΔTNF-α、ΔBW、ΔLVEF)，建立预测ΔLVEF 的多元线性回归模型。结果两组治疗后48h 内，试验组液体排出总量(尿量+超滤量)超过对照组(P＜0.001)。治疗48h后，与治疗前比较，试验组CRP、IL-6、IL-8、TNF-α水平下降(P＜0.05)，对照组CRP、IL-6、IL-8、TNF-α水平略有下降，但无统计学意义(P＞0.05)，两组体质量均较治疗前下降(P＜0.05)，两组LVEF 较治疗前升高(P＜0.05)；两组之间比较，试验组CRP、IL-6、IL-8、TNF-α水平低于对照组(P＜0.05)，体质量略低于对照组、LVEF 略高于对照组，但均无统计学意义(P＞0.05)；试验组体质量下降值(ΔBW)、LVEF 的升高值(ΔLVEF)均超过对照组(P＜0.001)。试验组ΔBW、ΔCRP、ΔIL-6、ΔIL-8 与ΔLVEF 呈正相关(P＜0.05)，多元线性回归模型显示，ΔBW、ΔTNF-α是ΔLVEF 的独立影响因子，其中ΔBW 是主要影响因子。对照组ΔBW 与ΔLVEF 呈正相关(P＜0.001)，ΔCRP、ΔIL-6、ΔIL-8、ΔTNF-α与ΔLVEF 无相关性(P＞0.05)，只有ΔBW 被纳入ΔLVEF 的回归方程。结论连续性血液透析滤过改善顽固性心力衰竭患者LVEF 的主要机制是减轻液体潴留、清除炎症因子，其中最重要的机制是减轻液体潴留。

关键词: 连续性静-静脉血液透析滤过, 顽固性心力衰竭, 左心室射血分数, 多元线性回归模型

Abstract: Objectives To investigate the improvement of cardiac function by continuous hemodiafiltration in patients with refractory heart failure. Methods Forty patients with refractory heart failure treated in Shihezi People’s Hospital from March 2013 to February 2015 were enrolled in this study. They were assigned into continuous venous- venous hemodiafiltration (CVVHDF) combined with conventional treatment group (experiment group, n=20) or conventional treatment group (control group, n=20) based on patient's preference. Urinary output before and after treatment was measured. Body weight (BW), plasma C-reactive protein
(CRP), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor alpha (TNF-α), and left ventricular ejection fraction (LVEF) were determined before treatment and after the treatment for 48 hours. Changes of these indicators (ΔCRP, ΔIL-6, ΔIL-8, ΔTNF-α, ΔBW, ΔLVEF) were then calculated. Multivariate linear regression model for predicting ΔLVEF was established. Results After the treatment for 48 hours, total fluid output (urine and ultrafiltration volume) was higher in experiment group than in control group (P＜0.001), and the levels of CRP, IL-6, IL-8 and TNF-α decreased significantly (P＜0.05) in experiment group but not in control group (P＞0.05) as compared with those before the treatment. BW became lower and LVEF became higher in both groups (P＜0.05) as compared with those before the treatment. Levels of CRP, IL-6, IL-8 and TNF-α were lower in experiment group than in control group (P＜0.05). BW was lower and LVEF was higher in experiment group than in control group but without statistical significance (P＞0.05). However, the increase of ΔLVEF and decrease of ΔBW were more in experiment group than in control group (P＜0.001). In experiment group, significantly positive correlations were found among ΔBW, ΔCRP, ΔIL-6, ΔIL-8, ΔTNF-αand ΔLVEF (P＜0.05); multiple linear regression analyses showed that ΔBW and ΔTNF-α were the independent factors for ΔLVEF, and ΔBW was the main independent factor for ΔLVEF. In control group, ΔLVEF was positively correlated with ΔBW (P＜0.001) but had no correlation with ΔCRP, ΔIL-6, ΔIL-8 and ΔTNF-α (P＜ 0.05); multiple linear regression analyses showed that only ΔBW was the independent factor for ΔLVEF. Conclusions Continuous hemodiafiltration increases LVEF in patients with refractory heart failure mainly through the clearance of inflammatory factors and especially through the removal of retained fluid.

Key words: Continuous venovenous hemodiafiltration, Refractory heart failure, Left ventricular ejection fraction, Multiple linear regression model