连续性肾替代治疗对多脏器功能不全综合征患者炎性介质清除及内皮细胞功能的影响

Effects of continuous renal replacement therapy on the removal of inflammatory mediators and the function of endothelial cells in patients with multiple organ dysfunction syndrome

目的研究连续性肾替代治疗（CRRT）对多脏器功能不全综合征（MODS）患者外周血炎性介质清除及内皮细胞功能的影响。方法选取我院30例MODS患者，行CRRT治疗，每次治疗时间不短于24h，分别于治疗开始时（0h）和治疗后3、6、12、24h取血检测肿瘤坏死因子α（TNF—α）、白细胞介素（IL）1B、IL-4、IL-6、IL-10、E-选择素、可溶性血管细胞黏附分子（sVCAM-1）、可溶性细胞间黏附分子1（sICAM-1）和血小板活化因子乙酰水解酶（PAF—AH）。结果CRRT14d存活19例（63．3％），28d存活17例（56．7％）。患者电解质和酸碱平衡于治疗6h后恢复正常。IL-1β、IL-4于治疗开始后下降，TNF-α、IL-6、IL-10在12h时浓度达峰值[（887．88±975．46）ng／L、（132．01±118．14）ng／L、（167．01±161．66）ng／L]，与治疗前[（462．24±331．03）ng／L、（106．39±90．82）ng／L、（124．51±118．39）ng／L]比较，差异有统计学意义（均P〈0．05）。但TNF-±、IL-1β、IL-4、IL-6、IL-10治疗前与治疗后24h差异无统计学意义。治疗后，死亡组IL-6[（145．45±14．28）ng／L]显著高于存活组[（106．03±10．86）ng／L]（P〈0．05）；死亡组IL-10[（94．93±16．09）ng／L]显著低于存活组[（143．06±12．24）ng／L]（P〈0．05）。内皮细胞E-选择素、sVCAM-1、sICAM-1于治疗开始后升高，于治疗12h达峰值，但治疗前后差异无统计学意义。PAF—AH治疗后开始升高，治疗后水平高于治疗前。死亡组E-选择素[（287．13±42．70）μg／L比（266．26±65．26）μg／L]、sVCAM-1[（1697．25±475．24）μg／L比（1488．10±691．67）μg／L]、sICAM—1[（975．33±142．50）μg／L比（835．40±332．41）μg／L]高于存活组；而PAF—AH低于存活组[（9．07±6．38）μg／L比（16．32±8．95）μg／L]。结论CRRT能纠正MODS患者机体紊乱的内环境，并能部分纠正内皮细胞功能，但外周血炎性介质水平治疗前后差异无统计学意义。IL-6、IL-10水平可作为临床转归的预测指标。

Objective To evaluate the effect of continuous renal replacement therapy （CRRT） on the remove of inflammatory mediators and the function of endothelial cells in patients with multiple organ dysfunction syndrome （MODS）. Methods Thirty patients with MODS were enrolled in this study. All of the patients underwent CRRT for at least 24 hours. Peripheral blood levels of IL-1β, IL-4, IL-6, IL-10, TNF-α, E-selectin, sVCAM-1, sICAM-1 and PAF-AH were measured at the beginning and 3, 6, 12, 24 h after initiation of CRRT. Results Nineteen patients survived after 14 days and 17 patients survived after 28 days during therapy. The clinical oxygenation and hemodynamics were improved after 6 h of CRRT. Among inflammatory mediators, the levels of TNF-α, IL-6, IL-10 rose gradually from the beginning [（462.24±331.03） ng/L, （106.39±90.82） ng/L, （124.51±118.39） ng/L）, and reached the peak at 12 h [（887.88±975.46） ng/L, （132.01±118.14） ng/L, （167.01±161.66） ng/L], and the levels of IL-1β, IL-4 decreased from initiation of CRRT. But there were no significant differences in the levels of above cytokines between at the beginning and at the end of CRRT. There were significant differences in the levels of cytokines between survival and death group. The level of IL-6 in death group [（145.45±14.28） ng/L] was significantly higher than that in survival group [（106.03±10.86） ng/L]. The level of IL-10 in death group [（94.93±16.09） ng/L] was significantly lower than that in survival group [（ 143.06± 12.24） ng/L]. Levels of E-select, sVCAM-1 and sICAM-I elevated from the beginning and reached the peak at 12 h, but no significant differences were found between intiation and the end of CRRT. The level of PAF-AH increased after initiation, and there was a significant difference between beginning and the end of CRRT. Levels of eytokines for endothelial cell function were significantly different, such as E-selectin [（287.13±42.70） μg/L vs （266.26±65.26） μg/L], sVCAM-1 [（ 1697.25± 475.24） μg/L vs （1488.10±691.67） μg/L], sICAM-1 [（975.33±142.50） μg/L vs （835.40±332.41） μg/L], and PAF-AH [（9.07±6.38） μg/L vs （16.32±8.95）μg/L]. Conclusions Clinical oxygenation and hemodynamics can be improved, and endothelial cell function can be improved partly by CRRT. There were no significant differences of inflammatory mediator levels between initiation and the end of CRRT. IL-6 and IL-10 can be used as predicators for prognosis of MODS patients.