间歇性高容量血液滤过对严重感染和感染性休克患者治疗效果的影响

Effects of intermittent high-volume hemofiltration in the treatment of patients with severe sepsis and septic shock

目的观察间歇性高容量血液滤过（IHVHF）对严重感染和感染性休克患者28d生存情况的影响。方法采用回顾性队列研究，收集因急性肾衰竭或多器官功能衰竭（MOF）接受IHVHF的严重感染或感染性休克患者的基础资料、IHVHF治疗方式及治疗期间的相关信息，采用COX风险比例模型分析患者IHVHF治疗后28d死亡的危险因素。结果共44例患者纳入本研究，按照患者进行IHVHF的平均剂量分为高剂量组（≥70ml·kg-1·h-1，17例）和低剂量组（〈70ml·kg-1·h-1，27例）。高剂量组和低剂量组患者除体质指数（kg／m2）有明显差异（20．7±3．2比25.3±3．0，P〈0．01）外，基础情况及IHVHF治疗方式均无明显差异。44例患者中28d内死亡17例，患者实际28d病死率明显低于预期病死率[38．6％比（61．8±21．9）％，P〈0．01]，且高剂量组28d病死率显著低于低剂量组[11．8％（2／17）比55．6％（15／27），P=0．004]。多因素COX风险比例模型分析发现，IHVHF前高序贯器官衰竭评分（SOFA）可增加28d死亡风险[相对危险度（Rn）=1．279，95％可信区间（95％CI）1．127-1．452，P〈0．001]，而高剂量IHVHF（RR=0．149，95％C10．032-0．694，P＝0．015）及IHVHF总时间长（RR=0．981，95％C10．966-0．997，P=0．016）可降低28d死亡风险。结论对于合并急性肾衰竭或MOF的严重感染和感染性休克患者，高剂量IHVHF（≥70ml·kg-1·h-1）是减少患者28d死亡的保护性因素，延长IHVHF时间可以降低28d病死率。

Objective To investigate the effects of intermittent high-volume hemofiltration （IHVHF） on 28-day survival in severe sepsis and septic shock patients. Methods A retrospective cohort study was conducted. Basic data, IHVHF treatment modality and related information during IHVHF treatment of patients with severe sepsis or septic shock receiving IHVHF because of acute renal failure or multiple organ failure （MOF） were collected. Cox proportional hazard model was used to analyze the risk factors of the patients＇ 28-day mortality after IHVHF treatment. Results Totally 44 patients were enrolled, the patients were divided into the high dose group （ ≥ 70 ml.kg-1.h-1, n= 17 ） and the low dose group （ 〈70 ml. kg-1. h-1, n = 27 ） according to the mean dose of IHVHF performed. Except for the significant differences of body mass index （kg/m2） between the high dose group and the low dose group （20.7 ± 3.2 vs. 25.3 ±3.0, P〈0.01 ）, there were no significant differences in basic data and IHVHF treatment method. In 44 patients 17 died within 28 days. The observed 28-day mortality of patients were significantly lower than the predicted mortality [38.6% vs. （61.8 ± 21.9）%, P〈0.01 ]. The mortality rate was significantly lower in the high dose group than in the low dose group [ 11.8% （2/17） vs. 55.6% （15/27）, P= 0.0041. Muhivariable Cox proportional hazard model analysis showed that the high the sequential organ failure assessment （SOFA） score before IHVHF was associated with increased risk of 28-day mortality [relative risk （RR）= 1.279, 95% confidence interval （95% CI）1.127 - 1.452, P〈0.0011, and high dose IHVHF （RR=0.149, 95%CI0.032- 0.694, P=0.015）, total hours ofIHVHF （RR=0.981, 95%CI 0.966 - 0.997, P=0.016） were associated with decreased risk of 28-day mortality. Conclusion For patients with severe sepsis and septic shock and complicated by acute renal failure or MOF, high dose IHVHF （ ≥ 70 m. kg-1.h-1） was a protective factor against 28-day mortality for these patients, and prolongation of IHVHF treatment could decrease 28-day mortality.