儿童严重脓毒症连续性血液净化治疗时肾素-血管紧张素-醛固酮系统的变化

Renin-angiotensin-aldosterone system changes in pediatric severe sepsis treated with continuous blood purification

目的 探讨连续性血液净化（continuous blood purification,CBP）治疗严重脓毒症患儿时肾素-血管紧张素-醛固酮系统的变化.方法 前瞻性研究,对象为上海交通大学附属儿童医院PICU2012年6月至2014年5月收治的严重脓毒症患儿35例.监测中心静脉压、动脉血压及平均动脉压,在抗生素、液体治疗等常规治疗基础上,进行连续性静-静脉血液滤过透析或高容量血液滤过模式治疗.放射免疫法测定CBP治疗前及CBP治疗后24 h时的血浆肾素活性及血管紧张素Ⅱ、醛固酮水平;并以同时期、同年龄段25例健康体检儿童作为对照组.结果 35例严重脓毒症患儿CBP治疗前后和对照组儿童血中肾素活性分别为（2.11±1.93）μg/（L·h）、（1.27±1.56） μg/（L·h）和（0.37±0.22） μg/（L·h）;血管紧张素Ⅱ分别为（426.78±332.37） ng/L、（364.40±325.51） ng/L和（41.70±10.81）;醛固酮分别为（255.12±218.18） ng/L、（134.92±104.13） ng/L和（106.88±43.18） ng/L.严重脓毒症患儿肾素活性及血管紧张素Ⅱ、醛固酮水平较对照组明显升高,CBP治疗后明显减低,醛固酮降至对照组水平,差异均有统计学意义（P＜0.01,P＜0.05）.35例患儿中,经治疗好转24例,死亡5例,放弃治疗6例.CBP治疗24 h后,脓毒症合并心血管功能障碍的26例患儿平均动脉压较治疗前显著上升（P＜0.01）;多巴胺用量下降（P＜0.01）.结论 严重脓毒症患儿肾素-血管紧张素-醛固酮系统反应水平明显升高;CBP治疗可降低严重脓毒症患儿血液中肾素活性及血管紧张素Ⅱ和醛固酮水平,但不加重或造成循环功能障碍.

Objective To explore the changes of renin-angiotensin-aldosterone system in pediatric severe sepsis treated with continuous blood purification（CBP）.Methods Prospective study,35 cases of critically ill children diagnosed with severe sepsis and admitted to PICU of Shanghai Children＇s Hospital of Shanghai Jiaotong University from June 2012 to May 2014 served as reseach objective.Based on the monitoring of vital signs,including central venous pressure,arterial blood pressure,mean arterial pressure,patients were treated with conventional therapy,as antibiotics,fluid therapy,and CBP by mode of continuous veno-venous hemodiafiltration or high volume hemofiltration.Plasma levels of rennin activity,angiontensin Ⅱ and aldosterone were measured by radioimmunoassay before and 24 h after CBP.Twenty-five cases of blood samples taken from the children collected from health care for liver function examination were matched as control group.Results Plasmalevelsofrenninactivitywere（2.11 ±1.93） pg/（L·h）,（1.27±1.56） μg/（L·h）,（0.37 ± 0.22） μg/（L· h） before and 24 h after CBP and control group,respectively.The levels of angiontensin Ⅱ were （426.78 ±332.37） ng/L,（364.40 ± 325.51） ng/L,（41.70 ± 10.81） ng/L,respectively.And the levels of aldosterone were （255.12 ± 218.18） ng/L,（134.92 ± 104.13） ng/L,（106.88 ±43.18） ng/L,respectively.The plasma levels of rennin activity,angiontensin Ⅱ,and aldosterone were higher in sepsis cases than in control group,while decreased obviously after CBP treatment（P ＜0.01,P ＜0.05）.Eleven cases died and mortality was 31.4％ （11/35）.After 24 h of CBP,the mean arterial pressure improved in 26 cases with septic shock and dopamine dose reduced（P ＜ 0.01）.Conclusion The reaction of renin-angiotensin-aldosterone system is increased significantly in pediatric severe sepsis.CBP can down-regulate the levels of rennin activity,angiotensin Ⅱand aldosterone,but not worsen the circulation function.