常规超滤与零平衡超滤对体外循环术后促炎症因子浓度及急性肾损伤关系的影响

Comparetive study of conventional vs.zero-balanced ultrafiltration in concentration of serum proinflammatory factors and incidence of acute kidney injury after cardio-pulmonary bypass procedures

目的：比较常规超滤与零平衡超滤对体外循环术后促炎症因子浓度、急性肾损伤（ AKI ）和临床预后的影响。方法将接受体外循环心内直视手术患者40例随机分成常规超滤组（A组，20例）和零平衡超滤组（B组，20例）。检测体外循环前（T0）、术中超滤前（T1）、超滤毕即刻（T2）、术后24 h（T3）、48 h（T4）、7 d（T5）时间点血浆肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、尿液肾损伤分子-1（KIM-1）、胱抑素C（CysC）、视黄醇结合蛋白（Rbp）、血肌酐、尿素氮。收集患者术前、术后相关资料。结果两组患者基线资料差异无统计学意义（ p〉0.05）；手术方式、体外循环时间、主动脉阻断时间、输血、自动复跳比例差异均无统计学意义（ p〉0.05）；体外循环开始后TNF-α和IL-6均开始上升，B组显著降低，T2、T3时间点炎症因子的浓度，与A组相比较差异有统计学意义（ p〈0.05）；零平衡超滤能不同程度降低肾损伤分子、胱抑素c、视黄醇结合蛋白、肌酐、尿素氮等肾损伤指标的浓度，尤以T2、T3、T4时间点明显；A组患者术后AKI Ⅰ级以上共11例，B组AKIⅠ级以上2例，B组AKIⅠ级以上的发病率显著低于A组（p〈0.01）。两组患者术后呼吸机使用时间、ICU滞留时间差异有统计学意义（p〈0.05）。术后并发症总发生率B组低于A组（p〈0.05），其他并发症和术后住院时间、术后30 d内死亡率差异均无统计学意义（ p〉0.05）。尽管A组行肾替代治疗的多于B组，但差异无统计学意义（ p〉0.05）。结论零平衡超滤能有效降低体外循环术后炎症因子水平，减轻肾损伤，改善临床预后，是一种成熟、安全、有效技术方式，值得推广。

Objective To compare the impact of conventional vs. zero-balanced ultrafiltration on serum pro-inflammatory factors,acute kidney injury and clinical prognosis after cardio-pulmonary bypass procedure. Methods Forty patients receiving cardiac surgery under cardio-pulmonary bypass procedures in Xiangyang Central Hospital during January 2013 to June 2013 were randomly divided into conventional ultrafiltration group（group A,n=20）and zero-balanced ultrafiltration group（group B,n=20）. Blood and urine samples were collected on different time points（ pre-operation,T0;pre-ultrafiltration,T1;immediately after ultrafiltration,T2;24 hours post-operation,T3;48 hours post-operation,T4;7 days post-operation, T5）. TNF-α,IL-6,KIM-1,CysC,serum creatinine and urea nitrogen were detected and compared. Pre-and post-operative clinical data were also collected. Results There was no difference in baseline data or intra-operative data（p〉0. 05）. TNF-αand IL-6 started to increase when the operation began. Compared with conventional ultrafiltration,zero-balanced ultrafiltration alleviated the increase of TNF-α and IL-6,espe-cially on T2,T3,and T4（p〈0. 05）. Zero-balanced ultrafiltration also decreased CysC,Rbp,serum creati-nine and urea nitrogen on T2,T3,and T4 compared with conventional ultrafiltration（p〈0. 05）. A total of 11 patients experienced AKI（ 〉grade I）in group A and 2 patients experienced in group B（p〈0. 01）. There were significant differences of ventilation time,total complication incidence and ICU stay time be-tween two groups. There was no difference in other complications,post-operative days in hospital or death rate within 30 days. Conclusion Though there is a trend of more patients receving renal replacement therapy,no statistical difference has been achieved. In conclusion,zero-balanced ultrafiltration can effec-tively decrease the concentration of serum pro-inflammatory factors,alleviate acute kidney injury and improve＆amp;nbsp;the clinical prognosis after cardio-pulmonary bypass procedures. It is a safe and reliable method valuable for promotion.