局部枸橼酸抗凝对脓毒症急性肾损伤血液滤过患者免疫功能的影响

Effects of regional citrate anticoagulation on immune function in patients with sepsis-induced acute kidney injury in hemofiltration

目的对比研究局部枸橼酸抗凝(RCA)与全身肝素抗凝对脓毒症急性肾损伤(SAKI)行连续性静脉-静脉血液滤过(CVVH)患者免疫功能的影响。方法选择南京医科大学附属无锡市人民医院2012年2月至2016年4月确诊的70例SAKI患者进行前瞻性研究,其中男性40例,女性30例;年龄36~82岁,平均年龄56.32岁。原发病:重症肺炎42例,急性重症胰腺炎12例,急性胆管炎10例,急性弥漫性腹膜炎6例。患者随机分为全身肝素抗凝组(A组,34例)和RCA组(B组,36例),两组患者均行CVVH 48 h。分别观察两组患者CVVH治疗0、12、24、48 h白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)水平,并监测两组CVVH治疗0 h和48 h CD3^+百分比、CD4^+百分比、CD4^+/CD8^+比值的变化。比较两组滤器使用寿命、28 d病死率。结果两组患者CVVH治疗12 h和24 h,A组IL-6值、TNF-α值均高于B组,差异均有统计学意义(P<0.05)。CVVH治疗48 h A组CD3+百分比、CD4^+百分比、CD4^+/CD8^+比值显著低于B组,差异均有统计学意义(P<0.05)。此外,A组滤器使用寿命(25.86±7.32)h,显著低于B组[(39.80±4.68)h],A组28 d病死率(48.72%)显著高于B组(29.56%),差异均有统计学意义(P<0.05)。结论与全身肝素抗凝比较,SAKI患者CVVH时使用RCA,能更有效清除炎性因子及调节患者T淋巴细胞亚群免疫稳态,改善患者预后。

Objective To compare the effects between regional citrate anticoagulation（RCA） and systemic heparin anti coagulation on the immune function of patients with sepsis-induced acute kidney injury（SAKI） in continuous veno-venous hemofiltration（CVVH）. Methods From February 2012 to April 2016, a total of 70 SAKI patients were enrolled, which included 40 males and 30 females, aged 36 - 82 years old with mean age of 56.32 years old. The original disease of severe pneumonia in 42 cases, acute severe pancreatitis in 12, acute cholangitis in 10 and acute diffuse peritonitis in 6. All of them divided into systemic heparin anticoagulation group（group A, n = 34） and RCA group（group B, n = 36）, and performed CVVH treatment for 48-hour. The changes of interleukin-6（IL-6） and tumor necrosis factor-α（TNF-α） were monitored in 0-, 12-, 24-, 48-hour of CVVH treatment. Meanwhile, the changes of CD3^＋ percentage, CD4^＋ percentage and CD4^＋/CD8^＋ ratio were monitored in 0-, 48-hour of CVVH treatment. The filter life, clinical incidence of bleeding, and 28-day mortality rate between 2 groups were compared. Results After 12-hour and 24-hour of CVVH treatment, the IL-6 and TNF-α＋ in group A were higher than those in group B, the differences were statistical significance（P 〈 0.05）. The 48-hour of CVVH treatment of CD3^＋ percentage, CD4^＋ percentage and CD4＋/CD8^＋ ratio in group A were significantly lower than those in group B, the differences were statistically significant（P 〈 0.05）. The filter life in group A was （25.86 ± 7.32） hours, which was much lower than that in group B[（39.80 ±4.68） hours], the difference was statistical significance（P 〈 0.05）. The 28-day mortality rate of group A（48.72 %） was significantly higher than that of group B（28.56 %）, the difference was statistical significance（P 〈 0.05）. Conclusion Comparing with systemic heparin anticoagulation, implement of RCA in CVVH for SAKI patients is efficient significantly, which could effec- tively remove inflammatory factors, change level of T lymphadenitis, prolong filter life and improve prognosis of patients.