杂合肾脏替代治疗对脓毒症合并急性肾损伤3期患者血清炎症因子水平的影响

Effects of hybrid renal replacement therapy on inflammatory cytokines in septic patients with acute kidney injury

目的:探讨杂合肾脏替代治疗(hybrid renal replacement therapy,HRRT)能否降低脓毒症合并急性肾损伤(acute kidney injury,AKI)3期患者血清炎症因子水平、28天全因病死率。方法:69例脓毒症合并AKI 3期患者随机进入试验组(n=35,入组后立即行HRRT)、对照组(n=34,出现紧急指征时开始HRRT),HRRT采用连续性血液透析滤过联合血液灌流模式。观察治疗7天前后患者血清炎症因子白细胞介素6(interleukin 6,IL-6)、肿瘤坏死因子α(tumor necrosis factor alpha,TNF-α)、超敏C反应蛋白(high sensitivity C-reactive protein,hs CRP)水平,治疗7天前后SOFA评分、APACHEⅡ评分,28天全因病死率。结果:试验组患者均接受了HRRT,对照组22例达到了紧急指征接受了HRRT。多因素COX回归分析显示,治疗前IL-6(HR=1.006,95%CI:1.002~1.010,P=0.002)、TNF-α(HR=1.165,95%CI:1.034~1.313,P=0.012)均为患者28天死亡的危险因素。治疗前两组IL-6、TNF-α、hs CRP无显著差异(P>0.05);治疗7天后两组IL-6、TNF-α、hs CRP水平均低于治疗前(P<0.05),且试验组低于对照组(P<0.05)。治疗前两组间SOFA评分及APACHEⅡ评分无显著差异(P>0.05)。治疗7天后,试验组SOFA评分、APACHEⅡ评分均低于治疗前(P<0.001),对照组略低于治疗前(P>0.05)。治疗7天后两组间SOFA评分无显著差异(P=0.111),试验组APACHEⅡ评分低于对照组(P=0.002)。28天全因病死率比较,试验组(34.3%)略低于对照组(35.3%),差异无统计学意义(P=0.930)。结论:(1)血清IL-6、TNF-α水平升高将增加脓毒症合并AKI 3期患者28天死亡风险;(2)杂合肾脏替代治疗可降低患者血清炎症因子IL-6、TNF-α、hs CRP水平,但未显著降低患者28天全因病死率。

Objective： To probe whether hybrid renal replacement therapy （HRRT） reduces the serum inflammatory cytokines level and 28-day all-cause mortality in patients who were sepsis combined with acute kidney injury （AKI） stage 3.Methods： 69 sepsis with AKI stage3 patients were enrolled and randomly assigned into experimental group （n=35） in which HRRT was initiated immediately after randomization, and control group which HRRT was initiated when emergency indications.HRRT mode was continuous hemodialysis filtration combined with hemoperfusion.Before and after 7 days of treatment, the serum levels of interleukin-6 （IL-6）, tumor necrosis factor alpha （TNF-α）, and high sensitivity C-reactive protein （hsCRP） were determined, and the change of sequential organ failure assessment （SOFA） score and acute physiology and chronic health evaluation （APACHE） Ⅱ score were observed.The 28-day all-cause mortality were recorded.Results： All patients were given HRRT in the experimental group, and 22 patients were given HRRT in the control group according to the emergency indications.Multivariate COX regression analysis of 28 days all-cause mortality showed that IL-6 （HR=1.006, 95%CI： 1.002～1.010,P=0.002）and TNF-α （HR=1.165, 95%CI： 1.034～1.313,P=0.012）before treatment were the risk factors.The IL-6, TNF-α and hsCRP before treatment were similar between the two groups（P〉0.05）.After 7 days treatment, the levels of IL-6, TNF-α and hsCRP became lower compared with it before the treatment in the two groups（P〈0.05）, and it was significantly lower in the experimental group than it in the control group （P〈0.05）.The SOFA score and the APACHE Ⅱ score before treatment were similar between the two groups（P〉0.05）.After7 days treatment, the SOFA score and APACHE Ⅱ score became lower compared with it before the treatment in the experimental group（P〈0.001）.In the control group, the score of SOFA and APACHE Ⅱ were lower than it before treatment, but there were no significant difference（P〉0.05）.The SOFA scores were similar between the two groups（P=0.111）, but the APACHE Ⅱ scores were significantly lower in the experimental group than it in the control group（P=0.002）.Mortality at day 28 did not different significantly between the experimental group （34.3%） and the control group （35.3%,P=0.930）.Conclusion： For sepsis combined with AKI stage 3 patients, IL-6 and TNF-α increase the risk of 28-day all-cause mortality.HRRT can reduce the patient＇s serum level of inflammatory cytokine IL-6, TNF-α and hsCRP.There was no significant decrease of 28 days all-cause mortality for the use of HRRT.