不同模式连续性血液净化对多器官功能障碍综合征患者的影响

Influence of continuous blood purification in different modes on multiple organ dysfunction syndrome

目的探讨连续性静脉血液透析滤过(continuous venovenous hemodiafiltration,CVVHDF)和高容量血液滤过(high-volume hemofiltration,HVHF)对多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)患者急性生理学与慢性健康状况评分系统Ⅱ(Acute Physiology and Chronic Health EvaluationⅡ,APACHEⅡ)评分及细胞因子水平的影响。方法 APACHEⅡ评分为15~25分的MODS患者18例,采用CVVHDF治疗9例为CVVHDF组,血流量为150mL/min,透析液流速2 500mL/h,置换液流速为1 000mL/h;采用HVHF治疗9例为HVHF组,血流量为180mL/min,置换液流速2 000 mL/h;2组均采用前稀释法输入,治疗时间24h。分别于治疗前、治疗后记录APACHEⅡ评分,采用ELISA法检测血清谷丙转氨酶(glutamic-pyruvic transaminase,GPT)、谷草转氨酶(glutamicoxaloacetic transaminase,GOT)、尿素氮、肌酐及肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)、白细胞介素(interleukin,IL)-6、IL-10水平。结果HVHF组与CVVHDF组治疗后GPT[(109.26±64.31)、(113.38±35.75)u/L]、GOT[(140.40±21.44)、(127.68±7.66)u/L]、尿素氮[(16.12±5.76)、(16.33±6.62)mmol/L]、肌酐[(300.29±142.96)、(281.97±181.64)μmol/L]、APACHEⅡ评分[(9.33±2.17)、(11.00±2.45)分]均低于治疗前[GPT:(243.16±133.08)、(236.02±189.46)u/L;GOT:(384.79±325.33)、(321.74±62.08)u/L;尿素氮:(28.31±6.22)、(27.68±7.66)mmol/L;血肌酐:(452.78±149.54)、(419.53±248.36)μmol/L;APACHEⅡ评分:(18.44±2.79)、(20.78±2.38)分](P<0.05),2组治疗后GPT、GOT、尿素氮、肌酐、APACHEⅡ评分比较差异无统计学意义(P>0.05);HVHF组与CVVHDF组治疗后血清TNF-α[(764.59±68.95)、(744.67±96.83)ng/L]、IL-6[(1 554.52±139.50)、(1 628.98±190.47)ng/L]、IL-10[(201.51±49.90)、(228.54±50.67)ng/L]水平均低于治疗前[TNF-α:(979.62±78.41)、(979.95±106.01)ng/L;IL-6:(1 789.50±146.68)、(1 790.53±202.17)ng/L;IL-10:(331.34±63.39)、(316.91±66.67)ng/L](P<0.05),HVHF组治疗后血清IL-6水平低于CVVHDF组(P<0.05),TNF-α、IL-10与CVVHDF组比较差异无统计学意义(P>0.05)。结论 CVVHDF、HVHF均可降低MODS患者APACHEⅡ评分,抑制炎性因子表达,改善患者肝、肾功能,但HVHF降低IL-6水平的作用更明显。

Objective To investigate the influence of continuous venovenous hemodiafiltration （CVVHDF） and high-volume hemofiltration （HVHF） on Acute Physiology and Chronic Health Evaluation Ⅱ（APACHEⅡ） score and cytokines in patients with multiple organ dysfunction syndrome （MODS）. Methods In 18 MODS patients with APACHE Ⅱ scores of 15 to 25, 9 patients received CVVHDF （CVVHDF group） with the blood flow of 150 mL/min, the dialysate flow rate of 2 500 mL/h and the replacement fluid flow rate of 1 000 mL/h, and the other 9 patients received HVHF （HVHF group） with the blood flow of 180 mL/min and the replacement solution of 2 000 mL/h. Both two groups were all infused by the pre-dilution method for 24 h. APACHE Ⅱ scores were recorded before and after treatment, and glutamic-pyruvic transaminase （GPT）, glutamic-oxaloacetic transaminase （GOT）, urea nitrogen, serum creatinine, tumor necrosis {actor-α （TNF-α）, interleukin （IL）-6 and IL-10 were measured by ELISA. Results The levels of GPT （（109.26~64.31）, （113.38±35.75） u/L）, GOT （（140.40±21.44）, （127.68±7.66） u/L）, urea nitrogen （（16.12±5.76）, （16.33±6.62） mmol/L）, serum creatinine （（300.29±142.96）, （281.97±181.64） μmol/L）, and APACHEⅡ scores （9.33±2.17, 11. 00±2.45） were significantly lower in both HVHF group and CVVHDF group after treatment than those before treatment （（243. 16±133.08）, （236.02±189.46） u/L; （384.79±325.33）, （321.74±62.08） u/L; （28.314-6.22）, （27. 68±7. 66） mmol/L; （452.78±149.54）, （419. 53±248. 36） μmol/L; 18. 44±2. 79, 20. 78±2.38） （P〈0.05）. There were no significant differences in the levels of GPT, GOT, urea nitrogen, serum creatinine and APACHEU between two groups after treatment （P〉0.05）. The levels of serum TNF-α （（764.59±68.95）, （744. 67± 96.83） ng/L）, IL 6 （（1 554. 52±139.50）, （1 628. 98±190.47） ng/L） and IL-10 （（201.51±49.90）, （228.54±50.67） ng/L） were significantly lower in both HVHF group and CVVHDF group after treatment than those before treatment （（979.62±78.41）, （979. 95±106.01） ng/L; （1 789. 50±146. 68）, （1 790.53±202. 17） ng/L; （331.34±63.39）, （316.9±66. 67） ng/L） （P〈0.05）. The level of serum IL-6 was significantly lower in HVHF group than that in CVVHDF group after treatment （P〈0.05）, and there were no significant differences in the levels of TNF-α and IL-10 between two groups （P〉 0.05）. Conclusion Both CVVHDF and HVHF can reduce APACHE Ⅱ score in MODS patients, inhibit the level of inflammatory factors and improve the function of liver and kidney, and HVHF is better than CVVHDF in reducing the level of IL-6.