杂合肾脏替代治疗脓毒症合并急性肾损伤3期患者的疗效

Therapeutic efficacy of hybrid renal replacement therapy for sepsis patients with acute kidney injury stage 3

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期患者的28 d全因病死率,以及分析影响患者死亡的因素。方法69例脓毒症合并AKI 3期患者随机进入观察组(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。主要终点事件是28 d内全因病死率,次要指标包括治疗后7 d内SOFA评分、APACHEⅡ评分以及炎症因子白细胞介素6(interleukin 6,IL-6)。结果观察组患者均接受了HRRT,对照组22例患者达到了紧急指征接受HRRT。28 d全因病死率比较,观察组(34.3%)略低于对照组(35.3%),差异无统计学意义(P=0.930)。治疗前两组间SOFA评分及APACHEⅡ评分差异无统计学意义(P>0.05)。观察组治疗7 d后SOFA评分、APACHEⅡ评分均较治疗前下降(P<0.001),对照组较治疗前略有下降(P>0.05)。治疗7 d后两组间SOFA评分差异无统计学意义(P=0.111),观察组APACHEⅡ评分低于对照组(P=0.002)。治疗前两组IL-6差异无统计学意义(P=0.579)。两组治疗7 d后IL-6水平均低于治疗前(P<0.001),且观察组低于对照组(P=0.009)。预测28 d死亡事件的多因素COX回归分析显示:(1)较高的体质量是患者的保护性因素[HR=0.914,95%CI:0.862～0.970,P=0.003];(2)高乳酸[HR=1.462,95%CI:1.207～1.771,P<0.001]、高SOFA评分[HR=1.291,95%CI:1.104～1.509,P=0.001]是患者死亡的危险因素。结论 (1)杂合肾脏替代治疗未能显著降低脓毒症合并AKI 3期患者的28天病死率。(2)HRRT可降低患者的SOFA评分、APACHEⅡ评分以及炎症因子IL-6的水平。(3)较高的体质量可降低患者的死亡风险,而高乳酸水平、高SOFA评分增加患者的死亡风险。

Objective To determine whether hybrid renal replacement therapy(HRRT)reduces 28-day all-cause mortality in patients who are sepsis combined with acute kidney injury(AKI)stage 3,and analyze fac-tors which affect the patient′s death.Methods Sixty-nine patients with sepsis combined AKI stage 3 were enrolled and randomLy assigned into experimental group(n=35)in which RRT was initiated immediately after randomiza-tion,or control group in which RRT was initiated when emergency indications.RRT mode was continuous hemodi-alysis filtration combined with hemoperfusion.The primary end point was mortality at 28 days after randomization.Secondary end points were included sequential organ failure assessment(SOFA)score,acute physiology and chronic health evaluation(APACHE)Ⅱscore within 7 days,and inflammatory cytokines interleukin 6(IL-6)within 7 days.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.Mortality at day 28 did not differ significantly between the experimental group(34.3%)and the control group(35.3%)(P=0.930).The SOFA score and the APACHEⅡscore before treatment were similar between two groups(P>0.05).After 7 days treatment,the SOFA score and APACHEⅡscore became lower as compared with it before the treatment in the experimental group(P<0.001).In the control group,the score of SOFA and APACHEⅡwere 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 APACHEⅡscores were significantly lower in the experimental group than it in the control group(P=0.002).The IL-6 before treatment were similar between the two groups(P=0.579).After 7 days treatment,the levels of IL-6 became lower as compared with it before the treatment in two groups(P<0.001),and it was signifi-cantly lower in the experimental group than it in the control group(P=0.009).Multivariate COX regression analy-sis of 28 days all-cause mortality showed that higher body mass was a protective factor for patients[HR=0.914,95%CI:0.862~0.970,P=0.003],and lactate[HR=1.462,95%CI:1.207~1.771]and SOFA score[HR=1.291,95%CI:1.104~1.509]were the risk factors before treatment.Conclusions For sepsis combined with AKI stage 3 patients,there was no significant decrease of 28 days all-cause mortality for the use of HRRT.HRRT can reduce the patient′s SOFA score,APACHEⅡscores,and the level of inflammatory cytokine IL-6.Higher body mass can decrease the risk of death,while high lactate levels and high SOFA scores increase the risk of death.