血浆置换治疗肌红蛋白异常增高患者的临床应用探讨

Investigation on clinical application of plasma exchange in patients with abnormally increased myoglobin

目的探讨血浆置换(PE)治疗肌红蛋白(Mb)异常增高患者的临床疗效及其影响因素。方法选择2014年3月至2016年12月于陆军军医大学第一附属医院接受PE治疗的57例Mb异常增高患者为研究对象。其中,男性患者为44例,女性为13例;年龄为(50.1±14.7)岁。采用回顾性研究方法分别收集患者接受PE治疗前和接受末次PE治疗后的血常规检查和凝血功能相关指标,以及患者每次接受PE治疗后血清Mb和血清肌酸酐(Scr)值。其中,血常规检查指标包括白细胞计数(WBC)、血红蛋白(Hb)值、血小板计数和血细胞比容(HCT);凝血功能指标包括活化部分凝血活酶时间(APTT)和凝血酶原时间(PT)。采用配对t检验或Wilcoxon符号秩和检验,对患者接受治疗前、后的血常规检查和凝血功能相关指标进行比较。采用Kaplan-Meier生存分析法对影响患者血清Mb和Scr值有效恢复率的因素(性别、年龄、疾病诱因、治疗前血清Mb和Scr值)进行单因素分析。本研究符合2013年修订的《世界医学协会赫尔辛基宣言》的要求。结果①本研究57例Mb异常增高患者接受PE治疗后,其WBC、Hb值、HCT及APPT均较治疗前下降,并且差异均有统计学意义(t=2.291,P=0.026;t=5.033,P<0.001;t=5.079,P<0.001;Z=2.111,P=0.035);治疗后血小板计数和PT虽然较治疗前有所下降,但是差异无统计学意义(Z=0.133,P=0.894;Z=1.624,P=0.104)。②本研究57例Mb异常增高患者接受PE治疗后,其中41例血清Mb值下降至<1 000 μg/L,血清Mb值有效恢复率为71.9%(41/57)。单因素分析结果显示,治疗前血清Mb及Scr值是患者接受PE治疗后血清Mb值有效恢复率的影响因素(P=0.031、0.037);疾病诱因、治疗前血清Mb及Scr值是患者接受PE治疗后Scr值有效恢复率的影响因素(P=0.036、<0.001、=0.003)。结论PE治疗能有效清除Mb异常增高患者体内的Mb,防止肾功能损伤。针对Mb异常增高患者的PE治疗应尽早实施,并且在患者肾功能明显受损之前,开展PE治疗能更大程度地避免其肾功能进一步损伤。

Objective To explore the effects and influential factors of plasma exchange (PE) in patients with abnormally increased myoglobin (Mb). Methods From March 2014 to December 2016, a total of 57 patients with abnormally increased Mb who underwent PE treatment at the First Hospital Affiliated to Army Medical University were selected as subjects. There were 44 male patients and 13 females;and the age of them was (50.1 ± 14.7) years old. A retrospective study was performed to collect blood routine examination and coagulation function indicators before PE treatment and after the last PE treatment, as well as serum Mb and serum creatinine (Scr) values after each PE treatment, respectively. Among them, blood routine examination indicators included white blood cell count (WBC), hemoglobin (Hb) value, platelet count and hematocrit(HCT);coagulation function indicators included activated partial thromboplastin time (APTT) and prothrombin time (PT). Paired t-test or Wilcoxon signed rank test was used to compare indicators of blood routine examination and coagulation function before and after PE treatment. Kaplan-Meier survival analysis was used to univariately analyze the factors (gender, age, disease inducement, serum Mb and Scr values before treatment) affecting the effective recovery rates of serum Mb and Scr values. This study met the requirements of the Helsinki Declaration of the World Medical Association revised in 2013. Results ① In this study, the WBC, Hb value, HCT and APPT of these 57 patients with abnormally increased Mb after PE treatment were lower than those before PE treatment, and the differences were statistically significant (t=2.291, P=0.026;t=5.033, P<0.001;t=5.079, P<0.001;Z=2.111, P=0.035). Platelet count and PT of patients decreased after treatment, but the differences were not statistically significant (Z=0.133, P=0.894;Z=1.624, P=0.104).② In this study, there were 41 patients whose serum Mb values decreased to <1 000 μg/L after PE treatment, and the effective recovery rate of serum Mb value was 71.9%(41/57). Results of univariate analysis showed that the serum Mb and Scr values before PE treatment were the influencing factors of the effective recovery rates of serum Mb value after PE treatment (P=0.031, 0.037);and the disease inducement, serum Mb and Scr values before PE treatment were the influencing factors of effective recovery rates of Scr value after PE treatment (P=0.036,<0.001,=0.003). Conclusions PE treatment could effectively eliminate serum Mb value in patients with abnormally increased Mb and prevent renal damage. The PE treatment should be implemented as early as possible, which is able to protect renal against extended impairment at the largest extent.