血浆置换联合连续性血浆透析滤过治疗慢加急性肝衰竭患者临床疗效及其对血浆细胞因子水平的影响

Application of plasma exchange and continuous plasma dialysis filtration in the treatment of patients with acute-on-chronic liver failure

目的研究使用连续性血浆透析滤过(CPDF)和血浆置换(PE)治疗慢加急性肝衰竭(ACLF)患者的临床疗效及其对血浆细胞因子水平的影响。方法2012年3月~2017年4月西京医院收治的ACLF患者92例,其中46例接受常规护肝和支持治疗,另46例观察组在常规治疗的基础上联合使用CPDF和PE治疗。采用ELISA法检测血清细胞因子水平,采用脂多糖法测定血清内毒素水平,使用L-8800氨基酸自动检测仪测定血清芳香族和支链氨基酸水平。结果在治疗后,观察组血清凝血酶原时间国际标准化比值(INR)和总胆红素(TBIL)水平显著低于,而血清白蛋白(ALB)水平显著高于对照组(P<0.05);观察组血清肿瘤坏死因子(TNF-α)、白介素(IL)-6和IL-8水平显著低于对照组[分别为(68.9±43.3)pg/ml对(89.7±39.5)pg/ml、(53.3±39.7)pg/ml对(69.4±41.2)pg/ml和(271.7±135.4)pg/ml对(307.6±147.2)pg/ml,P<0.05];观察组血清内毒素水平为0.2(0.2,0.4)EU/ml,显著低于对照组【1.1(0.8,1.7)EU/mL,P<0.05】,血氨水平为(64.8±19.4)μg/L,显著低于对照组【(80.3±31.1)μg/L,P<0.05】,芳香氨基酸水平为2.1(1.5,2.7)mg/dL,显著低于对照组【(2.3(1.8,2.5)mg/dL,P<0.05】,而支链氨基酸水平为(2.6±0.5)mg/dL,显著高于对照组【(2.1±0.1)mg/dL,P<0.05】;在治疗6个月末,观察组死亡15例(32.6%),而对照组死亡20例(43.5%,P>0.05)。结论使用PE联合CPDF治疗ACLF患者能降低血清毒素和细胞因子水平,短期改善肝功能指标,但是否能提高患者生存率,还需要继续研究。

Objective To investigate the efficacy of plasma exchange(PE)and continuous plasma dialysis filtration(CPDF)in the treatment of patients with acute-on-chronic liver failure(ACLF).Methods 92 patients with ACLF were recruited between March 2012 and April 2017,and 46 patients in the control was treated with routine supporting treatment and another 46 in the observation was treated with combination of PE and CPDF at the basis of conventional treatment.Serum cytokine,endotoxin,aromatic and branched-chain amino acid levels were assayed.Results After treatment,the international standardized ratio(INR)of prothrombin time and total serum bilirubin in the observation group were significantly lower than while serum albumin level were significantly higher than in the control(P<0.05);serum tumor necrosis factor,interleukin(IL)-6 and IL-8 levels in the observation group were significantly lower than those in the control group[(68.9±43.3)pg/ml vs.(89.7±39.5)pg/ml,(53.3±39.7)pg/ml vs.(69.4±41.2)pg/ml,and(271.7±135.4)pg/ml vs.(307.6±147.2)pg/ml,P<0.05];blood endotoxin level was 0.2(0.2,0.4)EU/ml,much lower than【1.1(0.8,1.7)EU/mL,P<0.05】,blood ammonia level was(64.8±19.4)μg/L,much lower than【(80.3±31.1)μg/L,P<0.05】,and aromatic amino acid levels was 2.1(1.5,2.7)mg/dL,much lower than【(2.3(1.8,2.5)mg/dL,P<0.05】,while branched-chain amino acid levels was(2.6±0.5)mg/dL,much higher than【(2.1±0.1)mg/dL,P<0.05】in the control;the fatality rates in the two groups at the end of six month treatment were not significantly different(32.6%vs.43.5%,P>0.05).Conclusion The application of PE and CPDF in treatment of patients with ACLF might decrease blood cytokine,endotoxin,ammonia and aromatic amino acid levels,which warrants further investigation for their clinical efficacy.