连续血液净化治疗对严重脓毒症患儿炎症介质清除和免疫状态的影响

Effect of continuous blood purification on the clearance of inflammatory mediators and immune status in children with severe sepsis

目的观察连续血液净化(CBP)治疗对严重脓毒症患儿炎症介质清除和免疫状态的影响。方法回顾性分析2015年6月至2018年10月在广西壮族自治区钦州市妇幼保健院儿科重症监护病房(PICU)接受治疗的62例严重脓毒症患儿的病历资料。均进行常规综合治疗,对常规综合治疗后无明显恢复迹象的31例患儿进行CBP治疗,纳入CBP组;单纯接受常规综合治疗的31例患儿为对照组。在CBP干预后第1、3、5、7、9、11天,检测血清肿瘤坏死因子α(TNF-α)、白细胞介素1β(IL-1β)、IL-6、IL-10和降钙素原水平,CD14+单核细胞人类白细胞抗原-DR等位基因(CD14+HLA-DR+)表达百分数,以及CD3+、CD4+、CD8+T淋巴细胞数量。结果与对照组相比,CBP组PICU住院时间更长,重症肺炎感染和发生急性呼吸窘迫综合征比例更高,差异均有统计学意义(均P <0. 05)。干预后CBP组患儿的血清IL-1β(P=0. 012)、IL-6(P=0. 024)和降钙素原(P=0. 005)呈逐渐降低趋势;CBP组第7、9、11天的血清TNF-α、IL-1β、IL-6和降钙素原水平明显低于对照组[第7天:(40±3) ng/L比(55±6) ng/L、(12. 5±2. 8) ng/L比(21. 2±4. 3) ng/L、(130±13) ng/L比(178±20) ng/L、(6±3)μg/L比(9±5)μg/L;第9天:(38±3) ng/L比(62±6) ng/L、(9. 4±3. 0) ng/L比(19. 6±4. 0) ng/L、(94±10) ng/L比(176±21) ng/L、(5±3)μg/L比(9±4)μg/L;第11天:(31±3) ng/L比(54±5) ng/L、(8. 8±2. 6) ng/L比(18. 7±4. 0) ng/L、(83±11) ng/L比(172±24) ng/L、(4±3)μg/L比(9±4)μg/L],差异均有统计学意义(均P <0. 05)。干预后CBP组患儿血液中CD14+HLA-DR+表达水平逐渐恢复,并且在第9天和第11天时明显高于对照组[(48±3)%比(41±4)%、(54±3)%比(43±4)%],差异均有统计学意义(均P <0. 05)。2组CD3+、CD4+和CD8+T淋巴细胞计数在干预期间差异均无统计学意义(均P> 0. 05)。结论在严重脓毒症儿童中应用CBP治疗有利于清除炎症介质和促进免疫状态恢复。

Objective To explore the effect of continuous blood purification(CBP)on the clearance of inflammatory mediators and immune status in children with severe sepsis.Methods A retrospective analysis was conducted on 62 children with severe sepsis hospitalized in pediatric intensive care unit(PICU)of Qinzhou Maternal and Children Health Care Hospital,Guangxi Zhuang Autonomous Region,from June 2015 to October 2018.All children had routine comprehensive treatments;31 children were treated with CBP(CBP group);other 31 children were control group.Levels of serum tumor necrosis factor-α(TNF-α),interleukin-1β(IL-1β),IL-6,IL-10 and procalcitonin(PCT),percentage of CD+14 monocyte human leukocyte antigen-DR(CD+14 HLA-DR+)and counts of CD+3,CD+4 and CD+8 T lymphocytes were analyzed on the 1st,3rd,5th,7th,9th,11th days after CBP intervention.Results Compared with control group,CPB group had longer PICU stay time,more severe pneumonia and acute respiratory distress syndrome(all P<0.05).Serum levels of IL-1β(P=0.012),IL-6(P=0.024)and PCT(P=0.005)decreased during CPB intervention,and the levels in CPB group were significantly lower than those in control group on the 7th,9th and 11th days[the 7th day:(40±3)ng/L vs(55±6)ng/L,(12.5±2.8)ng/L vs(21.2±4.3)ng/L,(130±13)ng/L vs(178±20)ng/L,(6±3)μg/L vs(9±5)μg/L;the 9th day:(38±3)ng/L vs(62±6)ng/L,(9.4±3.0)ng/L vs(19.6±4.0)ng/L,(94±10)ng/L vs(176±21)ng/L,(5±3)μg/L vs(9±4)μg/L;the 11th day:(31±3)ng/L vs(54±5)ng/L,(8.8±2.6)ng/L vs(18.7±4.0)ng/L,(83±11)ng/L vs(172±24)ng/L,(4±3)μg/L vs(9±4)μg/L](all P<0.05).After CPB intervention,CD+14 HLA-DR+expression gradually recovered and the expression levels on the 9th and 11th days were significantly higher than those in control group[(48±3)%vs(41±4)%,(54±3)%vs(43±4)%](both P<0.05).However,there were no significant differences in CD+3,CD+4 and CD+8 T lymphocyte counts between groups(all P>0.05).Conclusion CBP can improve the clearance of inflammatory mediators and the recovery of immune status in children with severe sepsis.