不同剂量血液滤过对脓毒血症患者肾功能 炎症反应 疾病程度及治疗转归的影响

Effects of different doses of hemofiltration on renal function,inflammatory response,disease degree and treatment outcome in patients with sepsis

目的探讨不同剂量血液滤过对脓毒血症患者的肾功能、炎症反应、疾病程度及治疗转归的影响。方法选取86例脓毒血症患者作为研究对象,所有患者均在常规治疗的基础上给予连续性静脉血液滤过(CVVH),持续时间>24 h,根据置换剂量不同分为A组(35 ml·kg^(-1)·h^(-1),40例)和B组(70 ml·kg^(-1)·h^(-1),46例),对比2组治疗前后肾功能指标[血肌酐(Scr)和血尿素氮(BUN)]、炎症指标[降钙素原(PCT)和C反应蛋白(CRP)]、疾病程度[急性生理与慢性健康状况评分Ⅱ(APACHEⅡ)和国际血栓与止血学会(ISTH)评分,弥散性血管内凝血(DIC)评分]和临床转归(CVVH持续时间、ICU住院时间和28 d死亡率);同时进行COX回归分析探讨导致脓毒血症死亡的影响因素。结果治疗前,A组和B组Scr、BUN、PCT、CRP、APACHEⅡ和ISTH DIC评分比较,差异均无统计学意义(P>0.05);治疗后,A组和B组Scr、BUN、PCT、CRP、APACHEⅡ和ISTH DIC评分均明显下降,其中B组Scr[(104±16)μmol/L与(127±18)μmol/L]、BUN[(13.8±2.0)μmol/L与(16.4±3.2)μmol/L]、PCT[(3.3±0.6)μg/L与(9.0±2.4)μg/L]、CRP[(5.4±1.3)mg/L与(12.5±2.8)mg/L]、APACHEⅡ[(9.0±2.8)分与(11.4±3.6)分]和ISTH DIC评分[(1.8±0.4)分与(2.9±0.7)分]均低于A组,差异均有统计学意义(t=6.389、4.447、15.901、15.630、3.331、9.345,P均<0.01)。与A组比较,B组CVVH持续时间[(5.2±1.2)d与(7.3±1.6)d]和ICU住院时间缩短[(12.2±2.5)d与(15.8±3.2)d],28 d死亡率降低11%(5/46)与30%(12/40),差异均有统计学意义(t=7.184、5.838,P均<0.01;χ^(2)=4.937,P<0.05)。以性别、年龄、发病时间、合并糖尿病、治疗前Scr、BUN、PCT、CRP、A-PACHEⅡ评分、ISTH DIC评分及置换剂量作为自变量,以死亡(终点事件)作为因变量进行COX回归分析,治疗前APACHEⅡ、ISTH DIC评分和置换剂量是导致脓毒血症患者死亡的重要因素(P<0.05)。结论与35 ml·kg^(-1)·h^(-1)置换剂量比较,70 ml·kg^(-1)·h^(-1)置换剂量通过降低Scr、BUN、PCT、CRP,改善APACHEⅡ和ISTH DIC评分,降低脓毒血症患者死亡率,其中治疗前APACHEⅡ、ISTH DIC评分和置换剂量是导致脓毒血症患者死亡的重要因素。

Objective To investigate the effects of different doses of hemofiltration on renal function,inflammatory response,disease degree and treatment outcome in patients with sepsis.Methods Eighty-six patients with sepsis were selected as the research object,and were given continuous venous hemofiltration (CVVH,duration>24 h) on the basis of routine treatment.According to the replacement dose,they were divided into group A[35 ml·kg^(-1)·h^(-1),n=40]and group B[70 ml·kg^(-1)·h^(-1),n=46].The renal function indexes[serum creatinine (Scr) and blood urea nitrogen(BUN)],inflammatory indexes[procalcitonin (PCT) and C-reactive protein (CRP)],disease degree[acute physiology and chronic health scoreⅡ(APACHEⅡ) and International Society of Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) score]and clinical outcome (CVVH duration,ICU hospitalization time and 28day mortality) were compared between the two groups before and after treatment.At the same time,Cox regression analysis was carried out to explore the influencing factors leading to sepsis death.Results Before treatment,there was no significant difference in the scores of Scr,BUN,PCT,CRP,APACHEⅡand ISTH DIC between group A and group B (P>0.05).After treatment,the scores of Scr,BUN,PCT,CRP,APACHEⅡand ISTH DIC in group A and group B decreased significantly.The scores of Scr[(104±16)μmol/L vs (127±18)μmol/L],BUN[(13.8±2.0)μmol/L vs(16.4±3.2)μmol/L],PCT[(3.3±0.6)μg/L vs (9.0±2.4)μg/L],CRP[(5.4±1.3)mg/L vs (12.5±2.8)mg/L],APACHEⅡ[(9.0±2.8) vs (11.4±3.6)]and ISTH DIC[(1.8±0.4) vs (2.9±0.7)]in group B were lower than those in group A,and the difference was statistically significant (t=6.389,4.447,15.901,15.630,3.331,9.345,all P<0.01).Compared with group A,the duration of CVVH[(5.2±1.2) d vs (7.3±1.6) d]and ICU hospitalization[(12.2±2.5) d vs (15.8±3.2) d]in group B were shortened,and the 28 days mortality[11%(5/46) vs 30%(12/40)]was reduced.The above differences were statistically significant (t=7.184,5.838,χ^(2)=4.937,P<0.05).Gender,age,onset time,diabetes mellitus,Scr,BUN,PCT,CRP,APACHEⅡscore,ISTH DIC score and replacement dose were taken as independent variables.Death (end point events) was used as a dependent variable for COX regression analysis.Before treatment,APACHEⅡ,ISTH DIC score and replacement dose were important factors leading to death in patients with sepsis.Conclusion Compared with 35 ml·kg^(-1)·h^(-1)replacement dose,70 ml·kg^(-1)·h^(-1)replacement dose can improve APACHEⅡand ISTH DIC scores and reduce the mortality of patients with sepsis by reducing Scr,BUN,PCT and CRP.APACHEⅡand ISTH DIC scores and replacement dose before treatment are important factors leading to the death of patients with sepsis.