配对血浆滤过吸附治疗脓毒症并多器官功能障碍综合征的研究

The Effects of Cpfa on the Mods Patients with Sepsis

作者: 专业:内科肾脏病学 导师:赵卫红 年度:2010 学位:硕士  院校: 南京医科大学

Keywords

CPFA, HVHF, MODS, Sepsis, in?ammatory mediators

        目的:比较连续性高容量血液滤过(high volume hemofiltration, HVHF)与新型血液净化模式配对血浆滤过吸附(coupled plasma filtration absorption, CPFA)治疗脓毒症并多器官功能障碍综合征(multiple organ dysfunction syndromes, MODS)的临床疗效及对患者血清细胞因子水平影响。方法:选择脓毒症并MODS的患者14例,随机分为HVHF治疗组及CPFA治疗组,在常规治疗基础上分别予HVHF或CPFA治疗10小时,观察两种治疗方式前后的血流动力学、电解质及酸碱平衡、急性生理及慢性健康状况评分Ⅱ(acute physiology and chronic health evaluation, APACHEⅡ)及感染相关性器官功能衰竭评分(sepsis-related organ failure assessment score, SOFA)等变化,并计算患者的预期死亡率。ELASA法检测两组患者治疗前、治疗5小时和治疗后血清高迁移率族蛋白-1(HMGB-1)、细胞间粘附分子-1(ICAM-1)、肿瘤坏死因子-α(TNF-α)、白介素-1受体抗体(IL-1Ra)水平的变化。结果: (1)两种治疗均能降低血尿素氮、肌酐水平,维持电解质、酸碱平衡,对白细胞、血小板、红细胞压积无明显影响。(2) CPFA治疗后PaO2/FiO2明显改善(P<0.05)、平均动脉压MAP明显升高(P<0.05)、SOFA评分及APACHEⅡ评分均明显下降(P<0.05);而HVHF治疗后仅见SOFA评分明显下降(P<0.05),PaO2/FiO2、MAP、及APACHEⅡ评分均无明显改变(P>0.05)。(3)两种方法治疗过程中均未出现出血、栓塞、过敏等并发症,HVHF组平均预期死亡率为52%,实际存活4例(4/7),CPFA组平均预期死亡率为56%,实际存活6例(6/7)。(4) CPFA治疗后患者血清HMGB-1, ICAM-1, IL-1Ra和TNF-α水平均明显降低(P<0.05),HMGB-1治疗5小时时即有明显下降。HVHF组,治疗5小时HMGB-1和IL-1Ra水平下降(P<0.05),治疗10小时与治疗前差异无统计学意义(P>0.05);ICAM-1和TNF-α水平在治疗过程中无明显改变(P>0.05)。结论: HVHF和CPFA治疗对脓毒症并MODS患者均有一定临床疗效,同样安全、有效。但后者在降低APACHEⅡ评分、改善患者愈后、对HMGB-1、IL-1Ra、TNF-α及ICAM-1几种炎症介质的清除方面更优于HVHF治疗,能够更好的维持脓毒症患者的免疫内稳态从而减轻组织器官的损伤,有很好的应用前景。
    Aims: The aim of the study was to evaluate the effects of a novel extra-corporeal blood purification therapy—coupled plasma filtration absorption (CPFA) and compare with high-volume haemofiltration (HVHF) on the MODS patients with sepsis.Methods: 14 patients diagnosed MODS with sepsis were enrolled and randomly separated into HVHF and CPFA group. The two groups received 10 hours of HVHF or CPFA treatment, respectively. The parameters of hemodynamic, electrolytes and acid-base balance, SOFA and APACHEⅡscore after HVHF or CPFA were examined. The levels of serum HMGB-1, TNF-α, IL-1Ra and ICAM-1 were also detected at the start, at 5 and 10 hours of each treatment.Results: (1) After the two therapies, blood urea nitrogen (BUN) and serum creatinine (Cr) all significantly decreased, electrolytes and acid-base balance were well maintained, and no visible influence was found in WBC, PLT or HCT. (2) After CPFA, SOFA score and APACHEⅡscore were decreased dramatically (P<0.05), MAP and the oxygenation index (PaO2/FiO2) were improved significantly (P<0.05). However, after HVHF, only SOFA score was found markedly decreased (P<0.05), no significant changes were found in MAP, oxygenation index or APACHEⅡscore (P>0.05). (3) No therapy related adverse reactions such as haemorrhage, hypersensitiveness or embolism were noted even in the aged during the two treatments. The average estimated mortality of HVHF group was 52%, 4 patients survived, while the average estimated mortality of CPFA group was 56%, 6 patients survived. (4) Serum levels of HMGB-1, ICAM-1, IL-1Ra and TNF-αdecreased markedly after 10 hours of CPFA therapy (P<0.05). Within the HVHF group HMGB-1 and IL-1Ra decreased at 5 hours but did not continue at 10 hours (P<0.05). TNF-α, ICAM-1 did not markedly change with HVHF (P>0.05).Conclusions: Both HVHF and CPFA therapies improved the clinical manifestations of the MODS patients with sepsis, and the effect of CPFA was superior to HVHF, which had implications in the optimal treatment of blood purification therapy in MODS.
        

配对血浆滤过吸附治疗脓毒症并多器官功能障碍综合征的研究

中文摘要4-6
英文摘要6-7
前言8-11
资料与方法11-15
结果15-21
讨论21-26
参考文献26-29
个例报告29-34
综述34-43
    参考文献41-43
附录43-45
    附录一 专业名词中英文对照表43-44
    附录二 学习期间发表论文44-45
致谢45
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