不同时机连续性肾脏替代治疗对多脏器功能障碍综合征患者的影响

目的 研究不同的时机进行连续性肾脏替代治疗(CRRT)对多脏器功能障碍综合征(MODS)患者血清细胞因子及预后的影响.方法 2008年7月至2010年10月江苏大学附属人民医院综合ICU收治并行CRRT治疗的MODS患者34例,根据患者发生MODS到进行CRRT治疗的时间为0～3 d的归为早期组16例,4～10 d的归为晚期组18例.两组MODS患者除CRRT治疗外,均给予常规治疗.两组患者在CRRT治疗前(0 h)及治疗后6、12、18、24、48、72 h测定血清6种细胞因子的水平:白细胞介素(IL)-1β、白细胞介素-1受体拮抗剂(IL-1Ra)、IL-6、肿瘤坏死因子(TNF)-α、可溶性肿瘤坏死因子受体1(sTNFR1)和IL-10,同时进行动态APACHEⅡ评分.结果 (1)早期组在72 h较0 h血清IL-1β、IL-6、IL-10水平明显降低,IL-1Ra及IL-1Ra/IL-1β比值明显升高(P<0.05).晚期组血清IL-1β、IL-6、TNF-α、IL-10的水平的降低,IL-1Ra及IL-1Ra/IL-1β比值的升高,主要集中出现在最初的24 h内(P<0.05).在72 h早期组血清IL-10水平明显低于晚期组(25±12) ng/L比(51±33) ng/L] (P<0.05),而IL-1Ra及IL-1Ra/IL-1β比值明显高于晚期组分别为(1382±899) ng/L比(683±188) ng/L,(54±10)比(23±6)] (均P<0.05).(2)早期组0 h APACHEⅡ评分明显低于晚期组(P<0.05),早期组72 h APACHEⅡ评分较0 h明显降低(P<0.05),晚期组差异无统计学意义.两组0 h脏器功能障碍数≥4个的患者数差异无统计学意义,早期组7 d脏器功能障碍数≥4个的患者数较0 h明显下降(P<0.05),晚期组差异无统计学意义.结论 调节抗炎/致炎因子的比值是CRRT调节免疫状态的关键,在MODS发生早期行CRRT治疗能够获得更大的临床收益.

Abstract：

Objective To explore the effects of continuous renal replacement therapy (CRRT) on serum cytokines and prognosis in multiple organ dysfunction syndrome (MODS) patients based on different therapeutic opportunities. Methods A total of 34 MODS patients in the treatment of CRRT after admission to ICU of our hospital between July 2008 and October 2010 were recruited. Based on the time interval from the onset of MODS to the initiation of CRRT, the patients were stratified into early group (0-3 days, n=16) and late group (4-10 days, n=18). Both groups of MODS patients received conventional treatment in addition to 72 hours of high-volume hemofiltration (HVHF). The serum levels of such inflammatory mediators as interleukin (IL)-1β, interleukin-1 receptor antagonist (IL-1Ra), IL-6, tumor necrosis factor (TNF)-α, soluble tumor necrosis factor receptor1 (sTNFR1) and IL-10 were detected by enzyme linked immunosorbent assay (ELISA) before CRRT (0 h) and 6, 12, 18, 24, 48 and 72 h during the treatment of CRRT. Dynamic APACHEⅡ scores were also evaluated. Results (1) The early group had lower serum levels of IL-1β, IL-6, IL-10 and higher IL-1Ra, L-1Ra/IL-1β ratio at 72 h than those of 0 h (P<0.05). And the late group had a declining serum level of IL-1β, IL-6, TNF-α and IL-10 and a rising ratio of IL-1Ra and IL-1Ra/IL-1β during the first 24 h (P<0.05). As compared with the late group, the early group had a lower level of IL-10 (25±12) vs (51±33) ng/L] and higher ratios of IL-1Ra and IL-1Ra/IL-1β at 72 h (1382±899 vs (683±188) ng/L, (54±10) vs (23±6)] (both P<0.05). (2) The early group had a lower APACHEⅡscore than the late group at 0 h (P<0.05). APACHEⅡscore at 72 h was significantly lower than 0 h in the early group. And there was no obvious change in the late group. There was no statistical difference in the numbers of MODS patients with dysfunctional organs number ≥ 4 at 0 h in both groups. The number of MODS patients with dysfunctional organs number ≥ 4 at 72 h was lower than 0 h in the early group (P<0.05). And there was no statistical difference in the late group. Conclusion Regulating the ratio of anti-inflammatory/pro-inflammatory mediators is critical in the immunomodulation of CRRT. And CRRT may provide more clinical benefits in the early phase (0-3 days) of MODS.

Effect of continuous renal replacement therapy started at different time on patients with multiple organ dysfunction syndrome

Objective To explore the effects of continuous renal replacement therapy (CRRT) on serum cytokines and prognosis in multiple organ dysfunction syndrome (MODS) patients based on different therapeutic opportunities. Methods A total of 34 MODS patients in the treatment of CRRT after admission to ICU of our hospital between July 2008 and October 2010 were recruited. Based on the time interval from the onset of MODS to the initiation of CRRT, the patients were stratified into early group (0-3 days, n=16) and late group (4-10 days, n=18). Both groups of MODS patients received conventional treatment in addition to 72 hours of high-volume hemofiltration (HVHF). The serum levels of such inflammatory mediators as interleukin (IL)-1β, interleukin-1 receptor antagonist (IL-1Ra), IL-6, tumor necrosis factor (TNF)-α, soluble tumor necrosis factor receptor1 (sTNFR1) and IL-10 were detected by enzyme linked immunosorbent assay (ELISA) before CRRT (0 h) and 6, 12, 18, 24, 48 and 72 h during the treatment of CRRT. Dynamic APACHEⅡ scores were also evaluated. Results (1) The early group had lower serum levels of IL-1β, IL-6, IL-10 and higher IL-1Ra, L-1Ra/IL-1β ratio at 72 h than those of 0 h (P<0.05). And the late group had a declining serum level of IL-1β, IL-6, TNF-α and IL-10 and a rising ratio of IL-1Ra and IL-1Ra/IL-1β during the first 24 h (P<0.05). As compared with the late group, the early group had a lower level of IL-10 (25±12) vs (51±33) ng/L] and higher ratios of IL-1Ra and IL-1Ra/IL-1β at 72 h (1382±899 vs (683±188) ng/L, (54±10) vs (23±6)] (both P<0.05). (2) The early group had a lower APACHEⅡscore than the late group at 0 h (P<0.05). APACHEⅡscore at 72 h was significantly lower than 0 h in the early group. And there was no obvious change in the late group. There was no statistical difference in the numbers of MODS patients with dysfunctional organs number ≥ 4 at 0 h in both groups. The number of MODS patients with dysfunctional organs number ≥ 4 at 72 h was lower than 0 h in the early group (P<0.05). And there was no statistical difference in the late group. Conclusion Regulating the ratio of anti-inflammatory/pro-inflammatory mediators is critical in the immunomodulation of CRRT. And CRRT may provide more clinical benefits in the early phase (0-3 days) of MODS.