【摘要】 目的:初步探讨配对血浆滤过吸附(CPFA)串联血液透析对多脏器功能障碍综合征(MODS)患者内皮细胞功能的影响。方法:选择MODS患者7例,均在常规治疗基础上加用CPFA串联血液透析(A)和高容量血液滤过(HVHF)(B)治疗,A,B治疗顺序随机,间隔一夜洗脱期(12h)。记录患者相关的临床情况并计算治疗前后APACHE II评分及最终人肾存活情况。分别在CPFA、HVHF治疗0、5、10h采集患者血浆,检测sE选择素、血栓调节蛋白(sTM)的浓度。另取不同治疗时间点患者血清与正常人脐静脉内皮细胞(HUVEC)共同孵育24h,检测上清液中sE选择素及sTM的浓度。结果:(1)两种治疗平均动脉压(MAP)均明显升高(99.00±18.02vs.120.75±20.02,92.33±18.33vs.115.33±18.50,P<0.05),且升压药剂量减少;CPFA后APACHE II评分有明显下降,差异有统计学意义(25.25±7.18vs.19.00±6.83,P<0.05);HVHF后APACHE II评分有下降趋势但差异无统计学意义(27.00±5.29vs.22.33±5.13,P>0.05);(2)患者体循环血清sE选择素、sTM浓度显著高于正常对照组(176.7±76.7vs.35.1±10.4,8.44±1.81vs.4.54±2.97,P<0.01);经过HVHF一个循环后E-选择及sTM水平略有下降(P>0.05),经过CPFA一个循环,这两种标志物的水平明显下降(179.1±77.4vs.161.3±74.3,8.42±1.90vs.6.83±1.39,P<0.05);HVHF或CPFA治疗后,患者体循环中血清sE选择素、sTM浓度有下降趋势,但均未达统计学意义(P>0.05);(3)HVHF治疗10h的血清刺激HUVEC,上清液中sTM水平明显下降(15.29±3.11vs.10.29±2.74,P<0.05),5h时上清液中sE选择素、sTM的浓度变化不明显(37.33±8.33vs.25.74±4.23,15.29±3.11vs.12.93±3.12,P>0.05);CPFA治疗5h的血清刺激HUVEC,上清液中sTM的水平已明显下降(15.01±2.99vs.11.41±2.72,P<0.05),到10h时上清液中sE选择素明显下降(37.99±8.75vs.21.64±3.12,P<0.05),sTM浓度下降更显著(15.01±2.99vs.9.32±3.21,P<0.01)。结论:MODS患者内皮细胞功能明显异常。CPFA较HVHF在一次循环中能更有效地清除sE选择素及sTM;体外实验表明相对于HVHF,CPFA能更早且更好的改善内皮细胞的功能。更多还原

【Abstract】 Objective:To investigate the effects of coupled plasma filtration adsorption(CPFA) and dialysis on endothelial cell function in patients with multiple organ dysfunction syndrome(MODS). Methodology:Seven patients who diagnosed as MODS underwent both CPFA and high volume hemofiltration(HVHF) besides routine therapy.CPFA and HVHF were scheduled randomly at intervals of 12 hours.The clinical manifestations and the ultimate survival of each patient were recorded and the APACHE II score was calculated before and after each treatment.The blood was taken from those patients at 0,5,and 10 hours during CPFA and HVHF.Serum soluble E-selectin and soluble thrombomodulin(sTM) were measured.Furthmore,the human umbilical vein endothelial cells(HUVEC) were incubated with patients’ serum from different therapy points.The supernatant liquid was also detected sE-selectin and sTM. Results:(1)Mean arterial pressure(MAP) increased(99.0±18.0 vs.121±20.0,92.3±18.3 vs.115±18.5,P<0.05),and dopamine requirement decreased after 10 hrs with CPFA or HVHF(P<0.05).APACHE II score decreased obviously with CPFA(25.3±7.18 vs.19.0±6.83,P<0.05),also decreased with HVHF,but this trend was no statistical significance(27.0±5.29 vs.22.3±5.13,P>0.05).(2)The serum levels of sE-selectin and sTM were significantly higher in patients with MODS than those of normal controls(177±76.7 vs.35.1±10.4,8.44±1.81 vs.4.54±2.97,P<0.01).Serum sE-selectin and sTM decreased remarkably after single circulation in CPFA(179±77.4 vs.161±74.3;8.42±1.90 vs.6.83±1.39,P<0.05),but not in HVHF(P>0.05).The levels of plasma sE-selectin and sTM in systemic circulation were just decreased slightly during CPFA or HVHF(P>0.05).(3)The level of sTM in supernatant liquid activated by serum from 10 hrs of HVHF was decreased obviously(15.3±3.11 vs.10.3±2.74,P<0.05),but sE-selectin and sTM concentrations did not change at 5 hrs of HVHF(37.3±8.33 vs.25.7±4.23,15.3±3.11 vs.12.9±3.12,P>0.05).The level of sTM in supernatant liquid activated by serum from 5 hrs of CPFA was decreased remarkably [15.0±2.99 vs.11.4±2.72(P<0.05),vs 9.32±3.25(P<0.01)],and the sE-selectin concentrations was also decreased obviously(37.9±8.75 vs.21.6±3.12,P<0.05) at 10 hrs of CPFA. Conclusion:Compared with HVHF,CPFA can eliminate sE-selectin and sTM more effectively.CPFA can improve the endothelial cell function more earlier and better than HVHF.更多还原