【作者】 徐鹏；

【导师】 赵剡；

【作者基本信息】 武汉大学 ， 急诊医学， 2017， 博士

【摘要】 背景:挤压综合征(Crush syndrome,CS)是地震灾害中仅次于直接创伤导致死亡的第二大原因。实验室研究主要依赖于动物模型的建立。急性肾损伤在挤压伤后十分常见,而腹膜透析作为常见的肾脏替代治疗手段,是否有利于减轻挤压伤后的肾脏损伤以及全身性损伤未见相关基础研究报道。目的:(1)建立兔挤压伤模型。(2)探讨早期腹膜透析结合容量复苏在兔挤压综合征中的保护作用及其机制。方法:(1)兔挤压综合征模型的建立:45只成年雄性新西兰大白兔随机分为3组:假手术组(SHAM,n = 15),挤压组 CP1(5 kg/kg 体重,n = 15)和 CP2(10 kg/kg体重,n= 15)。挤压6小时后液体复苏三小时,不同时间点测定血清AST、ALT、CK、MB、CK-MB以及血肌酐、尿素氮,同时进行血气分析、血常规分析和电解质测定,解除挤压后进行组织学评估和72小时生存分析并于不同时间点测定炎性细胞因子水平。全程监测血压、心率以及肛温。(2)利用成功建立的兔CS模型探讨早期腹透析结合容量复苏在挤压综合征中的保护作用:60只成年雄性新西兰大白兔随机分为4组:挤压组(CP,n= 15),容量复苏组(VR,n=15),早期腹膜透析组(PD,n=15),容量复苏+腹膜透析组(PD + VR,n= 15)。不同时间点进行血气分析、血常规分析、血清AST、ALT、CK、MB、CK-MB以及血肌酐、尿素氮、电解质检测,同时进行尿液中NGA以及β2-MG检测。此外,收集透析液,检测钾离子浓度、肌酐、尿素氮以及MB等含量。挤压结束后进行组织学评估和生存分析。全程监测血压、心率以及肛温。结果:(1)双侧10 kg/kg体重压力挤压实验动物,解除挤压后实验动物出现急剧的血压降低。生化分析显示实验动物出现明显的酸中毒,同时血清钾、CK、CK-MB以及MB明显升高,同基线水平以及其他组相比,差异均具有统计学意义(p<0.05)。血清AST、ALT、BUN以及肌酐亦出现明显上升,差异同其他组相比同样具有统计学意义(p<0.05)。此外,血清中促炎细胞因子IL-1β和TNF-α出现显著上升,其中分别于解除挤压后6小时和12小时达到峰值。抗炎因子IL-4与IL-10同样出现显著上升,二者均于解除挤压后12小时达到峰值。组织学分析显示挤压部位肌肉出现明显水肿和炎性细胞浸润。CP2组存活率(40%)明显低于CP1(80%)组和 SHAM 组(100%)(p<0.05)。(2)同CP组比较,VR组、PD组以及VR + PD组存活率明显上升。其中,VR + PD组72小时存活率为80%,PD组和VR组分别为50%和60%,VR + PD组存活率高于其他各组,差异均具有统计学意义(p<0.05)。此外,PD组、VR组以及PD+VR各组血清钾离子含量、血CK、CK-MB、MB、AST、BUN以及CRN均低于CP组,且以VR + PD组改善最为显著,各组间差异均具有统计学意义(p<0.05)。而VR组与PD + VR组解除挤压后MAP各时间点均高于PD组和CP组,且差异具有统计学意义((p<0.05)。此外,PD以及PD + VR组尿液中NAGL以及β2-MG均明显低于CP组(p<0.01)。结论:(1)成功利用兔建立CS的实验模型,兔CI后出现明显的系统性炎性反应,促炎细胞因子和抗炎细胞因子于CI后均出现明显升高;(2)早期腹膜透析结合容量复苏可以有效纠正CI后出现的低血容量,改善高钾血症和代谢性酸中毒,并有效清除循环内MB与CK,减轻急性肾损伤,有利于改善CI的预后。且效果优于单纯容量复苏和腹膜透析。但其安全性仍待进一步研究证实。更多还原

【Abstract】 Background Crush injury(CI),occurring as a consequence of traumatic events,including accidents and natural disasters,has been investigated from many angles to date.Its systematic manifestation was named as crush syndrome(CS),which is common in earthquakes.Objectives In this study,we aim to establish a new rabbit CS model and to investigate the effects of early peritoneal dialysis combined volume rescucitation in crush injury.Methods(1)Rabbit crash injury model.Forty-five rabbits were randomly devided into three groups:Sham group(n =15);Compression group 1(CP1,5 kg/kg,n = 15);Compression group 2(CP2,10 kg/kg,n = 15);In the CP1 and CP2 groups,rabbits were compressed on both hindlimbs for 6 hours.Fluid resuscitation were started at 1 hour before compreesion release and lasted for 4 hours.Blood samples were collected for the measurements of AST,ALT,CK,MB,CK-MB,BUN and CRN.Blood gazes and blood routine analysis were also carried out.Histological analysis of kidney and injured muscle were conducted at the end of study.Detection of proinflammatory and anti-inflammatory cytokines has been done at different time points after compression.A 72-h survival observation was conducted.(2)Using rabbit crush injury model to investigate the effects of peritoneal dialysis combined volume resuscitation in crush injury.Sixty rabbits were randomly devided into four groups:Compression group(CP,n = 15);Volume resuscitation group(VR,n = 10);Early peritoneal dialyasis group(PD,n = 15);Early peritoneal dialysis combined volume resuscitation group(PD + VR,n =15).Blood samples were collected at different time points after resuscitation for the measurements of AST,ALT,CK,MB,CK-MB,BUN and CRN.Urine samples were collected for the detection of NGAL and β2-MG.At the same time,dialysis fluid also collected for the measurements of BUN,CRN and MB.Histological analysis and survival ovbservation were also conducted at the end of experiments.Results(1)Compression with 10 kg/kg BW on the hindlimbs induced sharply decrease in MAP.Blood analysis showed significant metabolic acisosis and hyperkalemia after compression(p<0.05,resp.).In addition,serum AST,ALT,BUN and CRN were significantly increased in the CP2 group compared to the CP1 and Sham group(p<0.05,resp.).ELISA results suggested that inflammatory cytokines were significantly increased in the compression groups compared to the Sham group(p<0.05,resp.).In detail,TNF-α,IL-4 and IL-10 peaked at 12 h after compression while IL-1β peaked at 6 h after compression release.Histological analysis showed apparent muscle edema and inflammation infiltration.Furthermore,the survival rate in the CP2 group was significantly decreased compared to the CP1 and Sham group(p<0.05,resp.).(2)Compared to the CP group,the survival rate was significantly increased in the VR,PD and PD + VR groups(p<0.05,resp.).In addition,the survival rate in the PD + VR group(80%)was significantly higher than the PD(50%)and VR(60%)(p<0.05,resp.).Moreover,serum K+,CK.CK-MB,MB,AST,BUN and CRN were significantly higher in the PD + VR group than the other groups(p<0.05,resp.).Urine analysis of NAGL and β2-MG showed decreased acute kindey injury in the PD + VR group compared to other groups.Conclusion(1)We successfully established a rabbit crush injury model.Crush injury induced systemic inflammatory response.Both proinflammatory and antiinflammatory cytokines were significantly increased after crush injury.(2)Early peritoneal dialysis combined volume resuscitation successfully maintained blood pressure and attenuated hyperkalemia and metabolic acidosis after compression release.In addition,peritoneal dialysis effectively clear blood MB and CK.Finally,early peritoneal dialysis combined volume resuscitation increased survival rate of CI rabbits.However,further study is required to confirm the safty of early peritoneal dialysis in crush injury.更多还原