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目的观察持续性血液净化(CVVH)联合血液灌流(HP)对脓毒性休克患者单核细胞分泌功能的影响。方法将60例脓毒性休克患者随机分为治疗组和对照组。在内科常规治疗的基础上,治疗组采用CVVH联合HP,每日血液灌流一次;对照组采用CVVH。治疗时间均为3 d。运用酶联免疫吸附试验方法(ELLSA)方法检测两组患者治疗前、治疗后1 d、3 d的内毒素(LPS)及肿瘤坏死因子α(TNF-α)、白细胞介素-1β(IL-1β)、IL-6的浓度。分离的单核细胞体外培养后予LPS刺激,运用ELLSA方法检测其分泌TNF-α和IL-6的浓度。同时分析两组多器官功能障碍综合征(MODS)发生率、28 d死亡率。结果与同组治疗前比较,两组患者治疗1 d后LPS及TNF-α、IL-1β、IL-6浓度均有下降趋势,但差异均无统计学意义(t分别=0.44、0.98、1.02、1.24;0.53、0.83、1.25、1.11,P均>0.05),单核细胞分泌TNF-α和IL-6功能均无改善,差异亦均无统计学意义(t分别=-1.26、-0.92、-1.32、-0.91,P均>0.05);与同组治疗前比较,治疗3 d后两组患者LPS及TNF-α、IL-1β、IL-6浓度均有明显下降,差异均有统计学意义(t分别=3.68、4.74、2.58、2.42;2.43、4.01、2.47、2.43,P均<0.05),治疗组较对照组改善明显,差异均有统计学意义(t分别=3.07、2.59、2.40、3.13,P<0.05);两组单核细胞分泌TNF-α、IL-1β、IL-6功能较同组治疗前均有明显改善,差异均有统计学意义(t分别=2.85、2.72、2.45、-2.91,P均<0.05);治疗后3 d治疗组较对照组改善明显,差异均有统计学意义(t分别=2.32、2.62,P均<0.05)。治疗组患者MODS发生率和28 d死亡率均明显优于对照组,差异均有统计学意义(χ2分别=4.08、4.59,P均<0.05)。结论CVVH联合HP和单纯CVVH均能有效清除脓毒血症休克患者血浆中LPS及TNF-α、IL-1β、IL-6,改善单核细胞的分泌功能,调节免疫功能,改善临床症状。但CVVH联合HP在降低血浆中炎性介质浓度、LPS浓度,改善单核细胞分泌功能及提高患者28 d存活率等方面更具优势。
Objective To observe the effects of continuous blood purification (CVVH) combined with hemoperfusion (HP) on the monocyte secretory function in patients with septic shock. Methods Sixty patients with septic shock were randomly divided into treatment group and control group. On the basis of routine medical treatment, the treatment group was treated with CVVH combined with HP once daily for hemoperfusion and the control group with CVVH. Treatment time is 3 d. The levels of endotoxin (LPS), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) in the two groups before and after treatment were detected by enzyme linked immunosorbent assay (ELLSA) 1β), IL-6 concentration. Isolated monocytes were cultured in vitro LPS stimulation, the use of ELLSA method to detect the secretion of TNF-α and IL-6 concentration. At the same time, the incidence of multiple organ dysfunction syndrome (MODS) and mortality at 28 days were analyzed. Results Compared with the same group before treatment, the concentrations of LPS and TNF-α, IL-1β and IL-6 in both groups decreased after treatment for one day, but the differences were not statistically significant (t = 0.44,0.98,1.02 , 1.24; 0.53,0.83,1.25,1.11, P> 0.05), TNF-αand IL-6 secretion in monocytes did not improve, the difference was not statistically significant (t = -1.26, -0.92, -1.32, -0.91, P> 0.05). Compared with the same group before treatment, the concentrations of LPS and TNF-α, IL-1β and IL-6 in the two groups were significantly decreased after 3 days of treatment (T = 3.68,4.74,2.58,2.42 respectively; 2.43,4.01,2.47,2.43, P <0.05), the treatment group improved significantly compared with the control group, the differences were statistically significant (t = 3.07,2.59,2.40 , 3.13, P <0.05). The function of TNF-α, IL-1β and IL-6 secreted by monocytes in both groups were significantly improved compared with those before treatment (t = 2.85,2.72, 2.45, -2.91, P <0.05). After 3 days of treatment, the treatment group improved significantly compared with the control group, the differences were statistically significant (t = 2.32,2.62, P <0.05). The incidence of MODS and 28-day mortality in the treatment group were significantly better than those in the control group (χ2 = 4.08 and 4.59, respectively, P <0.05). Conclusions Both CVVH combined with HP and CVVH alone can effectively eliminate the plasma LPS, TNF-α, IL-1β and IL-6 in septic shock patients, improve the secretion of monocytes, regulate immune function and improve clinical symptoms. But CVVH combined with HP in reducing the concentration of inflammatory mediators in plasma, LPS concentration, improve monocyte secretion and improve the survival rate of patients in 28 d and so on.