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目的:观察连续性血液净化(CBP)治疗重症急性胰腺炎(SAP)患者的临床效果及其对免疫内稳状态的影响。方法:本文为前瞻性临床对照研究,12例男性SAP患者按随机原则分为Con组(常规治疗组,4例)和CBP治疗组(常规治疗+CBP治疗组,8例)。经72h治疗后对各组患者临床治疗效果进行比较(包括APACHE-Ⅱ评分及其它主要临床指标),同时在治疗0h、6h、12h、24h、48h和72h各时间点取血,动态观察SAP患者免疫内稳状态的变化,主要包括采用抗体芯片技术检测各组患者血浆细胞因子表达谱、Th1(促炎)/Th2(抗炎)细胞因子比例的变化,并观察治疗过程中单核细胞功能(HLA-DR表达)和单核细胞数目的变化。结果:(1)临床治疗效果比较:经72h治疗后,CBP组患者病情显著改善,血淀粉酶水平明显下降,肾功能恢复正常(P<0.05)。而Con组患者除血淀粉酶水平较治疗前有一定程度下降外,患者病情并无明显缓解,肾功能以及动脉血气等指标方面也无明显改善(P>0.05)。(2)免疫内稳状态指标的比较:除IL-4外,两组患者血浆中其它各种细胞因子水平均明显高于健康人群(P<0.05)。经72h治疗后,CBP组患者血IFN-γ,IL-1,IL-2和IL-5,IL-10,IL-13水平较治疗前明显降低(P<0.05);而血肿瘤坏死因子α(TNF-α)和IL-6水平虽较治疗前亦降低,但差异不具有统计学意义(P>0.05),IL-4水平则始终无明显变化。比值比提示经CBP治疗后SAP患者体内Th2类抗炎细胞因子IL-13、IL-10相对于Th1类促炎细胞因子IL-1、TNF-α水平下降显著。而且,经CBP治疗后,患者外周血单核细胞HLA-DR表达和单核细胞数目均较治疗前明显上升(P<0.05)。结论:CBP治疗除能快速有效改善SAP患者病情,纠正体内酸碱紊乱、清除体内代谢毒素外,还能清除体内过多生成的促炎和抗炎细胞因子,改善患者单核细胞抗原呈递能力,重建机体免疫系统内环境稳态,疗效明显优于传统疗法。经CBP治疗后SAP患者体内Th2类抗炎细胞因子IL-13、IL-10相对于Th1类促炎细胞因子IL-1、TNF-α水平下降显著,有利于改善患者体内的免疫抑制状态。
Objective: To observe the clinical effect of continuous blood purification (CBP) on patients with severe acute pancreatitis (SAP) and its effect on immune homeostasis. Methods: In this prospective clinical study, 12 male SAP patients were randomly divided into Con group (conventional treatment group, 4 cases) and CBP treatment group (conventional treatment + CBP treatment group, 8 cases). After 72 hours of treatment, the clinical effects of each group were compared (including APACHE-Ⅱ score and other major clinical indicators), and at the same time, the blood samples were taken at 0h, 6h, 12h, 24h, 48h and 72h to observe the changes of SAP patients Changes in immune homeostasis, including the use of antibody chip technology to detect plasma cytokine expression profiles of patients in each group, Th1 (proinflammatory) / Th2 (anti-inflammatory) cytokines ratio changes, and observation of mononuclear cells during treatment function HLA-DR expression) and the number of monocytes. Results: (1) Comparison of clinical effects: After 72 hours of treatment, the patients in CBP group improved significantly, serum amylase level decreased significantly, and renal function returned to normal (P <0.05). However, the level of serum amylase in Con group decreased to a certain extent compared with that before treatment, and there was no significant improvement in the patients’ condition, renal function and arterial blood gas index (P> 0.05). (2) Comparison of indicators of immune homeostasis: In addition to IL-4, the plasma levels of other cytokines in both groups were significantly higher than those in healthy people (P <0.05). The levels of serum IFN-γ, IL-1, IL-2 and IL-5, IL-10 and IL-13 in CBP group were significantly lower than those before CBP treatment (P <0.05) (TNF-α) and IL-6 levels were lower than before treatment, but the difference was not statistically significant (P> 0.05), IL-4 levels remained unchanged. The odds ratio indicated that the levels of Th2 anti-inflammatory cytokines IL-13 and IL-10 in patients with SAP after treatment with CBP were significantly lower than those in Th1 pro-inflammatory cytokines IL-1 and TNF-α. Moreover, after CBP treatment, the expression of HLA-DR and monocyte in peripheral blood mononuclear cells increased significantly (P <0.05). Conclusion: In addition to CBP treatment can quickly and effectively improve the condition of patients with SAP, correct acid-base disorders in vivo, remove metabolic toxins in vivo, but also eliminate excess proinflammatory and anti-inflammatory cytokines in vivo to improve monocyte antigen presenting ability, Reconstruction of the body’s immune system homeostasis, the effect was significantly better than traditional therapies. The levels of Th2 anti-inflammatory cytokines IL-13 and IL-10 in serum of patients with SAP after CBP treatment were significantly lower than those of Th1 pro-inflammatory cytokines IL-1 and TNF-α, which could help to improve the immunosuppressive status in patients.