重度急性胰腺炎的连续性肾替代治疗：合并或未合并急性肾损伤

doi:10.3877/cma.j.issn.2096-1537.2017.03.011

重度急性胰腺炎（SAP）是一种起病急、进展快、并发症多、病死率高的全身炎症反应性疾病。由于连续性肾替代治疗（CRRT）具有清除炎症因子的作用，在国内越来越多的SAP患者接受了CRRT，无论其是否伴有急性肾损伤（AKI）。本文就CRRT技术治疗SAP的病理生理学基础、炎症因子清除效果和临床疗效作一综述，以期临床能够更理性地认识CRRT对SAP的治疗价值。另外，本文还展望了集成血液净化技术治疗SAP的发展前景。

关键词: 重度急性胰腺炎, 急性肾损伤, 连续性肾替代治疗, 血液净化

Severe acute pancreatitis (SAP) is a systemic inflammatory disease characterized by sudden occurrence, complications and high mortality. Since continuous renal replacement therapy (CRRT) has a role in the removal of inflammatory cytokines, a growing number of SAP patients in China have received CRRT, regardless of whether the patient with acute kidney injury (AKI) or not. In this review, we talk about the pathophysiology, inflammatory factor clearance and clinical effect of CRRT in SAP in order to give a rational understanding of its therapeutic value. In addition, the prospects of hybrid blood purification technology in SAP treatment are also discussed.

Key words: Severe acute pancreatitis, Acute kidney injury, Continuous renal replacement therapy, Blood purification

表1 连续性肾替代治疗清除重度急性胰腺炎患者血浆炎症因子的研究

研究者	病例数	试验设计	治疗模式	细胞因子	治疗时间（h）					临床情况	APACHE-Ⅱ	病死率（例数/例数）
研究者	病例数	试验设计	治疗模式	细胞因子	6	12	24	48	72	临床情况	APACHE-Ⅱ	病死率（例数/例数）
Abe等^[12]	82	系列病例研究	CVVH	IL-6	NS	NS	NS	↓	↓	改善	NR	5/82
Jiang等^[13]	37	系列病例研究	CVVH	IL-1β	↓	NS	NS	NS	NS	NR	NR	7/37
				TNF-α	↓	↓	↓	↓	↓
				IL-6	NS	NS	NS	↓	↓
				IL-1	NS	NS	NS	NS	↓
Xie等^[14]	13	系列病例研究	CVVH	IL-1β	↓	NS	NS	NS	NS	改善	↓	4/13
				TNF-α	↓	↓	↓	↓	↓
Gu^o等^[15]	64	前瞻性队列研究	CVVH	TNF-α	NR	NR	NR	NR	↓	改善	↓	0/32（CVVH）
				IL-10	NR	NR	NR	NR	↓			0/32（control）
Yu等^[36]	16	系列病例研究	HVHF	IL-10	↓	↓	↓	↓	↓	NR	↓	NR
				TNF-α	↓	↓	↓	↓	↓
				IL-6	NS	NS	NS	↓	↓
				IL-1	NS	NS	NS	NS	↓
Gong等^[16]	12	前瞻性队列研究	HVHF	IL-10	↓	↓	↓	↓	↓	NR	NR	1/8（HVHF）
				TNF-α	↓	↓	↓	↓	↓			1/4（control）
				IL-13	NS	↓	NS	↓	↓
				IL-1	NS	NS	NS	NS	↓
				IL-2	NS	NS	NS	NS	↓
				IL-5	NS	NS	NS	NS	↓
				IFN-γ	NS	NS	NS	NS	↓
Guo等^[17]	61	前瞻性队列研究	HVHF	IL-6	NR	NR	NS	NR	↓	改善	↓	8/25（HVHF）
												15/29（control）
Chu等^[19]	30	前瞻性队列研究	pHVHF	IL-6	NR	NR	NR	NR	↓	改善	↓	3/15（pHVHF）
				IL-10	NR	NR	NR	NR	↓			5/15（CVVH）
				TNF-α	NR	NR	NR	NR	↓

表1 连续性肾替代治疗清除重度急性胰腺炎患者血浆炎症因子的研究

研究者	病例数	试验设计	治疗模式	细胞因子	治疗时间（h）					临床情况	APACHE-Ⅱ	病死率（例数/例数）
研究者	病例数	试验设计	治疗模式	细胞因子	6	12	24	48	72	临床情况	APACHE-Ⅱ	病死率（例数/例数）
Abe等^[12]	82	系列病例研究	CVVH	IL-6	NS	NS	NS	↓	↓	改善	NR	5/82
Jiang等^[13]	37	系列病例研究	CVVH	IL-1β	↓	NS	NS	NS	NS	NR	NR	7/37
				TNF-α	↓	↓	↓	↓	↓
				IL-6	NS	NS	NS	↓	↓
				IL-1	NS	NS	NS	NS	↓
Xie等^[14]	13	系列病例研究	CVVH	IL-1β	↓	NS	NS	NS	NS	改善	↓	4/13
				TNF-α	↓	↓	↓	↓	↓
Gu^o等^[15]	64	前瞻性队列研究	CVVH	TNF-α	NR	NR	NR	NR	↓	改善	↓	0/32（CVVH）
				IL-10	NR	NR	NR	NR	↓			0/32（control）
Yu等^[36]	16	系列病例研究	HVHF	IL-10	↓	↓	↓	↓	↓	NR	↓	NR
				TNF-α	↓	↓	↓	↓	↓
				IL-6	NS	NS	NS	↓	↓
				IL-1	NS	NS	NS	NS	↓
Gong等^[16]	12	前瞻性队列研究	HVHF	IL-10	↓	↓	↓	↓	↓	NR	NR	1/8（HVHF）
				TNF-α	↓	↓	↓	↓	↓			1/4（control）
				IL-13	NS	↓	NS	↓	↓
				IL-1	NS	NS	NS	NS	↓
				IL-2	NS	NS	NS	NS	↓
				IL-5	NS	NS	NS	NS	↓
				IFN-γ	NS	NS	NS	NS	↓
Guo等^[17]	61	前瞻性队列研究	HVHF	IL-6	NR	NR	NS	NR	↓	改善	↓	8/25（HVHF）
												15/29（control）
Chu等^[19]	30	前瞻性队列研究	pHVHF	IL-6	NR	NR	NR	NR	↓	改善	↓	3/15（pHVHF）
				IL-10	NR	NR	NR	NR	↓			5/15（CVVH）
				TNF-α	NR	NR	NR	NR	↓

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Continuous renal replacement therapy in severe acute pancreatitis patients: with or without acute kidney injury

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Continuous renal replacement therapy in severe acute pancreatitis patients: with or without acute kidney injury