益气温阳补肾法联合CRRT干预脓毒症急性肾功能损害的临床研究

发布时间：2018-01-06 18:18

本文关键词：益气温阳补肾法联合CRRT干预脓毒症急性肾功能损害的临床研究　出处：《南京中医药大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的：探讨益气温阳补肾法联合CRRT对脓毒症急性肾功能损害患者的疗效。方法：收入2014年4月至2015年01月入住江苏省中医院ICU符合脓毒症合并急性肾功能损害(AKI)诊断标准的67名患者。67例患者中有21例拒绝行CRRT治疗,归为非CRRT组,并将其随机分为两个亚组常规治疗组(n=10,仅接受常规治疗)和中药治疗组(n=11,在常规治疗的基础上加用益气温阳补肾汤剂治疗)。46例患者同意CRRT治疗,归为CRRT组,并将其随机分为两个亚组单纯CRRT组(n=23,在常规治疗的基础上加用CRRT治疗)和CRRT+中药组(n=23,在常规治疗的基础上加用CRRT和益气温阳补肾汤剂联合治疗)。通过评价血清IL-6、IL-10和’TNF-a的水平变化以及序贯器官衰竭评分(SOFA)、氧合指数(OI)、平均动脉压(MAP)、血肌酐Scr、Cys-C,评价益气温阳补肾法联合CRRT疗法对脓毒症合并急性肾损害患者的疗效。结果：1：IL-6：各组血清IL-6水平在治疗前无统计学差异(P0.05)。治疗后3d,各组血清IL-6水平较治疗前均出现不同程度下降,CRRT组(t=2.980,P=0.003)和CRRT+中药组(t=3.424,P=0.001)最为明显。而在治疗后7d时,CRRT+中药组血清IL-6水平下降最为明显(1=4.554, P0.001 vs治疗后3d;t=3.457, P=0.002 vs单纯CRRT组治疗后7d)。2：IL-10：各组血清IL-10水平在治疗前无统计学差异(P0.05)。治疗后3d各组血清IL-10水平较治疗前也无明显统计学差异(P0.05)。治疗后7d,可见CRRT中药组患者血清IL-10水平较治疗前明显升高(t=2.980,P=0.003 vs.治疗后3d；t=2.345,P=0.013vs.单纯CRRT组治疗后7d)。3:TNF-a:各组血清TNF-a水平在治疗前无统计学差异(P0.05)。治疗3d后,各组血清TNF-a水平较治疗前均出现不同程度下降,但未见明显统计学差异(P0.05)。治疗后7d,各组血清TNF-a水平较治疗前均出现不同程度下降(常规治疗组：t=1.987,P=0.028；中药组：t=1.986,P=0.028,；单纯CRRT组：1=2.433, P=0.010; CRRT+中药组：t=2.356, P=0.012), CRRT组和CRRT+中药组最为明显。而在治疗后7d时,CRRT+中药组血清TNF-a水平下降最为明显(t=1.768, P=0.043 vs治疗后3d)。4：OI:各组患者氧合指数OI在治疗前均无统计学差异(P0.05)。治疗后,在治疗3d后,单纯CRRT组(t=1.768,P=0.043)和CRRT+中药组(t=1.768,P=0.043)患者0I明显上升,而在治疗后7d,四组患者OI水平均较治疗前明显上升(常规治疗组：t=1.758,P=0.044；中药组：t=1.955,P=0.030,；单纯CRRT组：t=1.933,P=0.031;CRRT+中药组：t=2.155,P=0.019),其中CRRT+中药组明显优于单纯CRRT组(t=2.365,P=0.010)。而CRRT+中药组患者在治疗7d后较治疗3d时OI水平上升幅度更快(t=2.363,P=0.012)。5：MAP：各组患者平均动脉压MAP在治疗前均无统计学差异(P0.05)。在治疗3d后,仅CRRT+中药组患者MAP明显上升(t=1.957,P=0.032),而在治疗后7d,四组患者OI水平均较治疗前明显上升(常规治疗组：t=1.901,P=0.040；中药组：t=1.755,P=0.044,；单纯CRRT组：t=2.133,P=0.018;CRRT+中药组：t=2.187,P=0.017)。6：Scr:各组患者血肌酐Scr水平在治疗前均无统计学差异(P0.05)。在治疗3d后,CRRT组和CRRT+中药组患者Scr水平明显回落(t=2.702,P=0.002),而在治疗后7d,四组患者Scr水平均较治疗前明显回落(常规治疗组：t=1.702,P=0.047；中药组：t=2.221,P=0.017,；单纯CRRT组：t=2.185,P=0.016；CRRT+中药组：t=2.567,P=0.007)。7:Cys-C:各组患者血Cys-C水平在治疗前均无统计学差异(P0.05)。在治疗3d后,各组患者血Cys-C水平均有不同程度回落,但未见统计学差异(P0.05),而在治疗后7d,单纯CRRT组和CRRT4中药组患者血Cys-C水平均较治疗前明显回落(t=2.112,P=0.021),但与治疗后3d比较,未见明显统计学差异(t=1.789,P=0.042)。8:SOFA:各组治疗前SOFA评分无统计学差异(P0.05),治疗后3d可见CRRT组(t=1.754,P=0.043)和CRRT+中药组(t=2.002,P=0.027)SOFA评分均显著下降。治疗后7d各组SOFA评分均较治疗前显著下降(常规治疗组：t=1.874,P=0.036;中药组：t=2.531,P=0.011,；单纯CRRT组：t=2.147,P=0.023；CRRT+中药组：t=2.548,P=0.008)。9：死亡风险的评估：COX回归分析显示脓毒症急性肾损伤患者使用CRRT治疗后,较非CRRT组患者的预后明显改善。接受CRRT治疗患者入ICU第3、7、14、30天死亡风险分别降低12%,5%,10%和3%,而第3天和第14天结果存在统计学差异(P3d=0.02,P14d=0.01)。同时cOx回归分析显示接受CRRT治疗的患者患者联合使用中药治疗后,较单纯CRRT治疗的预后有一定的优势,入院第3天和30天死亡风险降低9%和16%,而入院7天和14天死亡率增加分别2%和1%,其中第14天和第30天有统计学意义(P14d=0.04, P30d=0.03)。结论：益气温阳补肾法联合CRRT更具有优势,比单纯CRRT疗法能更有效清除炎症介质,阻断炎性反应的瀑布样效应,改善组织灌注及氧合,有效保护脏器功能,尤其能够减少肾功能损害,有助于肾功能的早期恢复,从而改善患者预后并降低死亡率,对脓毒症合并急性肾功能损害的患者疗效确切。此研究对中医药在危重患者临床救治中的作用和地位作出了肯定,也为更深层次研究奠定了一定的基础。
[Abstract]:Objective: To investigate the effect of Yiqi Wenyang Bushen recipe combined with the efficacy of CRRT in sepsis acute kidney injury patients. Methods: income from April 2014 to 2015 01 months in Jiangsu Province Traditional Chinese Medicine Hospital ICU with acute kidney injury in patients with sepsis (AKI) in 67 patients with.67 patients with diagnostic criteria in 21 cases refused to underwent the treatment of CRRT. For non CRRT group, and were randomly divided into two sub groups: conventional treatment group (n=10, only receiving routine treatment) and treatment group (n=11, on the basis of conventional therapy plus treatment with Tonifying Qi and warming yang and Tonifying Kidney Decoction).46 patients agreed to CRRT treatment, classified as group CRRT, and they were divided into two sub groups (n=23, CRRT group treated by CRRT on the basis of conventional treatment in Chinese medicine group (n=23) and CRRT+, with CRRT and Bushen Yiqi Wenyang decoction combined with treatment based on routine treatment). Through the evaluation of serum IL-6, IL-10 and TNF-a level Change and sequential organ failure assessment (SOFA), oxygenation index (OI), mean arterial pressure (MAP), serum creatinine Scr, Cys-C, evaluation of Yiqi Wenyang Bushen recipe combined with CRRT therapy with curative effect in patients with acute kidney injury in sepsis patients. Results: 1:IL-6: there was no significant difference in the serum level of IL-6 in the treatment group the 3D (P0.05). After treatment, the serum levels of IL-6 group before treatment were decreased, CRRT group (t=2.980, P=0.003) and CRRT+ of Chinese medicine group (t=3.424, P=0.001) is the most obvious. And after treatment 7d, CRRT+ of Chinese medicine group serum IL-6 level decreased significantly (1=4.554, P0.001 after the treatment of vs 3D t=3.457, P=0.002 vs; CRRT group after treatment 7d.2:IL-10): there was no significant difference in the serum levels of IL-10 group before treatment (P0.05). After treatment, the serum levels of IL-10 group 3D than before treatment had no significant difference (P0.05). After the treatment of 7D, visible CRRT traditional Chinese medicine group The level of serum IL-10 was significantly higher than that before treatment (t=2.980, P=0.003 vs. t=2.345, P=0.013vs. 3D after treatment; only after treatment in group CRRT, 7D) there was no significant difference in the serum level of TNF-a.3:TNF-a: in each group before treatment (P0.05). After 3D treatment, the serum levels of TNF-a group before treatment were decreased, but no significant the difference (P0.05). 7d after treatment, the serum levels of TNF-a group before treatment were decreased (conventional treatment group: t=1.987, P=0.028; Chinese medicine group: t=1.986, P=0.028, 1=2.433, CRRT group; P= 0.010; CRRT+ traditional Chinese medicine group: t=2.356, P=0.012), CRRT group and CRRT+ group for the traditional Chinese medicine obviously. After treatment 7d, CRRT+ of Chinese medicine group serum TNF-a level decreased significantly (t=1.768, P=0.043, vs after treatment in.4:OI: group 3D) oxygenation index in patients with OI before treatment had no statistically significant difference (P0.05). After the treatment, in the treatment of After 3D treatment, CRRT group (t=1.768, P=0.043) and CRRT+ of Chinese medicine group (t=1.768, P=0.043) in patients with 0I significantly increased in 7d after treatment, patients with OI levels of the four groups were significantly increased than before treatment (routine treatment group: t=1.758, P=0.044; Chinese medicine group: t=1.955, P=0.030; CRRT group: t=1.933, P=0.031; CRRT+: t=2.155 P=0.019), Chinese medicine group, the CRRT+ traditional Chinese medicine group was significantly better than group CRRT (t=2.365, P=0.010). The CRRT+ traditional Chinese medicine in the treatment of patients after 7d treatment than 3D when OI levels rise faster (t=2.363, P=0.012).5:MAP: the changes of mean arterial pressure in patients with MAP before treatment had no statistical difference (P0.05). In the treatment of 3D, only CRRT+ of Chinese medicine group were significantly increased MAP (t=1.957, P=0.032), and in patients with 7d after treatment, OI levels of the four groups were significantly increased than before treatment (routine treatment group: t=1.901, P =0.040; Chinese medicine group: t=1.755, P=0.044, CRRT group; : t=2.133, P=0.018; CRRT+ t=2.187 P=0.017), Chinese medicine group:.6:Scr: blood creatinine level in patients with Scr were no significant difference before treatment (P0.05). In the treatment of 3D, CRRT group and CRRT+ group Scr levels dropped significantly (t=2.702, P=0.002), and at 7d after treatment, patients with Scr levels in the four groups there were significantly lower (conventional treatment group: t=1.702, P=0.047; Chinese medicine group: t=2.221, P=0.017, CRRT group: t=2.185; P=0.016; CRRT+ traditional Chinese medicine group: t=2.567, P=0.007) Cys-C level of patients with.7:Cys-C: in both groups had no significant difference before treatment (P0.05). In the treatment of 3D, Cys-C levels were the blood groups of different degrees of decline, but there was no statistical difference (P0.05), and at 7d after treatment, CRRT group and CRRT4 group serum Cys-C levels were significantly lower (t=2.112, P=0.021), but after treatment with 3D comparison, no statistically significant The difference (t=1.789, P=0.042).8:SOFA: groups before treatment SOFA score was no significant difference (P0.05), 3D after treatment in CRRT group (t=1.754, P=0.043) and CRRT+ of Chinese medicine group (t=2.002, P=0.027) SOFA scores were significantly decreased after treatment. 7d SOFA score were significantly lower than before treatment (routine treatment group: t=1.874. P=0.036; Chinese medicine group: t=2.531, P=0.011, CRRT group: t=2.147; P=0.023; CRRT+ traditional Chinese medicine group: t=2.548, P=0.008).9: assessment of the risk of death: COX regression analysis showed that patients with sepsis induced acute kidney injury after treatment of CRRT, compared with non CRRT group patients had significantly improved prognosis. Patients treated with CRRT ICU day 3,7,14,30 the risk of death was decreased by 12%, 5%, 10% and 3%, while the third and fourteenth day results there were significant differences (P3d=0.02, P14d=0.01). COx regression analysis showed that patients treated with CRRT in patients with combined treatment of traditional Chinese medicine, There are some advantages in treatment and prognosis compared with CRRT alone, on the third day and 30 day mortality risk decreased by 9% and 16%, and on the 7 day and 14 day mortality increased 2% and 1% respectively, which was significant in the fourteenth and thirtieth days (P14d=0.04, P30d=0.03). Conclusion: Yiqi Wenyang Bushen recipe combined with CRRT is more the advantages, compared with the simple CRRT therapy can effectively remove inflammatory mediators, blocking the waterfall like effect of inflammatory reaction, improve tissue perfusion and oxygenation, effective protection of organ function, especially can reduce renal damage, contributes to recovery of renal function in the early stage, so as to improve the prognosis and reduce mortality in patients with acute renal function the damage of sepsis. The study on the exact and status of TCM in clinical treatment of critically ill patients in the role of the affirmative, but also for the deeper research has laid a foundation.

【学位授予单位】：南京中医药大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R459.7

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