体外血液净化技术对脓毒症临床预后及细胞因子影响的Meta分析

Effect of extracorporeal hemopurification for clinical prognosis and cytokine levels of septic:A meta-analysis

摘要:

目的 系统评价体外血液净化技术(extracorporeal hemopurification, EH)对脓毒症患者临床预后的影响,并探讨相关细胞因子水平变化与临床预后的关联。方法 检索Pubmed, Web of Science, Cochrane Library, 中国知网数据库,纳入从2010年1月至2020年1月所有符合标准的,有关EH对脓毒症患者影响的相关文献,使用Review Manager 5.3进行森林图分析,探讨EH与脓毒症患者的住院病死率(in-hospital mortality, IHM)和重症监护室住院时长的关联,并进一步分析细胞因子水平的改变与临床预后关联。结果 共28篇文献纳入研究,累计2 587例患者,Meta分析结果显示EH(血液灌注、血液滤过、血液吸附、细胞因子吸附等)可显著降低脓毒症患者的IHM(OR=0.83, P=0.04),但并不影响患者的重症监护室住院时长(OR=-0.50, P=0.69)。亚组分析提示:高容量血液滤过或多黏菌素B血液灌注,并不能降低脓毒症患者的IHM(P=0.22;P=0.87);同样EH不能改善烧伤性脓毒症以及脓毒症性急性肾衰竭患者的IHM(P=0.08;P=0.77)。针对EH带来相关细胞因子水平降低的脓毒症患者,虽然IHM没有显著下降(P=0.48), 但是重症监护室的住院时长明显缩短(OR=-17.58,P=0.04)。结论 脓毒症患者,若无相关禁忌证,建议行体外血液净化作为辅助治疗。在治疗过程中,对相关细胞因子水平的调控,是有效缩短重症监护室住院时长的关键。

Abstract:

Objective The purpose of this study is to systematically analyze the effect of extracorporeal hemopurification(EH)for clinical prognosis,and the association between EH-related cytokines levels and clinical prognosis for septic patients.Methods Available studies accessing the effect of extracorporeal hemopurification for septic patients were collected from Pubmed,Web of Science,Cochrane Library and China National Knowledge Internet between January 2010 and January 2020.Relationships between EH and in-hospital mortality(IHM)and length of intensive care unit in sepsis patients were calculated and systematically analyzed by Forest Plot in Review Manager 5.3.We further analyzed the correlation between changing of cytokine levels and clinical prognosis.Results Twenty-eight researches which covered a total of 2587 patients were included in this meta-analysis.The results indicated that EH(hemoperfusion,hemofiltration,hemoadsorption,cytosorb,et.al)could significantly decrease IHM(OR=0.83,P=0.04)without affecting the length of intensive care unit(OR=-0.50,P=0.69).Subgroup analysis suggested that High-volume Hemofltration or Hemoperfusion with Polymyxin B-immobilized cartridge failed to improve IHM(P=0.22;P=0.87);meanwhile,EH showed little therapy efficiency in severe burn septic patients or septic patients with acute kidney injury(P=0.08;P=0.77).During the whole EH period,septic patients with lower cytokine levels at last presented no benefit for a lower risk of IHM(P=0.48),but the length of intensive care unit was significantly decreased(OR=-17.58,P=0.04).Conclusion Routine EH is recommended for septic patients with no contraindication.Controlling relative levels of cytokines during the whole treatment is a useful way to shorten the length of intensive care unit.