目的 探讨血必净注射液对社区获得性肺炎(CAP)伴发急性肾损伤(AKI)患者的疗效和机制.方法 选择2009 年12 月至2012 年3月收治的CAP 患者,根据RIFLE(危险、损伤、衰竭、肾功能丧失、终末期肾病)诊断标准和肌酐(Cr)水平诊断是否伴发AKI,最终纳入CAP 伴发AKI 患者105 例,按随机原则分为对照组(50 例,给予常规治疗)和血必净组(55 例,在对照组基础上加用血必净注射液每日100 ml,疗程14 d).观察治疗前后两组患者白细胞计数(WBC)、尿素氮(BUN)、Cr、C- 蛋白(CRP)、肿瘤坏死因子-α(TNF-α)、白细胞介素(IL-6、IL-10)、外周血T 淋巴细胞亚群和肺炎严重度指数(PSI)≥Ⅳ级、是否发展为严重脓毒症、是否入住重症监护病房(ICU)、机械通气、使用正性肌力药物支持的比例,以及住院时间和30 d 病死率的变化.结果 对照组和血必净组治疗前WBC、BUN、Cr、CRP、TNF-α、IL-6、IL-10、外周血T 淋巴细胞亚群(CD3+、CD4+、CD8+、CD4+/CD8+ 比值)比较差异均无统计学意义(均P 0.05).对照组和血必净组治疗后WBC、BUN、Cr、CRP、TNF-α、IL-6 均较治疗前明显下降,IL-10、CD3+、CD4+、CD4+/CD8+ 比值较治疗前明显升高,但以血必净组上述指标改善更显著〔WBC( ×109/L):9.5±1.9 12.5±1.7,BUN( mmol/L):5.62±2.10 比7.12±2.12,Cr( mol/L):61.70±18.56 比90.76±23.62,CRP(mg/L):123±32 比206±38,TNF-α(ng/L):38±12 比89±13,IL-6(ng/L):21±6 比37±12,IL-10(ng/L):168±45 比126±32,CD3+:53.5±8.2 比40.5±3.4,CD4+:45.9±3.2 比33.7±5.8,CD4+/CD8+:1.92±0.43 比1.58±0.42,均P ＜0.05〕,CD8+ 比较差异无统计学意义(P ＞0.05).血必净组治疗后PSI 评分≥Ⅳ级(14.5%)、发展为严重脓毒症(9.1%)、入住ICU( 16.4%)、需要机械通气(5.5%)和使用正性肌力药物支持(14.5%)患者的比例均低于对照组(分别为30.0%、20.0%、32.0%、24.0%、28.0%,均P ＜0.01),血必净组住院时间较对照组明显缩短(d:16±5 比20±4,P ＜0.05),30 d 病死率较对照组明显降低(15.4% 比32.0%,P ＜0.01).结论 血必净注射液可以保护CAP 伴发AKI 患者的肾功能并改善其预后,其机制可能是血必净抑制促炎因子的释放和增加抗炎因子的表达以及调节患者免疫功能有关.%Objective To explore the therapeutic effects of Xuebijing injection on community acquired pneumonia ( CAP) patients accompanied by acute kidney injury (AKI) and its mechanism. Methods In cases with CAP admitted into the hospital from December 2009 to March 2012, according to RIFLli diagnostic criteria (risk, injury, failure, loss of kidney function, end stage renal disease) and the level of creatinine (Cr)to diagnose whether there was the presence of complication of AKI, finally 105 cases with CAP accompanied by AKI were enrolled and randomly divided into two groups ; control group (50 cases, routine therapy) and Xuebijing injection group (55 cases, routine therapy plus 100 ml Xuebijing injection, once a day for consecutive 14 days). The count of white blood cell (WBC), blood urea nitrogen ( RUN), Cr, C-reactive protein ( CRP), tumor necrosis factor-α ( TNT-α ), interleukin (IL-6, 1L-10), T lymphocyte subpopulation in peripheral blood , pneumonia severity index (PSI, ≥Ⅳ grade), percentages of patients with severe sepsis, transferred into intensive care unit (ICU), requiring mechanical ventilation (MV) and inotropic support (IS), length of hospital stay and 30-day mortality were observed before and after treatment in the two groups. Results Before treatment, the count of WBC, the level BUN and Cr, CRP, TNT-α, IL-6, IL-10, CD3+ CD4+, CDS+ lymphocytes and the ratio of CD4+/CD8+ of two groups had no significant differences (all P＞ 0.05). After treatment, in the two groups, WBC. BUN, Cr. CRP, TNF-α . IL-6 were decreased obviously and IL-10, CD3+, CD4+ lymphocytes and the ratio of CD4+/CD8+ were increased significantly. However, the improvement of above indicators in Xuebijing injection group was more prominent than those in control group ( WBC (×109/L) ; 9.5±1.9 vs. 12.5±1.7, BUN (mmoI/L) : 5.62±2.10 vs. 7.12±2.12, Cr (μmmol/L) ; 61.70±18.56 vs. 90.76±23.62, CRP (mg/L) : 123±32 vs. 206± 38, TNF-α (ng/L) ; 38±12 vs. 89±13, IL-6 (ng/L) :21±6 vs. 37±12, IL-10 (ng/L): 168±45 vs. 126132, CD3+ : 53.5±8.2 vs. 40.5±3.4, CD4+ : 45.913.2 vs. 33.7±5.8, CD4+CD8+ : 1.92±0.43 vs. 1.58±0.42, all P＜0.05). there was no significant difference in CD8+(25.3±3.8 vs. 19.2±4.1 .P＞0.05). The percentages of patients with PSI after treatment ( ≥Ⅳ grade, 14.5%), severe sepsis development (9.1%), ICU admission (16.4%) and requirement for MV (5.5%) and IS (14.5%) were much lower in Xuebijing injection group than those in control group (respectively 30.0%, 20.0%. 32.0%. 24.0%, 28.0%, all P＜0.01).The length of stay in hospital (day; 16±5 vs. 20±4,P＜0.05) was significantly shorter and 30-day mortality (15.4% vs. 32.0%, P＜0.01) was obviously lower in Xuebijing injection group than those, in control group. Conclusions Xuebijing injection has a protective effect on renal function of CAP patients accompanied with AKI and can improve their prognosis. The mechanism may be related to the inhibition of release of pro-inflammatory factors, promotion of the expression of anti-inflammatory factors and regulation of immune function.
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