Yamato Masafumi, Asahina Yuta, Koizumi Shintaro, Shigeki Takatomo, Yajima Ayako, Kimura Yoshiki, Iwatani Hirotsugu
Department of Nephrology, National Hospital Organization Osaka National Hospital, Osaka, Japan.
Ther Apher Dial. 2020 Oct;24(5):492-498. doi: 10.1111/1744-9987.13544. Epub 2020 Aug 11.
We have previously reported that combination therapy with polymyxin-B direct hemoperfusion (PMX-DHP) and recombinant thrombomodulin (rTM) is effective in patients with septic shock accompanied by disseminated intravascular coagulation (DIC). Two previous studies reporting the favorable effect of early initiation of PMX-DHP for septic shock did not focus on the combination therapy of PMX-DHP and rTM. This retrospective study included 47 consecutive patients who underwent the combination therapy of PMX-DHP and rTM for septic shock with DIC from August 2011 to August 2016. Main exposure was early or late initiation of PMX-DHP. PMX-DHP initiated within 12 hours after catecholamine administration was designated as early group (N = 25) and later than 12 hours as late group (N = 22). Main outcome was 28-day survival rate. The patient characteristics were age median 73 (IQR 68-78) years, 26 men (55%), APACHE II score 32.7 ± 7.7 and lactate 26.0 (18.0-41.0) mg/dL. The 28-day survival rate after PMX-DHP initiation was 76.6% and was not significantly different in the two groups. In the early group, APACHE II score was lower (P = .02), and lactate was higher (P = .005) than in the late group. Lactate was the only predictor of 28-day mortality [odds ratio (95%CI) per 1 mg/dL, 1.08 (1.03-1.19); P = .037] in multivariate logistic regression analysis adjusted with age, sex, APACHE II score, lactate and timing of PMX-DHP initiation. Late PMX-DHP initiation did not lead to statistically worse 28-day survival rate in this combination therapy. The combination therapy of PMX-DHP and rTM may improve the therapeutic effect of PMX-DHP and modify the effect of early PMX-DHP on the prognosis. Lactate may be an appropriate indicator rather than time after catecholamine administration if we discuss when to start PMX-DHP in this combination therapy.
我们之前曾报道，多粘菌素B直接血液灌流（PMX-DHP）与重组血栓调节蛋白（rTM）联合治疗对伴有弥散性血管内凝血（DIC）的感染性休克患者有效。之前两项报道早期启动PMX-DHP治疗感染性休克有良好效果的研究，并未聚焦于PMX-DHP与rTM的联合治疗。这项回顾性研究纳入了2011年8月至2016年8月期间连续接受PMX-DHP与rTM联合治疗感染性休克合并DIC的47例患者。主要暴露因素是PMX-DHP的早期或晚期启动。在给予儿茶酚胺后12小时内启动PMX-DHP被指定为早期组（N = 25），12小时后启动的为晚期组（N = 22）。主要结局是28天生存率。患者特征为年龄中位数73（四分位间距68 - 78）岁，男性26例（55%），急性生理与慢性健康状况评分系统（APACHE）II评分为32.7±7.7，乳酸水平为26.0（18.0 - 41.0）mg/dL。启动PMX-DHP后的28天生存率为76.6%，两组间无显著差异。早期组的APACHE II评分较低（P = 0.02），乳酸水平高于晚期组（P = 0.005）。在对年龄、性别、APACHE II评分、乳酸水平及PMX-DHP启动时间进行校正的多因素逻辑回归分析中，乳酸是28天死亡率的唯一预测因素[每1mg/dL的比值比（95%置信区间），1.08（1.03 - 1.19）；P = 0.037]。在这种联合治疗中，晚期启动PMX-DHP并未导致28天生存率在统计学上更差。PMX-DHP与rTM联合治疗可能会提高PMX-DHP的治疗效果，并改变早期PMX-DHP对预后的影响。如果我们讨论在这种联合治疗中何时启动PMX-DHP，乳酸可能是一个比给予儿茶酚胺后的时间更合适的指标。
