© Borgis - Postępy Nauk Medycznych 7/2017, s. 357-361
Ruslan E. Yakubtsevich1, Viktor A. Predko1, Tomasz Ilczak2, Katarzyna Starosta-Głowińska3, Tomasz Kulpok-Bagiński4, Michał Kucap5, Klaudiusz Nadolny6, Marzena Wojewódzka-Żelezniakowicz7, Łukasz Szarpak8, *Jerzy Robert Ładny7
The influence of plasmapheresis and hemosorbtion through “Ovosorb” hemosorbent on albumin binding capacity in patients with sepsis
Wpływ plazmaferezy i hemosorbcji przez hemosorbent „Ovosorb” na wiążącą funkcję albuminy u chorych na sepsę
1Voivodeship Clinic Hospital in Grodno, Public University Medical in Grodno
Head of Clinic: Professor Ruslan E.Yakubtsevich, MD, PhD
2Institute of Emergency Services, Department of Nursing and Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biała
Head of Institute: Associate Professor Rafał Bobiński, MD, PhD
3Institute of Emergency and Disaster Medicine, Medical University of Łódź
Head of Institute: Dariusz Timler, MD, PhD
4Institute of Public Health, Faculty of Public Health, Medical University of Silesia in Katowice
Head of Institute: Elżbieta Grochowska-Niedworok, PhD (Pharmacy)
5Voivodeship Rescue Service in Katowice
Head of Service: Artur Borowicz
6College of Strategic Planning in Dąbrowa Górnicza
Head of College: Anna Rej-Kietla, MD, PhD, LLM
7Department of Emergency Medicine and Disaster, Medical University of Białystok
Head of Department: Professor Jerzy Robert Ładny, MD, PhD
8Department of Emergency Medicine, Medical Univeristy of Warsaw
Head of Department: Zenon Truszewski, MD, PhD
Streszczenie
Wstęp. Sepsa jest poważnym problemem współczesnej medycyny. Zauważono, że podczas rozwoju choroby funkcja albuminy surowicy krwi się zmienia.
Cel pracy. Celem pracy jest badanie właściwości funkcjonalnych albuminy w leczeniu sepsy.
Materiał i Metody. Badaniom poddano 60 osób, z których 34 miały zapalenie trzustki, 12 – zapalenie otrzewnej, 10 – zapalenie układu moczowego, 2 – zapalenie płuc, 2 – próchnicę. W każdym przypadku choroba była powikłana sepsą. Wszyscy chorzy byli leczeni zachowawczo: antybiotykoterapia, wlewy dożylne krystaloidów lub koloidów, immunoterapia, terapia oddechowa, wyrównywanie zaburzeń elektrolitowych, kwasowo-zasadowych, poziomu glikemii oraz hemoglobiny, zaburzeń hemostazy. Dla oceny stanu chorych podczas hospitalizacji była wykorzystana skala APACHE II.
Pacjenci byli podzieleni na 3 grupy. W przypadku, gdy liczba punktów wynosiła 30 i więcej, pacjentom przeprowadzano plazmoferezę, jak zaznaczono powyżej – terapię „rozpaczy”. Gdy stan pacjentów oceniono na 30 i mniej punktów w skali APACHE II, chorych losowo podzielono, przy pomocy programu komputerowego, na dwie grupy: kontrolną i doświadczalną.
Wyniki. U chorych na sepsę zaobserwowano nagły spadek wiążącej funkcji albumin. Zastosowanie hemosorbcji z wykorzystaniem hemosorbentu „Ovosorb” odnowiło straconą funkcję albuminy, poprawiło stan chorego według skali APACHE II i zmniejszyło długotrwałość leczenia. Ponadto zauważono, że wykorzystanie plazmaferezy też zmienia wiążącą funkcję albuminy, ale w nieco mniejszym stopniu w porównaniu do sorbentu „Ovosorb”.
Wnioski. Plazmafereza polepsza funkcję wiążącą albuminy, jednak w porównaniu do hemosorbcji efekt jest mniejszy. Pozwala to dojść do wniosku, że uzasadnionym jest wykorzystanie hemosorbcji, która pozwala zachować białka i inne – nie mniej ważne dla organizmu – związki, zwłaszcza u chorych w bardzo ciężkim stanie, kiedy w ustroju gromadzą się autoprzeciwciała i toksyny, nieodwracalnie zmieniające funkcje transportu albuminy.
Summary
Introduction. Sepsis continues to be one of the most serious diseases in modern medicine. It is associated with changes in serum albumin qualities.
Aim. The aim of the study is the evaluation of functional properties of albumins in sepsis treatment.
Material and methods. Study included 60 patients, among which 34 had pancreatitis, 12- peritonitis, 10 – urinary tract inflammation, 2 – pneumonia, 2 – caries. In every case, the disease has been complicated with sepsis. All patients underwent preservative treatment: antibiotic therapy, intravenous infusions of crystalloids or colloids, immunotherapy, respiratory therapy, alignment of electrolyte and acid – base disturbances, glycemia and hemoglobin levels as well as hemostasis disorders. For evaluation of patients condition during hospitalization, APACHE II scale has been used.
Patients were divided into 3 groups. In case when the number o points was 30 and more, patients underwent plasmaphoresis, as it was stated above the therapy of “despair”. When the condition of patients has been estimated for 30 points or less according to APACHE II scale, they were randomly divided by a computer software into two groups: examined and control.
Results. We’ve determined that albumin coupling capacity is decreased drastically with sepsis. Hemosorption with “Ovosorb” hemosorbent restores albumin functioning, improves condition status according to APACHE II and reduces general treatment time. Plasmapheresis also improves coupling capacity, but not so much as “Ovosorb” hemosorbent.
Conclusions. Plasmaphoresis improved albumin binding function, however, in comparison to hemosorbtion the effect is less visible. It brings a conclusion that application of hemosorbtion is reasonable and allows to preserve proteins and other – less important – compounds especially in patients in severe condition when the body accumulates auto antibodies and toxins irreversibly changing albumin transport function.
Introduction
Estimation data regarding United States recall 750 000 cases of sepsis per year, among which 215 000 were fatal (1).
Every year, the number of patients with sepsis increases all over the world and the discussion about the treatment is constantly raised.
Sepsis is a generalized inflammatory reaction, immunological mechanisms and biochemical mechanism of which have not been examined sufficiently and there are no specific markers for determination of those processes (2).
In sepsis pathogenesis, the important stage is human organism reaction to microorganisms activity inducing uncontrolled mediator reaction leading to generalized failure of internal organs (3). Bacteria lipopolysaccharides, cytokines and other mediators of inflammatory status influence functional properties of albumin in human blood serum (4). It is possible that in sepsis, albumin pathological changes, as a protein which serves as a transporter, as well as toxic substances accumulation lead to the impairment of metabolites elimination which have been created during severe generalized inflammatory reaction (5).
For a long period of time, in the evaluation of patient condition, quantitative biochemical indicators of albumin content in serum a have been used. Research conducted in recent years revealed one more important fact: not only the amount of protein is important but also its quality which means its ability to bind and transfer different substances i.e. to transport and remove toxic metabolites, inflammatory mediators, free oxygen radical etc. from organism (6, 7).
Binding capacity of albumin in serum, availability of its centers binding low molecular weight ligands significantly change in critical state (4, 5). It has been determined that in case of sepsis and septic shock in patients with hipoproteinemia leukemia, albumin binding capacity of blood serum is decreased of 33% (8). It is possible that assay of protein binding function in case of sepsis deforms organism condition and efficiency of applied treatment.
In recent years, one of important directions in sepsis treatment is extracorporeal detoxification (9-12).
At the end of 20th century, in scientific journals, first information about plasmapheresis (PF) application in sepsis and septic shock treatment has appeared (11-18). In 1996, Stegmayr proved the efficiency of PF application in sepsis and septic shock treatment. In his study, he proved that PF may increase septic patients survival up to 75%. However, it eliminates from blood not only toxic substances but also many of those necessary for proper functioning which proves that the method is not completely safe (17, 18). Analysis of published by Stegmayr articles allows to sate that PF appeared to be the therapy of “despair” in severe multiorgan dysfunction and disseminated intravascular coagulation syndrome which influences patients survival rate – up to 80% (15, 16).
In our country, hemosorbent “Ovosorb” has been tested. Beneficial influence of hemosorbtion with “Ovosorb” removing from blood serin proteases (trepsin, chemotrepsin, elastasis and others) is well known (10).
Aim
The aim of the study is the evaluation of functional properties of albumins in sepsis treatment.
Material and methods
Study included 60 patients, among which 34 had pancreatitis, 12 – peritonitis, 10 – urinary tract inflammation, 2 – pneumonia, 2 – caries. In every case, the disease has been complicated with sepsis. All patients underwent preservative treatment: antibiotic therapy, intravenous infusions of crystalloids or colloids, immunotherapy, respiratory therapy, alignment of electrolyte and acid – base disturbances, glycemia and hemoglobin levels as well as hemostasis disorders. For evaluation of patients condition during hospitalization, APACHE II scale has been used.
Patients were divided into 3 groups. In case when the number o points was 30 and more, patients underwent plasmaphoresis, as it was stated above the therapy of “despair” (15, 16). When the condition of patients has been estimated for 30 points or less according to APACHE II scale, they were randomly divided by a computer software into two groups: examined and control.
Control group included 15 patients. This group underwent preservative treatment without extracorporeal detoxification. Average age of patients in this group was 39.2 ± 17.4.
Examined group consisted of 35 patients in which hemosorbtion with “Ovosorb” (Belarus) using BP-742 (“Fresenius”, Germany) pump has been applied. The blood passed through the gap with sorbent and then returned to the circulatory system. The speed of blood perfusion was 80-90 ml/min and the full time of the procedure – 60 minutes. In every patient in this group, 3 to 7 procedures have been performed; the average of patients was 47.3 ± 17.5.
The group of patients who underwent plasmaphoresis included 10 persons. The procedure has been conducted with AS.TEC 204 (Fresenius) device. The amount of removed plasma was 2500 ± 150 ml. In this group, 2 to 5 procedures have been performed, the average of patients was 45 ± 17.4.
In all patients during the admission and after intense treatment, leucocytic intoxication index was controlled according to Kalf-Kalif scale and patients condition according to APACHE II and SOFA scales.
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Piśmiennictwo
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