CC BY
2
UDK 616-083.98-08:615.382
Akentiev S.O., candidate of medical science
Associate professor of the department of Anesthesiology and Resuscitation
Berezova M.S., candidate of medical science Assistant of the department of Internal Medicine of Higher State Educational Institution of Ukraine «Bukovinian State Medical University»
Ukraine, Chernivtsi CHANGING THE INDICATOR ENZYME LEVELS IN THE
DETOXICATION PROCESS WITH INCLUSION OF PLASMA SORPTION IN THE STAGE OF INTENSIVE TREATMENT
Abstract. The study involved 55 patients with hepatic, renal and hepatic-renal failure syndromes. The changes in levels of indicator enzymes in the process of plasma-sorption have been examined. Reducing the excess of ALT, AST, ALP promotes regression of endotoxicosis and decreases functional load on the liver.
Key words: plasma sorption, indicator enzymes, liver failure, kidney failure.
Резюме. На 55 пациентах с синдромами печеночной, почечной и печеночно-почечной недостаточности исследовано изменение уровней индикаторных ферментов в процессе проведения плазмосорбции. Снижение увеличенных АЛТ, АСТ, ЛФ способствует регрессу эндотоксикоза и уменшению функциональной нагрузки на печень.
Ключевые слова: плазмосорбция, индикаторные ферменты, печеночная недостаточность, почечная недостаточность.
Comprehensive treatment of severe diseases that are accompanied by liver (acute and chronic), renal (acute and chronic) and hepatic-renal failure syndromes, requires intensification of therapeutic measures involving the introduction of efferent therapy (plasmapheresis, hemosorption, plasma sorption, etc.) [1, 2]. The implementation of procedures for extracorporeal detoxification under conditions of liver and hepatic-renal failure syndromes may be problematic as there are disorders in the patient's coagulation system.
Direct damage to the liver parenchyma, its functional load under the conditions of these syndromes is due to the depth of cytolytic processes, characterized by an increase in the level of indicator enzymes: alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and others.
The purpose was to study the dynamics of levels of indicator enzymes of ALT, AST, ALP, and others in the process of extracorporeal detoxification.
The studies were conducted in three groups of patients with hepatic failure syndromes (9 patients), kidney failure (20 patients) and liver failure (26 patients). All patients underwent plasma sorption (PS) for detoxification. PS was carried out through routine intermittent (fractional) way. The blood was separated into the globular and cellular components by gravity forces. The process of the PS
included the following steps: a) preparation of the system with hemosorbent («CKH-4M», «CKH-2K»); b) preparation of the patient for detoxification (puncture of both subclavian veins); c) sampling the first portion of blood in plastic containers of the type "Gemacon - 500/300" or glass bottles of 500 ml; d) centrifugation of blood (centrifuge "PC-06", operating mode - 2 thousand revolutions per minute, centrifugation time 15 minutes); e) separation of plasma from the blood corpuscles by means of the plasma extractor "nE-01"; f) returning the blood corpuscles and purified plasma to the patient; e) repeated cycles of sampling, purification and return of biological fluids to the patient; g) ending the session of the PS.
11 sessions of the PS were carried out in the group of patients with liver failure syndrome (on average, one session per patient). During a session, 1200 ml of plasma was obtained, purified and returned. The following nosological forms caused severe hepatic failure: cirrhosis of the liver, viral hepatitis, toxic hepatitis, purulent cholangitis, hepatosis. The amount of ALT in the blood, on average, amounted to 93.6 ± 23.8 ^mol / L before the session, after separation of the cell pool, separately in the plasma, the activity of the enzyme was 81.3 ± 23.4 ^mol / L. After conducting the sorption itself its activity decreases to 53.6 ± 19.9 ^mol / l. Significant was the decrease in the activity of the enzyme on the first day after the PS - 55.3 ± 21.5 ^mol / l. The tendency to decrease the activity of the enzyme persisted in the following days. The content of AST in blood before the PS was 101.7 ± 13.9 ^mol / L, in the plasma before the sorption - 85.3 ± 7.9 ^mol / L, after the sorption on the hemosorbent column the ALT activity decreased to 58.3 ± 3,3 ^mol / l. Beginning with the first day after the PS there is a clear tendency to decrease the AST activity similar to ALT. The content of ALP before the sorption in the blood was 568.7 ± 68.5 ^mol / L, in plasma before the sorption - 459.0 ± 36.1 ^mol / L, in plasma after the PS - 252.3 ± 90.1 ^mol / L. On the next day after the PS in the blood, the ALP was 213.0 ± 20.0 ^mol / L. Similarly to the dynamics of previous enzymes ALP also had a clear tendency to decrease.
In the group with renal failure syndrome the patients underwent 37 sessions of the PS, on average 2 sessions per patient. During the session, 800-1200 ml of plasma was obtained, purified and returned. The structure of nosological forms included both acute cases and exacerbation of chronic diseases: chronic glomerulonephritis, chronic pyelonephritis, acute glomerulonephritis, sepsis, peritonitis of various genesis, pancreatic necrosis, calculous cholecystitis, dysentery, acute intestinal obstruction, obliterative atherosclerosis of the vessels of the lower extremities, state after surgery. The influence of PS on the dynamics of individual enzymes is given below in the table (Table 1). The list of enzymes in the table includes, along with ALT, AST, ALP, lactate dehydrogenase (LDH), gammaglutamyltranspeptidase (GGTP), creatine phosphokinase (CPK).
Table 1
Dynamics of the level of some blood enzymes under the influence of PS (in _pmol / L)_
Enzyme Enzyme activity in the blood before surgery PS
Before sorption After sorption
ALT 45,4±15,0 36,5±16,6 25,6±13,6
AST 75,9±15,0 60,0±20,3 49,5±18,2
LDH (total) 552,0±198,0 488,9±150,0 315,2±126,0
GGTP 45,3±6,3 35,2±13,3 19,6±5,2
ALP 197,6±35,9 135,8±18,5 88,2±11,7
CPK 918,4±406,0 812,9±367,5 614,9±329,0
In the third group the patients underwent 55 sessions of the PS, with an average of 2 sessions per patient. During a session 1200-1400 ml of plasma was obtained, purified and returned to the body. This group included patients with leptospirosis, toxic hepatitis, mechanical jaundice, pancreatic necrosis, sepsis, peritonitis, acute cholecystopancreatitis. PS was conducted on the first 1-2 days of admission of patients to the intensive care unit against the background of oliguria or oligoanuria. The structure of endotoxicosis was characterized by accumulation of metabolites and toxins as a result impaired functions of both liver and kidneys. Characteristics of changes in levels of indicator enzymes ALT, AST, ALP and others did not differ from those in the previous two groups. Characteristic of the absorbent capacity of the sorbent in relation to the investigated enzymes is given below in the table (Table 2).
Table 2
Descreption of absorption capacity of sorbent in relation to blood enzymes __in p.mol / l__
Enzyme PS % of absorption
before after
AST 67,6±3,1 28,1±3,3 58
ALT 54,9±7,6 25,4±3,96 54
CPK 395,6±111,7 257,9±79,2 35
LDH (total) 455,3±156,9 336,1±140,9 24
ALP 230,7±11,9 117,1±16,3 49
GGTP 64,0±21,7 48,9±21,6 24
Therefore, the PS is a powerful detoxification method in which the reduction of the excess of enzymes in the blood is carried out through the absorption capacity of the sorbent to these substances. The activity of indicator enzymes decreases most actively, which affects the reduction of the load on the liver and promotes its functional rest. Reduction of the level of cytolytic enzymes, along with the reduction of bilirubinemia correlated with the data of toxicological control. For instance, in analyzing the leukocyte index of intoxication (LII), its decrease was detected on the first two days after the PS in different patients from 8.2-12.8 to 4.5-7.8 units. There was a decrease in the level of "medium" molecules at a wavelength of 282 nm on average by 52%, and at a wavelength of 253 nm -
by 36%. Along with this, the general condition of the vast majority of patients improved (80%). The growth of endotoxicosis ceased, there was a tendency for its regression and the patients' coming out a critical condition.
References:
1. Северов М., Вороненко В., Сев7герова М. Экстракорпоральная детоксикация при печеночной недостаточности// Врач. - 2004. - №12. - С. 22-25.
2. Пщпрний Я.М. Плазмаферез у комплексны штенсивнш терапп гостро!' печшково!' дисфункцп: мiфи та реальнють // Бшь, знеболювання та штенсивна терапiя. - 2007. - №4. - С. 15-23.
