Журнал «Медицина неотложных состояний» Том 16, №3, 2020

The objective of the paper is to optimize the treatment of patients with severe hepatonephric insufficiency using the method of plasma sorption (PS). PS (55) was performed in 26 patients: 12 men and 14 women. By age: up to 30 years — 2; to 40 — 1; up to 50 — 3; to 60 — 11; over 60 — 9 individuals. This group included patients with leptospirosis, toxic hepatitis, mechanical jaundice, pancreatic necrosis, sepsis, peritonitis, acute cholecystopancreatitis. PS was performed on the first 1–2 days of admitting the patients in the intensive care unit against the background of oliguria or oligoanuria in a usual intermittent way. The “ГСГД” sorbent with a capacity of 100 ml known in its quality characteristics was used to purify plasma. During one session 1400–1600 ml of plasma was purified and returned to the patient in parallel with the return of the formed elements. Inclusion criteria: presence of mixed liver and kidney failure (total blood bilirubin — 240–260 μmol/l; urea — 18–30 mmol/l; creatinine — 430–520 mmol/l; diuresis < 1 L/day). Exclusion criteria: independent hepatic and renal insufficiency syndromes, fulminant forms, critical states (shocks, terminal states). Comparison groups: a) 26 patients with similar nosologies, who underwent hemosorption (HS); b) 11 patients who underwent plasmapheresis (PP). Criteria for using repeated PS sessions: ineffectiveness of 1 session of the PS — preservation of the patient's previous state and of the level of metabolites in the blood. Criteria for termination of PS sessions: improvement of the general condition of the patient, a decrease in jaundice, itchy skin, weakness and tiredness, absence of a “drainage” effect on the level of blood metabolites, their gradual decrease in the blood, appetite improvement, increased diuresis, increased sensitivity of the body to drugs. Basic therapy: infusion therapy (glucose, albumin, dextran, etc.), diuretics, antiagregants, antibiotics, vitamins, hepatoprotectors, antioxidants. As a result, 80 % of patients experienced a significant improvement: they had a stabilized condition or there was a regression of endotoxicosis, there was a positive dynamics of the level of metabolites (a gradual decrease in total bilirubin and its fractions starting with the 3rd — 4th days, nitrogenous slags — from the 2nd — 3rd days) and medium sized molecular oligopeptides, there was a stability of the content of protein in the blood, decreased jaundice, unbearable itching of the skin stopped and the appetite improved. An important and perhaps a turning point in the treatment was an increase in diurnal diuresis: 874.0 ± 52.0 in the FS, and on the third day — 1600.0 ± 65.0 ml, which correlated with the dynamics of metabolites and “middle molecules” in the blood. In 6 patients, progressive oliguria with the transition to anuria required an addition of more radical efferent methods of detoxification — hemodialysis with hemosorption and hemofiltration.

Thus, in the immediate postoperative period, the PS, unlike the HS and PP, does not reduce the total protein of the blood, which makes it possible to use the PS in conditions of hypoproteinemia. PS compared with HS and PP causes a greater diuretic effect, which makes it important to use it in case of oliguria and oligoanuria. In contrast to the PP in the PS, there is no need for the transfusion of large doses of donor plasma and other plasma-substituting solutions.