急性敌草快中毒杂合式血液净化治疗策略

Hybrid Blood Purification Strategies for Acute Diquat Poisoning

摘要: 目的：系统总结血液灌流(hemoperfusion, HP)联合连续性肾脏替代治疗(continuous renal replacement therapy, CRRT)在急性敌草快(diquat, DQ)中毒救治中的应用依据、疗效影响因素和优化方向。方法：围绕DQ毒代动力学、器官损害、预后评估及血液净化治疗等主题，对已阅读全文的中英文文献进行叙述性归纳。结果：DQ中毒缺乏特效解毒剂，氧化应激、炎症反应、线粒体损伤及细胞死亡通路参与其肾、肝、肺、中枢神经和循环系统损害。HP可在中毒早期快速降低血液DQ浓度，但存在再分布和反跳现象；CRRT可持续清除中小分子溶质、纠正水电解质与酸碱紊乱、控制容量负荷并辅助清除炎症介质。现有低质量证据提示，早期HP联合CVVH、CVVHDF或CRRT可能改善肝肾功能、炎症指标、氧合状态和短期死亡率，但证据确定性低至极低，且现有研究多为单中心回顾性研究，治疗方案和终点指标不统一。结论：在证据确定性低至极低的前提下，HP联合CRRT可暂定位为“早期毒物吸附 + 持续内环境和器官支持”的综合策略。未来应依据服毒量、就诊时间、血药浓度、白细胞/中性粒细胞、乳酸、肌酐、肝酶、低血压和神经系统损害进行分层，并通过多中心前瞻性研究优化启动时机、治疗强度和疗程。

Abstract: Objective: To summarize the rationale, current evidence, prognostic determinants and optimization strategies of hemoperfusion (HP) combined with continuous renal replacement therapy (CRRT) for acute diquat (DQ) poisoning. Methods: A narrative review was conducted on Chinese and English studies that addressed DQ toxicokinetics, target-organ injury, prognostic assessment and blood purification. Results: DQ is a bipyridyl herbicide with no specific antidote. After absorption, it induces redox cycling, excessive production of reactive oxygen and nitrogen species, mitochondrial dysfunction, inflammatory activation and multiple regulated cell-death pathways. These mechanisms jointly contribute to gastrointestinal injury, acute kidney injury, hepatic injury, lung injury, toxic encephalopathy, circulatory collapse and multiple organ dysfunction. HP can rapidly adsorb circulating toxin during the early phase, but experimental and clinical observations indicate that plasma DQ may rebound after HP, probably because of redistribution from tissues to blood. CRRT is therefore not only a toxin-removal modality but also a continuous organ-support platform that can correct fluid overload, electrolyte and acid-base disturbances, acute kidney injury and systemic inflammatory burden. Current low-quality evidence suggests that early HP combined with continuous veno-venous hemofiltration, continuous veno-venous hemodiafiltration or other CRRT-based hybrid modalities may improve liver and kidney function, oxygenation, inflammatory markers, toxin clearance time and short-term mortality in selected patients, but the certainty of evidence is low to very low. However, most available studies are retrospective, single-center and heterogeneous in terms of patient selection, HP frequency, adsorber type, CRRT mode, blood flow, replacement dose, anticoagulation, treatment duration and outcome definitions. Important determinants of therapeutic effect include ingested dose, time from ingestion to hospital arrival, plasma or urinary DQ concentration, white blood cell and neutrophil counts, lactate, serum creatinine, liver enzymes, hypotension, respiratory failure, central nervous system injury and the timing and intensity of blood purification. Conclusion: Given the low-to-very-low certainty of evidence, HP combined with CRRT should be regarded as a provisional strategy integrating early toxin adsorption with sustained homeostasis and organ support, rather than as a single detoxification procedure. In clinical practice, candidates should be stratified according to exposure history, toxicological testing, early biomarkers and organ dysfunction. Early HP may be prioritized when exposure is confirmed or highly suspected, whereas CRRT should be added or continued in patients with acute kidney injury, metabolic acidosis, shock, respiratory failure, multiple organ dysfunction or a high risk of toxin rebound. Future multicenter prospective studies should standardize treatment protocols and evaluate whether individualized blood purification can improve survival and functional outcomes in acute DQ poisoning.