Method of immune insufficiency correction in patients with mechanical jaundice of non-tumour genesis

FIELD: medicine.

SUBSTANCE: invention relates to medicine, can be applied in resuscitation science, surgery, clinical immunology. For correction of immune insufficiency in patients with mechanical jaundice of non-tumour genesis in addition to complex traditional therapy of post-operational period from the first day after operation one time per day intravenously introduced is 1 ml of 1%-solution of glutoxim on autoblood, with its preliminary 30 minute incubation with 20 ml of autoblood. Treatment course is 5 sessions.

EFFECT: method makes it possible to increase treatment efficiency, reduce lethality, reduce duration of patient's presence in hospital.

2 tbl, 1 ex

 

The invention relates to medicine, can be used in surgery, intensive care, clinical immunology.

Intoxication, growing in acute inflammatory diseases biliary tract, disrupts the functioning of the immune system. This is manifested in the decrease in the number of circulating cellular elements, inhibition of growth, maturation and migration, accumulation of excessive amounts of circulating complexes of the antibody-antigen in the serum due to violations of the processes of elimination [1, 4].

The need to improve the results of surgical treatment of complicated forms of gallstone disease requires studying the features of violations of local and systemic immunity and ways of their correction, as well as the development of methods of prevention of postoperative complications [2, 8].

Given that all surgical patients with mechanical jaundice in some degree impaired functioning of the immune system, they are shown holding immunocorrective therapy from the first day of the disease [3, 7]. However, the high economic costs necessary for the acquisition of immunomodulators, do not allow all patients to carry out adequate immunotherapy.

Currently known methods targeted transport of drugs, which allow, along with the creation in C is not, covered pathological process, to create a high concentration of an administered drug, to minimize unwanted reactions to medication, can reduce therapeutic dose and the administration frequency. These methods can be based on the use of different media, with trapnest to specific organs or cells. In addition, this goal can be achieved by applying microcontainer, which can be liposomes, capsules of human albumin magnetic microspheres, microcapsules made of nylon and autoclutch blood [5].

Methods based on the use of cells autologous blood for the purpose of modifying their properties for directed transport under the General title of extracorporeal pharmacotherapy. From the point of view of biocompatibility in vitro pharmacotherapy is the most beneficial for targeted transport of drugs. Cells used for directional transport, called "universities etc" [7].

Now for immune in various diseases use Glutoxim[6, 8, 9, 10]. This preparation allowed 10.09.98 Pharmacological Committee of Russia for clinical use as a medicinal product, which is the modifier biological engineering is th answer with immunomodulatory properties (registration number 98/279/3).

According VFS (42-3195-98, 42-3408-99) drug Glutoxim is a chemically synthesized biologically active compound is a Hexapeptide with stabilized by a disulfide bond bis-(gamma-L-glutamyl)-L-cystinyl-bis-glycine disodium salt, with a total formula C20H20N6Na2O12S2[9]. Drug Glutoxim is a structural analogue of the natural metabolite of oxidized glutathione. Under the influence of Glutoxim is the proliferation and differentiation of normal cells of the immune system and activates the apoptosis of transformed cells. Artificial stabilizing disulfide bond of oxidized glutathione allows enhancement of multiple physiological effects, natural remotefilename oxidized glutathione. Glutoxim activates antivarikoznye the enzyme glutathion reductase, glutationtransferase and glutathione peroxidase, which in turn activate intracellular reactions of thiol metabolism and is necessary for normal functioning of the intracellular regulatory systems. The cells in the new redox mode determines immunomodulatory and cytoprotective system effect of the drug. Based on the mechanisms of action of this drug can distinguish the following main functions: a ) endogenous products, modification and reproduction effects of cytokines; 2) selective effect on normal and transformed cells. Glutoxim it is recommended to enter systemically (intravenously, intramuscularly, subcutaneously) and regional (intrapleural, intrahepatic, intraperitoneally) [9, 10].

The disadvantage of these techniques is that for effective metabolic and immunocorrective action Glutoxim insufficient permeability of the membrane of lymphocytes. Bioavailability of Glutoxim is 80%, with an increase in membrane permeability of the lymphocyte to Glutoxim may enhance the bioavailability and thus increase immunocorrective effect of this drug.

The objective of the invention is the increased efficiency results after surgical treatment and immunotherapy in patients with mechanical jaundice nonneoplastic Genesis, reducing mortality, reducing the length of stay of patients in hospital.

The task to solve due to the fact that additional intravenously injected Glutoxim 1%1 ml pre-incubated with 20 ml of whole autologous blood, once daily therapy 5 sessions.

The method is as follows. From the first day of the postoperative period carry out intravenous infusion of antibiotics, colloid and crystalloid solutions, solutions,correcting acid-base status and electrolyte balance, and additionally injected Glutoxim 1%1 ml pre-incubated with 20 ml of whole autologous blood within 30 minutes, once a day, the course of therapy 5 sessions.

For evaluation of immune status of patients was determined indicators leukogram, indicators of cellular, humoral immunity.

To determine leukogram patients in the morning on an empty stomach collect blood from a finger. The absolute number of leukocytes is determined in the Goryayev camera according to the standard technique. The morphology of leukocytes and the percentage of each population estimate after staining the smear of blood surasena. Next, calculate the absolute number of lymphocytes.

Simultaneously with blood sampling from the finger conduct blood from the cubital vein for isolation of lymphocytes, which are further used to phenotype by monoclonal antibodies and determination of structural and metabolic parameters (enzyme activities and lipid profile). The preservative is 0.6 percent cooled to 4-5°C buffer solution at physiological solution, which is mixed with blood in a ratio of 1:9. Allocate a suspension of lymphocytes from the blood. For the subsequent determination of enzymes activity of lymphocytes separated 1 million cells and freeze them at -20°C, to study lipid spectrum freeze 2 million cells.

Phenotypicaly the th lymphocytes carried out by indirect immunofluorescence using mouse monoclonal antibodies to molecules of different CD-receptors of lymphocytes. Sample analysis is performed on a fluorescent microscope Lumam And-1. In the use of murine monoclonal antibodies JSC "Sorbent" to CD3 (T-lymphocytes), CD4 (T-helper cells), CD8 (T-suppressor), CD 19 (b-lymphocytes).

The number of b-lymphocytes is determined by the expression of receptors type 19 in the reaction of indirect immunofluorescence. The functional activity of b-lymphocyte count at the level of the main classes of immunoglobulins in the serum IgA, IgG, IgM. The concentration of serum immunoglobulins A, M, G determined by the method of radial immunodiffusion using diagnostic monospecific human sera. This method is based on measuring ring precipitation formed when making the test serum in wells cut in the layer of agar, which is pre-dispersed monospecific serum. In standard conditions experience the diameter of the ring precipitation is directly proportional to the concentration of the studied immunoglobulin. The immunoglobulin set relative to a reference human serum with a known concentration of immunoglobulins.

The study included 43 patients with mechanical jaundice of non-neoplastic origin. Were diagnosed on the basis of complaints, anamnesis, clinical and laboratory data, results of examination and ultrasound hepato-pancre then-duodenal area, and on the testimony was performed endoscopic retrograde cholangiopancreatography (ERCP). Surgery was performed in all patients at different times after admission to the hospital. The scope of the operation was to laparotomy, choledocholithotomy, establishing drainage of the choledochus.

All patients from the first day the early postoperative period conducted intensive therapy, including antibiotics and infusion therapy, detoxification treatment in the intensive care unit and intensive care.

The patients were divided into 3 groups. The first group consisted of patients who received postoperative traditional intensive therapy. In the second group, along with traditional treatment, patients received Glutoxim 1%1 ml, administered intravenously. Patients of the third group in addition to treatment was administered intravenous Glutoxim 1%1 ml pre-incubated with 20 ml of whole autologous blood within 30 minutes, once a day, therapy - 5 sessions.

All patients in the dynamics of clinical, biochemical and immunological blood tests.

The data obtained immune status were analyzed according to the main rules of interpretation immunograms. When processing the results of a study in patients with mechanical jaundice nonneoplastic Genesis revealed a number of features that differentiate them from regional indicators of leukogram and immunograms healthy person.

The results are presented in table 1, show that in patients receiving conventional therapy (group 1), on the 5th day after the treatment remains leukocytosis, lymphopenia, monocytosis. Patients of the second group receiving Glutoxim intravenously, was marked lymphocytosis and monocytosis, but unlike the patients of the first group, the total number of leukocytes was close to normal. In the patients on the background of traditional therapy in vitro drug therapy (group 3), indicators leukogram strive to normal.

When using the proposed method, the faster the relief of acute inflammatory reactions and reduced toxicity. Along with this and figure lymphocytes reaches the norm and becomes 2 times higher than in the group of patients receiving conventional therapy, which also confirms expressed detoxifying effect of our proposed method (table 1).

The results of immunological indexes presented in table 2, show that patients of the first group who received traditional therapy, on the 5th day after the treatment was preserved lymphopenia, T-immunodeficiency mild decline immunoregulatory index, due to the reduction of T-helper cells and the increase in T-suppressor cells, humoral link of an increased rate of immunoglobulin A.

Patients of the second group, polucha is their Glutoxim subcutaneously, in comparison with the indicators of the first group, continued T-immunodeficiency mild, but the level of lymphocytes and immunoregulatory index increased by increasing the level of T-helper cells and reduced T-suppressors.

In patients of the third group treated against the background of traditional therapy extracorporeal pharmacotherapy is a minor T-immunodeficiency, although the numbers of T-helper cells increased, respectively, the T-suppressor decreased, immunoregulatory index is close to the norm, humoral also is within normal limits.

By the 5th day of therapy in patients of the third group was achieved normalization of clinical and laboratory parameters that were not detected in patients first and second groups.

Mortality in the first group was 28%in the second group, 24% and in the third group of 10%. The duration of hospital stay decreased from 28.2 in the first group, to 17.4 in the second group, to 8.4 bed-day in the third group of patients.

Causes of death in the first and second groups was the development of pronounced syndrome of endogenous intoxication, multiple organ failure or purulent septicemic complications. In the third group cause of death (one patient) were advanced age (82 years) of the patient, which revealed severe concomitant pathology./p>

The effectiveness of the proposed method is proved by clinical observations of patients with mechanical jaundice of non-neoplastic origin. The proposed method can effectively influence the immune system by creating in immunocompetent cells high concentrations of metabolic immunocorrector - Glutoxim. As a result of exposure on metabolic and energetic processes in the immunocompetent cells decreased the degree of immunodeficiency in mechanical jaundice nonneoplastic origin and correspondingly increased the effectiveness of treatment, decreased mortality, decreased duration of hospital stay.

Example.

Patient T., born in 1961, was admitted in surgical ward Road clinical hospital at the station Krasnoyarsk 15.10.2008, with complaints about the yellowness of the skin and sclera, pressing pain and feeling of heaviness in the right hypochondrium, weakness. From the anamnesis: ill 3 days ago, when after errors in diet (fried pork meat, alcoholic drinks) appeared moderate pain and feeling of heaviness in the right hypochondrium. After one day the patient noticed the yellowing of sclera and skin, with pain intensified; analgesics (aspirin, baralgin) and antispasmodics (drotaverine, papaverine) is without effect. Caused the brigade emergency medical the first means, delivered in Road clinical hospital of Krasnoyarsk.

On physical examination, the patient's condition is moderate, there is a yellowness of the skin and sclera. The rhythmic heart sounds, pulse 86 beats per 1 minute, satisfactory filling. HELL 140/95 mm Hg vesicular Breath, wheezing is not heard. Belly symmetrical, moderately tense, painful in the right hypochondrium. In the clinical analysis of blood: erythrocyte sedimentation rate (ESR) 35 mm/h, WBC 17,8*109/l; stab 10%; segmented 50%; lymphocytes 16%; monocytes 9%; eosinophils 6%. Blood biochemical parameters: bilirubin 84,72 µmol/l, alanine aminotransferase 78,84 U/l, aspartate aminotransferase 57,33 U/l, alkaline phosphatase 254,36 U/l, gammaglutamyltranspeptidase 397,53 U/L. Immunological indicators: reduction of T-helper cells to 22,55%; a sharp decline in T-suppressor to 11,53%, increasing ratio of CD4/CD8 (immunoregulatory index) - 1,95. Ultrasound of the abdomen: hepatomegaly. Diffuse changes in the pancreas and liver. Dilatation of the common bile duct to 1.3 cm in the distal of which there is a calculus to 1.0 cm in diameter. The thickened wall of the gallbladder to 0.9 cm in the lumen are multiple concretions from 0.3 to 1.1 cm in diameter.

Clinical diagnosis: cholelithiasis. Choledocholithiasis. Mechanical is Kai jaundice.

In an emergency procedure performed ERCP and endoscopic papillosphincterotomy, lithoextraction. In the postoperative period the patient on the background of integrated traditional antispasmodic, antibacterial and detoxifying therapy in addition to treatment was administered intravenous Glutoxim 1%1 ml pre-incubated with 20 ml of whole autologous blood within 30 minutes, once a day, the course of therapy 5 sessions. The postoperative course was satisfactory, there were no complications, jaundice cropped, indicators of bilirubin, liver enzymes and immunological blood counts are normal. The patient was discharged on the 8th day in a satisfactory condition.

Sources of information

1. Wagner, E.A., V.V. Khlebnikov, Terekhina N.A. and other Antioxidants in the treatment of patients with cholelithiasis // News, surgery, 1997, No. 5, p.36-39.

2. Hulman M.I., Vinnik US, Cherdantsev A.I. and other Surgical tactics in various forms calculous cholecystitis in patients with high surgical risk // Sovr. chirurgic. Technology, Krasnoyarsk, 2006, p.50-57.

3. The Danovich SUPERVISION, Levers G.P., Nazarenko, M. the Role of ERCP in the diagnostic algorithm of pancreatobiliary disease // Ann. chirurgic. Hepatology, 2004, Vol.3, No. 3, p.55-56.

4. Nazarov I.P., Vinnik US, Sagar PV and other Immunity in surgery. Volume 2. - Krasnoyarsk, 2006. - 336 S.

5. To salacova N.I. Immunotherapy in treatment of purulent surgical infection: author. dis. Kida. the honey. Sciences. - Krasnoyarsk, 1990. - 21 S.

6. Borisov A.M. Clinical application of national drug polyoxidonium in secondary immunodeficiencies adults / Amerisave, Lventions, Nchsicdciwho // Therapist, architect. - 1998 - No. 10. - P.52-57.

7. Yoshino M., Murakami, K. Role of glutamate dehidrogenase reaction in the control of citrate pool in yeast // Int.J.Biochem. - 1993. - Vol.25, No. 12. - P.1723-1729.

8. RF patent №2190422, A61K 38/08, BIPM No. 28, 10.10.2002,

9. RF patent №2311174, A61K 31/11, BIPM No. 33, 27.11.2007,

10. RF patent №2197984, A61K 38/08, BIPM No. 4, 10.02.2003,

Treatment of immune deficiency in patients with mechanical jaundice nonneoplastic origin, characterized in that perform the surgery, then from the first day have integrated traditional therapy postoperative period and once daily intravenously injected 1 ml of 1%solution Glutoxim on autologous blood, with its pre-incubated for 30 min with 20 ml of autologous blood, the treatment course of 5 sessions.



 

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