在线血液透析滤过

Title,Subject,Author(c)Copyright30/12/2014在线血液透析滤过Onlinehemodiafiltration(oLHDF)费森尤斯医学部杨洪莹FreseniusMedicalCare–THERENALCOMPANYPage2议程•传统的血液透析治疗的局限性•血液透析滤过在临床上的益处-置换剂量•血液透析滤过的定义-滤过分数•HDF治疗的实现FreseniusMedicalCare–THERENALCOMPANYPage3传统的血液透析的局限性:长期FreseniusMedicalCare–THERENALCOMPANYPage4尿毒症毒素是一组不同成分的化合物可溶于水的小分子物质蛋白结合的中分子Asymmetricdimethylarginine3-DeoxyglucosoneAdrenomedullinBenzylalcoholCMPF*Atrialnatriureticpeptideß-GuanidinopropionicacidFructoselysineß2-Microglobulinß-LipotropinGlyoxalß-EndorphinCreatinineHippuricacidCholecystokininCytidineHomocysteineClaracellproteinGuanidineHydroquinoneComplementfactorDGuanidinoaceticacidIndole-3-aceticacidCystatinCGuanidinosuccinicacidIndoxylsulfateDegranulationinhibitingproteinIHypoxanthineKinurenineDelta-sleep-inducingpeptideMalondialdehydeKynurenicacidEndothelinMethylguanidineMethylglyoxalHyaluronicacidMyoinositolN-carboxymethyllysineInterleukin1ßOroticacidP-cresolInterleukin6OrotidinePentosidineKappa-IglightchainOxalatePhenolLambda-IglightchainPseudouridineP-OHhippuricacidLeptinSymmetricdimethylarginineQuinolinicacidMethionine-enkepahlinUreaSpermidineNeuropeptideYVanholderR.etalNewinsightsinuremictoxins.KidneyInt,2003,63;84:S6–S10钠水钾…2微球蛋白瘦素…对甲酚硫酸吲哚酚…分子量500d500d500–12000dFreseniusMedicalCare–THERENALCOMPANYPage5oLHDF原理•结合弥散和对流–弥散=HFHD–对流HFHD•超纯透析•通过特殊的细菌内毒素过滤系统在线生成无菌置换液FreseniusMedicalCare–THERENALCOMPANYPage6oLHDF治疗模式•具体模式–前稀释Pre-dilution–后稀释Post-dilutionFreseniusMedicalCare–THERENALCOMPANYPage7普通血液透析（超滤)模式简图超滤泵透析液泵FreseniusMedicalCare–THERENALCOMPANYPage8oLHDF前稀释模式简图置换液泵透析液泵超滤泵FreseniusMedicalCare–THERENALCOMPANYPage9oLHDF后稀释模式简图超滤泵置换液泵透析液泵FreseniusMedicalCare–THERENALCOMPANYPage10oLHDF临床上的优势与普通血液透析相比:•中大分子毒素清除更好•血流动力学更稳定•改善促红细胞生成素反应•更好地改善微炎症状态•更好地改善营养状况•更好的病人生存率FreseniusMedicalCare–THERENALCOMPANYPage11溶质清除的特点FreseniusMedicalCare–THERENALCOMPANYPage12溶质清除率的具体数据ArhenholzetalIntJArtifOrg1997;20:81-90SoluteHighFluxHDPre-DilutionHDF(Qs180ml/min)Post-DilutionHDF(Qs80ml/min)Urea(60)182(7.3)188(6.1)211(5.4)Phosphate(96)156(5.8)152(2.7)179(8.0)Creatinine(113)152(3.5)149(4.4)164(2.9)2M(11,818)33(1.3)52(0.9)62(1.1)FreseniusMedicalCare–THERENALCOMPANYPage13HDF比HFHD清除毒素效果更好post-HDF与HFD比较VitaminB12(1355Da)50%clearance菊粉(5200Da)100%clearance骨钙素(5800Da)71%vs54%β2-微球蛋白(11,800Da)73%vs47%瘦素(16,000Da)31%vs10%肌红蛋白(17,200Da)62%vs25%泌乳素(23,000Da)50%vs22%D因子(23,500Da)33%vs0%a1-微球蛋白(33,000Da)30%vs0%Variousmembranes,variousfiltrationratesFreseniusMedicalCare–THERENALCOMPANYPage14oLHDF治疗具有更好的血液动力学特性FreseniusMedicalCare–THERENALCOMPANYPage15oLHDF血流动力学更稳定尽管HDF病人脱水率更高，但其在透析过程的低血压反应事件却比普通血液透析患者更少Vilar,Eetal.C.JASN4:1944–1953,2009152,043sessionsweredeliveredasHDFand291,222ashigh-fluxHDHFDHDFHFDHDF0.05(IQR0.08)0.03(IQR0.05)0.03(IQR0.04)0.02(IQR0.03)HypotensiveEpisodes/txi.vSalinebolus/txp0.001p0.001FreseniusMedicalCare–THERENALCOMPANYPage16oLHDF改善病人生存率FreseniusMedicalCare–THERENALCOMPANYPage17观察性研究显示HDF改善病人生存率6000个病人的分析结果显示：HDF治疗患者比HFHD生存几率提高30-40%FreseniusMedicalCare–THERENALCOMPANYPage18置换液剂量15L/次比较HDF和HD患者的死亡风险：DOPPS研究的欧洲结果KidneyInternational（2006）FreseniusMedicalCare–THERENALCOMPANYPage19CONTRASTStudyJASN23:1087–1096,2012在线HDF对全因死亡率和心血管事件的影响：CONTRAST研究FreseniusMedicalCare–THERENALCOMPANYPage20CompositecardiaceventsHD与HDF病人生存率相似AllcausemortalityCompositeCVeventFreseniusMedicalCare–THERENALCOMPANYPage21后置换-置换液量的作用aAdjustedfordeterminantsofmortality,i.e.,age,sex,previousvasculardisease,diabetes,previoustransplantation,spKt/V,baselineeGFR,baselinealbumin,baselinecreatinine,baselinehematocrit,anduseofa-andb-blockers,calciumantagonists,andangiotensinconvertinginhibitorsatbaselinebAdjustedfortheabove-mentioneddeterminatesaswellasforcenterdifferences置换液量21.95L可以使总死亡率降低~35-40%但对心血管死亡率影响不大FreseniusMedicalCare–THERENALCOMPANYPage22NephrolDialTransplant(2012)死亡率和心血管事件在线HDF和高通量HD的比较：土耳其研究FreseniusMedicalCare–THERENALCOMPANYPage23HDF与HD病人生存率相似FreseniusMedicalCare–THERENALCOMPANYPage24置换液量对患者生存率的影响置换液量17.4L时病人生存率明显改善FreseniusMedicalCare–THERENALCOMPANYPage25JASNFebruary28,201324:487-497高效的后稀释在线HDF降低透析患者的全因死亡率：ESHOL研究FreseniusMedicalCare–THERENALCOMPANYPage26ESHOL研究的主要结果FreseniusMedicalCare–THERENALCOMPANYPage27次级终点FreseniusMedicalCare–THERENALCOMPANYPage28置换液量对生存率的影响Mortalityintheintermediatetertile(23.1–25.4L)anduppertertile(25.4L)waslowerthanthatinpatientsonHD(HR,0.60;95%CI,0.39–0.90;andHR0.55;95%CI,0.34–0.84,respectively).置换液量超过23L病人生存率明显改善pvalueFreseniusMedicalCare–THERENALCOMPANYPage29如何评价oLHDF对病人生存率的影响效果•基于目前的研究证据（包括RCT和大规模的观察性研究结果）来看，onlineHDF在临床实践中优势还是确实存在的。就像HFHD优于LFHD一样！•高置换液剂量的oLHDF的益处非常明显！•将来随着接受HDF治疗的病人不断增加，HDF治疗成本必将逐步下降，有助于onlineHDF治疗更普及FreseniusMedicalCare–THERENALCOMPANYPage30血流量扮演了一个重要角色在置换剂量的实现中100L/次416ml/minx240min每次治疗的总的血液的数量25L/次总超滤量‘好的’血流量70L/次292ml/minx240min每次治疗的总的血液的数量25L/次‘欠佳的’血流量FF0.37FF0.25滤过分数QUFQB滤过分数=in%FreseniusMedicalCare–THERENALCOMPANYPage31Post-dilutionhemodiafiltration后稀释模式图10ml/min500500110ml/min350340TMPresultofUFpump+substitutionpump100ml/min240hct36%X60minx4hr=24LFreseniusMedicalCare–THERENALCOMPANYPage32Pre-dilutionhemodiafiltration10ml/min5005001