持续性静脉-静脉血液滤过治疗重症急性肾衰竭的临床疗效

2001年6月至2005年12月我们应用血液净化抢救56例重症ARF患者，报道如下。 资料与方法 临床资料：2001年6月至2005年12月我院共收治56例重症急性肾衰竭患者，其中29例行持续性静脉-静脉血液滤过（CVVH组），27例行间歇性血液透析（IHD组）。CVVH组男16例、女13例，平均年龄（36．1±9．7）岁；IHD组男15例、女12例，平均年龄（35．4±9．5）岁。[第一段]     

连续性肾脏替代治疗进展

自从1977年Kramer开创了连续性动脉-静脉血液滤过（CAVH）技术以来，连续性肾脏替代治疗（continuous renal replacement therapy，CRRT）技术得到了蓬勃发展，正以不断增长的速度在肾病及危重病领域应用起来。起初CAVH置换量仅16ml／min，为增加溶质清除率通常要加做间断血液透析（IHD），由此又发展出连续性动脉-静脉血液透析（CAVHD）技术。随着血泵引入使用，又发展出静脉-静脉模式（CWH、CVVHD、CVVHDF），     

间断血液透析与连续性血液滤过透析对非脓毒症急性肾衰竭患者的疗效比较

非感染性疾病的危重症如创伤、休克、心肺复苏等患者,在早期阶段出现急性肾衰竭（ARF）,是病情迅速恶化的一个重要信号,临床上除针对病因治疗外,血液净化治疗是一种重要手段。间断血液透析（IHD）和连续性静脉静脉血液滤过透析（CVVHD）是当前广泛使用的两种方法,为评价两种治疗方法在非感染性危重病ARF患者的临床治疗效果,我们对近年来我院该类患者的临床治疗资料进行回顾。     

血液净化抢救急危重症58例分析

血液净化技术近年在医学领域中进展迅速,技术日臻完善,我院自2003年开展血液净化治疗以来,运用血液透析（HD）、血液透析滤过（HDF）、血液透析灌流（HD＋HP）治疗急危重症疾病,取得了较好的临床疗效。现将58例病例报告如下。     

血液灌流串联血液透析治疗对终末期糖尿病肾病患者胰岛素抵抗与营养状态的影响

目的：探讨血液灌流串联血液透析治疗对终末期糖尿病肾病（ESDN）患者胰岛素抵抗、微炎症状态与营养不良的关系.方法：入选ESDN患者75例,其中单纯血液透析组（HD组）25例、血液透析联合血液滤过组（HD＋ HDF组）28例、血液透析串联血液灌流组（HD ＋HP组）22例,比较各组患者治疗前、后与胰岛素抵抗、C反应蛋白（CRP）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、血红蛋白（Hb）、血清白蛋白（Alb）、空腹胰岛素（FINS）、空腹血糖（FBS）及体重指数（BMI）的相关性,应用Daugirdas公式计算透析充分性（KT/V）,分析血液灌流串联血液透析对ESDN患者胰岛素抵抗、微炎症状态与营养不良的影响;健康人16例作为对照组.结果：治疗前,3组胰岛素抵抗、微炎症状态与营养状态差异无统计学意义（P＞0.05）,而CRP、TNF-α及IL-6均高于正常对照组（P＜0.001）;治疗12周后,血液灌流治疗与胰岛素抵抗、CRP、TNF-α、IL-6、Hb、Alb及BMI均显著相关;胰岛素抵抗和营养状态：HD＋ HP组治疗前后有改善（P＜0.05）,较HD组和HD＋ HDF组差异有统计学意义（P＜0.05）;炎症因子：HD＋ HP组治疗前后、以及较其他两组显著降低（P＜0.01）,较正常对照组仍增高（P＜0.05）,HD＋ HDF组与HD组之间差异也有统计学意义（P＜0.05）,HD组治疗前后差异无统计学意义（P＞0.05）.结论：血液透析的ESDN患者体内长期存在的胰岛素抵抗、微炎症状态和营养不良,血液灌流可有效清除炎症介质,降低ESDN患者的胰岛素抵抗,改善营养状态.     

血液灌流联合血液透析对血地高辛清除率的影响

目的观察血液灌流联合血液透析（HP＋HD）、血液透析（HD）对维持性血液透析（MHD）患者血地高辛清除率的影响。方法选择30例MHD患者每周行HP＋HD治疗1次、HD治疗2次,每次治疗4h。采用自身前后对照研究,每例患者分别观察HP＋HD治疗1次、HD治疗1次,总计60例次,分为HD＋HP组30例次和HD组30例次。观察2组透析前后血地高辛浓度、尿素氮（BUN）,比较2组治疗前后血地高辛浓度、地高辛清除率、尿素下降率（URR）和单室模型尿素清除指数（spKt／V）。结果2组治疗前血地高辛浓度、URR和spKt／V比较无统计学差异（P〉O．05）。2组治疗后血地高辛浓度均显著低于治疗前（P〈0．01）,但HD＋HP组血地高辛清除率明显高于HD组（P〈0．01）。结论两种透析方式对血液中地高辛均有清除作用,HP＋HD治疗对地高辛清除率较HD治疗效果高。     

连续性血液净化治疗危重症患者的研究进展

连续性肾脏替代治疗（continuous renal replacement,CRRT）是在间歇性血液透析（intermittent hemodialysis,IHD）的基础上发展起来的,包括所有连续性清除溶质,对肾脏功能起支持作用的各种血液净化技术。随着技术的不断发展和成熟,CRRT的应用范围不仅包括最早的重症急性肾衰竭,更包含了临床各种危重症的抢救,     

五种血液净化手段单次治疗对肾衰竭患者血磷的影响

目的:了解常规间歇性血透(IHD)、IHD串联活性炭吸附器YTS-200、IHD串联树脂吸附器HA-330、持续缓慢低效血液透析(SLED)、日间持续性静脉-静脉血液滤过(CVVH)5种治疗模式对急慢性肾衰竭患者血磷的清除情况。方法:慢性维持性血透患者30例交叉行IHDI、HD YTS-200I、HD HA-330治疗;20例危重急慢性肾衰竭患者交叉行SLED、CVVH治疗。治疗前后检查血磷和血尿素,计算其下降率,比较治疗模式对其影响。结果:上5种治疗模式对肾衰竭患者血磷均有明显的清除,磷下降率(P-RR):IHD 41.16±13.774I、HD YTS-200 50.236±10.968I、HD HA-33045.67±17.05、SLED 54.12±17.277、CVVH为28.06±22.71;秩和检验示SLED与IHD YTS-200治疗之间无差异,IHD与IHD HA-330治疗之间无差异(P>0.05),其余的模式间比较均有统计学差异(P<0.05)。BUN下降率(URR):IHD77.39±5.38I、HD YTS-200 74.82±6.36I、HD HA-330 73.80±5.45、SLED 80.59±9.9、CVVH 43.66±18.19;配对T检验示同一治疗URR明显高于P-RR(P<0.05)。结论:IHDI、HD YTS-200I、HD HA-330、SLED、日间CVVH5种治疗模式对肾衰竭患者血磷的清除不同于BUN,每次每种治疗P-RR明显小于URR;YTS-200吸附器对血磷有显著的吸附效果;IHD YTS-200、SLED治疗对血磷的清除效果类似,显著高于其他3种血液净化模式;SLED的P-RR显著高于相同时间日间CVVH(10 h);SLED对高血磷治疗有高性价比优势。     

血液净化抢救重度有机磷中毒的疗效分析

急性重度有机磷中毒经内科常规治疗效果较差,病死率较高。近年来,我院应用血液灌流（HP）或血液灌流联合血液透析（HP＋HD）技术抢救急性重度有机磷中毒患者,取得较好疗效,现报道如下。     

不同透析方式对维持性血液透析患者微炎症状态的影响

目的：比较低通量血液透析（LFHD）、高通量血液透析（HFHD）、血液透析＋血液灌流（HD＋HP）3种血液净化方式对维持性血液透析（MHD）患者微炎症状态的影响。方法：32例MHD患者,交叉对照设计,每例患者每隔4周随机接受LFHD、HFHD、HD＋HP3种之一治疗,每种治疗持续12周,清洗期4周。治疗前、后检测超敏C反应蛋白（hs-CRP）、白细胞介素-6（IL-6）、肿瘤坏死因子α（TNF-α）和β2微球蛋白（β2-MG）的水平。比较3种治疗对血清hs-CRP、IL-6、TNF-α、β2-MG的影响。结果：（1）3种治疗方式治疗前hs-CRP、IL-6、TNF-α、β2-MG、血清白蛋白（Alb）水平组间比较,差异无统计学意义。治疗12周后,LFHD组hs-CRP、IL-6、TNF-α、β2-MG水平均较治疗前上升;HFHD组及HD＋HP组hs-CRP、IL-6、TNF-α、β2-MG水平均较治疗前下降（P〈0.05或0.01）,HD＋HP组较HFHD组下降更明显,两组差异有统计学意义（P〈0.01）;三组Alb水平与治疗前相比差异无统计学意义（P〉0.05）。（2）单次治疗前后,每两组之间相比hs-CRP、IL-6、TNF-α、β2-MG下降差异均有统计学意义（P〈0.01）,HD＋HP组下降最明显。结论：HFHD、HD＋HP可以降低MHD患者的血清hs-CRP、IL-6、TNF-α、β2-MG水平,改善微炎症状态,以HD＋HP效果最好。     

Worldwide supply of blood and blood products

Blood services have achieved a high degree of sophistication, but there remain serious logistic problems which interfere with the adequacy of blood supplies. Many countries have not been able to implement modern component therapy. Supplies of certain specialized products, such as factor VIII, are insufficient almost everywhere. There is a lively international trade in blood products, and corresponding evidence of disease transmission when the rate of infection is relatively high in the exporting region. The answer to these problems lies in the development everywhere of effective blood programs, based on the organization of nonremunerated blood donors.

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Resumen Los servicios de banco de sangre han alcanzado un alto grado de sofisticación, pero hay todavía serios problemas logísticos que interfieren con la debida provisión. Muchos países no han logrado organizar programas de terapia con componentes sangurneos. La provisión de ciertos productos especializados, tales como el factor VIII, es insuficiente casi en todas partes. Existe un activo comercio internacional de productos sanguíneos con la correspondiente evidencia de transmisión de enfermedades cuando la tasa de infección es relativamente alta en la región exportadora. La respuesta a estos problemas recae en el desarrollo universal de programas efectivos de banco de sangre basados en la organización de donantes no remunerados.

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Résumé Les services de transfusion sanguine ont atteint un haut degré d'organisation mais des problèmes logistiques persistent en particulier en ce qui concerne les sources de sang. Dans de nombreux pays il n'a pas été possible de mettre en oeuvre l'emploi de constituants isolés du sang. L'approvisionnement en certaints produits spécialisés tels que le facteur VIII est insuffisant presque dans le monde entier. Il existe par ailleurs un actif commerce international de produits sanguins avec pour conséquence la transmission possible de maladies, lorsque le taux de l'infection est relativement élevé dans le pays exportateur. La réponse adéquate à ces problèmes consiste dans le développement dans chaque pays d'un programme autonome basé sur le recrutement de donneurs volontaires non rémunérés.

     

Use of blood and blood products in trauma

According to the global study of the burden of disease, violence and accidental injury account for 12% of deaths worldwide; 30-40% of trauma mortality is attributable to haemorrhage. The highly complex haemostatic system is severely impaired as a result of haemorrhagic shock, acidosis, hypothermia, haemodilution, hyperfibrinolysis, and consumption of clotting factors. Thus it is important to prioritize the prevention of the development of coagulopathy. Timely transfusion of red blood cells and plasma products becomes essential to restore tissue oxygenation, support perfusion, and maintain the pool of active haemostatic factors. The limits to this strategy to compensate for the loss of blood and coagulation factors are discussed. In the absence of international guidelines, there is an ongoing debate about a generally accepted treatment algorithm, mass transfusion protocols, and adverse events that have been observed as a result of transfusion. Thus many recommendations are based upon expert opinion rather than on evidence. In this chapter we address key issues of transfusions of red blood cells and plasma products in the acute control of bleeding in traumatized patients.     

Crystalloids,colloids, blood,blood products and blood substitutes

Understanding the physiology of fluid distribution within the human body is fundamental to the practice of anaesthetists and intensivists of all grades. There is a necessity to recognize the range of actions and consequences of the commonly infused intravenous fluids if safe patient care is to be provided. There are many historical and on-going trials surrounding fluid therapy and it is important for the physician to keep up to date with current guidelines.There is a continued drive to improve the safety of donor blood and prevent transfusion errors. Knowledge of how blood products are collected separated and stored is essential to prevent harm to patients through transfusions. Work in producing blood substitutes is progressing, but to date, trials have failed to market a product in Europe and the USA with an acceptable risk profile.     

Perioperative blood and blood component therapy

This overview examines blood, blood components, their indications and contra-indications, from an anaesthetist's viewpoint. The dangers of any blood transfusion, including infection transmission and immune suppression, as well as the risks of massive and rapid transfusions, are discussed. Autologous predonation, intraoperative haemodilution and salvage are described to help prevent some of the risks of homologous blood transfusion. Preoperatively an acceptable individualised haemoglobin concentration should be calculated for each patient and a history for potential bleeding problems taken. In most patients perioperative anaemia does not adversely influence patient morbidity and mortality. However, if blood is required, 4 ml.kg-1 body weight of packed red blood cells will raise the patient's haemoglobin concentration by 1 g.dl-1. The bleeding time as a test of platelet function does not predict perioperative blood loss. However, it remains a useful test in patients with a known bleeding problem or in operations where even small amounts of bleeding increase the surgical difficulty and patient morbidity. If bleeding is due to thrombocytopaenia it is usually slow enough to allow time to check platelet number and function before ordering and transfusing them. Fresh plasma is a much overused product which should mainly be used for coagulation factor replacement, in adequate volumes (4-8 packs in dilutional coagulopathy). The well-informed anaesthetist should be better able to use blood products which, while they may be life saving, are neither innocuous nor inexpensive.     

Crystalloids,colloids, blood,blood products and blood substitutes

The choice of fluid in a given clinical scenario relies on knowledge of the physiology and pharmacology of the fluid. A broad range of fluids are discussed in this article, with particular emphasis on problems associated with excess administration of 0.9% saline. Colloids, blood, blood products and blood substitutes are also discussed. Balancing the risks of allogenic blood transfusion for a patient and transfusion thresholds are considered. The potential of haemoglobin substitutes are still yet to be realized; however PolyHeme is currently in a phase 3 pre-hospital trauma trial.     

Deformability of red blood cells and its relation to blood trauma in rotary blood pumps

In this study, mechanical trauma to red blood cells was evaluated by conventional hemolysis test and a newly developed cyclically reversing shear flow generator. The fresh porcine blood obtained from a local slaughterhouse was subjected to the conventional hemolysis test using a commercial centrifugal blood pump for the duration of 8 h. The measurements consisted of (i) plasma-free hemoglobin based on the standard optical measurement and (ii) the deformability of red blood cells (RBCs) using a cyclically reversing shear flow generator and microscope image acquisition system. The deformability of RBCs was expressed by the L/W value where L and W were the longer and shorter axes of the elongated RBCs' images. Although the plasma-free hemoglobin level increased with the pumping duration, the L/W remained unchanged for the duration of 8 h of pumping to indicate no alteration in the deformability. It was speculated that (i) although RBCs might have been circulated for so many times through the test pump, after each exposure to mechanical stress, RBCs might have recovered, and net effect due to shear stress-exposure time might have been small; and (ii) RBCs' deformability might be maintained near normal until sudden burst or membrane rupture, or the hemoglobin might have continuously leaked through the pores of the thinned membrane created by the mechanical stress. The deformability testing under a fluctuating shear flow could be a new method to quantify subhemolytic mechanical damage that has been accumulated in the RBCs' membrane and that may not be assessed by the conventional hemolysis test.