体外膜肺联合血液滤过治疗肺肾衰竭的实验研究

目的 观察体外膜氧合器（ECMO）联合高容量血液滤过（HVHF）对急性呼吸窘迫综合征（ARDS）、急性肾功能衰竭（ARF）的治疗作用。 方法 采用实验犬32只，随机分为A、B、C、D 4组。静脉注射油酸复制ARDS模型及双侧输尿管结扎复制急性肾功能衰竭模型。A组用ARDS呼吸机治疗；B组ARDS用ECMO治疗；C组ARDS＋ARF用HVHF治疗；D组ARDS＋ARF用ECMO联合HVHF治疗。监测血气、血流动力学以及血生化等指标。 结果 治疗后B组氧分压（PaO2）逐步上升，在治疗4 h后高于A组[（95.58±8.14） 比（82.79±12.37） mm Hg，P < 0.05]； C组PaO2治疗中较成模时无明显改善；D组PaO2呈逐渐上升趋势，在各时间点均高于C组（P < 0.05）。各组血流动力学指标在治疗中保持稳定。C、D组HVHF治疗后Scr、BUN明显降低[C组：Scr (320.89±65.42) 比(655.04±181.22) μmol/L，BUN (20.42±6.65) 比（41.53±10.59）mmol/L；D组：Scr (334.15±45.97)比（697.48±101.66） μmol/L，BUN (19.12±6.39) 比（39.10±11.60） mmol/L，P均< 0.01]。 结论 ECMO可以有效地改善ARDS低氧血症，联合HVHF可以提供肺肾功能联合支持。     

高容量血液滤过治疗多器官功能障碍综合征的分析

目的研究高容量血液滤过 (HVHF)在多器官功能障碍综合征 (MODS)治疗中的作用。方法 19例MODS患者 ,随机选择 10例行HVHF ,另 9例行常规连续性静脉 静脉血液滤过 (CVVH)。于治疗前和治疗开始后 2、4、8h动脉采血 ,检测血气、血肌酐 (Scr)、尿素氮 (BUN)、肿瘤坏死因子(TNFα)、白细胞介素 1(IL 1β)、白细胞介素 6 (IL 6 )的变化。 结果HVHF组与CVVH组于治疗开始后4h血Scr、BUN均显著下降 ,肾功能改善。HVHF组血TNFα、IL 1β、IL 6治疗前分别为 ( 1795± 5 0 6 )ng/L、( 96 4± 185 )ng/L、( 1332± 4 15 )ng/L ,治疗开始后 4h为 ( 12 6 5± 397)ng/L、( 5 11± 12 4 )ng/L、( 72 6±2 4 3)ng/L ,差异有显著意义 ,P <0 0 5。CVVH组血TNFα治疗前为 ( 1799± 5 11)ng/L ,治疗开始后 4h为 ( 132 7± 4 2 1)ng/L ,差异有显著意义 ,P <0 0 5。HVHF组死亡 3例 ( 3/ 10 ) ,CVVH组死亡 5例 ( 5 / 9) ,差异有显著意义 ,P <0 0 5。结论HVHF可通过对流和AN6 9膜的吸附作用清除大量炎症介质 ,改善MODS患者的预后     

Complete hepatic venous isolation and extracorporeal chemofiltration as treatment for human hepatocellular carcinoma: A phase I study

Background: We performed a phase I study of a novel system of complete hepatic venous isolation and extracorporeal chemofiltration in patients with unresectable hepatocellular carcinoma (HCC) to determine (a) whether systemic exposure to doxorubicin could be limited after high-dose hepatic arterial infusion (HAI), and (b) the hepatic maximum tolerated dose (MTD) of doxorubicin. Methods: Ten patients with biopsy-proven HCC were treated with 20-min HAI of doxorubicin (17 total treatments). Two patients were treated with doxorubicin 60 mg/m², three patients were treated at 90 mg/m², and five patients received 120 mg/m². A newly developed dual-balloon vena cava catheter was advanced from the femoral vein, and the balloons were inflated to isolate and capture total hepatic venous outflow. The hepatic venous blood was pumped through extracorporeal carbon chemofilters before return of the blood to the systemic circulation. Results: Peak systemic doxorubicin levels were an average 85.6% lower than were peak prefilter levels (p<0.01). Because all catheters were placed percutaneously and because the chemofiltration markedly limited systemic chemotherapy exposure, patients were discharged 1 day after 16 of the 17 treatments. The hepatic and systemic MTD of doxorubicin in this treatment protocol was 120 mg/m². Conclusions: This novel system of complete hepatic venous isolation and chemofiltration limits systemic chemotherapy toxicity and will allow use of higher doses of chemotherapeutic agents to treat HCC. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Effect of high volume hemofiltration on CHOP protein from a canine model of multiple organ dysfunction syndrome

Objective To observe the effect of high volume hemofiltration (HVHF) on the expression of CCAAT enhancer binding protein(CHOP) during the treatment of multiple organ dysfunction syndrome (MODS). To investigate the role of CHOP protein act in apoptosis pathway mediated by the endoplasmic reticulum stress. Methods Twelve Beagle dogs were subjected to hemorrhagic shock plus resuscltation and endotixemia to establish MODS model, then they were randomly divided into two groups: HVHF group (n=6) and MODS group (n=6). After endotoxin injection completed, the HVHF group received HVHF treatment for 24 hours; MODS group did not receive. Vivo experiments: Blood samples were obtained at different time points(before operation, 0 h, 6 h, 12 h, 24 h after the injection of endotoxin). The dogs were killed and the tissue samples from lung, liver and kidney were took, then the expression of CHOP mRNA was determined. Vitro experiments: human umbilical vein endothelial cells (HUVECs) were induced by two groups’ blood samples to establish the apoptosis model. Gene expression, protein quantification and cell apoptosis rate were determined before and after the interference. Results Vivo experiments: The levels of CHOP mRNA from lung, liver and kidney had no significant difference between the two groups (P＞0.05). Vitro experiments: (1)The expression of CHOP mRNA: Compared with MODS group, the expression levels of CHOP mRNA were significantly decreased in HVHF group at 6 h, 24 h after the injection of endotoxin (P＜0.05). Compared with before, the expression levels of CHOP mRNA in the two groups were both significantly decreased after CHOP siRNA interference (P＜0.05). (2)The expression of CHOP protein: Compared with MODS group, the expression levels of CHOP protein were significantly decreased in HVHF group at each time points (P＜0.05). Compared with before, the expression levels of CHOP protein in the two groups were both significantly decreased after CHOP siRNA interference(P＜0.05). (3)Endothelial cell apoptosis rate: Compared with the preoperative rate, the two group’s endothelial cell apoptosis rate was decreased significantly at each time points(P＜0.05). Compared with MODS group, the endothelial cell apoptosis rate was significantly decreased in HVHF group at each time points(P＜0.05). Compared with before, the endothelial cell apoptosis rate in the two groups was both significantly decreased after CHOP siRNA interference(P＜0.05). Conclusion In the treatment of MODS process, HVHF can reduce endothelial cell apoptosis which may be related to the inhibition of CHOP mRNA expression and protein synthesis.     

2013年广西血液净化治疗基础现状调查

目的：了解广西血液净化基础现状。方法对广西14个地市115家具备血液净化准入资质的医院进行血液净化基础现状调查,内容包括机器、医生、护师、技师数量,2013年全年开展血液净化治疗的总例次及血液透析、血液透析滤过、血液灌流、血浆置换、连续性血液净化的例次,不良反应发生例次。结果广西拥有血液净化机器1745台,具备血液净化诊疗资质的医生348名,护士828名,技师110名。2013年开展血液净化治疗的总例次为928155例次,血液透析855154例次、血液透析滤过36959例次、血液灌流24714例次、血浆置换1306例次、连续性血液净化10022例次,不良反应发生11097例次。结论广西血液净化诊疗机器设备与医护比例匹配,治疗模式主要是血液透析、血液透析滤过和血液灌流,需要加强对不良反应的监测。     

A NOVEL METHOD FOR REGIONAL CITRATE ANTICOAGULATION IN CONTINUOUS VENOVENOUS HEMOFILTRATION (CVVHF)

Background: Continuous renal replacement therapy (CRRT) is increasingly used in managing acute renal failure (ARF) as it offers hemodynamic stability and significant solute clearance in this setting. However, it also requires anticoagulation. Traditionally, heparin has been the anticoagulant of choice but this increases hemorrhagic risk in already high-risk ARF patients. Regional citrate anticoagulation offsets this risk. However, it can be difficult to manipulate regional anticoagulation in CRRT. Moreover, citrate CRRT has been plagued by short optimal filter patency times. Methods: We designed a novel citrate-based anticoagulation schema for continuous venovenous hemofiltration (CVVHF). We implemented this schema prospectively in caring for 24 individuals admitted to the intensive care unit with ARF requiring CRRT. Each individual had a contraindication to systemic anticoagulation. We evaluated filter patency using Kaplan-Meier methodology, comparing the effect of this citrate-CVVHF system to historical, saline-flush control CVVHF systems. Results: 58 filters ran for a total of 2637.5 h. Average filter patency time was 45.4 ± 25.5 h. At 48 h, 70% of the CVVHF-citrate system filters remained patent compared to only 16% of historical control saline-flush systems (p = 0.0001). The average filtered urea nitrogen/blood urea nitrogen ratio was 0.84 ± 0.06 with an average urea clearance of 28.5 ± 4.1 mL/min for CVVHF-citrate-treated individuals. Only three patients experienced transient complications related to CVVHF-citrate with resolution of these complications within 24 h. Ultimately, 58.3% of the CVVHF-citrate-treated patients survived to ICU discharge. Conclusions: This novel CVVHF-citrate system achieved excellent clearance and dramatically improved filter patency compared to saline-flush systems. Moreover, it did so with minimal toxicity.     

POSSIBLE STRATEGIES TO PROLONG CIRCUIT LIFE DURING HEMOFILTRATION: THREE CONTROLLED STUDIES

Background and Aims: The prevention of filter clotting is an important goal in the management of continuous renal replacement therapy (CRRT). Anticoagulation is the mainstay of such prevention. However, other strategies might prolong filter life without increasing the risk of bleeding. We tested the effectiveness of three strategies (use of flat plate configuration, heparin administration into the air chamber and use of a larger membrane surface) aimed at prolonging circuit life without increasing the dose of anticoagulation. Methods: Thirty-one critically ill patients with acute renal failure (ARF) managed with continuous venovenous hemofiltration (CVVH) were studied. Filters were randomized in a crossover design to three consecutive studies: (1) filtration with either hollow-fiber or flat-plate hemofilters, (2) administration of heparin dose pre-filter or divided into pre-filter and directly into the bubble trap chamber and (3) use of two different surface areas with Filtral 8 (surface area 0.75 m²) vs. Filtral 12 (surface area 1.30 m²) hemofilters. Results: Mean circuit life for flat-plate and hollow-fiber hemofilters (cohort 1) was 14.7 ± 4.7 h and 17.1 ± 2.8 h respectively (NS). Mean circuit life for single heparin administration site vs. double site administration (cohort 2) was 17 ± 3.2 h and 18 ± 3.1 h respectively (NS). Mean circuit lifespan for 0.75 m² and 1.30 m² hemofilters was 16 ± 12.2 h and 15.7 ± 14.3 h respectively (NS) (cohort 3). Visible clot formation in the bubble trap chamber was a frequent cause of circuit failure. Conclusion: Neither flat plate membrane configuration nor increasing membrane surface area, nor heparin administration in the air chamber prolong circuit life during CVVH. The bubble trap chamber is a frequent site of circuit clotting.     

Acute Sodium Chlorite Poisoning Associated with Renal Failure

Background and Objectives: Different techniques of continuous renal replacement therapy (CRRT) might have different effects on azotemic control. Accordingly, we tested whether continuous veno-venous hemodiafiltration (CVVHDF) or continuous veno-venous hemofiltration (CVVH) would achieve better control of serum creatinine and plasma urea levels. Design: Retrospective controlled study. Setting: Two tertiary Intensive Care Units. Patients: Critically ill patients with acute renal failure (ARF) treated with CVVHDF (n = 49) or CVVH (n = 50). Interventions: Retrieval of daily morning urea and creatinine values before and after the initiation of CRRT for up to 2 weeks of treatment. Measurements and Results: Before treatment, serum urea and creatinine concentrations were significantly lower in the CVVH group than in CVVHDF group (urea: 31.0 ± 15.0 mmol/L for CVVHDF and 24.7 ± 16.1 mmol/L for CVVH, p = 0.01, creatinine: 547 ± 308 µmol/L vs. 326 ± 250 µmol/L, p < 0.0001). These differences were still significant after 48 h of treatment (urea: 20.1 ± 8.3 mmol/L vs. 14.1 ± 6.1 mmol/L; p = 0.0003, creatinine: 360 ± 189 µmol/L vs. 215 ± 118 µmol/L; p < 0.0001). Throughout the duration of therapy, mean urea levels (22.3 ± 9.0 mmol/L for CVVHDF vs. 16.7 ± 7.8 mmol/L for CVVH, p < 0.0001) and mean creatinine levels (302 ± 167 vs. 211 ± 103 µmol/L, p < 0.0001) were better controlled in the CVVH group. Conclusions: CRRT strategies based on different techniques might have a significantly different impact on azotemic control.     

Early Classic Hemofiltration Exhibits No Benefits in Severe Acute Pancreatitis With Early Organ Failure: A Retrospective Case‐Matched Study

Continuous venovenous hemofiltration (CVVH) is an important organ supportive technique. This study aimed to evaluate the impact of early classic CVVH on the outcomes of severe acute pancreatitis (SAP) patients with early organ failure (EOF). Between 2008 and 2012, a total of 44 SAP patients with EOF were admitted to our department. The 44 patients were classified into two groups according to whether they received early classic CVVH (2 L/h, initiated within 24 h after admission): 25 patients received early CVVH (ECVVH group), and 19 patients did not receive early CVVH (control group). The two groups were matched for age and Acute Physiology and Chronic Health Evaluation II scores. The severity of organ dysfunctions was evaluated by Sequential Organ Failure Assessment (SOFA) scores. Each group included 19 patients. The baseline characters between the two groups were balanced. The SOFA scores in the ECVVH group increased compared with those in the control group. The time to weaning from mechanical ventilation was significantly longer in the ECVVH group (log‐rank test: χ² = 4.007, P = 0.045). Renal support was also significantly prolonged in the ECVVH group (the number of patients receiving CVVH 72 h after admission: 10 vs. 3, respectively, P = 0.038). Nine patients died in the ECVVH group versus six patients in the control group (P = 0.508). In conclusion, our study failed to prove that early classic CVVH had any benefits on the outcomes of SAP patients with EOF. Unexpectedly, early classic CVVH worsened organ functional capacity. However, it is possible that CVVH using advanced techniques may be beneficial in SAP patients with EOF.     

连续性床旁血液滤过对毛细血管渗漏综合征患者全身氧代谢的影响

目的探讨连续性床旁血液滤过（CRRT）对毛细血管渗漏综合征（CLS）患者全身氧代谢的影响。方法观察CLS患者连续性床旁血液滤过治疗前,治疗后6、12、24、48、72h氧分压（PaO2）、中心静脉血氧饱和度（ScvO2）、血乳酸（LAC）、氧输送（DO2）、氧耗量（VO2）及氧摄取率（02ER）的变化,并进行统计学处理,评价CRRT对CLS患者全身氧代谢的影响。结果CLS患者经CRRT治疗6h后PaO2、ScvO2、DO2升高（P〈0．05）,LAC明显下降（P〈0．05）;VO2在12h后升高（P〈0．05）,02ER在治疗24h后升高（P〈0．05）。结论CLS患者全身组织器官氧代谢差,CRRT治疗能改善CLS患者的全身氧代谢,改善组织器官的功能。