自动压力控制模式在血液透析滤过中的临床应用

目的探讨自动压力控制模式在血液透析滤过中的应用效果。方法入选70例维持性血液透析患者,每2周行血液透析滤过1次,后稀释法输注置换液,给予传统容量控制补液模式6次和自动压力控制补液模式6次,自身交叉对照,观察不同模式下的置换液量、Duo瘙痒评分、高压报警次数及凝血情况。结果自动压力控制模式置换液量比传统容量控制模式显著增加(16.1±1.8L比13.5±1.4L,t=14.49,P0.001);Duo瘙痒评分明显降低(12.3±1.0比16.1±2.2,t=-13.57,P0.001);高压报警发生率显著降低(0比15.47%,P0.001);透析器及管路凝血发生率显著下降(0比2.6%,P0.001)。结论自动压力控制模式的血液透析滤过可增加置换液量,降低凝血风险,改善患者瘙痒症状。     

自动压力控制补液模式血液透析滤过对中分子物质清除效果的临床研究

目的探讨自动压力控制模式血液透析滤过(hemodiafiltration with automated pressure control of convection mode,ULTRAc-HDF)对尿毒症患者血β_2-微球蛋白(β_2-Microglobulin,β_2-MG)、甲状旁腺激素(parathyroid hormone,PTH)等中分子毒素的清除效果。方法选择30例病情稳定的维持性血液透析患者,后稀释法输注置换液,分别给予自动压力控制补液模式血液透析滤过(ULTRAc-HDF)和容量控制补液模式血液透析滤过(volume-controlled mode,VOLc-HDF)治疗,自身交叉对照,观察不同模式下置换液量、跨膜压报警次数、凝血情况等,并比较2种模式HDF对β_2-MG、PTH等中分子物质的清除效果。结果 ULTRAc-HDF比VOLc-HDF时置换液量显著增加[(20.78±1.41)L比(18.30±0.27)L,t=9.417,P=0.000];跨膜压高压报警次数显著降低(0比16例次),高压报警发生人次的比较(χ~2=9.231,P=0.002),差异有统计学意义;透析器及管路凝血分级显著下降,透析器及管路发生凝血人次比较(χ~2=7.680,P=0.006),差异有统计学意义;ULTRAc-HDF组血PTH下降率为(57.40±4.19)%,VOLc-HDF组血PTH下降率为(51.23±6.54)%,两者对比差异有统计学意义(t=4.352,P=0.000)。ULTRAc-HDF组血β_2-MG下降率为(72.51±2.82)%,VOLc-HDF组血β_2-MG下降率为(70.81±2.93)%,两者对比差异无统计学意义(t=2.289,P=0.062),但从趋势上来分析,ULTRAc-HDF组血β_2-MG下降率较高。结论自动压力控制补液模式HDF治疗能增加置换液量,更好的清除β_2-MG、PTH等中分子物质,且可减少跨膜压高压报警次数,降低凝血风险。     

内毒素过滤器的特性及临床应用

正从Babb和Scribner在1971年提出"中分子"假说,Henderson提出血液滤过(hemofiltration,HF)的概念至今,已经有40多年了~([1-3])。随着技术的不断发展,血液透析滤过(hemodiafiltraion,HDF)的模式也从最初的经典HDF——使用非在线制备的置换液,平均置换液量为9L/每次治疗,后稀释模式——发展到现在的在线血液透析滤过(On-line Hemodiafiltration,On-line HDF)、配对透析滤过(Paired Filtration Dialysis,PFD)以及推拉式血     

连续性血液透析滤过在MODS患者治疗中的临床疗效

目的观察连续性血液透析滤过在治疗MODS患者的临床疗效.及其容量平衡的情况。方法中南大学湘雅二医院20例MODS患者行床旁CBP治疗,采用Aquarius机器、AV600s透析膜行床旁连续性静脉-静脉血液透析滤过(CVVHDF)治疗,置换液流量2～4L/h,透析液流量4～6L/h,治疗时间6～10h/天,观察治疗前、后患者血清尿素氮(BUN)、肌酐(SCr)、尿酸(UA)及血清电解质钾、钠、氯、钙、磷及二氧化碳结合力的变化,比较设定治疗剂量与实际治疗剂量,设定净超滤量与实际净超滤量的差值。结果20例患者均很好地耐受治疗。治疗后BUN、SCr及Ua下降率分别为(42±13)%、(36±9)%及(52±11)%,血清钾、钠、氯、钙及二氧化碳水平无显著变化,血磷水平明显下降(P<0.01)。设定治疗量为(47.2±8.1)L,而实际治疗量为(45.8±6.7)L,误差率为2.9%(中位数,95%范围0.3%～8.3%)。设定净超滤量为(3112±1002)ml,实际净超滤量为(2921±927)ml,误差率为6.8%(中位数,95%范围2.9%～9.9%)。总的容量误差率为0.51%(中位数,95%范围0.21%～0.96%)。结论连续性血液透析滤过能有效用于MODS患者的救治,毒素清除能力强,能保持水、电解质及酸碱平衡,很好地保持容量平衡。     

2种不同稀释方式在连续性静脉-静脉血液透析滤过治疗中应用效果分析

目的比较2种不同稀释方式在无抗凝剂连续性静脉-静脉血液透析滤过治疗模式下的应用疗效。方法采用前瞻性自身前后对照的研究设计,选择2017年1～12月在四川大学华西医院使用Prismaflex V8.0机器进行连续性静脉-静脉血液透析滤过治疗的20例患者,随机进行前后稀释或后稀释治疗,再进行后稀释与前后稀释治疗。比较前后2组的体外循环寿命。结果治疗过程中患者的凝血功能指标变化无统计学差异(t=0.654,P=0.521),2组模式下平均每小时因静脉压力、动脉压力报警导致血泵暂停的次数无统计学差异(t值分别为0.539,0.705;P值分别为0.232,0.415);后稀释治疗模式下体外循环管路使用寿命平均为(28.80±16.85)h,短于前后稀释治疗模式下体外循环管路使用寿命(40.25±20.32)h,2者比较差异具有统计学意义(t=3.712,P=0.001);2组治疗方式的肌酐、尿素清除效率差异均无统计学意义(t值分别为-0.669,0.030;P值分别为0.512,0.977)。结论前后稀释治疗模式与后稀释治疗模式比较,疗效相当,但前后稀释可以延长体外循环管路及滤器使用寿命,在临床实践中更具有临床意义和价值。     

血液透析滤过对无肝素抗凝法治疗时的防凝效果

<正>在工作中,我们发现血液透析滤过在治疗需要无肝素抗凝或小剂量肝素抗凝的患者时,通过前稀释置换法和后稀释置换法交替进行能达到比较满意的效果。现报告如下。方法:在患者有活动性出血或外科手术前后需要进行血液净化治疗时应优先选择血液透析滤过治疗方式。保证充足的血流量达到300 ml/min。治疗开始2 h内选择后稀释置换法,先进行高效清除毒素。随着患者体内的水分被排出,血液被浓缩,在后稀释治疗2 h后选择前稀释治疗1 h,增加置换液     

REXEED^TM15UC透析器在线血液透析滤过中白蛋白丢失的实验研究

目的评价REXEEDTM-15UC透析器在在线血液透析滤过（on-line HDF）过程中白蛋白丢失特性。方法建立等容on-line HDF体外循环装置,采用新鲜牛血3～4L,Hct为（31±2）%。使用REXEEDTM-15UC透析器,并以HF-80S高通量透析器为对照;Qb=350mL/min,Qd=800ml/min,按置换液输入模式分为后稀释组（Quf=40ml/min,60ml/min）和前稀释组（Quf=80ml/min,120mL/min）每组重复3次,每次240min。实验开始后0、1、2、4、6、8、10、20、30、40、50、60、120、180、240min,采集透析滤过废液5ml,用酶联免疫法测定白蛋白浓度,根据曲线下面积计算每次HDF过程中丢失白蛋白总量。结果REXEED-15UC和HF-80S透析器在4h前稀释和后稀释on-line HDF过程中,白蛋白丢失量均小于1.0g（0.261g～0.963g）。在后稀释模式不同置换液剂量（Qf=40ml/min和60mlS/min）时,白蛋白丢失量分别为：（0.261±0.189）g和（0.496±0.338）g（P〉0.05）,（0.300±0.030）g和（0.488±0.264）g（P〉0.05）。在前稀释模式不同置换液剂量（Qf=80ml/min和120ml/min）时,白蛋白丢失量分别为：（0.788±0.406）g和（0.469±0.325）g（P〉0.05）,（0.614±0.284）g和（0.963±0.701）g（P〉0.05）。各组白蛋白丢失峰值出现在HDF开始时至开始后10min。结论REXEEDTM 15UC在on-line HDF过程中,白蛋白丢失量小,在临床可接受范围内。     

改良式追加预冲在双重血浆置换病人中的运用

[目的]探讨双重血浆置换病人在传统机器全自动预冲基础上采用改良式追加预冲方法的应用效果。[方法]选择2018年1月-2018年12月在我院行双重血浆置换28例病人,共行双重血浆置换71例次,排除最后一次治疗,组成70例次双重血浆置换病例资料。根据病人双重血浆置换顺序排列单号、双号分为两组,每组35例次,单号为对照组(行传统预冲方法),双号为观察组(行传统预冲基础上追加预冲方法)。比较两组预冲方法后双重血浆置换血浆滤过器残余气泡、滤过器及管路凝血情况、病人变态反应的发生、二级滤过器跨膜压(TMP)检测以及静脉双腔留置导管口渗血情况。[结果]两组病人血浆滤过器的残余气泡、滤过器及管路凝血情况、病人变态反应的发生、二级滤过器TMP压力,比较差异有统计学意义(P<0.05);两组静脉双腔留置导管口渗血情况差异无统计学意义(P>0.05)。[结论]改良式追加预冲方法在双重血浆置换治疗中安全、简单、易操作、效果好。     

两种在线预冲方法对血液透析滤过凝血的影响

目的探讨两种在线预冲方法对血液透析滤过凝血的影响。方法对既往行血液透析滤过治疗发生凝血的20例患者分别采用传统法和改良法两种在线预冲方法各治疗200例次,比较治疗中各治疗参数和压力指标以及治疗后滤器凝血情况。结果改良法凝血等级低于传统法(P0.01);改良法置换液总量多于传统法(P0.01),跨膜压和静脉压值低于传统法(P0.01)。结论在不增加抗凝剂用量的情况下,改良法可充分湿化滤器;肝素钠在预冲中适量合理使用,可以保证治疗安全,并减少凝血发生。     

高渗性昏迷的治疗与护理研究进展

对高渗性昏迷传统静脉补液、胃管补液、血糖控制过程中液体种类的选择、补液量的估计及输液速度的调控、胃管补液量及注入方式、胰岛素的应用时机及用量限制、血糖下降速度的控制等方面进行综述,并对近年出现的血液透析、血液滤过、结肠补液治疗及护理方法进行分析与展望。     

低钙血液透析滤过治疗血液透析患者顽固性高血压病的疗效分析

目的：观察低钙血液透析滤过对慢性肾衰竭维持性血液透析患者顽固性高血压病的疗效。方法选择62例维持性血液透析伴顽固性高血压病患者,随机分为对照组、血液透析滤过组、低钙血液透析滤过组。在相同治疗方案的基础上,对照组行常规血液透析治疗,血液透析滤过组改行血液透析滤过治疗,低钙血液透析滤过组除改血液透析滤过外,换用1.25 mmol／L 低钙透析液,疗程为12周。结果治疗12周后,血液透析滤过组和低钙血液透析滤过组的血压、β2微球蛋白、血浆肾素、血管紧张素均比治疗前明显下降（P 均＜0.05）,低钙血液透析滤过组血压下降更为明显（P 均＜0.05）。血液透析滤过组和低钙血液透析滤过组头晕、头痛及胸闷、气促发生率均低于对照组（P 均＜0.05）。结论血液透析滤过能有效治疗维持性血液透析患者顽固性高血压病,加用低钙透析液效果更佳。     

Resuscitation aspects of ultrafiltration and haemodialysis

Results of using the method of sequential ultrafiltration with hemodialysis and that of hemodiafiltration in the treatment of 70 patients with acute and chronic renal failure in terminal states are described. The patients were under observation in the course of 202 procedures of hemodiafiltration and 175 sequential ultrafiltration with hemodialysis. Apart from this, 21 procedures of isolated ultrafiltration were carried out in patients with pronounced cardiac failure, irreversible pulmonary edema resulting from acute myocardial infarction and heart diseases. Sequential ultrafiltration and hemodialysis were performed by means of home-produced equipment SGD using Cuprofan dialysis film and capillary dialyzators. The volume of ultrafiltration ranged from 1 to 8 litres/procedure at a rate of 17-500 ml/min, at a transmembrane pressure 100-400 mmHg. It was found that sequential ultrafiltration with hemodialysis was indicated for patients in terminal states complicated by renal failure in the presence of severe fluid retention, pulmonary edema, patients with low tolerance to hemodiafiltration, and those in critical states (including irreversible pulmonary edema) of cardiological genesis.     

联机血液透析滤过抢救急性脑血管病并发高渗性非酮症糖尿病昏迷

目的 评估联机血液透析滤过抢救ACVD并发HNDc的疗效及安全性.方法 前瞻性选取荆门市第一人民医院2006年1月至2007年6月收治的11例ACVD并发HNDc患者,行治疗前后的对照研究.确诊后1 h行联机血液透析滤过抢救,时间为90 min,采用德国Fressnius 4008S型的双泵血透机,F60的血滤器和管道,血流量150～180 ml/min,置换液后稀释方式输入50～60ml/min,碳酸氢盐透析液流量500 ml/min,在治疗前1 h及治疗后6 h取血测定血钠、血钾、血糖、血尿素氮和血浆渗透压;评估治疗中有无脑水肿或心功能不全加重;观察治疗后24 h的神志改变及不良反应.结果 所有患者在治疗中无脑水肿及心功能不全的加重;治疗后6 h血糖、血钠、血尿素氮及血浆渗透压均有明显下降,与治疗前比较差异具有统计学意义(P<0.01);8例患者于治疗后24 h意识障碍明显好转,3例死亡,抢救成功率为73%.结论 联机血液透析滤过抢救ACVD并发HNDC的患者,效果显著,并发症少,安全性高,可缩短病程,降低病死率,是抢救此类患者的有效方法.     

Usefulness of plasma exchange plus continuous hemodiafiltration to reduce adverse effects associated with plasma exchange in patients with acute liver failure.

OBJECTIVE: To efficiently remove middle-molecular-weight substances such as hepatic toxins and minimize adverse effects associated with plasma exchange implementation, we have performed plasma exchange slowly in combination with continuous hemodiafiltration. This study was designed to determine the usefulness of plasma exchange with continuous hemodiafiltration in reducing the adverse effects associated with implementation of plasma exchange alone. DESIGN: A retrospective clinical study. SETTING: University teaching hospital. PATIENTS: The study involved 90 patients with liver failure who had been treated with plasma exchange in our department over the past 12 yrs. We examined these patients by dividing them into two groups (48 patients treated with plasma exchange alone and 42 patients treated with plasma exchange plus continuous hemodiafiltration at the time of plasma exchange implementation). MEASUREMENTS AND MAIN RESULTS: Baseline blood Na+ concentration, HCO3- concentration, and colloid osmotic pressure were followed after implementation of plasma exchange to compare the frequency of development of three adverse effects (hypernatremia, metabolic alkalosis, and sharp decrease in colloid osmotic pressure) in the two groups. Hypernatremia was found in 26.7% of treatments in the group with plasma exchange alone and 3.3% in the group of plasma exchange plus continuous hemodiafiltration, and metabolic alkalosis was found in 30.6% of treatments in the group with plasma exchange alone and 4.9% in the group of plasma exchange plus continuous hemodiafiltration; both percentages were significantly higher in the group with plasma exchange alone (p <.001). A sharp decrease in colloid osmotic pressure occurred in 13.3% of treatments in the group with plasma exchange alone but was not observed at all in the patients treated with plasma exchange plus continuous hemodiafiltration. CONCLUSIONS: We conclude that adverse effects associated with plasma exchange for artificial liver support for liver failure can be alleviated with use of plasma exchange plus continuous hemodiafiltration instead of plasma exchange alone.     

连续性静脉-静脉血液滤过在主动脉夹层术后急性肾衰竭中的应用

目的 探讨连续性静脉-静脉血液滤过(CVVH)在主动脉夹层术后急性肾衰竭(ARF)中应用的临床意义.方法 15例术后ARF患者,采用CVVH治疗,比较治疗前后血电解质、尿素氮、肌酐等相关指标的变化,以及全身水肿情况.结果 11例存活,4例死亡.存活患者血液滤过后尿素氮[(37.2±12.1)mmol/L与(22.1±6.8)mmol/L]和血肌酐[(351.4±160.9)μmol/L与(185.7±97.6)μmol/L]均逐渐下降直至恢复正常,尿量分别于滤过后6～40 d恢复正常,肾功能恢复时间为8～60 d.所有患者血液滤过后水肿得到明显改善.结论 CVVH是治疗主动脉夹层术后ARF的一种有效、方便而安全的方法.     

Ways of intensification of hemodialysis therapy

Three methods of intensive hemodialysis were compared: routine hemodialysis (HD) (12 h/m2/week), HD on a highly permeable membrane with ultrafiltration (ordinary in volume and increased up to 10.5 l), and hemodiafiltration with the replacement of 16.4 l. Clearance, pre- and postdialysis concentration in the plasma of urea, creatinine, phosphate and average molecular mass substances were analyzed during investigation; dynamometry was used at the beginning and end of investigation to assess right forearm muscle strength. Better results were obtained with hemodiafiltration. The successive use of three methods of hemodialysis resulted in the patients' improved somatic state and a significant increase in muscle strength. In the authors' opinion, the use of hemodiafiltration would facilitate rehabilitation and reduce a period of preparation of uremic patients for kidney transplantation.     

Venous return in hemorrhagic shock after application of Military Anti-Shock Trousers

The effect of Military Anti-Shock Trousers (MAST) on inferior vena cava blood flow was studied during graded hypovolemia using a pump reservoir system and an in-line electromagnetic flowprobe. During hemorrhagic shock MAST inflation increased cardiac output 25.4% (Control: 0.92 ± 0.09 l/min) and arterial pressure 50% (Control: 60 ± 2 mmHg). The socalled “autotransfusion” effect due to blood displacement from the lower part of the body into the central circulation was found to be only 4.3 ± 0.6 ml/kg, a volume much less than previously estimated in the literature. We conclude that MAST inflation reliably improves cardiac output and systemic blood pressure above the diaphragm in dogs subjected to hemorrhagic shock. This effect is mainly due to a diversion of the cardiac output to the upper half of the body due to impedance of flow to the abdomen and lower extremities, rather than to a significant volume shift constituting an autotransfusion of blood from the lower part of the body.     

间断血液透析滤过对尿毒症患者血管内皮细胞功能的影响

目的 探讨血液透析间断联合血液透析滤过对终末期肾病(end stage renal disease,ESRD)患者血管内皮功能及预后的影响.方法 ESRD患者按标准入选60例,随机分为血液透析组(HD组,n=30)和血液透析联合血液透析滤过组(HD/HDF组,n=30).选择10例健康人作为正常对照.彩色超声检测肱动脉血管舒张功能;并检测血清C反应蛋白(C-reactive protein,CRP)、肿瘤坏死因子(tumor necrosis factor α,TNFα)α、可溶性细胞间黏附分子-1(soluble intercellular adhesion molecule-1,sICAM)变化.同时观察2年内患者心脑血管疾病及病死率发生情况.结果 ①2组患者内皮依赖性舒张功能(endothelium dependent dilation,EDD)、非内皮依赖性舒张功能(endothelium independent dilation,EID)、反应性充血血流量及含服用硝酸甘油后血流量低于正常对照组者,血清CRP、TNFα、sICAM-l水平高于正常对照组,差异有统计学意义(均 P＜0.05);2组患者间治疗前上述各项指标差异均无统计学意义(均 P＞0.05).②2组患者随治疗时间的延长,EDD、EID、反应性充血血流量、含服硝酸甘油后血流量均逐渐降低,差异有统计学意义(均 P＜0.05),但HD/HDF组治疗后与HD组相同时间点比较,EDD、EID、反应性充血血流量、含服硝酸甘油血流量均高,sICAM-1 低,差异有统计学意义(均P＜0.05).③ HD组心脑血管疾病发生率高于HD/HDF组,差异有统计学意义(χ 2=6.239,P=0.012),HD与HD/HDF2组病死率分别为16.7%、3.3%,差异无统计学意义(χ 2= 3.208,P=0.073).结论 ESRD患者血管内皮功能紊乱;间断血液透析滤过能改善血管内皮功能,对减少ESRD患者心脑血管疾病的发生可能有一定的作用.     

On-line hemodiafiltration in critical care.

On-line products of substitution fluid permits virtually unlimited fluid volume exchange during continuous hemodiafiltration (CHDF) to critical care. In on-line hemodiafiltration (HDF), endotoxin free dialysate obtained using pyrogen cut filters is infused into the blood circuit, and HDF is automatically performed using the closed-loop balancing system of the dialysis machine. On-line CHDF is the application of this on-line HDF to continuous renal replacement therapy in the critical care field. We performed on-line CHDF on 376 acute renal failure patients during a 5 year period, and the mean survival rate was 62.5%. We concluded that the on-line CHDF system is safe and effective at maintaining acute renal failure patients.     

Pharmacokinetic simulation of different modes of renal replacement therapy

Based on the results of examination of patients with severe acute renal failure and multiorgan insufficiency, the authors give a comparative analysis of different modes of renal replacement therapy, such as intermittent hemofiltration, continuous arteriovenous hemofiltration, and continuous venovenous hemodiafiltration. Kinetic simulation in terms of urea and creatinine, by employing a one- and two-pool model for the disposition of these substances in the patient's body was taken as a basic method. The analysis led to the conclusion that continuous hemodiafiltration (CHDF) with an actually large volume of filtration and dialysis was the optimum technique for correcting uremic impairments of homeostasis in critically ill patients. CHDF failed to induce a significant metabolic stress and to noticeably affect the rate of urea and creatinine generation. Overall, all the filtration treatments are an effective means of eliminating low-molecular-weight nitrogenous metabolites that are characterized by the high rate of generation and the large volume of disposition in the organism. It is necessary only to correctly select a dose of renal therapy.