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.     

血浆置换联合血液透析滤过治疗肝衰竭的临床应用

目的观察血浆置换（PE）联合血液透析滤过（HDF）治疗肝衰竭的临床效果和预后。方法48例肝功能衰竭患者行PE＋HDF治疗182例次，采用间歇治疗模式，间隔1-3天，每次历时3-4h。结果PE＋HDF治疗后意识障碍好转，黄疸、乏力、恶心、呕吐、腹胀等症状明显缓解，食欲增加，尿量增多，短期存活率（30d）为72．9％（35／48例）；血压、血氧饱和度、白蛋白、白细胞、红细胞和血小板无显著变化（P〉0．05）；总胆红素、直接胆红素、总胆汁酸、血氨分别较治疗前下降28．8％、29．8％、44．8％、28．4％（尸值均〈0．01）；单次治疗后凝血酶原时间由治疗前的（23．70±0．56）秒缩短为（16．60±0．67）秒（P〈0．01），临床出血倾向明显减轻。4例急性肝衰竭患者（8．3％）治疗痊愈出院，10例（20．8％）成功过渡至肝移植，21例（43．8％）治疗后15-30天好转，13例（27．1％）在治疗2414天内死亡，死亡原因为多脏器功能衰竭和内脏出血。结论PE＋HDF治疗有助于抢救急、慢性肝衰竭患者，安全性好，近期疗效显著，可作为肝移植前的过渡手段。     

Cytokine removal by plasma exchange with continuous hemodiafiltration in critically ill patients.

The effectiveness of plasma exchange (PE) with continuous hemodiafiltration (CHDF) in the treatment of critically ill patients was evaluated based on changes in cytokine levels. Twenty-six patients with acute hepatic failure were treated with PE (PE group) or PE and CHDF (PE+CHDF group), and the levels of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8 were determined before and after treatment. Bilirubin levels were significantly lower after treatment in both the PE and PE+CHDF groups. There were no significant differences in TNF-alpha levels before and after treatment in the PE group, but the TNF-alpha level was significantly lower after treatment in the PE+CHDF group. There were no significant differences in the IL-6 levels before and after treatment in both the PE and PE+CHDF groups. There were no significant differences in IL-8 levels before and after treatment in the PE group, but the IL-8 level was significantly lower after treatment in the PE+CHDF group. PE with CHDF therapy was given to 5 patients with acutely aggravated autoimmune diseases, 2 patients with hemorrhagic shock and encephalopathy syndrome, and 3 patients with thrombotic microangiopathy. The results suggested that PE with CHDF therapy are useful in critically ill patients with suspected hypercytokinemia.     

血浆置换联合连续性肾脏替代疗法在重症急性胰腺炎患者中的应用研究

目的探讨早期血浆置换联合连续性肾脏替代疗法（CRRT）在重症急性胰腺炎（SAP）患者中的应用效果。 方法选取2016年3月至2018年9月青岛大学附属医院ICU和急诊ICU收治的135例SAP患者,按住院号末位的奇偶数将其分为常规组（69例）和血浆置换组（66例）,常规组入科后立即行CRRT治疗72 h,血浆置换组入科后立即行血浆置换联合CRRT治疗72 h。比较两组患者的治疗效果、住院时间、血清学相关指标、并发症发生率及平均滤器寿命。 结果血浆置换组患者治疗有效率明显优于常规组[87.88%（58/66）vs. 65.22%（45/69）,χ² = 9.579,P = 0.002]。血浆置换组患者住院时间明显短于常规组[（11.4 ± 1.5）d vs.（21.3 ± 2.8）d,t = 2.979,P = 0.004]。治疗后,血浆置换组患者血清学相关指标血清淀粉酶[（103 ± 24）U/L vs.（267 ± 60）U/L,t = 2.419,P = 0.021]、C反应蛋白[（51 ± 8）mg/L vs.（129 ± 19）mg/L,t = 4.574,P< 0.001]、白细胞计数水平[（8.9 ± 0.5）× 10⁹/L vs.（11.5 ± 1.0）× 10⁹/L,t = 2.059,P = 0.046],以及并发症急性呼吸窘迫综合征[6.06%（4/66）vs. 34.78%（24/69）,χ² = 16.930,P<0.001]、多器官功能障碍综合征[7.58%（5/66）vs. 30.43%（21/69）,χ² = 11.340,P<0.001]和胰性脑病的发生率[9.09%（6/66）vs. 39.13%（27/69）,χ² = 16.480,P = 0.002]均明显低于常规组。同时,血浆置换组平均滤器寿命明显长于常规组[（24.7 ± 2.3）h vs.（12.1 ± 1.4）h,t = 4.829,P<0.001]。 结论血浆置换联合CRRT治疗SAP患者疗效显著,能够明显改善患者的临床症状及血清学相关指标,减少并发症的发生率,延长滤器寿命,提高体外循环治疗质量,值得临床推广应用。     

缓慢性血浆置换同步并联血液滤过治疗慢性重型肝炎的观察及护理

目的总结缓慢性血浆置换同步并联血液滤过治疗慢性重型肝炎的观察及护理。方法 2007年1月至2008年8月26例慢性乙型重型肝炎作为观察组,2005年1月至2006年8月29例慢性重型乙型肝炎为对照组。两组均在内科治疗的基础上采用血浆置换和血液滤过进行血液净化,观察组实施同步并联治疗,对照组行序贯治疗,评价两组治疗效果。结果两组肝功能指标组内治疗前后比较多数有统计学意义;两组治疗后肝功能指标及治疗效果比较,差异无统计学意义,但观察组每次治疗时间较对照组短。结论缓慢性血浆置换同步并联血液滤过治疗慢性重型肝炎疗效确切,但必须加强护理工作。     

血浆置换联合连续性血液净化治疗妊娠合并高脂血症性急性重症胰腺炎

目的探讨血浆置换联合连续性血液净化治疗妊娠合并高脂血症性急性重症胰腺炎的疗效。方法回顾29例妊娠合并高脂血症性急性重症胰腺炎患者资料,按收治时间分组:对照组(n=11)行传统的胰腺炎治疗,治疗组(n=18)在传统治疗同时行血浆置换联合连续性血液净化治疗,观察两组患者治疗前后48h急性生理和慢性健康评价指标Ⅱ(APACHEⅡ)评分、禁食天数、住院天数、治疗前后血清甘油三酯、总胆固醇水平。结果治疗组治疗48h后APACHEⅡ评分明显低于对照组,禁食天数及住院天数明显少于对照组,差异均有统计学意义(t分别=3.61、4.58、3.95,P均<0.05);治疗组甘油三酯及总胆固醇水平治疗6d后均明显低于对照组,差异均有统计学意义(t分别=3.16、4.16,P均<0.05);两组治疗后血清甘油三酯、总胆固醇水平较治疗前均降低,差异均有统计学意义(t分别=5.12、6.02、3.12、3.02,P均<0.05);治疗组无产妇死亡;对照组1例产妇死亡,死于感染并发多脏器功能衰竭。结论血浆置换联合连续性血液净化可以迅速降低甘油三酯及总胆固醇,是治疗妊娠并高脂血症性急性重症胰腺炎安全而有效的方法之一。     

血浆置换联合连续性血液净化治疗肝衰竭疗效观察

目的:探讨人工肝辅助装置血浆置换(PE)联合连续性静-静脉血液滤过(CVVH)治疗重型肝炎肝衰竭的疗效、安全性及可行性。方法:对25例重型肝炎肝衰竭患者应用上述人工肝方法进行治疗70次,通过比较治疗前后患者临床症状、肝功能、凝血酶原活动度(PTA)、血氨、胆碱酯酶等指标判断临床疗效,观察治疗相关的不良反应及患者耐受情况,判断安全性及可行性。结果:患者意识模糊、黄疸、乏力、腹胀、纳差等症状均明显缓解,血清总胆红素治疗后较治疗前降低,PTA上升,治疗后近期有效率达72%,不良反应主要以血浆过敏居多,未发生大出血、休克等严重并发症,患者耐受良好。结论:在内科综合治疗的基础上PE联合CVVH可显著改善重型肝炎肝衰竭患者临床症状及生化指标,提高近期存活率,且安全可行,值得在国内推广应用。     

血浆置换联合血液滤过治疗急性肝衰竭16例效果观察

目的:探讨血浆置换(PE)联合血液滤过(HF)治疗各种原因引起的急性肝衰竭危重患者的效果。方法:将31例患者随机分为PE组15例与PE+HF组16例。观察并比较两组患者并发症情况、住院天数。结果:PE+HF组患者并发症发生率明显低于PE组(P<0.05),住院天数明显少于PE组(P<0.05)。结论:对于急性肝衰竭的危重患者,在其未并发肾衰竭前在行PE的基础上早期联合HF治疗可缩短其住院天数,减少并发症。     

持续缓慢血浆置换加血液透析滤过治疗重型肝炎临床研究

目的探讨持续缓慢血浆置换加血液透析滤过治疗重型肝炎患者的临床疗效及安全性。方法选择解放军302医院重型肝炎患者,治疗组41例(其中慢性乙型肝炎重型34例),单纯对照组37例(其中慢性乙型肝炎重型32例)。2组患者均有不同程度的并发症,均在内科治疗的基础上加用日本KURARAY公司产的KM-8900型人工肝治疗仪进行人工肝治疗。结果治疗组患者治愈好转率51.22%,高于对照组(32.43%),差异有统计学意义(P<0.05);治疗组能很好的纠正电解质紊乱,清除尿素氮(BUN)、肌酐(Scr)、血氨,而对照组则不能(P<0.01);治疗组治疗用血浆量及废弃血浆量均明显少于对照组(P<0.01);治疗组患者治疗结束时总胆红素下降幅度高于对照组(P>0.05),但治疗组在治疗48h后总胆红素“反弹”幅度小于对照组(P<0.05);结论持续缓慢血浆置换加血液透析滤过治疗重型肝炎可有效改善患者临床症状及生化指标,延缓治疗后胆红素“反弹”,提高治愈好转率,且安全可行,操作简单,值得在国内推广应用。     

双重血浆分子吸附联合血浆置换治疗慢加急性肝衰竭的疗效分析

目的 观察双重血浆分子吸附系统（DPMAS）联合血浆置换（PE）治疗慢加急性肝衰竭（ACLF）的疗效及安全性。方法 回顾性分析2016年1月至2018年12月我科收治并行人工肝治疗的乙型肝炎ACLF患者69例,其中DPMAS联合PE组32例,单纯PE组37例。观察两组治疗前后血清生化指标、凝血指标和血小板（PLT）的变化,观察疗效及不良反应。结果 两组4周总有效率和12周生存率差异无统计学意义。两组治疗后总胆红素（TBil）、白蛋白（ALB）、总胆汁酸（TBA）差异有统计学意义。两组治疗后与治疗前比较,肝功能及凝血功能均明显好转,差异有统计学意义;联合组PLT治疗前后差异有统计学意义。两组不良反应发生率差异无统计学意义（P＞0.05）。结论 DPMAS联合PE治疗ACLF疗效确切,能减少血浆用量,安全性较高。     

Clearance of imipenem/cilastatin in acute renal failure patients treated by continuous hemodiafiltration (CAVHD)

In patients with acute renal failure, who were treated with continuous arteriovenous hemofiltration (CAVH) or continuous arteriovenous hemodiafiltration (CAVHD), we measured clearance rates of imipenem and cilastatin (Tiënam-500^®). Literature data on volume of distribution and on the endogenous clearance in normals and in anuric patients and the observed clearance rates by CAVH/CAVHD were used to develop guidelines for dose adaptations. Based on the desired peak levels of imipenem, normal subjects should receive the fixed imipenem/cilastatin dose combination (500 mg/500 mg) q.i.d. and patients with acute renal failure should receive the same dose b.i.d. After starting treatment with either CAVH, CAVHD or continuous venovenous hemofiltration (CVVH), no further dose adjustment is necessary. The non-renal clearance rate of cilastatin is very low compared to that of imipenem. If a patient develops anuria, the clearance rate of imipenem decreases from the normal value of 245 ml/min to 116 ml/min. Clearance rate of cilastatin, however, decreases from 230 ml/min to 3 ml/min. Therefore, in patients with renal failure accumulation of cilastatin will occur. On the other hand, if the patient is treated by CAVHD, the relative contribution of the dialyser clearance to the total drug clearance is much greater for cilastatin than for imipenem. As a result, the accumulation of cilastatin is reversed. During treatment by CAVHD, the clearance rate of imipenem raises 15%–25% and that of cilastatin 335%–600%. For this reason, we conclude that the use of the fixed dose combination (500 mg/500 mg) b.i.d. in patients with acute renal failure treated by CAVHD may be justified.     

A prospective study of continuous venovenous hemodiafiltration in critically ill patients with acute renal failure

We studied the biochemical and the clinical consequences of the application of continuous venovenous hemodiafiltration to the management of acute renal failure in critically ill patients. One hundred consecutive surgical and medical ICU patients with acute renal failure were entered into a prospective clinical study at an intensive care unit of tertiary institution. INTERVENTION: included assessment of illness severity by APACHE II score on admission and by organ failure score prior to initiation of renal replacement therapy; treatment of patients with continuous venovenous hemodiafiltration; and measurement of biochemical variables prior to and after therapy. Outcome assessment included incidence of complications, duration of oliguria, duration of intensive care and hospital stays, and survival to hospital discharge. MEASUREMENTS AND MAIN RESULTS: included the following: mean patient age was 60.9 years (range 21-81 yr); mean APACHE II score, 28.6 (95% confidence interval; 27.4-29.8); and number of failing organs, mean, 4.1 (95% confidence interval; 3.8-4.4). At commencement of continuous venovenous hemofiltration with dialysis, 79% of patients were receiving inotropic drugs and 72% were septic, and, in 35%, bacteremia or fungemia was demonstrated. Renal replacement therapy was applied for a mean duration of 186.2 hours (95% confidence interval; 149.2-223.7), with a mean hourly net ultrafiltrate production of 621 mL (95% confidence interval; 594-648) and a mean urea clearance of 28.1 mL/min (95% confidence interval; 26.7-29.5). Azotemia was controlled in all patients (plasma urea < 30 mmol/L). During the more than 18,000 hours of treatment, there was no therapy-associated hemodynamic instability. Complications were rare. They included two cases of hemofilter rupture with minor blood loss and a single case of bleeding at the site of the vascular-access catheter. Forty-three patients survived to ICU discharge, and 40 survived to hospital discharge. Continuous venovenous hemodiafiltration is a safe and an effective form of renal replacement therapy in critically ill patients. In such patients, who have a high predicted mortality rate, it was associated with a 40% survival rate. These findings suggests that continuous venovenous hemodiafiltration may be ideally suited to patients with multisystem organ failure with acute renal failure.     

连续性肾脏替代治疗对急性肾功能衰竭患者血浆细胞因子的影响

目的探讨连续性肾脏替代治疗(CRRT)对急性肾功能衰竭(ARF)患者血浆细胞因子的影响。方法对42例急性肾功能衰竭患者进行CRRT治疗,使用ELISA法检测治疗前和治疗后4、12、24、48 h血浆肿瘤坏死因子-α(TNF-α)、白细胞介素-1β(IL-1β)、IL-6、IL-8的浓度,并与同期健康人群做比较。结果 ARF患者TNF-α、IL-1β、IL-6、IL-8血浆浓度均显著高于正常对照组(P<0.01),4种细胞因子在CRRT治疗4 h开始后显著下降,12 h时浓度降至最低,24～48 h有不同程度的回升,但仍低于治疗前水平。结论 CRRT能有效清除ARF患者血浆细胞因子,从而阻断炎症反应。     

Dialyzer-augmented whole blood and plasma exchange for patients with hepatic or hepatorenal failure.

We have utilized new methods of dialyzer-augmented whole blood and plasma exchange tranfusion in the treatment of hepatic coma. The method employs the new fast flow Buselmeier shunt so that the exchange can be done from a peripheral radial artery shunt site rather than a shunt site in a more major vessel, such as the brachial artery. The method employs in-line dialysis of citrated (CPD) blood or plasma to normalize pH, electrolytes, and blood sugar while infusion heparinization decreases heparin requirements. The application of a single roller pump to the administration and withdrawal lines (placed in opposite directions) helps equalize inflow and outflow where whole blood exchange is done while identical opposing pumps accomplish the same with plasma exchange. The administration of albumin and metaraminol bitartate prevents hypotension due to fluid shifts or compartmental venous dilatation. A closed circuit which does not require disconnection throughout the 30- 60-minute whole blood exchange or the 2 1/2-hour plasma exchange decreases the risk of septic contamination to both medical staff and patients.     

Alternating therapeutic plasma exchange (TPE) with double plasma molecular adsorption system (DPMAS) for the treatment of fulminant hepatic failure (FHF)

Alternating therapeutic plasma exchange with double plasma molecular adsorption system can rapidly remove bilirubin and ammonia and supplement the essential substance from the blood, which could be used as an effective treatment for fulminant hepatic failure.     

Kinetic modeling during continuous hemodiafiltration in patients with sepsis and multiorgan failure

Kinetic simulation in terms of urea and creatinine is the best way of prescribing a dialysis dose and assessing its quality as it considers differences in a patient's body weight, the level of catabolism, the rate of equilibration, including the recirculation phenomenon noticeably observed under shock. A 2-pool model of distribution of urea and creatinine was employed in the study. The latter was carried out in 31 patients (17 males and 14 females) with sepsis and multi-organ failure receiving 50 sessions of continuous hemodiafiltration (CHDF). The mean duration of CHDF was 73.8 +/- 7.0 (4.0-207.0) hours, the daily volumes of a substitute, a dialysate, and an effluent (filtrate + dialysate) were 33 +/- 1.0 (5.0-60.0), 43.9 +/- 0.8 (2.6-62.0), and 80.4 +/- 1.6 (12.0-122.3) liters a day, respectively. An analysis confirmed the high efficiency of CHDF close to that of the daily volume-body weight ratio and showed that such conditions of the procedure are optimal in maintaining azotemia at the subnormal level irrespective of the degree of cababolism.     

大黄联合床边血浆置换治疗重症高脂血症性急性胰腺炎疗效观察

目的：评估重症高脂血症性急性胰腺炎应用大黄联合床边血浆置换治疗的临床疗效。方法：47例确诊为重症高脂血症性急性胰腺炎患者分为大黄联合床边血浆置换治疗组（24例）和对照组（23例）,观察血浆置换的安全性,两组患者的甘油三酯（TG）、炎症因子、呼吸功能、肠道功能、BalthazarCT评分、急性生理和慢性健康状况评分Ⅱ（APACHEⅡ）、住院时间、住院费用和病死率等。结果：24例床边血浆置换有4例发生轻微并发症,无严重并发症;治疗组治疗第2天和第8天TG和炎症因子与对照组比较明显降低（均P〈0.05）;治疗组机械通气人数和时间少于对照组,治疗组治疗第2天和第8天氧合指数和胸腔积液与对照组比较差异有统计学意义（均P〈0.05）;治疗组治疗第2天和第8天腹内压均低于对照组,肛门首次排便时间和肠内营养开始时间均早于对照组（均P〈0.05）;治疗组治疗第2天APACHEⅡ评分、第8天APACHEⅡ评分和BalthazarCT评分与对照组比较差异有统计学意义（均P〈0.05）;治疗组住院时间、住院费用和病死率均低于对照组（均P〈0.05）。结论：床边血浆置换有良好的安全性;大黄联合床边血浆置换对重症高脂血症性急性胰腺炎有良好的临床疗效。     

血浆置换联合持续性血液滤过透析对慢性重型乙型病毒性肝炎临床症状及生化指标的影响——附87例报告

目的:探讨血浆置换联合持续性血液滤过透析治疗对慢性重型乙型病毒性肝炎(慢重肝)临床症状及生化指标的影响.方法:记录87例慢重肝患者(A组)在应用血浆置换及持续性血液滤过透析联合内科综合治疗前后临床症状和生化指标的改善情况,并与94例行血浆置换联合内科综合治疗的慢重肝患者(B组)进行对比.结果:治疗后,A组临床症状改善100%(87/87),低钾血症复常率为80%(33/41)、低钠血症复常率为93%(27/29),肝性脑病清醒率55%(12/22);B组则相应为48%(45/94)、7%(3/42)、7%(2/30)和20%(5/25),2组上述各项指标比较差异均有统计学意义(均为P＜0.05).A组近期有效率、近期生存率分别为80%、48%,B组为47%、31%,2组比较差异均有统计学意义(均为P＜0.05).不良反应以血浆过敏反应为主,均未发生低血压、肺水肿等严重不良反应.结论:血浆置换及持续性血液滤过透析联合内科综合治疗可有效纠正慢重肝患者的电解质紊乱,保持内环境平衡,且能提高其近期生存率和肝性脑病清醒率,为慢重肝的治疗提供了新的选择.     

血浆置换治疗32例肝衰竭患者的临床效果

目的探讨血浆置换治疗肝衰竭患者的临床效果。方法收集32例肝衰竭患者,在综合治疗的基础上,采用血浆置换技术对其进行治疗。分别于治疗前、后检测患者临床生化指标:天门冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、清蛋白(ALB)、总胆红素(TBil)、直接胆红素(DBil)、凝血酶原时间(PT)、肌酐(Cr)、国际标准化比率(INR)、总胆汁酸(TBA)。结果本组患者血浆置换治疗总有效率为78.13%。早期肝衰竭患者有效率94.73%,中期肝衰竭患者有效率70.00%,晚期肝衰竭患者全部无效死亡。生化指标AST、ALT、ALB、TBil、DBil、PT、Cr、INR、TBA治疗后较治疗前均有明显改善(P<0.05)。结论血浆置换治疗肝衰竭患者效果较好,越早治疗效果越好。     

CVVHDF在老年患者多器官功能衰竭中的应用

目的观察连续性静脉-静脉血液透析滤过（CVVHDF）用于老年多器官功能衰竭（multi-ple organ failure in the elderly,MOFE）患者的临床疗效。方法15例MOFE患者,年龄63～87（72．9±5．6）岁。观察CVVHDF治疗前后患者SIRS指标（体温、心率、呼吸、动脉血二氧化碳分压及外周血白细胞总数）的改变,监测其肾功能、电介质、动脉血气、中心静脉压的变化。结果CVVHDF治疗后患者SIRS反应明显减轻,血管活性药物逐渐减量,13例机械通气患者6例成功撤离呼吸机,3例心跳呼吸骤停患者2例神志转清。血清尿素氮、肌酐、血钾较治疗前显著降低,低氧血症、酸中毒、心衰得到纠正,治疗前、后比较差异有显著性（P〈0．05）。结论CVVHDF治疗MOFE患者,可明显抑制患者SIRS反应,全面改善心肺脑肾功能,是MOFE患者重要的治疗手段之一。