危重患者连续静脉-静脉血液滤过治疗中滤液蛋白丢失

目的 探讨危重患者连续静脉-静脉血液滤过治疗(CVVH)中滤液蛋白丢失及其主要影响因素.方法 对2008年9月至2009年9月收治的18例脓毒症或重症急性胰腺炎合并急性肾功能衰竭患者的临床资料进行分析.其中男性12例,女性6例,平均年龄45岁(39～62岁),均行24 h CVVH.置换液流速4000 mL/h,跨膜压(TMP)、血流量和超滤率分别为(173±48)mm Hg(1 mmHg=0.133 kPa)、(277±89)ml/h、(179±4)ml/min.采集滤前和滤后血液,连续收集24 h滤液,测定血浆和滤液总蛋白浓度,计算滤液蛋白丢失量并进行统计学分析.结果 滤液蛋白平均浓度(231±67)mg/L,滤液蛋白丢失量(22±6)g/d.CVVH治疗前后血浆蛋白水平差异无统计学意义(56±6)g/L比(55±10)g/L,P＞0.05].滤液蛋白浓度和m浆蛋白平均浓度之间存在较弱相关性(r=0.481,P＜0.05),和TMP之间存在显著相关性(r=0.564,P＜0.01),多元逐步回归分析表明TMP和血浆蛋白浓度是影响滤液蛋白丢失的主要因素.结论 CVVH除了肾脏替代治疗作用外,也会引起血浆蛋白质经滤器丢失,其中,TMP和血浆蛋白浓度是影响滤液蛋白丢失的主要因素.在对接受CVVH治疗的危重患者制定营养方案时,必须考虑经滤器额外丢失的蛋白质.

Protein loss in critically ill patients during continuous veno-venous hemofiltration

Objective To evaluate protein loss in critically ill patients with acute renal failure during continuous veno-venous hemofiltration(CVVH)and analysis the major factor impacting protein clearance.Methods A analysis was carried out iu eighteen(twelve male and six female)sepsis or severe acute panreatitis patients with acute renal failure from September 2008 to September 2009.The average age was 45 years(39-62 years).CVVH was conducted for 24 h in all patients.Effluent volume.blood speed,ultrafiltration rate and transmembrane pressure(TMP)were 4000 ml/h,(277±89)ml/h,(179±4)ml/min and(173±48)mm Hg(1 mm Hg=0.133 kPa)respectively.Blood samples were collected before and after filtration in order to detect protein concentration.Ultrailltrate was obtained hourly to measure protein concentration and calculate protein loss during session.Results Mean protein concentration was (231±67)mg/L and protein loss was(22±6)g/d in ultrafiltrate samples.The difference in serum protein level during hemofiltration was not significant(56±6)g/L vs.(55±10)g/L,P＞0.05],while there was a weak.but statistically significant correlation between the uhrafiltrate protein concentration and the corresponding value for serum protein(r=0.481,P＜0.05).However,there was a strong and statistically significant correlation between the ultrafiltrate protein concentration and the TMP(r=0.564.P＜0.01).Stepwise multiple regression analysis showed that TMP and serum protein concentration played a pivotal role in ultrafiltrate protein loss.Conclusions In addition to renal replacement therapy.serum protein would be cleared through hemofilter during CVVH.TMP and serum protein concentration are the main factors that affect protein loss in ultrafiltrate.As a result.it is necessary to take account of the protein legg in uhrafiltrate when setting nutritional schedule.