比较HDF和HD患者的死亡风险：DOPPS研究的欧洲结果
Kidney International（2006）
置换液剂量 > 15 L/次
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在线HDF对全因死亡率和心血管事件的影响： CONTRAST研究
High Flux HD Pre-Dilution HDF (Qs 180 ml/min) 182 (7.3) 156 (5.8) 152 (3.5) 33 (1.3) 188 (6.1) 152 (2.7) 149 (4.4) 52 (0.9)
Post-Dilution HDF (Qs 80 ml/min) 211 (5.4) 179 (8.0) 164 (2.9) 62 (1.1)
中分子
Adrenomedullin Atrial natriuretic
ß 2-Microglobulin ß -Endorphin 2微球蛋 Cholecystokinin 白 Clara cell protein 瘦素 Complement factor D … Cystatin C Degranulation Delta-sleep-inducing Endothelin Hyaluronic acid Interleukin 1ß Interleukin 6 Kappa-Ig light chain Lambda-Ig light chain Leptin MethionineNeuropeptide Y
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普通血液透析（超滤)模式简图
透析液泵
超滤泵
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oLHDF前稀释模式简图
透析液泵
超滤泵
置换液泵
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oLHDF后稀释模式简图
在线血液透析滤过
Online hemodiafiltration (oLHDF)
费森尤斯医学部
杨洪莹
Title, Subject, Author (c) Copyright 30/12/2014
议程
• 传统的血液透析治疗的局限性
• 血液透析滤过在临床上的益处
-置换剂量 • 血液透析滤过的定义 -滤过分数 • HDF治疗的实现
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后置换-置换液量的作用
a Adjusted for determinants of mortality, i.e., age, sex, previous vascular disease, diabetes, previous transplantation, spKt/V, baseline eGFR, baseline albumin, baseline creatinine, baseline hematocrit, and use of a- and b-blockers, calcium antagonists, and angiotensin converting inhibitors at baseline b Adjusted for the above-mentioned determinates as well as for center differences
可溶于水的小分子物质
Asymmetric dimethylarginine Benzylalcohol peptide ß -Guanidinopropionic acid ß -Lipotropin Creatinine Cytidine Guanidine Guanidinoacetic acid Guanidinosuccinic acid inhibiting protein I 钠 Hypoxanthine peptide 水 Malondialdehyde 钾… Methylguanidine Myoinositol Orotic acid Orotidine Oxalate Pseudouridine Symmetric dimethylarginine enkepahlin Urea
– 对流>>HFHD
• 超纯透析 • 通过特殊的细菌内毒素过滤系统在线生成无菌置换液
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oLHDF治疗模式
• 具体模式 – 前稀释Pre-dilution
– 后稀释Post-dilution
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置换液量超过23L病人生存率明显改善
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如何评价oLHDF对病人生存率的影响效果
透析液泵
超滤泵
置换液泵
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oLHDF临床上的优势
与普通血液透析相比:
• 中大分子毒素清除更好
• 血流动力学更稳定 • 改善促红细胞生成素反应 • 更好地改善微炎症状态 • 更好地改善营养状况 • 更好的病人生存率
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溶质清除的特点
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溶质清除率的具体数据
Solute Urea (60) Phosphate (96) Creatinine (113) 2M (11,818)
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传统的血液透析的局限性: 长期
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尿毒症毒素是一组不同成分的化合物
分子量 < 500 d
Arhenholz et al Int J Artif Org 1997; 20: 81-90
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HDF比HFHD清除毒素效果更好
post-HDF与HFD比较 Vitamin B12 (1355 Da) 菊粉 (5200 Da) 骨钙素 (5800 Da) 50% clearance 100% clearance 71% vs 54%
30% vs 0%
Various membranes, various filtration rates
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oLHDF治疗具有更好的血液动力学特性
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CONTRAST Study JASN 23: 1087–1096, 2012
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HD与HDF病人生存率相似
All cause mortality
Composite cardiac events Composite CV event
置换液量 > 21.95 L 可以使总死亡率降低~35-40% 但对心血管死亡率影响不大
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死亡率和心血管事件在线HDF和 高通量HD的比较：土耳其研究
Nephrol Dial Transplant (2012)
i.v Saline bolus / tx HFD HDF 0.03 (IQR 0.04) 0.02 (IQR 0.03) p < 0.001
Vilar, E et al. C.JASN 4: 1944–1953, 2009 Fresenius Medical Care – THE RENAL COMPANY Page 15
oLHDF改善病人生存率
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观察性研究显示HDF改善病人生存率
> 6000个病人的分析结果显示： HDF治疗患者比HFHD生存几率提高30-40%
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Vanholder R. et al New insights in uremic toxins. Kidney Int, 2003, 63; 84: S6–S
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oLHDF原理
• 结合弥散和对流 – 弥散=HFHD
β2-微球蛋白 (11,800 Da)
瘦素 (16,000 Da) 肌红蛋白 (17,200 Da) 泌乳素 (23,000 Da)
73% vs 47%
31% vs 10% 62% vs 25% 50% vs 22%
D因子 (23,500 Da)
a1-微球蛋白 (33,000 Da)
33% vs 0%
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HDF与HD病人生存率相似