Bimodal Dialysis: An Integrated Approach to Renal Replacement Therapy
Bimodal Dialysis: An Integrated Approach to Renal Replacement Therapy
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双模式透析：肾脏替代治疗的综合方法
DOI：
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发表时间：
2004
影响因子：
2.8
通讯作者：
C. McIntyre
中科院分区：
文献类型：
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作者：
C. McIntyre
腹膜透析（PD）和血液透析（HD）都被广泛用作终末期肾病（ESRD）的唯一治疗方法。就患者预后而言，哪种（如果有的话）更好仍存在争议。腹膜透析具有长时间、缓慢、连续超滤的优点，并可能增强对残余肾功能（RRF）的保护。相比之下，HD提供了优越的溶质去除效果，但代价是高钠和高水去除率对心血管的不良耐受性。本研究的目的是探讨两种方式联合治疗的临床可行性[双峰透析（BMD）]对突发终末期肾病患者。我们着手调查是否有可能在良好的患者可接受性的情况下利用两种方式的内在优势。方法对8例患者进行前瞻性研究。他们是在esrd前阶段从一家低清除率专科诊所招募的。形成动静脉瘘并插入腹膜导管。BMD包括每周2,3小时，高效，大容量HD疗程，结合每天2次PD交换，以提供一定程度的溶质清除和所有超滤。每个模式的充分性是独立测量的。除RRF（肌酐清除率和EDTA清除率）、超声心动图（左心室质量和心室功能）、治疗结果、患者症状和并发症外，还使用标准范围的评估对患者进行随访。结果平均BMD时间为346±74.9（245 ~ 431）天。腹膜炎发生率为21个月/次（平均0.6±0.9,0 - 2次/例）。平均腹膜超滤量为1.58±0.32 (1.3 - 2.1)L / d。交付Kt/V和每周PD Kt/V变化不显著。在整个研究期间，患者的RRF保持不变，血清白蛋白和血清磷的控制也是如此。通过减少降压药的使用，血压得到了控制。左心室质量指数在治疗期间下降，从平均194±31.2 (161 - 265)g/m2降至156±21.2 (138 - 189)g/m2 （p = 0.05）。研究期间心室功能保持不变[射血分数50.4±11.1(38 - 67)%至48±8.0(48 - 67)%]。单纯HD组平均BMD时间为4.2±6.9（0 - 16）天，单纯PD组平均BMD时间为9.2±10.6（0 - 25）天。结论BMD是治疗ESRD的一种可行方法。它与充分的溶质清除和良好的血流动力学/容量控制有关，并允许增加治疗灵活性，以应对通常需要求助于临时中心静脉通道的计划外HD的并发症。
Background Peritoneal dialysis (PD) and hemodialysis (HD) are both widely used as sole therapies for end-stage renal disease (ESRD). There is still controversy over which (if either) is superior in terms of patient outcomes. Peritoneal dialysis offers the advantages of long, slow, continuous ultrafiltration and potentially enhanced protection of residual renal function (RRF). In contrast, HD offers superior solute removal at the cost of undesirable cardiovascular tolerance of high rates of sodium and water removal. The aim of this study was to investigate the clinical feasibility of offering a combined treatment of both modalities [bimodal dialysis (BMD)] to incident patients reaching ESRD. We set out to investigate if it might be possible to utilize the intrinsic advantages of both modalities within a setting of good patient acceptability. Methods We prospectively studied 8 patients. They were recruited in the pre-ESRD phase from a specialist low clearance clinic. An arteriovenous fistula was formed and peritoneal catheters were inserted. The BMD consisted of 2, 3-hour, high efficiency, euvolemic HD sessions per week in combination with 2 PD exchanges per day to provide a degree of solute clearance and all of the ultrafiltration. Adequacy was measured independently for each modality. Patients were followed using the standard range of evaluations in addition to RRF (by creatinine clearance and EDTA clearance), echocardiography (left ventricular mass and ventricular performance), treatment outcomes, patient symptoms, and complications. Results Mean time on BMD was 346 ± 74.9 (range 245 – 431) days. Peritonitis rate was 21 months per episode (mean 0.6 ± 0.9, 0 – 2 episodes per patient). Mean peritoneal ultrafiltration volume was 1.58 ± 0.32 (1.3 – 2.1) L per day. Delivered Kt/V and weekly PD Kt/V did not change significantly. Patients’ RRF was maintained over the study period, as were serum albumin and control of serum phosphorus. Blood pressure was controlled with a reduction in the number of antihypertensive agents. Left ventricular mass index reduced over the treatment period, from a mean of 194 ± 31.2 (161 – 265) to 156 ± 21.2 (138 – 189) g/m2 (p = 0.05). Ventricular performance remained unchanged over the study [ejection fraction 50.4 ± 11.1 (38 – 67) % to 48 ± 8.0 (48 – 67) %]. Mean time during BMD spent on HD alone was 4.2 ± 6.9 (0 – 16) days, and on PD alone 9.2 ± 10.6 (0 – 25) days. Conclusion This study suggests that BMD is a feasible treatment for ESRD. It is associated with adequate solute removal and good hemodynamic/volume control, and allows increased treatment flexibility for coping with complications normally requiring recourse to unplanned HD with temporary central venous access.