Hemodiafiltration--a new treatment option for hyperphosphatemia in hemodialysis patients.
Hemodiafiltration--a new treatment option for hyperphosphatemia in hemodialysis patients.
复制标题
血液透析滤过——血液透析患者高磷血症的新治疗选择。
作者：
C. Zehnder;J. Gutzwiller;K. Renggli
背景
血液透析滤过用于增加对流转运，从而消除小分子和中分子，主要是穿过透析膜的β 2-微球蛋白（β 2-M）。关于体内血液透析滤过期间尿素、肌酐、β 2-M和主要磷酸盐动力学的信息很少。在这项前瞻性研究中，我们评价了在高通量血液透析（HD）和后稀释血液透析滤过（HDF）期间跨膜溶质质量清除（TSR）和尿素、肌酐和磷酸盐的清除率（Kd）以及血清β 2-M降低率（β 2-MRR）和透析液加超滤液中收集的β 2-M。
患者和方法
16名患者在2个为期一周的阶段内使用聚砜毛细滤器（表面积1.6 m2，纤维内径40 μ m，壁厚200 μ m）进行研究：第一周HD 1.6 m2和第二周HDF 1.6 m2。治疗时间为4小时，血液流速300 ml/min，HD和HDF期间透析液和超滤率恒定。在周中治疗期间评估TSR、Kd、β 2-MRR和β 2-M采集。在研究的第二部分中，我们使用第二个高通量聚砜毛细管过滤器（2.4 m2表面积，30 microm纤维直径和150 microm壁厚）重复相同的方案。
结果
HDF未改善尿素和肌酐的TSR和Kd，但HDF增加了磷酸盐的TSR和Kd。磷酸盐清除率从120（HD 1.6 m2）至159（HDF 1.6 m2）（p < 0.005）和146（HD 2.4 m2）至206（HDF 2.4 m2）（p < 0.005）ml/min。β 2-MRR从64.1 +/- 8.6增加到77.7 +/- 8.2% HDF 1.6 m2和HDF 2.4 m2期间分别为75.0 +/- 5.1至82.9 +/- 8.5%（p < 0.005）。采集的β 2-M保持不变。这种差异似乎是由于HDF期间聚砜膜对β 2-M的吸附增强所致。
结论
我们的研究结果提供了强有力的证据，证明HDF在体内尿素和肌酐清除方面不优于HD。然而，HDF确实改善了磷酸盐的消除，应将其视为透析患者高磷血症的额外治疗选择。HDF可显著改善β 2-M的消除。
BACKGROUND
Hemodiafiltration is used to increase the convective transport and thereby the elimination of small and middle molecules, mainly beta2-microglobulin (beta2-M) across the dialysis membranes. There is little information concerning urea, creatinine, beta2-M and principally phosphate kinetics during hemodiafiltration in vivo. In this prospective study, we evaluated the transmembrane solute mass removal (TSR) and clearance (Kd) of urea, creatinine and phosphate as well as serum beta2-M reduction rate (beta2-MRR) and collected beta2-M in dialysate plus ultrafiltrate during high-flux hemodialysis (HD) and post-dilutional hemodiafiltration (HDF).
PATIENTS AND METHODS
16 patients were studied using a polysulfone capillary filter (1.6 m2 surface area, 40 microm fiber internal diameter and 200 microm, wall thickness) during 2 one-week periods: first week HD 1.6 m2 and second week HDF 1.6 m2. Treatment time was 4 hours, blood flow rate 300 ml/min with constant dialysate and ultrafiltration rates for HD and HDF periods. TSR, Kd, beta2-MRR and beta2-M collection were assessed during the mid-week treatment. In a second part of the study, we repeated the same protocol using a second high-flux polysulfone capillary filter (2.4 m2 surface area, 30 microm fiber diameter and 150 microm wall thickness).
RESULTS
TSR and Kd of urea and creatinine were not improved by HDF, however, HDF increased TSR and Kd of phosphate. Phosphate clearance rose from 120 (HD 1.6 m2) to 159 (HDF 1.6 m2) (p < 0.005) and from 146 (HD 2.4 m2) to 206 (HDF 2.4 m2) (p < 0.005) ml/min. Beta2-MRR increased from 64.1 +/- 8.6 to 77.7 +/- 8.2% (p < 0.005) and from 75.0 +/- 5.1 to 82.9 +/- 8.5% (p < 0.005) during HDF 1.6 m2 and HDF 2.4 m2, respectively. Collected beta2-M remained unchanged. This discrepancy seems to be due to an enhanced beta2-M adsorption to the polysulfone membrane during HDF.
CONCLUSION
Our results provide a strong evidence that HDF has no advantage over HD with respect to urea and creatinine removal in vivo. However, HDF did improve the elimination of phosphate and should be considered as an additional treatment option for hyperphosphatemia in dialysis patients. HDF improves significantly the elimination of beta2-M.