高截留分子量超濾膜在臨床中的應(yīng)用

1、crrt高截留分子量超濾膜在臨床中的應(yīng)用高截留分子量超濾膜在臨床中的應(yīng)用14/3/20222 基本概念 高截留分子量超濾膜 高截留分子量超濾膜在臨床中的應(yīng)用內(nèi)容目錄4/3/20223截留分子量截留分子量截留分子量截留分子量CO是指對有孔材料孔徑大小的一種描述。在能自由通過某種有孔材料的分子中最大分子的分子量即為該材料的截留分子量。大于截留分子量的分子，被材料截留；小于截留分子量的分子，則可自由通過。一般濾器膜的截留分子量分子的篩選系數(shù)為0.1，即通過濾器膜能力為10%的分子的分子量定義為截留分子量。DEFINITION: The cut-off point of a solute for an

2、y membrane is a sieving coefficient of 0.1 . This means that 10% of the molecules will pass and 90% will not pass .4/3/20224篩選系數(shù)-SC篩選系數(shù)SC（seiving coeffcient)為超濾液中溶質(zhì)濃度與濾器前血漿溶質(zhì)濃度比值，是溶質(zhì)通過濾器膜能力的一個定量指標(biāo)SC越高，表明CRRT治療清除的 溶質(zhì)越多，SC接近1，提示溶質(zhì)近乎可自由通過濾器膜濾器膜的性質(zhì)會影響SC值SIEVING COEFFICIENT1.0MOLECULAR WEIGHT=SOLUTE SIZE

3、DEFINITION:The cut-off point of a solute for any membrane is a sieving coefficient of 0.1 . This means that 10% of the molecules will pass and 90% will not pass .0.560 ureaCut-off pointO.1篩選系數(shù)與截留分子量篩選系數(shù)與截留分子量Solute Classes by Molecular WeightDaltons Inflammatory Mediators (1,200-50,000)“small”“middl

4、e”“l(fā)arge”crrt高截留分子量超濾膜高截留分子量超濾膜RR-AB-34 Jan 2011New functional membrane with defined larger pore sizeHCO membrane 0,01 m 0,02 m 0,09 m 0,30 m: pore diameterhigh fluxhigh cut-off*protein separation membraneplasma separation membraneVariation of membrane pore sizeElectron micrographs of inner membrane

5、 surfacesieving coefficient100100010000100000100000000.81Molecular weight DClassical Filter30 kD human kidneyhigh cut-offHigh Cut-Off Hemofilter 00,20,40,60,811000100001000001000000Molecular Weight DaltonSieving CoefficientMolecular Weight DaStandard HighFluxHigh Cut-OffHF, UF=1L/h, t=2hMed

6、ian, 25th-75th percentiles)ICM (2002) 28:651-655HCO Membrane with increased permeability for inflammatory mediatorsmembrane characteristics crrt高截留分子量超濾膜的臨床應(yīng)用高截留分子量超濾膜的臨床應(yīng)用12HCO treatment reduces significantly inflammatory mediator plasma levels高截留分子量超濾膜的臨床應(yīng)用IL-6 in PROWESSNon-survivorsSurvivorsKina

7、sewitz et al, Crit Care 2004PROWESS （Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis)StudyAt study entry, evaluated IL-6 was present in 98.5% patentsLimited Effect of “Standard” CRRT on Plasma Inflammatory Mediator LevelsHerring et al, Kidney Blood Press Res 2003Course of

8、 IL-6 plasma level during treatment with septeX/HCOIntensive Care Med 2003;29:1989-95N=24 pts CVVHSubstantial Reduction of Plasma IL-6 LevelsInterleukin-6 plasma valuesCrit Care Med. 2006;34:2099-04.N=10 pts CVVHN=20 pts CVVHIL-6 ClearancemL / minSieving coefficient: Morgera S,Bellomo R et al.Crit C

9、are Med. 2006;34:2099-04CVVHUF-rate 2.5L/hRecent HPHF Studies in Sepsis:Clearance rates for IL-6 were significantly higher in the high cutoff hemofiltration group (p .0001).Cellular immunomodulation through HCO treatment高截留分子量超濾膜的臨床應(yīng)用Muret et alShock 2000 Hoffmann et alKidney Int. 1995Heidecke et al

10、Am J Surg. 1999T-Lymhocyte Proliferation is Reduced in SepsisMonocyte phagocytosis is elevated in SepsisSpark JI, Scott DJ. Br J Surg. 2001;88:1583-9.Simms HH, DAmico R. Blood. 1994;83:1398-407Cellular immunomodulationHuman sepsis studies:HCO treatment restores lymphocyte proliferation in septic pat

11、ients NDT, 2003;18:2570-6.N=28 pts CVVH與HCO可以濾除淋巴細(xì)胞增殖的阻滯物質(zhì)有關(guān)HCO treatment reduces monocyte phagocytosis rate of septic patientsNephron Clin Pract. 2003;94:75-80 CVVHClinical benefits through HCO treatment高截留分子量超濾膜的臨床應(yīng)用Norepinephrine requirement is reduced with HCO Crit Care Med. 2006;34:2099-04.N=20

12、 pts CVVHN=10 pts CVVHP=0.1103P=0.5717MAP mmHg MAP mmHg Improvement in Simplified Acute Physiology Score (SAPS) IICrit Care Med. 2006;34:2099-04.N=20 pts CVVHN=10 pts CVVHClearance Rates for HCO Filter: CVVH vs CVVHD 2Morgera et al, Am J Kidney Dis 2004clinical safety- data高截留分子量超濾膜的臨床應(yīng)用Stable album

13、in plasma levels during treatmentN=24 ptsCVVH/ CVVHDAm J Kidney Dis. 2004, 43:444-53. Coagulation Status During High Cut-Off HemofiltrationIntensive Care Med 2003;29:1989-95N=16 pts CVVH Days on Norephrinine (10,0 9 vs 11,3 9) Days on Ventilation (13,9 11 vs 16,1 11) Need for RRT (9,1 8 vs 9,5 8)HCO

14、 versus standard high flux Recent HPHF Studies in SepsisHigh-FluxHCO N= 81 pts CVVHDHICOSS (High Cut-Off Sepsis Study) Multicenter study with HCO in septic AKI Reduction of catecholamine requirements by High Cut off-CVVHD : clinical improvements and Safety (albumin levels), SOFA Days 28 mortality (3

15、1 vs 33%) both groups lower than predicted by APACHE score Days in ICU (1912 vs 1911) HCO vs standard high flux Recent HPHF Studies in Sepsis:HCOHigh-Flux N= 81 pts CVVHDHICOSS (High Cut-Off Sepsis Study) Multicenter study with HCO in septic AKI Reduction of catecholamine requirements by High Cut of

16、f-CVVHD : clinical improvements and Safety (albumin levels), SOFA HCO versus standard high flux Safety: Stable plasma albumin levels with HCO compared to standard high flux -CVVHDN= 81 pts CVVHD Recent HPHF Studies in Sepsis: HICOSS (High Cut-Off Sepsis Study) Multicenter study with HCO in septic AK

17、I Reduction of catecholamine requirements by High Cut off-CVVHD : clinical improvements and Safety (albumin levels), SOFA HCO versus standard high flux Recent HPHF Studies in Sepsis: Synergy with HVHF ?CVVH + HPHF= 1l/h = 16.6 ml/kg/hHVHF+HPHF = 6 l/h = 80 ml/kg/h Uchino el al , Int Care Med 2002; 2

18、8: 651-6554/3/202234百特HF系列濾器特點1百特HF系列是高截留分子量HCO ，聚砜膜血濾器的一種，合理的篩漏系數(shù)，截流，聚砜膜血濾器的一種，合理的篩漏系數(shù)，截流分子量為分子量為65KD膜生產(chǎn)技術(shù)充分考慮了白蛋白的丟失的可能，可安全放心使用細(xì)胞因子、毒性物質(zhì)及免疫復(fù)合物清除效果顯著，調(diào)節(jié)免疫促進(jìn)內(nèi)環(huán)境的穩(wěn)定和臟器功能恢復(fù)，改善患者預(yù)后4/3/202235百特HF系列濾器特點2百特HF系列濾器安全穩(wěn)定，不易凝血適當(dāng)?shù)挠H水、疏水基團(tuán)和電荷配比，不易造成孔隙堵塞無甘油聚砜膜，生物相容性好主要通過超濾有效清除毒性物質(zhì)，可長時有效的維持膜孔的完整性強調(diào)：濾器最重要的功能在于濾過而不是吸

19、附；吸附功能強大的膜，例如：有報道13小時需要更換濾器來克服吸附帶來的清除能力下降Haase M, Silvester W, Uchino S, et al. A pilot study of high-adsorption hemofiltration in human septic shock.Int J Artif Organs.Feb 2007;30(2):108-117.4/3/202236Baxter PSHF 高截留分子量聚砜膜濾器4/3/202237常見的常見的CRRTCRRT治療的濾器和高通透析器分類治療的濾器和高通透析器分類q用于危重癥用于危重癥CRRT治療的血濾器治療的血

20、濾器：百特PSHF系列金寶AN69、AN69ST系列費森 AV 系列q用于急、慢性腎衰竭患者的腎臟支持治療用于急、慢性腎衰竭患者的腎臟支持治療-單次使用的高通量單次使用的高通量透析器透析器百特 exeltra 210金寶 Hemofilter 6s費森 F 604/3/202239 BrandFeatureCodeBaxter-HF FilterPS、HCO=65kHF400,HF700,HF1200FMC-AV seriesPS、Steam sterilization、HCO=33kAV400s,AV600s,AV1000sGambro-AN69 SeriesPAN、Strong AdsorptionAN69(ST60,100,150);AN69ST（M60,M100,M150)B.Braun- Diaca