Ward Richard A, Schmidt Bärbel, Hullin Jeannine, Hillebrand Günther F, Samtleben Walter
Department of Medicine, University of Louisville, Louisville, Kentucky.
Department of Medicine I, Klinikum Grosshadern, University of Munich, Munich.
J Am Soc Nephrol. 2000 Dec;11(12):2344-2350. doi: 10.1681/ASN.V11122344.
Some of the morbidity associated with chronic hemodialysis is thought to result from retention of large molecular weight solutes that are poorly removed by diffusion in conventional hemodialysis. Hemodiafiltration combines convective and diffusive solute removal in a single therapy. The hypothesis that hemodiafiltration provides better solute removal than high-flux hemodialysis was tested in a prospective, randomized clinical trial. Patients were randomized to either on-line postdilution hemodiafiltration or high-flux hemodialysis. The groups did not differ in body size, treatment time, blood flow rate, or net fluid removal. The filtration volume in hemodiafiltration was 21 +/-1 L. Therapy prescriptions were unchanged for a 12-mo study period. Removal of both small (urea and creatinine) and large (ss(2)-microglobulin and complement factor D) solutes was significantly greater for hemodiafiltration than for high-flux hemodialysis. The increased urea and creatinine removal did not result in lower pretreatment serum concentrations in the hemodiafiltration group. Pretreatment plasma beta(2)-microglobulin concentrations decreased with time (P< 0.001); however, the decrease was similar for both therapies (P = 0.317). Pretreatment plasma complement factor D concentrations also decreased with time (P<0.001), and the decrease was significantly greater with hemodiafiltration than with high-flux hemodialysis (P = 0.010). The conclusion is that on-line hemodiafiltration provides superior solute removal to high-flux hemodialysis over a wide molecular weight range. The improved removal may not result in lower pretreatment plasma concentrations, however, possibly because of limitations in mass transfer rates within the body.
一些与慢性血液透析相关的发病率被认为是由于大分子量溶质的潴留所致，这些溶质在传统血液透析中通过扩散难以清除。血液透析滤过在单一治疗中结合了对流和扩散溶质清除。在一项前瞻性、随机临床试验中，对血液透析滤过比高通量血液透析能更好地清除溶质这一假设进行了检验。患者被随机分为在线后稀释血液透析滤过组或高通量血液透析组。两组在体型、治疗时间、血流速率或净液体清除方面无差异。血液透析滤过中的滤过量为21±1L。在12个月的研究期间，治疗方案保持不变。血液透析滤过对小溶质（尿素和肌酐）和大溶质（β2-微球蛋白和补体因子D）的清除均显著高于高通量血液透析。血液透析滤过组中尿素和肌酐清除增加并未导致治疗前血清浓度降低。治疗前血浆β2-微球蛋白浓度随时间下降（P<0.001）；然而，两种治疗的下降情况相似（P = 0.317）。治疗前血浆补体因子D浓度也随时间下降（P<0.001），且血液透析滤过组的下降显著大于高通量血液透析组（P = 0.010）。结论是，在线血液透析滤过在较宽的分子量范围内比高通量血液透析能提供更好的溶质清除。然而，清除改善可能不会导致治疗前血浆浓度降低，这可能是由于体内传质速率的限制。
