在重症监护病房急性肾衰竭中确定平衡的间歇性血液透析剂量

Prescribing an equilibrated intermittent hemodialysis dose in intensive care unit acute renal failure.

作者信息

Kanagasundaram Nigel S, Greene Tom, Larive A Brett, Daugirdas John T, Depner Thomas A, Garcia Michelle, Paganini Emil P

机构信息

Section of Dialysis and Extracorporeal Therapy, Department of Hypertension/Nephrology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

出版信息

Kidney Int. 2003 Dec;64(6):2298-310. doi: 10.1046/j.1523-1755.2003.00337.x.

DOI:10.1046/j.1523-1755.2003.00337.x

PMID:14633155

Abstract

BACKGROUND

Prospective, formal, blood-side, urea kinetic modeling (UKM) has yet to be applied in intermittent hemodialysis for acute renal failure (ARF). Methods for prescribing a target, equilibrated Kt/V (eKt/V) are described for this setting.

METHODS

Serial sessions (N= 108) were studied in 28 intensive care unit ARF patients. eKt/V was derived using delayed posthemodialyis urea samples and formal, double-pool UKM (eKt/Vref), and by applying the Daugirdas-Schneditz venous rate equation to pre- and posthemodialysis samples (eKt/Vrate). Individual components of prescribed and delivered dose were compared. Prescribed eKt/V values were determined using in vivo dialyzer clearance estimates and anthropometric (Watson and adjusted Chertow) and modeled urea volumes.

RESULTS

eKt/Vref (mean +/- SD = 0.91 +/- 0.26) was well-approximated by eKt/Vrate (0.92 +/- 0.25), R= 0.92. Modeled V exceeded Watson V by 25%+/- 29% (P < 0.001) and Adjusted Chertow V by 18%+/- 28% (P < 0.001), although the degree of overestimation diminished over time. This difference was influenced by access recirculation (AR) and use of saline flushes. The median % difference between Vdprate and Watson V was reduced to 1% after adjusting for AR for the 22 sessions with < or =1 saline flush. The median coefficients of variation for serial determinations of Adjusted Chertow V, modeled V, urea generation rate, and eKt/Vref were 2.7%, 12.2%, 30.1%, and 16.4%, respectively. Because of comparatively higher modeled urea Vs, delivered eKt/Vref was lower than prescribed eKt/V, based on Watson V or Adjusted Chertow V, by 0.13 and 0.08 Kt/V units. The median absolute errors of prescribed eKt/V vs. delivered therapy (eKt/Vref) were not large and were similar in prescriptions based on the Adjusted Chertow V (0.127) vs. those based on various double-pool modeled urea volumes (approximately 0.127).

CONCLUSION

Equilibrated Kt/V can be derived using formal, double-pool UKM in intensive care unit ARF patients, with the venous rate equation providing a practical alternative. A target eKt/V can be prescribed to within a median absolute error of less than 0.14 Kt/V units using practical prescription algorithms. The causes of the increased apparent volume of urea distribution appear to be multifactorial and deserve further investigation.

摘要

背景

前瞻性、正式的血液侧尿素动力学建模（UKM）尚未应用于急性肾衰竭（ARF）的间歇性血液透析。本文描述了在此情况下设定目标平衡Kt/V（eKt/V）的方法。

方法

对28例重症监护病房ARF患者的108次连续透析治疗进行了研究。使用透析后延迟尿素样本和正式的双池UKM（eKt/Vref），以及将Daugirdas-Schneditz静脉速率方程应用于透析前后样本（eKt/Vrate）来推导eKt/V。比较规定剂量和实际给予剂量的各个组成部分。使用体内透析器清除率估计值以及人体测量学指标（Watson和校正后的Chertow）和建模尿素容积来确定规定的eKt/V值。

结果

eKt/Vrate（0.92±0.25）与eKt/Vref（平均±标准差=0.91±0.26）拟合良好，R=0.92。建模的V比Watson V高25%±29%（P<0.001），比校正后的Chertow V高18%±28%（P<0.001），尽管随着时间推移高估程度有所降低。这种差异受通路再循环（AR）和盐水冲洗使用情况的影响。在22次使用≤1次盐水冲洗的治疗中，校正AR后，Vdprate与Watson V之间的中位百分比差异降至1%。校正后的Chertow V、建模的V、尿素生成率和eKt/Vref的连续测定的中位变异系数分别为2.7%、12.2%、30.1%和16.4%。由于建模的尿素V相对较高，基于Watson V或校正后的Chertow V，实际给予的eKt/Vref比规定的eKt/V低0.13和0.08 Kt/V单位。规定的eKt/V与实际给予的治疗（eKt/Vref）之间的中位绝对误差不大，基于校正后的Chertow V（0.127）的处方与基于各种双池建模尿素容积的处方（约0.127）相似。