Bosch Thomas
Nephrology Division, Department I of Internal Medicine, University Hospital Munich-Grosshadern, D-81377 Munich, Germany.
Transfus Apher Sci. 2004 Oct;31(2):83-8. doi: 10.1016/j.transci.2004.07.002.
Direct adsorption of lipoproteins (DALI) from whole blood is the first LDL-hemoperfusion procedure. The present paper addresses practical questions of DALI apheresis in order to optimise DALI therapy in sometimes critically ill coronary patients. The reduction of LDL and Lp(a) by DALI can be optimised by increasing the treated blood volume and the DALI adsorber volume. Hypotension (1.2% of sessions) may be minimised by fluid intake before the session, isovolemic connection of the patient to the ECC, reduced blood flow and low ACD-A ratio. Hypocalcemia may be avoided by low citrate anticoagulation (1:40) and reduced blood flow. Bradykinin release peaks at ca. 1000 ml of treated blood volume and may cause Quincke edema (tight throat), hypotension and flush. Reduction of the blood flow rate and decrease of citrate admixture as well as administration of iv. calcium may be helpful. While ACE inhibitors are contraindicated in DALI patients, sartans may be used without problems. Some "intrinsic" PTT increase is caused by adsorption of coagulation factors; undue PTT prolongations after DALI may be avoided by reduction of the heparin dosage during priming and treatment. In patients prone to alkalosis and hypokalemia, a reduction of the ACD-A ratio is recommended. Rises of adsorber inlet pressure may be due to insufficient anticoagulation and adsorber clotting or malfunctioning of the venous access. Rinsing of the adsorber with saline, administration of a heparin bolus and increase of the citrate admixture as well as a rinse and/or repositioning of the venous access are helpful measures. If these basic rules are followed, DALI LDL-apheresis is a safe, efficient, rapid and user-friendly LDL-apheresis procedure as evidenced by more than 80,000 DALI sessions successfully performed to date.
全血直接吸附脂蛋白（DALI）是首个低密度脂蛋白血液灌流程序。本文探讨了DALI血液分离术的实际问题，以便在部分重症冠心病患者中优化DALI治疗。通过增加处理的血量和DALI吸附器体积，可以优化DALI对低密度脂蛋白（LDL）和脂蛋白（a）[Lp(a)]的降低效果。低血压（占治疗疗程的1.2%）可通过治疗前补液、患者与体外循环（ECC）的等容连接、降低血流速度和低ACD - A比例来尽量减少。低钙血症可通过低枸橼酸盐抗凝（1:40）和降低血流速度来避免。缓激肽释放量在处理约1000毫升血量时达到峰值，可能导致昆克水肿（咽喉发紧）、低血压和潮红。降低血流速度、减少枸橼酸盐混合液用量以及静脉注射钙剂可能会有帮助。虽然DALI患者禁用血管紧张素转换酶（ACE）抑制剂，但沙坦类药物使用时没有问题。一些“内在”的部分凝血活酶时间（PTT）延长是由凝血因子吸附引起的；通过在预充和治疗期间减少肝素用量，可以避免DALI后PTT过度延长。对于易发生碱中毒和低钾血症的患者，建议降低ACD - A比例。吸附器入口压力升高可能是由于抗凝不足、吸附器凝血或静脉通路故障。用生理盐水冲洗吸附器、推注肝素、增加枸橼酸盐混合液用量以及冲洗和/或重新调整静脉通路是有效的措施。如果遵循这些基本规则，DALI低密度脂蛋白血液分离术是一种安全、高效、快速且操作简便的低密度脂蛋白血液分离术，迄今为止已成功进行了超过80000次DALI治疗疗程，这一点得到了证明。
