Ricci Zaccaria, Ronco Claudio, Bachetoni Alessandra, D'amico Giuseppe, Rossi Stefano, Alessandri Elisa, Rocco Monica, Pietropaoli Paolo
Department of Intensive Care, Policlinico Umberto I, Rome, Italy.
Crit Care. 2006;10(2):R67. doi: 10.1186/cc4903.
The best modality, for continuous renal replacement therapy (CRRT) is currently uncertain and it is poorly understood how transport of different solutes, whether convective or diffusive, changes over time.
We conducted a prospective cross over study in a cohort of critically ill patients, comparing small (urea and creatinine) and middle (beta2 microglobulin) molecular weight solute clearance, filter lifespan and membrane performance over a period of 72 hours, during 15 continuous veno-venous dialysis (CVVHD) and 15 continuous veno-venous hemofiltration (CVVH)sessions. Both modalities were administered based on a prescription of 35 ml/kg/h and using polyacrylonitrile filters.
Median filter lifespan was significantly longer during CVVHD (37 hours, interquartile range (IQR) 19.5 to 72.5) than CVVH (19 hours, IQR 12.5 to 28) (p = 0.03). Median urea time weighted average (TWA) clearances were not significantly different during CVVH (31.6 ml/minute, IQR 23.2 to 38.9) and CVVHD (35.7 ml/minute, IQR 30.1 to 41.5) (p = 0.213). Similar results were found for creatinine: 38.1 ml/minute, IQR 28.5 to 39, and 35.6 ml/minute, IQR 26 to 43 (p = 0.917), respectively. Median beta2m TWA clearance was higher during convective (16.3 ml/minute, IQR 10.9 to 23) than diffusive (6.27 ml/minute, IQR 1.6 to 14.9) therapy; nonetheless this difference did not reach statistical significance (p = 0.055). Median TWA adsorptive clearance of beta2m appeared to have scarce impact on overall solute removal (0.012 ml/minute, IQR -0.09 to 0.1, during hemofiltration versus -0.016 ml/minute, IQR -0.08 to 0.1 during dialysis; p = 0.79). Analysis of clearance modification over time did not show significant modifications of urea, creatinine and beta2m clearance in the first 48 hours during both treatments. In the CVVHD group, the only significant difference was found for beta2m between 72 hours and baseline clearance.
Polyacrylonitrile filters during continuous hemofiltration and continuous hemodialysis delivered at 35 ml/kg/h are comparable in little and middle size solute removal. CVVHD appears to warrant longer CRRT sessions. The capacity of both modalities for removing such molecules is maintained up to 48 hours.
目前，连续肾脏替代疗法（CRRT）的最佳模式尚不确定，人们对不同溶质（无论是对流还是扩散）的转运如何随时间变化也知之甚少。
我们对一组危重症患者进行了一项前瞻性交叉研究，在15次连续性静脉-静脉血液透析（CVVHD）和15次连续性静脉-静脉血液滤过（CVVH）治疗期间，比较了小分子量（尿素和肌酐）和中分子量（β2微球蛋白）溶质清除率、滤器使用寿命和膜性能，为期72小时。两种模式均按照35 ml/kg/h的处方给药，并使用聚丙烯腈滤器。
CVVHD期间滤器的中位使用寿命（37小时，四分位间距（IQR）19.5至72.5）显著长于CVVH（19小时，IQR 12.5至28）（p = 0.03）。CVVH（31.6 ml/分钟，IQR 23.2至38.9）和CVVHD（35.7 ml/分钟，IQR 30.1至41.5）期间的尿素时间加权平均（TWA）清除率无显著差异（p = 0.213）。肌酐的结果相似：分别为38.1 ml/分钟，IQR 28.5至39，以及35.6 ml/分钟，IQR 26至43（p = 0.917）。对流治疗期间β2m的中位TWA清除率（16.3 ml/分钟，IQR 10.9至23）高于扩散治疗（6.27 ml/分钟，IQR 1.6至14.9）；尽管如此，这种差异未达到统计学意义（p = 0.055）。β2m的中位TWA吸附清除率似乎对整体溶质清除影响不大（血液滤过期间为0.012 ml/分钟，IQR -0.09至0.1，而透析期间为-0.016 ml/分钟，IQR -0.08至0.1；p = 0.79）。两种治疗前48小时内尿素、肌酐和β2m清除率随时间的变化分析未显示出显著变化。在CVVHD组中，仅在72小时和基线清除率之间发现β2m有显著差异。
以35 ml/kg/h进行的连续性血液滤过和连续性血液透析期间的聚丙烯腈滤器在小分子量和中分子量溶质清除方面具有可比性。CVVHD似乎可以保证更长的CRRT治疗时间。两种模式清除此类分子的能力在48小时内保持稳定。
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