Daugirdas John T, Levin Nathan W, Kotanko Peter, Depner Thomas A, Kuhlmann Martin K, Chertow Glenn M, Rocco Michael V
Semin Dial. 2008 Sep-Oct;21(5):377-84. doi: 10.1111/j.1525-139X.2008.00483.x.
A number of denominators for scaling the dose of dialysis have been proposed as alternatives to the urea distribution volume (V). These include resting energy expenditure (REE), mass of high metabolic rate organs (HMRO), visceral mass, and body surface area. Metabolic rate is an unlikely denominator as it varies enormously among humans with different levels of activity and correlates poorly with the glomerular filtration rate. Similarly, scaling based on HMRO may not be optimal, as many organs with high metabolic rates such as spleen, brain, and heart are unlikely to generate unusually large amounts of uremic toxins. Visceral mass, in particular the liver and gut, has potential merit as a denominator for scaling; liver size is related to protein intake and the liver, along with the gut, is known to be responsible for the generation of suspected uremic toxins. Surface area is time-honored as a scaling method for glomerular filtration rate and scales similarly to liver size. How currently recommended dialysis doses might be affected by these alternative rescaling methods was modeled by applying anthropometric equations to a large group of dialysis patients who participated in the HEMO study. The data suggested that rescaling to REE would not be much different from scaling to V. Scaling to HMRO mass would mandate substantially higher dialysis doses for smaller patients of either gender. Rescaling to liver mass would require substantially more dialysis for women compared with men at all levels of body size. Rescaling to body surface area would require more dialysis for smaller patients of either gender and also more dialysis for women of any size. Of these proposed alternative rescaling measures, body surface area may be the best, because it reflects gender-based scaling of liver size and thereby the rate of generation of uremic toxins.
为了替代尿素分布容积（V），人们提出了一些用于调整透析剂量的分母。这些包括静息能量消耗（REE）、高代谢率器官（HMRO）的质量、内脏质量和体表面积。代谢率不太可能作为分母，因为它在不同活动水平的人群中差异极大，且与肾小球滤过率的相关性很差。同样，基于HMRO进行调整可能并非最佳选择，因为许多高代谢率的器官，如脾脏、大脑和心脏，不太可能产生大量的尿毒症毒素。内脏质量，尤其是肝脏和肠道，作为调整的分母具有潜在的优势；肝脏大小与蛋白质摄入量有关，并且已知肝脏和肠道是疑似尿毒症毒素产生的原因。体表面积作为肾小球滤过率的一种长期使用的调整方法，其与肝脏大小的缩放方式类似。通过将人体测量方程应用于参与HEMO研究的一大组透析患者，对目前推荐的透析剂量可能如何受到这些替代调整方法的影响进行了建模。数据表明，根据REE进行调整与根据V进行调整没有太大差异。根据HMRO质量进行调整将要求为较小的男性或女性患者大幅提高透析剂量。在所有体型水平上，根据肝脏质量进行调整将要求女性比男性进行更多的透析。根据体表面积进行调整将要求较小的男性或女性患者进行更多的透析，并且对于任何体型的女性也需要更多的透析。在这些提议的替代调整措施中，体表面积可能是最好的，因为它反映了基于性别的肝脏大小缩放，从而反映了尿毒症毒素的产生速率。
