Thomas George, Jaber Bertrand L
Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Semin Dial. 2009 Nov-Dec;22(6):610-4. doi: 10.1111/j.1525-139X.2009.00665.x.
The increasing number of patients requiring renal replacement therapy poses a challenge to maintain quality of care in the setting of limited resources. The commonly used modalities include hemodialysis and peritoneal dialysis, and using a "urea-centric" model to increase the clearance of small molecular weight uremic toxins beyond current guidelines does not appear to confer additional clinical benefits in terms of morbidity and mortality. Convective therapies including hemofiltration and hemodiafiltration, which also have higher middle molecule clearances, might offer significant benefits compared to diffusive therapy. We review the available evidence on convective therapies and their effects on middle molecular weight uremic toxins, particularly beta2 microglobulin because of its known associated morbidity. It is the authors' opinion that more emphasis should be placed on true uremic toxins such as beta2 microglobulin rather than surrogate uremic toxins like urea. Larger studies are also needed to study the merits of convective therapies, with a focus on cardiovascular morbidity and mortality.
需要肾脏替代治疗的患者数量不断增加，这对在资源有限的情况下维持医疗质量构成了挑战。常用的治疗方式包括血液透析和腹膜透析，采用“以尿素为中心”的模式来增加小分子尿毒症毒素的清除率，使其超出当前指南的标准，在发病率和死亡率方面似乎并未带来额外的临床益处。包括血液滤过和血液透析滤过在内的对流治疗，其对中分子物质的清除率也更高，与扩散治疗相比可能具有显著优势。我们回顾了关于对流治疗及其对中分子尿毒症毒素影响的现有证据，特别是β2微球蛋白，因为其已知的相关发病率。作者认为，应更多地关注像β2微球蛋白这样真正的尿毒症毒素，而不是像尿素这样的替代尿毒症毒素。还需要开展更大规模的研究来探讨对流治疗的优点，重点关注心血管发病率和死亡率。
