Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, the Netherlands.
Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, the Netherlands.
Am J Kidney Dis. 2014 Aug;64(2):247-56. doi: 10.1053/j.ajkd.2014.02.016. Epub 2014 Apr 1.
Intensive hemodialysis (HD) may have significant benefits. Recently, the role of extended hemodiafiltration (HDF) has gained interest. The aim of this study was to evaluate the acute effects of extended HD and HDF on hemodynamic response and solute removal.
Randomized crossover trial.
SETTINGS & PARTICIPANTS: Stable patients with end-stage renal disease undergoing conventional HD.
13 patients randomly completed a single study of 4-hour HD (HD4), 4-hour HDF (HDF4), 8-hour HD (HD8), and 8-hour HDF (HDF8), with a 2-week interval between study sessions. Between study sessions, patients received routine conventional HD treatments.
Acute hemodynamic effects and uremic toxin clearance.
Blood pressure and heart rate, pulse wave analysis, cardiac output, and microvascular density by sublingual capillaroscopy, as well as relative blood volume and thermal variables, were measured. Clearance and removal of uremic toxins also were studied.
Long treatments showed more stability of peripheral systolic blood pressure (change during HD4, -21.7±15.6 mm Hg; during HDF4, -23.3±20.8 mm Hg; during HD8, -6.7±15.2 mm Hg [P=0.04 vs. HD4; P=0.08 vs. HDF4]; and during HDF8, -0.5±14.4 mm Hg [P=0.004 vs. HD4; P=0.008 vs. HDF4]). A similar observation was found for peripheral diastolic and central blood pressures. Cardiac output remained more stable in extended sessions (change during HD4, -1.4±1.5 L/min; during HDF4, -1.6±1.0 L/min; during HD8, -0.4±0.9 L/min [P=0.02 vs. HDF4]; and during HDF8, -0.5±0.8 L/min [P=0.06 vs. HD4; P=0.03 vs. HDF4), in line with the decreased relative blood volume slope in long dialysis. No differences in microvascular density were found. Energy transfer rates were comparable (HD4, 13.3±4.7 W; HDF4, 16.2±5.6 W; HD8, 14.2±6.0 W; and HDF8, 14.5±4.3 W). Small-molecule and phosphate removal were superior during long treatments. β2-Microglobulin and fibroblast growth factor 23 (FGF-23) reduction ratios were highest in HDF8.
Small sample size, only acute effects were studied.
Treatment time, and not modality, was the determinant for the hemodynamic response. HDF significantly improved removal of middle molecules, with superior results in extended HDF.
强化血液透析（HD）可能具有显著的益处。最近，扩展血液透析滤过（HDF）的作用引起了关注。本研究旨在评估扩展 HD 和 HDF 对血液动力学反应和溶质清除的急性影响。
随机交叉试验。
接受常规 HD 的终末期肾病稳定患者。
13 名患者随机完成了 4 小时 HD（HD4）、4 小时 HDF（HDF4）、8 小时 HD（HD8）和 8 小时 HDF（HDF8）的单次研究，两次研究之间间隔 2 周。在研究期间，患者接受常规常规 HD 治疗。
急性血液动力学效应和尿毒症毒素清除。
血压和心率、脉搏波分析、心输出量和舌下毛细血管镜检查的微血管密度，以及相对血容量和热变量，均进行了测量。还研究了尿毒症毒素的清除和去除。
长时间治疗显示外周收缩压更稳定（HD4 期间的变化为-21.7±15.6 mm Hg；HDF4 期间为-23.3±20.8 mm Hg；HD8 期间为-6.7±15.2 mm Hg[P=0.04 与 HD4 相比；P=0.08 与 HDF4 相比]；HDF8 期间为-0.5±14.4 mm Hg[P=0.004 与 HD4 相比；P=0.008 与 HDF4 相比]）。外周舒张压和中心血压也有类似的观察结果。心输出量在延长治疗中更稳定（HD4 期间的变化为-1.4±1.5 L/min；HDF4 期间为-1.6±1.0 L/min；HD8 期间为-0.4±0.9 L/min[P=0.02 与 HDF4 相比；P=0.03 与 HDF4 相比），与延长透析期间相对血容量斜率的降低一致。微血管密度无差异。能量传递率相当（HD4，13.3±4.7 W；HDF4，16.2±5.6 W；HD8，14.2±6.0 W；HDF8，14.5±4.3 W）。小分子和磷酸盐的清除在长时间治疗中更优越。β2-微球蛋白和成纤维细胞生长因子 23（FGF-23）的降低率在 HDF8 中最高。
样本量小，仅研究了急性效应。
治疗时间而非治疗方式是血液动力学反应的决定因素。HDF 显著提高了中分子的清除率，并且在扩展 HDF 中效果更好。
