Schaefer Betti, Ujszaszi Akos, Schaefer Susanne, Heckert Karl Heinz, Schaefer Franz, Schmitt Claus Peter
Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany; and.
Institute of Pathophysiology, Semmelweis University, Budapest, Hungary.
Clin J Am Soc Nephrol. 2014 Sep 5;9(9):1563-70. doi: 10.2215/CJN.12581213. Epub 2014 Jul 3.
Patients with immune-mediated kidney disease and liver failure often require plasma exchange (PE) and hemodialysis (HD). Combining both methods (i.e., connecting the PE and HD circuits in series [tandem dialysis]) should allow for a more efficient treatment. This work reviews the authors' experience with tandem blood purification.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Chart review was utilized to retrospectively analyze the efficacy and tolerability of 92 combined PE/HD (cPE/HD) sessions in 26 children in comparison with 113 sequential PE/HD (sPE/HD) treatments performed in 32 children between 1988 and 2012 at the University of Heidelberg Center for Pediatric and Adolescent Medicine. Eleven children received both treatment modalities.
The mean treatment duration was 3.8 ± 2.2 hours per cPE/HD and 5.9 ± 1.6 hours per sPE/HD session (P<0.001). Dialyzer surface areas per body surface area (in meters squared) and blood flow rates were similar. Although a 3-fold higher initial bolus of heparin was administered with cPE/HD, the heparin dose per hour was similar with both modalities and the total heparin load was only slightly lower with cPE/HD, with a median 2939 IU/m(2) per session (interquartile range, 1868, 4189) versus 3341 IU/m(2) per session (interquartile range, 2126, 4792). In sessions with regional anticoagulation, equal citrate and calcium infusion rates were applied. Plasma turnover, ultrafiltration rates, and solute removal were comparable. Procedure-related problems developed in 14.0% of cPE/HD and 7.0% of sPE/HD sessions (P=0.37). Clinical symptoms occurred in 19.6% and 6.2% (P=0.05), necessitating treatment discontinuation in 12.0% and 5.3% of the sessions (P=0.14). Intra-individual comparison of both dialysis methods in 11 children reconfirmed these findings.
cPE/HD is a time-saving procedure relative to sPE/HD, but may be associated with a higher rate of procedure-related and clinical adverse events.
免疫介导性肾病和肝衰竭患者常需进行血浆置换（PE）和血液透析（HD）。将这两种方法结合（即串联连接PE和HD回路[串联透析]）应能实现更有效的治疗。本文回顾了作者在串联血液净化方面的经验。
设计、场所、参与者及测量：通过病历回顾，回顾性分析了海德堡大学儿童与青少年医学中心1988年至2012年间26例儿童92次联合PE/HD（cPE/HD）治疗的疗效和耐受性，并与32例儿童的113次序贯PE/HD（sPE/HD）治疗进行比较。11名儿童接受了两种治疗方式。
cPE/HD每次治疗的平均时长为3.8±2.2小时，sPE/HD每次治疗为5.9±1.6小时（P<0.001）。每单位体表面积（平方米）的透析器面积和血流量相似。尽管cPE/HD初始肝素推注量高3倍，但两种方式每小时的肝素剂量相似，且cPE/HD的肝素总用量仅略低，cPE/HD每次治疗的中位数为2939 IU/m²（四分位间距为1868, 4189），sPE/HD每次治疗为3341 IU/m²（四分位间距为2126, 4792）。在采用局部抗凝的治疗中，枸橼酸盐和钙的输注速率相同。血浆周转率、超滤率和溶质清除率相当。cPE/HD治疗中有14.0%出现与操作相关的问题，sPE/HD治疗中有7.0%出现（P = 0.37）。临床症状发生率分别为19.6%和6.2%（P = 0.05）, 导致12.0%和5.3%的治疗中断（P = 0.14）。对11名儿童两种透析方法的个体内比较再次证实了这些结果。
相对于sPE/HD，cPE/HD是一种节省时间的治疗方法，但可能与更高的操作相关及临床不良事件发生率相关。
