Gayrard Nathalie, Ficheux Alain, Duranton Flore, Guzman Caroline, Szwarc Ilan, Vetromile Fernando, Cazevieille Chantal, Brunet Philippe, Servel Marie-Françoise, Argilés Àngel, Le Quintrec Moglie
RD-Néphrologie and EA7288, University of Montpellier, Montpellier, France.
Centre de dialyse Néphrologie Dialyse St Guilhem, Sète, France.
PLoS One. 2017 Feb 6;12(2):e0171179. doi: 10.1371/journal.pone.0171179. eCollection 2017.
Recent randomised controlled trials suggest that on-line hemodiafiltration (OL-HDF) improves survival, provided that it reaches high convective volumes. However, there is scant information on the feasibility and the consequences of modifying convection volumes in clinics.
Twelve stable dialysis patients were treated with high-flux 1.8 m2 polysulphone dialyzers and 4 levels of convection flows (QUF) based on GKD-UF monitoring of the system, for 1 week each. The consequences on dialysis delivery (transmembrane pressure (TMP), number of alarms, % of achieved prescribed convection) and efficacy (mass removal of low and high molecular weight compounds) were analysed.
TMP increased exponentially with QUF (p<0.001 for N >56,000 monitoring values). Beyond 21 L/session, this resulted into frequent TMP alarms requiring nursing staff interventions (mean ± SEM: 10.3 ± 2.2 alarms per session, p<0.001 compared to lower convection volumes). Optimal convection volumes as assessed by GKD-UF-max were 20.6 ± 0.4 L/session, whilst 4 supplementary litres were obtained in the maximum situation (24.5 ± 0.6 L/session) but the proportion of sessions achieving the prescribed convection volume decreased from 94% to only 33% (p<0.001). Convection increased high molecular weight compound removal and shifted the membrane cut-off towards the higher molecular weight range.
Reaching high convection volumes as recommended by the recent RCTs (> 20L) is feasible by setting an HDF system at its optimal conditions based upon the GKD-UF monitoring. Prescribing higher convection volumes resulted in instability of the system, provoked alarms, was bothersome for the nursing staff and the patients, rarely achieved the prescribed convection volumes and increased removal of high molecular weight compounds, notably albumin.
近期的随机对照试验表明，联机血液透析滤过（OL-HDF）可提高生存率，但前提是要达到高对流容量。然而，关于在临床中改变对流容量的可行性及后果的信息却很少。
12名稳定的透析患者使用高通量1.8平方米聚砜透析器，并根据系统的肾小球滤过率-超滤（GKD-UF）监测设置4个对流流量（QUF）水平，每个水平治疗1周。分析了对透析输送（跨膜压（TMP）、警报次数、达到规定对流的百分比）和疗效（低分子量和高分子量化合物的清除量）的影响。
TMP随QUF呈指数增加（对于N>56,000个监测值，p<0.001）。超过21L/次时，这导致频繁的TMP警报，需要护理人员进行干预（平均值±标准误：每次治疗10.3±2.2次警报，与较低对流容量相比，p<0.001）。通过GKD-UF-max评估的最佳对流容量为20.6±0.4L/次，而在最大情况下可获得4升额外的量（24.5±0.6L/次），但达到规定对流容量的治疗次数比例从94%降至仅33%（p<0.001）。对流增加了高分子量化合物的清除，并使膜截留分子量向更高分子量范围移动。
根据GKD-UF监测将血液透析滤过（HDF）系统设置在最佳条件下，按照近期随机对照试验（RCTs）的建议达到高对流容量（>20L）是可行的。规定更高的对流容量会导致系统不稳定，引发警报，给护理人员和患者带来困扰，很少能达到规定的对流容量，并增加高分子量化合物的清除，尤其是白蛋白。
