Verrina E, Brendolan A, Gusmano R, Ronco C
Department of Nephrology, Istituto Gaslini, Genova, and Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy.
Kidney Int. 1998 Nov;54(5):1690-6. doi: 10.1046/j.1523-1755.1998.00135.x.
The dialysis dose, Kt/V, and Solute Removal Index (SRI) have been proposed as tools to measure and compare adequacy of different renal replacement therapies in adults. The aim of our study was to elucidate whether the Kt/V and SRI could be appropriate parameters to compare different treatments and define adequacy targets in children.
Twenty-two pediatric chronic dialysis patients (2 to 17 years) were prospectively studied. Six patients were on continuous ambulatory peritoneal dialysis (CAPD), 7 patients were on automatic nightly peritoneal dialysis (ANPD), and 9 were on hemodialysis (HD). Patients had no peritonitis and were not hospitalized during the previous two months and, as proved by growth and subjective well being, were in steady state condition at the initiation of the protocol. As a consequence, the treatment delivered was assumed to be adequate and the prospective analysis was carried out within one month. Urea levels in dialysate, plasma and urine were measured to determine urea kinetics and measure adequacy parameters.
Instantaneous urea clearance was much higher when hemodialysis was used (124.67 +/- 32.04 ml/min) compared to CAPD (2.79 +/- 0.29 ml/min) and ANPD (6.60 +/- 1.42 ml/min), as expected. The Urea dialytic clearance per week was greater in HD (67320 +/- 17299 ml) than in CAPD(28144 +/- 2895 ml) and ANPD (29910 +/- 4234 ml). Residual renal function contributed to the overall weekly clearance by 47% in CAPD, while it was only by 19% in HD and 26% in ANPD. The overall weekly clearance was therefore 79,842 ml/week in HD, 53,340 ml/week in CAPD and 41,012 ml/week in ANPD. Weekly dialytic Kt/V results were much higher in HD (3.75) than in CAPD (1.78) and ANPD (2.37). To these values, the renal Kt/V was added, reaching the values of overall (dialytic + renal) weekly Kt/V of 4.53 in HD, 3.41 in CAPD and 3.41 in ANPD. Although higher Kt/V values were observed in HD, when the SRI % was considered, HD appeared to be less efficient compared with the other two techniques. Since postdialytic rebound in HD patients averaged 22.5%, we may speculate that hemodialysis in children is less efficient than continuous or daily peritoneal dialysis because of a remarkable cardipulmonary recirculation and solute sequestration.
In the global evaluation, dialysis SRI% appears to be more reliable as an index of adequacy compared to Kt/V in children. At least an integration between the two indices is strongly recommended.
透析剂量、Kt/V 和溶质清除指数（SRI）已被提议作为衡量和比较成人不同肾脏替代疗法充分性的工具。我们研究的目的是阐明 Kt/V 和 SRI 是否可以作为比较不同治疗方法和确定儿童充分性目标的合适参数。
对 22 名儿科慢性透析患者（2 至 17 岁）进行了前瞻性研究。6 名患者接受持续性非卧床腹膜透析（CAPD），7 名患者接受夜间自动化腹膜透析（ANPD），9 名患者接受血液透析（HD）。患者在过去两个月内无腹膜炎且未住院，并且根据生长情况和主观健康状况证明，在方案开始时处于稳定状态。因此，假定所给予的治疗是充分的，并在一个月内进行前瞻性分析。测量透析液、血浆和尿液中的尿素水平以确定尿素动力学并测量充分性参数。
正如预期的那样，与 CAPD（2.79±0.29 ml/min）和 ANPD（6.60±1.42 ml/min）相比，使用血液透析时的即时尿素清除率要高得多（124.67±32.04 ml/min）。HD 每周的尿素透析清除率（67320±17299 ml）高于 CAPD（28144±2895 ml）和 ANPD（29910±423 ml）。残余肾功能对 CAPD 每周总清除率的贡献为 47%，而在 HD 中仅为 19%，在 ANPD 中为 26%。因此，HD 的每周总清除率为 79842 ml/周，CAPD 为 53340 ml/周，ANPD 为 41012 ml/周。HD 的每周透析 Kt/V 结果（3.75）远高于 CAPD（1.78）和 ANPD（2.37）。将肾脏 Kt/V 加到这些值上，HD 的每周总（透析 + 肾脏）Kt/V 值达到 4.53，CAPD 为 3.41，ANPD 为 3.41。尽管在 HD 中观察到较高的 Kt/V 值，但当考虑 SRI%时，与其他两种技术相比，HD 的效率似乎较低。由于 HD 患者透析后的反跳平均为 22.5%，我们可以推测，由于明显的心肺再循环和溶质潴留，儿童血液透析的效率低于持续性或每日腹膜透析。
在整体评估中，与 Kt/V 相比，透析 SRI%作为儿童充分性指标似乎更可靠。强烈建议至少将这两个指标结合起来。
