高截留分子量超滤膜在临床中的应用

1、crrt高截留分子量超滤膜在临床中的应用高截留分子量超滤膜在临床中的应用12/22/20222 基本概念 高截留分子量超滤膜 高截留分子量超滤膜在临床中的应用内容目录2/22/20223截留分子量截留分子量截留分子量截留分子量CO是指对有孔材料孔径大小的一种描述。在能自由通过某种有孔材料的分子中最大分子的分子量即为该材料的截留分子量。大于截留分子量的分子，被材料截留；小于截留分子量的分子，则可自由通过。一般滤器膜的截留分子量分子的筛选系数为0.1，即通过滤器膜能力为10%的分子的分子量定义为截留分子量。DEFINITION: The cut-off point of a solute for

2、any membrane is a sieving coefficient of 0.1 . This means that 10% of the molecules will pass and 90% will not pass .2/22/20224筛选系数-SC筛选系数SC（seiving coeffcient)为超滤液中溶质浓度与滤器前血浆溶质浓度比值，是溶质通过滤器膜能力的一个定量指标SC越高，表明CRRT治疗清除的 溶质越多，SC接近1，提示溶质近乎可自由通过滤器膜滤器膜的性质会影响SC值SIEVING COEFFICIENT1.0MOLECULAR WEIGHT=SOLUTE S

3、IZEDEFINITION:The cut-off point of a solute for any membrane is a sieving coefficient of 0.1 . This means that 10% of the molecules will pass and 90% will not pass .0.560 ureaCut-off pointO.1筛选系数与截留分子量筛选系数与截留分子量Solute Classes by Molecular WeightDaltons Inflammatory Mediators (1,200-50,000)“small”“mi

4、ddle”“large”crrt高截留分子量超滤膜高截留分子量超滤膜RR-AB-34 Jan 2011New functional membrane with defined larger pore sizeHCO membrane 0,01 m 0,02 m 0,09 m 0,30 m: pore diameterhigh fluxhigh cut-off*protein separation membraneplasma separation membraneVariation of membrane pore sizeElectron micrographs of inner membr

5、ane surfacesieving coefficient100100010000100000100000000.81Molecular weight DClassical Filter30 kD human kidneyhigh cut-offHigh Cut-Off Hemofilter 00,20,40,60,811000100001000001000000Molecular Weight DaltonSieving CoefficientMolecular Weight DaStandard HighFluxHigh Cut-OffHF, UF=1L/h, t=2h

6、Median, 25th-75th percentiles)ICM (2002) 28:651-655HCO Membrane with increased permeability for inflammatory mediatorsmembrane characteristics crrt高截留分子量超滤膜的临床应用高截留分子量超滤膜的临床应用12HCO treatment reduces significantly inflammatory mediator plasma levels高截留分子量超滤膜的临床应用IL-6 in PROWESSNon-survivorsSurvivorsK

7、inasewitz et al, Crit Care 2004PROWESS （Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis)StudyAt study entry, evaluated IL-6 was present in 98.5% patentsLimited Effect of “Standard” CRRT on Plasma Inflammatory Mediator LevelsHerring et al, Kidney Blood Press Res 2003Course

8、 of IL-6 plasma level during treatment with septeX/HCOIntensive Care Med 2003;29:1989-95N=24 pts CVVHSubstantial Reduction of Plasma IL-6 LevelsInterleukin-6 plasma valuesCrit Care Med. 2006;34:2099-04.N=10 pts CVVHN=20 pts CVVHIL-6 ClearancemL / minSieving coefficient: Morgera S,Bellomo R et al.Cri

9、t Care Med. 2006;34:2099-04CVVHUF-rate 2.5L/hRecent HPHF Studies in Sepsis:Clearance rates for IL-6 were significantly higher in the high cutoff hemofiltration group (p .0001).Cellular immunomodulation through HCO treatment高截留分子量超滤膜的临床应用Muret et alShock 2000 Hoffmann et alKidney Int. 1995Heidecke et

10、 alAm J Surg. 1999T-Lymhocyte Proliferation is Reduced in SepsisMonocyte phagocytosis is elevated in SepsisSpark JI, Scott DJ. Br J Surg. 2001;88:1583-9.Simms HH, DAmico R. Blood. 1994;83:1398-407Cellular immunomodulationHuman sepsis studies:HCO treatment restores lymphocyte proliferation in septic

11、patients NDT, 2003;18:2570-6.N=28 pts CVVH与HCO可以滤除淋巴细胞增殖的阻滞物质有关HCO treatment reduces monocyte phagocytosis rate of septic patientsNephron Clin Pract. 2003;94:75-80 CVVHClinical benefits through HCO treatment高截留分子量超滤膜的临床应用Norepinephrine requirement is reduced with HCO Crit Care Med. 2006;34:2099-04.N

12、=20 pts CVVHN=10 pts CVVHP=0.1103P=0.5717MAP mmHg MAP mmHg Improvement in Simplified Acute Physiology Score (SAPS) IICrit Care Med. 2006;34:2099-04.N=20 pts CVVHN=10 pts CVVHClearance Rates for HCO Filter: CVVH vs CVVHD 2Morgera et al, Am J Kidney Dis 2004clinical safety- data高截留分子量超滤膜的临床应用Stable al

13、bumin plasma levels during treatmentN=24 ptsCVVH/ CVVHDAm J Kidney Dis. 2004, 43:444-53. Coagulation Status During High Cut-Off HemofiltrationIntensive Care Med 2003;29:1989-95N=16 pts CVVH Days on Norephrinine (10,0 9 vs 11,3 9) Days on Ventilation (13,9 11 vs 16,1 11) Need for RRT (9,1 8 vs 9,5 8)

14、HCO versus standard high flux Recent HPHF Studies in SepsisHigh-FluxHCO N= 81 pts CVVHDHICOSS (High Cut-Off Sepsis Study) Multicenter study with HCO in septic AKI Reduction of catecholamine requirements by High Cut off-CVVHD : clinical improvements and Safety (albumin levels), SOFA Days 28 mortality

15、 (31 vs 33%) both groups lower than predicted by APACHE score Days in ICU (1912 vs 1911) HCO vs standard high flux Recent HPHF Studies in Sepsis:HCOHigh-Flux N= 81 pts CVVHDHICOSS (High Cut-Off Sepsis Study) Multicenter study with HCO in septic AKI Reduction of catecholamine requirements by High Cut

16、 off-CVVHD : clinical improvements and Safety (albumin levels), SOFA HCO versus standard high flux Safety: Stable plasma albumin levels with HCO compared to standard high flux -CVVHDN= 81 pts CVVHD Recent HPHF Studies in Sepsis: HICOSS (High Cut-Off Sepsis Study) Multicenter study with HCO in septic

17、 AKI Reduction of catecholamine requirements by High Cut off-CVVHD : clinical improvements and Safety (albumin levels), SOFA HCO versus standard high flux Recent HPHF Studies in Sepsis: Synergy with HVHF ?CVVH + HPHF= 1l/h = 16.6 ml/kg/hHVHF+HPHF = 6 l/h = 80 ml/kg/h Uchino el al , Int Care Med 2002

18、; 28: 651-6552/22/202234百特HF系列滤器特点1百特HF系列是高截留分子量HCO ，聚砜膜血滤器的一种，合理的筛漏系数，截流，聚砜膜血滤器的一种，合理的筛漏系数，截流分子量为分子量为65KD膜生产技术充分考虑了白蛋白的丢失的可能，可安全放心使用细胞因子、毒性物质及免疫复合物清除效果显著，调节免疫促进内环境的稳定和脏器功能恢复，改善患者预后2/22/202235百特HF系列滤器特点2百特HF系列滤器安全稳定，不易凝血适当的亲水、疏水基团和电荷配比，不易造成孔隙堵塞无甘油聚砜膜，生物相容性好主要通过超滤有效清除毒性物质，可长时有效的维持膜孔的完整性强调：滤器最重要的功能在于滤

19、过而不是吸附；吸附功能强大的膜，例如：有报道13小时需要更换滤器来克服吸附带来的清除能力下降Haase M, Silvester W, Uchino S, et al. A pilot study of high-adsorption hemofiltration in human septic shock.Int J Artif Organs.Feb 2007;30(2):108-117.2/22/202236Baxter PSHF 高截留分子量聚砜膜滤器2/22/202237常见的常见的CRRTCRRT治疗的滤器和高通透析器分类治疗的滤器和高通透析器分类q用于危重症用于危重症CRRT治疗的

20、血滤器治疗的血滤器：百特PSHF系列金宝AN69、AN69ST系列费森 AV 系列q用于急、慢性肾衰竭患者的肾脏支持治疗用于急、慢性肾衰竭患者的肾脏支持治疗-单次使用的高通量单次使用的高通量透析器透析器百特 exeltra 210金宝 Hemofilter 6s费森 F 602/22/202239 BrandFeatureCodeBaxter-HF FilterPS、HCO=65kHF400,HF700,HF1200FMC-AV seriesPS、Steam sterilization、HCO=33kAV400s,AV600s,AV1000sGambro-AN69 SeriesPAN、Strong AdsorptionAN69(ST60,100,150);AN69ST（M60,M100,M150)B.Braun- Diac