高截留分子量超滤膜在临床中的应用课件.ppt

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11/11/20232 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1/11/20233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 a

2、ny membrane is a sieving coefficient of 0.1.This means that 10%of the molecules will pass and 90%will not pass.1/11/20234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 SIZEDEF

3、INITION: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”“middle”“large”

4、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 membrane surfacesi

5、eving coefficient100100010000100000100000000.20.40.60.81Molecular 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=2hMedian,25th-75t

6、h 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-survivorsSurvivorsKinasewitz et al,Cr

7、it 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 of IL-6 plasma level dur

8、ing 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.Crit Care Med.2006;34:2099-04CVV

9、HUF-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 alAm J Surg.1999T-Lymhocyte Pro

10、liferation 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 patients NDT,2003;18:2570-6.N=28 pts CV

11、VH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=20 pts CVVHN=10 pts CVVHP=0.1103P=0.5717M

12、AP 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 albumin plasma levels during treatmentN=24 ptsCVVH

13、/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)HCO versus standard high flux Recent HPHF Studies in Seps

14、isHigh-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(31 vs 33%)both groups lower than predicted by APACHE score Days

15、 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 off-CVVHD:clinical improvements and Safety(albumin levels),SOFA HCO ve

16、rsus 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 AKI Reduction of catecholamine requirements by High Cut off-CVVHD:clinical impro

17、vements 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;28:651-6551/11/202334百特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

18、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1/11/202335百特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 hig

19、h-adsorption hemofiltration in human septic shock.Int J Artif Organs.Feb 2007;30(2):108-117.1/11/202336Baxter PSHF 高截留分子量聚砜膜滤器1/11/202337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-单次使用的高通量透析器单次使用的高通量透析器百特 e

20、xeltra 210金宝 Hemofilter 6s费森 F 601/11/202339 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-Diacap Acute PS、sterilization by radialDiaca

21、p Acute S,M,LASAHI-ExcelfloPS、sterilization by radialAEF-03,AEF-07,AEF-10,AEF-13中国市场主要滤器简介中国市场主要滤器简介AN-69AN-69系列系列-G-Gambroambro对中大分子的清除以吸附作用为主。对中大分子的清除以吸附作用为主。合成膜的疏水性和表面电荷使其能吸附炎症介质水凝胶膜（AN69）的膜表面与孔道均参与吸附，故吸附量最大Lonnemann et al13在進一步的活體研究中14-18證明PAN濾膜只是吸收而不是濾過IL-1。Heidelberg,Germany,Springer-Verlag,19

22、93,pp 613-623。AN-69AN-69系列系列-Gambro-GambroVriese ASD，JASN 1999；10：84615例脓毒血症病人，AN69膜CVVH说明：2hr内清除作用明显，2hr 后清除作用减弱；6hr后无清除作用，浓度逐渐升高；12hr 更换滤器，治疗24小时后没见到明显的毒素浓度降低。AN-69AN-69系列系列-Gambro-Gambro强大吸附作用带来的副作用强大吸附作用带来的副作用2hr 后膜孔逐渐堵塞，对各类分子的清除效果都急剧降低吸附后的膜表面粗燥，启动凝血链，减少滤器使用时间。（PAN的寿命比PS平均要少34小时）。AVAV系列系列-FMC-FMC 聚砜膜 种类：截流分子量 30 KD 特色：蒸汽消毒44 以上有不当之处，请大家给与批评指正，谢以上有不当之处，请大家给与批评指正，谢谢大家！谢大家！