高截留分子量超滤膜在临床中的应用.ppt

高截留分子量超滤膜在临床中的应用,1,12/18/2019,2,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,12/18/2019,3,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:Thecut-offpointofasoluteforanymembraneisasievingcoefficientof0.1.Thismeansthat10%ofthemoleculeswillpassand90%willnotpass.,12/18/2019,4,筛选系数-SC,筛选系数SC（seivingcoeffcient)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,SIEVINGCOEFFICIENT,1.0,0,5600inulin,11800b2-m,21000RBP,44000orosomucoide,54000a1AT,66500albumin,MOLECULARWEIGHT=SOLUTESIZE,DEFINITION:Thecut-offpointofasoluteforanymembraneisasievingcoefficientof0.1.Thismeansthat10%ofthemoleculeswillpassand90%willnotpass.,0.5,60urea,Cut-offpoint,O.1,筛选系数与截留分子量,SoluteClassesbyMolecularWeight,Daltons,高截留分子量超滤膜,RR-AB-34Jan2011,Newfunctionalmembranewithdefinedlargerporesize,HCOmembrane,0,01m,0,02m,0,09m,0,30m,:porediameter,highflux,highcut-off*,proteinseparationmembrane,plasmaseparationmembrane,Variationofmembraneporesize,Electronmicrographsofinnermembranesurface,HighCut-OffHemofilter,MolecularWeightDa,StandardHighFlux,HighCut-Off,HF,UF=1L/h,t=2h,Median,25th-75thpercentiles),ICM(2002)28:651-655,HCOMembranewithincreasedpermeabilityforinflammatorymediators,membranecharacteristics,高截留分子量超滤膜的临床应用,12,HCOtreatmentreducessignificantlyinflammatorymediatorplasmalevels,高截留分子量超滤膜的临床应用,IL-6inPROWESS,Non-survivors,Survivors,Kinasewitzetal,CritCare2004,PROWESS（RecombinantHumanActivatedProteinCWorldwideEvaluationinSevereSepsis)Study,Atstudyentry,evaluatedIL-6waspresentin98.5%patents,LimitedEffectof“Standard”CRRTonPlasmaInflammatoryMediatorLevels,Herringetal,KidneyBloodPressRes2003,CourseofIL-6plasmalevelduringtreatmentwithsepteX/HCO,IntensiveCareMed2003;29:1989-95,N=24ptsCVVH,SubstantialReductionofPlasmaIL-6Levels,Interleukin-6plasmavalues,CritCareMed.2006;34:2099-04.,N=10ptsCVVH,N=20ptsCVVH,IL-6Clearance,mL/min,Sievingcoefficient:,MorgeraS,BellomoRetal.CritCareMed.2006;34:2099-04,CVVHUF-rate2.5L/h,RecentHPHFStudiesinSepsis:,ClearanceratesforIL-6weresignificantlyhigherinthehighcutoffhemofiltrationgroup(p.0001).,CellularimmunomodulationthroughHCOtreatment,高截留分子量超滤膜的临床应用,MuretetalShock2000HoffmannetalKidneyInt.1995HeideckeetalAmJSurg.1999,T-LymhocyteProliferationisReducedinSepsis,MonocytephagocytosisiselevatedinSepsis,SparkJI,ScottDJ.BrJSurg.2001;88:1583-9.,SimmsHH,DAmicoR.Blood.1994;83:1398-407,Cellularimmunomodulation,Humansepsisstudies:,HCOtreatmentrestoreslymphocyteproliferationinsepticpatients,NDT,2003;18:2570-6.,N=28ptsCVVH,与HCO可以滤除淋巴细胞增殖的阻滞物质有关,HCOtreatmentreducesmonocytephagocytosisrateofsepticpatients,NephronClinPract.2003;94:75-80,CVVH,ClinicalbenefitsthroughHCOtreatment,高截留分子量超滤膜的临床应用,NorepinephrinerequirementisreducedwithHCO,CritCareMed.2006;34:2099-04.,N=20ptsCVVH,N=10ptsCVVH,P=0.1103,P=0.5717,MAPmmHg,MAPmmHg,ImprovementinSimplifiedAcutePhysiologyScore(SAPS)II,CritCareMed.2006;34:2099-04.,N=20ptsCVVH,N=10ptsCVVH,ClearanceRatesforHCOFilter:CVVHvsCVVHD,2,Morgeraetal,AmJKidneyDis2004,clinicalsafety-data,高截留分子量超滤膜的临床应用,Stablealbuminplasmalevelsduringtreatment,N=24ptsCVVH/CVVHD,AmJKidneyDis.2004,43:444-53.,CoagulationStatusDuringHighCut-OffHemofiltration,IntensiveCareMed2003;29:1989-95,N=16ptsCVVH,DaysonNorephrinine(10,09vs11,39)DaysonVentilation(13,911vs16,111)NeedforRRT(9,18vs9,58),HCOversusstandardhighflux,RecentHPHFStudiesinSepsis,HonorePMetal.10thCongressofWFSICCM.Florence2009,HICOSS(HighCut-OffSepsisStudy)MulticenterstudywithHCOinsepticAKIReductionofcatecholaminerequirementsbyHighCutoff-CVVHD:clinicalimprovementsandSafety(albuminlevels),SOFA,Days28mortality(31vs33%)bothgroupslowerthanpredictedbyAPACHEscoreDaysinICU(1912vs1911),HCOvsstandardhighflux,RecentHPHFStudiesinSepsis:,HCO,High-Flux,HonorePMetal.10thCongressofWFSICCM.Florence2009,HICOSS(HighCut-OffSepsisStudy)MulticenterstudywithHCOinsepticAKIReductionofcatecholaminerequirementsbyHighCutoff-CVVHD:clinicalimprovementsandSafety(albuminlevels),SOFA,HCOversusstandardhighflux,Safety:StableplasmaalbuminlevelswithHCOcomparedtostandardhighflux-CVVHD,N=81ptsCVVHD,RecentHPHFStudiesinSepsis:,HonorePMetal.10thCongressofWFSICCM.Florence2009,HICOSS(HighCut-OffSepsisStudy)MulticenterstudywithHCOinsepticAKIReductionofcatecholaminerequirementsbyHighCutoff-CVVHD:clinicalimprovementsandSafety(albuminlevels),SOFA,HCOversusstandardhighflux,RecentHPHFStudiesinSepsis:SynergywithHVHF?,CVVH+HPHF=1l/h=16.6ml/kg/h,HVHF+HPHF=6l/h=80ml/kg/h,Uchinoelal,IntCareMed2002;28:651-655,12/18/2019,34,百特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,12/18/2019,35,百特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,HaaseM,SilvesterW,UchinoS,etal.Apilotstudyofhigh-adsorptionhemofiltrationinhumansepticshock.IntJArtifOrgans.Feb2007;30(2):108-117.,12/18/2019,36,BaxterPSHF高截留分子量聚砜膜滤器,12/18/2019,37,滤器介绍BaxterPSHF系列滤器介绍主要竞品滤器介绍,目录,常见的CRRT治疗的滤器和高通透析器分类,用于危重症CRRT治疗的血滤器：百特PSHF系列金宝AN69、AN69ST系列费森AV系列,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百特exeltra210金宝Hemofilter6s费森F60,12/18/2019,39,中国市场主要滤器简介,AN-69系列-Gambro,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,Lonnemannetal13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