以血浆作透析液的血液透析联合高容量血液滤过治疗高胆红素血症的机制研究

Effect of hemodialysis with plasma-based dialysate plus high volume hemofiltration on serum bilirubin in patients with heperbilirubinemia

目的前瞻性观察以人体新鲜冰冻血浆作透析液行血液透析(HD-PBD)后继续进行高容量血液滤过(HVHF),评价其对高胆红素血症患者血清胆红素的清除机制。方法选择第四军医大学第一附属医院15例肝衰竭患者行HD-PBD治疗6h后,应用同一滤器(AV600)继续行HVHF治疗24h。全部患者分别在HD-PBD治疗初始(0h)及开始后2h、4h和6h取滤器动脉端和静脉端血液、流入端和流出端透析液,HVHF治疗0h、6h、12h和24h取滤器前及滤器后血液,同时留取滤液。观察治疗前后胆红素水平的变化。结果①HD-PBD对胆红素的清除较HVHF明显(P<0.05)。②HD-PBD治疗初始的TB溶质清除率(Kd)为(23.0±3.4)ml/min,滤器使用4～6h后弥散作用下降。③HD-PBD治疗初始通过弥散和吸附的体外清除量分别为(15.6±5.6)mmol/min和(10.3±3.2)mmol/min,滤器使用4～6h后作用下降。④HVHF以吸附清除为主,其中治疗初始吸附清除量最大,12h以后吸附清除量而滤过清除量相对恒定。⑤HD-PBD治疗初始的体外清除总量高于HVHF[(25.9±8.2)mmol/minvs(7.17±3.34)mmol/min,P<0.05。结论HD-PBD联合HVHF治疗对血清胆红素有明显降低作用,其清除机制主要为弥散和吸附,对流作用较小。

Objective To prospectively evaluate the effect of hemodialysis with fresh frozen plasmabased dialysate （HD-PBD） plus high volume hemofiltration （HVHF） for the clearance of serum bilirubin in patients with heperbilirubinemia. Methods Fifteen patients with liver failure were included in this study. After HD-PBD therapy for the first 6 hours, patients were then treated with HVHF for 24 hours using the same AV600 filter. Blood and the plasma-based dialysate from vein and artery end of the filter were taken at 0, 2, 4 and 6h during HD-PBD. Blood before and after filtration as well as the ultrafiltrate were also taken at 0, 6, 12 and 24h during HVHF. Bilirubin was determined in dialysate, ultraafiltrate and plasma. Results ① The clearance rate of serum bilirubin with HD-PBD for 6 hours was significantly higher than that with HVHF for 24 hours （P〈0.05）. ② The Kd for serum total bilirubin （TB） was （23.0 ± 3.4） ml/min at the beginning of HD-PBD. After HD-PBD for 4-6 hours, the Kd for TB decreased significantly. ③ At the beginning of HD-PBD, the total clearance amount of TB by dispersion and adsorption were （15.6 ± 5.6） mmol/min and （10.3 ± 3.2） mmol/min, respectively, and then decreased significantly after using the filter for 4-6 hours. ④ In HVHF, TB was mainly removed by adsorption. After HVHF for 12h, clearance by adsorption decreased significantly, but the amount of clearance by ultrafiltration remained stable. ⑤The clearance amount of TB by HD-PBD at the beginning decreased significantly but higher than those by HVHF for 24 hours （P〈0.05）. Conclusion HD-PBD plus HVHF, a newly proposed modality for patients with liver failure, can decrease serum bilirubin efficiently. Dispersion and adsorption are the major mechanisms of serum bilirubin clearance in HD-PBD, of which the ability decreased gradually after 4 hours of dialysis. Convection and adsorption are the major mechanisms of serum bilirubin clearance in HVHF, but the efficiency is relatively low.