不同血液净化模式对维持性血液透析患者蛋白结合类毒素的清除效果

Removal efficacy of protein-bound uraemic toxins by different blood purification strategies

目的:探讨不同血液净化方式对维持性血液透析(MHD)患者蛋白结合类毒素清除的效果。方法:选取符合入选标准的MHD患者136例,经4周洗脱期,随机分成4组:低通量血液透析(LFHD)组、高通量血液透析(HFHD)组,血液透析滤过(HDF)组和血液透析联合血液灌流(HD+HP)组,采用高效液相色谱串联质谱法(HPLC-MS/MS)方法测定不同血液净化方法治疗前后血清、透析废液和血液灌流器中马尿酸(HA)、硫酸对甲酚(PCS)、硫酸吲哚酚(IS)、3-羧基-4-甲基-5-丙基-2-呋喃丙酸(CMPF)的浓度,观察对蛋白结合类毒素的清除效果。结果:四种模式皆能有效清除HA,各组之间无差异。对血清PCS的清除,HDF组和HD+HP组的下降率高于LFHD组(P<0.01)和HFHD组(P<0.05,P<0.01)。对血清IS的清除,HDF组和HD+HP组高于LFHD组、HFHD组(均P<0.05)。对于血清CMPF的清除,HD+HP组和HDF组明显高于LFHD组、HFHD组(P<0.01),HD+HP组高于HDF组(P<0.01),LFHD组与HFHD组相比无差别(P>0.05)。结论:四种方式对于蛋白结合力较低的蛋白结合类毒素清除效率接近于小分子毒素的清除效果;HDF、HD+HP对中等蛋白结合力的蛋白结合类毒素的清除能力优于HFHD、LFHD;HD+HP清除高蛋白结合力的蛋白结合毒素的能力最佳,HDF次之,LFHD和HFHD几乎无效。

Objective：To compare the efficiency of protein-bound uraemic toxins removal by four main strategies [ low-flux hemodialysis （ LFHD ）, high-flux hemodialysis （ HFHD ）, hemodiafihration （HDF） and hemoperfusion （ HD ＋ HP）.] Methodology： This study was a prospective, randomized clinical trial. 136 maintenance hemodialysi （MHD） patients were selected and after four weeks of run-in period they were randomly divided into four groups ： LFHD group, HFHD group,HDF group and HD＋HP group.Removal of hippuric acid（HA） ,p-cresyl sulfate （PCS） ,indoxyl sulfate （IS） and 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid（CMPF） was determined by reduction ratios （RRs） and total solute removal （TSR） in continuously collected dialysate and HD ＋ HP apparatus by high-performance liquid chromatography tandem mass spect-rometry （ HPLC-MS/MS ）. Results： Plasma levels of the protein-bound toxins were significantly decreased by all treatment forms,but the removal effective were different.As for HA,the reduction rate were no difference in each group （P〉0.05）.As for PCS,HDF and HD＋HP have higher RR than LFHD （P〈0.01） and HFHD （P〈0.05,P〈 0.01） .As for IS,HDF and HD＋HP have higher RR than LFHD （P〈O. 05） and HFHD （P〈0. 05）. CMPF can hardly remove in LFHD and HFHD ,while HDF and HD＋HP have higher RR than LFHD （P〈0. O1 ） and HFHD （P〈O. 01 ）. And HD＋HP was higher than HDF （P〈0. 01 ）. Conclusion：The remove efficacy of low affinity to human serum albumin protein-bound toxin were not significant different among groups. To remove middle affinity to human serum albumin protein- bound toxins, HDF and HD ＋ HP were superior to HFHD and LFHD. To remove high affinity to human serum albumin protein-bound toxins, HDF and HD＋HP can be partially removed, and HD＋HP is the best. While HFHD and LFHD were hardly to remove.