高截留分子量超滤膜在临床中的应用--课件

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1ppt课件高截留分子量超滤膜在临床中的应用1ppt课件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基本概念内容目录2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 any membrane is a sieving coefficient of 0.1.This means that 10%of the molecules will pass and 90%will not pass.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4筛选系数-SC筛选系数SC（seiving coeffciSIEVING COEFFICIENT1.00 05600 inulin11800 b2-m21000 RBP44000 orosomucoide54000 a1 AT66500albuminMOLECULAR WEIGHT=SOLUTE SIZEDEFINITION: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5SIEVING COEFFICIENT1.005600 inSolute Classes by Molecular WeightDaltons Inflammatory Mediators(1,200-50,000)“small”“middle”“large”6Solute Classes by Molecular Wecrrt高截留分子量超滤膜高截留分子量超滤膜7ppt课件高截留分子量超滤膜7ppt课件New functional membrane with defined larger pore sizeHCO membrane8New functional membrane with d 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 surface9 0,01 m 0,02 m 0,09sieving coefficient100100010000100000100000000.20.40.60.81Molecular weight DClassical Filter30 kD human kidneyhigh cut-offHigh Cut-Off Hemofilter 10sieving coefficient10010001000Molecular Weight DaStandard HighFluxHigh Cut-OffHF,UF=1L/h,t=2hMedian,25th-75th percentiles)ICM(2002)28:651-655HCO Membrane with increased permeability for inflammatory mediatorsmembrane characteristics 11Molecular Weight DaStandard 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12ppt课件高截留分子量超滤膜的临床应用12ppt课件HCO treatment reduces significantly inflammatory mediator plasma levels高截留分子量超滤膜的临床应用13HCO treatment reduces significIL-6 in PROWESSNon-survivorsSurvivorsKinasewitz 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%patents14IL-6 in PROWESSNon-survivorsSLimited Effect of“Standard”CRRT on Plasma Inflammatory Mediator LevelsHerring et al,Kidney Blood Press Res 200315Limited Effect of“Standard”CCourse of IL-6 plasma level during treatment with septeX/HCOIntensive Care Med 2003;29:1989-95N=24 pts CVVHSubstantial Reduction of Plasma IL-6 Levels16Course of IL-6 plasma level duInterleukin-6 plasma valuesCrit Care Med.2006;34:2099-04.N=10 pts CVVHN=20 pts CVVH17Interleukin-6 plasma valuesCriIL-6 ClearancemL/minSieving coefficient:Morgera S,Bellomo R et al.Crit 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).18IL-6 ClearancemL/minSieving Cellular immunomodulation through HCO treatment高截留分子量超滤膜的临床应用19高截留分子量超滤膜的临床应用19Muret et alShock 2000 Hoffmann et alKidney Int.1995Heidecke et 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:20T-Lymhocyte Proliferation HCO treatment restores lymphocyte proliferation in septic 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21HCO treatment restores lymphocHCO treatment reduces monocyte phagocytosis rate of septic patientsNephron Clin Pract.2003;94:75-80 CVVH22HCO treatment reduces monocyteClinical benefits through HCO treatment高截留分子量超滤膜的临床应用23高截留分子量超滤膜的临床应用23Norepinephrine requirement is reduced with HCO Crit Care Med.2006;34:2099-04.N=20 pts CVVHN=10 pts CVVHP=0.1103P=0.5717MAP mmHg MAP mmHg 24Norepinephrine requirement is Improvement in Simplified Acute Physiology Score(SAPS)IICrit Care Med.2006;34:2099-04.N=20 pts CVVHN=10 pts CVVH25Improvement in Simplified AcutClearance Rates for HCO Filter:CVVH vs CVVHD 2Morgera et al,Am J Kidney Dis 200426Clearance Rates for HCO Filterclinical safety-data高截留分子量超滤膜的临床应用27高截留分子量超滤膜的临床应用27Stable albumin plasma levels during treatmentN=24 ptsCVVH/CVVHDAm J Kidney Dis.2004,43:444-53.28Stable albumin plasma levels d Coagulation Status During High Cut-Off HemofiltrationIntensive Care Med 2003;29:1989-95N=16 pts CVVH29 Coagulation Status During Hig 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 SepsisHigh-FluxHCO Honore PM et alHonore PM et al.10th Congress of WFSICCM.Florence 200910th Congress of WFSICCM.Florence 2009 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 30ppt课件 Days on Norephrinine(10,0 Days 28 mortality(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 Honore PM et alHonore PM et al.10th Congress of WFSICCM.Florence 200910th Congress of WFSICCM.Florence 2009N=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 versus standard high flux 31ppt课件HCO vs standard high flux Rec Safety:Stable plasma albumin levels with HCO compared to standard high flux-CVVHDN=81 pts CVVHD Recent HPHF Studies in Sepsis:Honore PM et alHonore PM et al.10th Congress of WFSICCM.Florence 200910th Congress of WFSICCM.Florence 2009HICOSS(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 versus standard high flux32 Safety:Stable plasma albumi 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;28:651-655 Uchino el al,Int Care Med 2002;28:651-65533 Recent HPHF Studies in Sepsis百特HF系列滤器特点1百特HF系列是高截留分子量HCO，聚，聚砜膜血膜血滤器的一种，合理的器的一种，合理的筛漏系数，截流漏系数，截流分子量分子量为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 high-adsorption hemofiltration in human septic shock.Int J Artif Organs.Feb 2007;30(2):108-117.35百特HF系列滤器特点2百特HF系列滤器安全稳定，不易凝血HBaxter PSHF 高截留分子量聚砜膜滤器36Baxter PSHF 高截留分子量聚砜膜滤器36 滤器介绍滤器介绍 Baxter PSHFBaxter PSHF系列滤器介绍系列滤器介绍系列滤器介绍系列滤器介绍 主要竞品滤器介绍主要竞品滤器介绍主要竞品滤器介绍主要竞品滤器介绍目目目目录录37目录37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 6038常见的CRRT治疗的滤器和高通透析器分类用于危重症CRRT治 中国市中国市场主要主要滤器器简介介39 中国市场主要滤器简介39AN-69AN-69系列系列-Gambro-Gambro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,1993,pp 613-623。40ppt课件AN-69系列-Gambro对中大分子的清除以吸附作用为主。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。41ppt课件AN-69系列-GambroVriese ASD，JASNAN-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）。42ppt课件AN-69系列-Gambro强大吸附作用带来的副作用2hr 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43ppt课件 AV系列-FMC聚砜膜43ppt课件