血液透析滤过课件

HDF与常规血透的比较与常规血透的比较文献复习文献复习近年新的近年新的RCT研究研究Meta分析分析结论与反思结论与反思HDF能否改善血透患者的预后？能否改善血透患者的预后？Prospectiverandomizedcross-overlong-termcomparisonofonlinehaemodiafiltrationandultrapurehigh-fluxhaemodialysisEurJMedRes.2007Jan31;12(1):26-33prospectivecrossoverclinicalevaluation76patientswererandomizedtohigh-fluxhaemodialysisoronlinehaemodiafiltration(24months)andswitchedtothealternativetreatment(24months).RESULTS:Removalofurea(Kt/V)andphosphatewassignificantlygreaterforonlinehaemodiafiltrationthanforhaemodialysis.Bothhigh-fluxhaemodialysisandhaemodiafiltrationwereassociatedwithsustainedreductionsofpretreatmentbeta2microglobulinlevels,however,thedecreasewasgreaterwithhaemodiafiltration.BothmodesofrenalreplacementtherapysignificantlyimprovednutritionalstatusandthehaematopoieticresponsetorHuEPO.Underunmatchedconditions(sodiumandenergybalance)haemodiafiltrationwasassociatedwithalowernumberofhypotensiveepisodesandpartialimprovementofqualityoflife.Theincidenceofdeathwaslowinbothgroupsanddidnotdifferamongthetwomodesofrenalreplacementtherapy.Long-termoutcomesinonlinehemodiafiltrationandhigh-fluxhemodialysis:acomparativeanalysisClinJAmSocNephrol.2009Dec;4(12):1944-53858incidentpatientsRetrospectivestudiesSurvivalcomparisonsHDFHDFvsvsHighFluxHD-SurvivalDataHighFluxHD-SurvivalDataVilarE.LongtermoutcomesinHDFandHD.ClinJAmSocNephrol,2009HemofiltrationandHemodiafiltrationReduceIntradialyticHypotensioninESRDFrancescoLocatellietal.J Am Soc Nephrol 21:17981807,2010.LocatelliFetal.JASN2010;21:1798-18072010byAmericanSocietyofNephrologyMorepatientsshiftoutofHFthanothertreatmentmodalities.LocatelliFetal.JASN2010;21:1798-18072010byAmericanSocietyofNephrologyCONTRAST-The Dutch Convective Transport StudyProspective,randomized,multicentertrialwith714patientstreatedwithon-lineHDForlow-fluxHDandfollowedupforamean3yearsPrimaryoutcome:allcausemortality,fatal&non-fatalCVeventsThemainsecondaryendpointwasacompositeofmajorcardiovascularevents近年新的近年新的RCT研究：研究：JASN,23:1087-1096,2012CONTRAST:DutchHDFRCT,Pre-dialysis2-microglobulinlevelsCONTRAST:DutchHDFRCT:AllcausemortalityTheincidenceofbothall-causemortalityandcardiovasculareventswasnotaffectedbytreatmentassignment.GrootemanMPetal.JASN2012;23:1087-10962012byAmericanSocietyofNephrologyInconclusion,thistrialdidnotdetectabeneficialeffectofhemodiafiltrationonall-causemortalityandcardiovasculareventscomparedwithlow-fluxhemodialysis.On-treatmentanalysissuggeststhepossibilityofasurvivalbenefitamongpatientswhoreceivehigh-volumehemodiafiltration,althoughthissubgroupfindingrequiresconfirmation.TheTurkishHDFstudyDesign:prospective,randomized,multicenter,openObjective:compare2-yearsurvivalinprevalentESRDpatientsrandomizedtoon-line,post-dilutionHDForhigh-fluxHDEnrollment:782patientsenrolledJan2007toMarch2010Primaryoutcome:compositeofallcausemortalityandnonfatalCVeventsSecondaryoutcome:CVmortality,hospitalization,intradialyticcomplications,medication,cardiacparameters,bloodchemistryRef:ClinTrialsGov004111977Nephrol Dial Transplant(2013)28:192202TurkishHDFStudy,2011-Result782patientsonhigh-fluxHDorpost-dilutiononline-HDFMeanconvectionvolume17.2LSurvivalandnon-fatalcardiovasculareventsmonitoredover2yrNodifferencesbetweenmaingroupsSubgroupanalysisshowedsuperiorityofHDFwhensubstitutionvolumeexceeded17.4L46%reductioninoverallmortality,71%riskreductionforCVSmortalityinhighvolumeHDFgroupCompositeevent-freesurvivalinpatientstreatedwithOL-HDFandhigh-fluxHD.OkEetal.Nephrol.Dial.Transplant.2013;28:192-202Overall(A)andcardiovascularsurvival(B)amongthetreatmentgroups.OkEetal.Nephrol.Dial.Transplant.2013;28:192-202Conclusions.Thecompositeofall-causemortalityandnonfatalcardiovasculareventratewasnotdifferentintheOL-HDFandinthehigh-fluxHDgroups.Inaposthocanalysis,OL-HDFtreatmentwithsubstitutionvolumesover17.4Lwasassociatedwithbettercardiovascularandoverallsurvival.ESHOL:TheCatalonianHDFon-lineRCTDesign:prospective,randomized,multicenter,openObjective:compare3-yearsurvivalinprevalentESRDpatientsrandomizedtoon-lineHDFortocontinueonstandardHD(low-fluxorhigh-flux)Enrollment:906patientsenrolledMay2007toSept2008Primaryoutcome:compositeofallcausemortalityandCVeventsSecondaryoutcomes:includedcardiovascularmortality,all-causehospitalization,treatmenttolerability,andlaboratorydata.Ref:ClinTrialsGov00694031&JNephrol,2011Inconclusion,high-efficiencypostdilutionOL-HDFreducesall-causemortalitycomparedwithconventionalhemodialysis.真相是什么？Conclusions:Treatmenteffectsofconvectivedialysisareunreliableduetolimitationsintrialmethodsandreporting.Convectivedialysismayreducecardiovascularbutnotall-causemortality,andeffectsonnonfatalcardiovasculareventsandhospitalizationareinconclusive.AmJKidneyDis.2014;63(6):954-967反思：反思：HDF置换液的剂量？HDF的透析频率？HDF并发症？经济效益与社会效益？