2 連續(xù)性腎臟替代治療

連續(xù)性腎臟替代治療CRRT

所用縮略語

1AKI急性腎損傷2Cr肌酐3CRRT連續(xù)性腎臟替代治療4CWH連續(xù)性靜脈血液濾過5CWHD連續(xù)性靜脈血液透析6CWHDF連續(xù)性靜脈血液透析濾過7HD血液透析8IHD間歇性血液透析所用縮略語

9K+鉀10LIJ左頸內(nèi)靜脈11PBP血泵前12RIJ右頸內(nèi)靜脈13SCUF緩慢持續(xù)超濾14RRT腎臟替代治療15TNF腫瘤壞死因子16UF超濾目錄CRRT定義CRRT要求/考慮因素血液濾器轉(zhuǎn)運(yùn)機(jī)制CRRT溶液劑CRRT模式流速關(guān)系管路抗凝血液濾過導(dǎo)管加溫CRRT并發(fā)癥CRRT定義BellomoRet.al.NomenclatureforContinuousRenalReplacementTherapies.1996.體外血液凈化治療旨在長期替代受損的腎功能并應(yīng)用24小時(shí)/天或旨在應(yīng)用24小時(shí)/天CRRT要求/考慮因素血管通路CRRT監(jiān)護(hù)儀（設(shè)備）濾器/管線血液透析/血液濾過置換液抗凝方法加溫治療參數(shù)、抗凝選擇和設(shè)置血液濾器濾器結(jié)構(gòu)DaugirdasJet.al.HandbookofDialysis.5thed.2015.血液流入血液流出透析液流入流出液流出橫斷面中空纖維膜內(nèi)部外部（透析液和超濾液）血液濾器用于CRRT的現(xiàn)代高通量血液濾器具有合成和生物相容性。膜類型的示例包括：聚丙烯腈聚砜聚醚砜聚酰胺聚甲基丙烯酸甲酯膜的結(jié)構(gòu)為中空纖維，性質(zhì)為高通量。這意味著它們具有較大的孔徑，可以清除大量的水和分子DaugirdasJet.al.HandbookofDialysis.5thed.2015.血液濾器膜結(jié)構(gòu)SharfuddinAet.al.AcuteKidneyInjury.InBrenner&Rector’sTheKidney.9thed.2012.血液濾器具有半透膜，允許特定大小的溶質(zhì)通過膜將血室與透析液/超濾液室分開溶質(zhì)轉(zhuǎn)運(yùn)速率取決于：溶質(zhì)大小溶質(zhì)濃度-壓力-膜滲透性-膜壁厚度-膜表面積濾器橫斷面膜結(jié)構(gòu)顯微膜結(jié)構(gòu)血液濾器膜孔徑分子大小和孔徑?jīng)Q定溶質(zhì)是否能通過半透膜小分子容易通過擴(kuò)散和對(duì)流驅(qū)動(dòng)的膜小孔徑分子大小小孔徑血液濾器膜孔徑大孔徑中到大分子主要通過對(duì)流清除高通量膜通常可清除分子量高達(dá)50,000Da的溶質(zhì)血漿蛋白，如白蛋白（約65,000Da），清除不明顯分子大小小孔徑血液濾器篩分系數(shù)（SC）是指物質(zhì)通過膜從血液進(jìn)入超濾室的能力1的SC將允許自由通過，而0的SC將不允許物質(zhì)通過例如，K+的SC是1；Cr是0.95；白蛋白是0轉(zhuǎn)運(yùn)機(jī)制清除溶質(zhì)和水?dāng)U散超濾對(duì)流吸附擴(kuò)散對(duì)流液體+溶質(zhì)超濾壓力梯度吸附轉(zhuǎn)運(yùn)機(jī)制擴(kuò)散擴(kuò)散是指分子通過半透膜從高濃度區(qū)域移動(dòng)到低濃度區(qū)域擴(kuò)散的驅(qū)動(dòng)力是膜兩側(cè)的濃度差異。轉(zhuǎn)運(yùn)機(jī)制擴(kuò)散速率取決于分子大小，擴(kuò)散更適合小分子。濾器表面積、溶質(zhì)濃度差異和透析液流速與血液流速的比值也會(huì)影響擴(kuò)散率通過將透析液的流動(dòng)方向設(shè)置為與血流方向相反促進(jìn)擴(kuò)散擴(kuò)散DaugirdasJet.al.HandbookofDialysis.5thed.2015.AmlaniG.Continuousrenalreplacementtherapy.2012.轉(zhuǎn)運(yùn)機(jī)制超濾超濾是指水由跨膜壓力梯度驅(qū)動(dòng)的跨膜移動(dòng)流出液泵產(chǎn)生負(fù)壓，拉動(dòng)血液室（壓力為正）中的血漿水跨膜壓力梯度越高，轉(zhuǎn)運(yùn)的水越多AmlaniG.Continuousrenalreplacementtherapy.2012.a.正壓b.負(fù)壓轉(zhuǎn)運(yùn)機(jī)制對(duì)流對(duì)流是溶質(zhì)隨水跨膜移動(dòng)。也稱為溶劑拖拽當(dāng)水通過膜超濾時(shí)，分子隨水一起被“拖拽”。水流越快，被拖拽的溶質(zhì)越多對(duì)流可清除小分子至中分子（小于膜孔徑）在大多數(shù)情況下，在清除大量超濾液的同時(shí)會(huì)向血液管路中注入置換液，以防止出現(xiàn)低血容量癥DaugirdasJet.al.HandbookofDialysis.5thed.2015.AmlaniG.Continuousrenalreplacementtherapy.2012.轉(zhuǎn)運(yùn)機(jī)制吸附吸附是指溶質(zhì)分子粘附在半透膜表面或內(nèi)部發(fā)生吸附需要液體移動(dòng)

4AmlaniG.Continuousrenalreplacementtherapy.2012.5DeVrieseAet.al.CytokineRemovalduringContinuousHemofiltrationinSepticPatients.1999.6DoiKet.al.AssociationsofPolyethylenimine-CoatedAN69STMembraneinContinuousRenalReplacementTherapywiththeIntensiveCareOutcomes:ObservationsfromaClaimsDatabasefromJapan.2017.7ChanardJ.Biocompatiblemembranesmustbehemocompatible:theroleofheparinadsorptionontodialysismembranes.2003.8BoumanCet.al.CytokineFiltrationandAdsorptionduringPre-andPostdilutionHemofiltrationinFourDifferentMembranes.1998.9GoldfarbSet.al.ProinflammatoryCytokinesandHemofiltrationMembranes.1994.CRRT溶液劑需要CRRT溶液劑，主要是作為轉(zhuǎn)運(yùn)介質(zhì)。通常用于CRRT的輸液袋是5L無菌、市售輸液袋使用透析液提供跨膜濃度梯度，促進(jìn)清除血液中多余的分子CVVHD和CVVHDF模式需要透析液輸液袋將置換液注入血液管線中，以置換超濾過程中清除的血漿水。可在濾器前或?yàn)V器后輸注溶液劑CVVH和CVVHDF模式需要置換液輸液袋

DaugirdasJet.al.HandbookofDialysis.5thed.2015.CRRT溶液劑CRRT溶液劑含有某種形式的緩沖液，以預(yù)防/糾正酸中毒。這些溶液還旨在置換CRRT期間丟失的碳酸氫鹽使用醋酸鹽作為緩沖液由來已久。目前可選擇碳酸氫鹽或乳酸鹽作為緩沖液RRT的現(xiàn)行指南建議對(duì)AKI患者使用碳酸氫鹽而非乳酸鹽；尤其是合并循環(huán)休克、肝衰竭或乳酸血癥的患者在枸櫞酸抗凝方案中，枸櫞酸鹽也被視為緩沖液，主要在肝臟中轉(zhuǎn)化為碳酸氫鹽DaugirdasJet.al.HandbookofDialysis.5thed.2015.KierdorfHet.al.Lactate-orbicarbonate-bufferedsolutionsincontinuousextracorporealrenalreplacementtherapies.1999.HeeringPet.al.Acid-basebalanceandsubstitutionfluidduringcontinuoushemofiltration.1999.KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.CRRT溶液劑DaugirdasJet.al.HandbookofDialysis.5thed.2015.AucelleaFet.al.DialysateandReplacementFluidCompositionforCRRT.2007.CRRT溶液劑通常含有生理濃度的電解質(zhì)對(duì)于某些臨床情況，可使用具有替代成分的專用輸液袋專用輸液袋的示例包括：鉀含量的選擇無鈣含磷CRRT模式BellomoRet.al.NomenclatureforContinuousRenalReplacementTherapies.1996.DaugirdasJet.al.HandbookofDialysis.5thed.2015.PannuNet.al.Renalreplacementtherapyintheintensivecareunit.2005.GrootendorstAet.al.Practicalaspectsofhaemofiltration.2004.AntounTet.al.SelectionofModalityofRenalReplacementTherapy.2009.早期CRRT管路稱為動(dòng)靜脈（AV）。在該系統(tǒng)中，血液通過患者動(dòng)脈進(jìn)入并通過靜脈返回。這種類型的CRRT使用患者自身心搏出量驅(qū)動(dòng)血液通過管路由于入路并發(fā)癥、外部管路泵進(jìn)步以及維持充分代謝控制困難，現(xiàn)已不再使用AV如今，CRRT使用外部管路泵從主干靜脈抽取血液并返回主干靜脈。這被稱為靜脈-靜脈或VVCRRT模式的術(shù)語通常使用開頭的字母CVV，代表連續(xù)性靜脈-靜脈。這意味著該模式在性質(zhì)上是連續(xù)的，從患者的靜脈抽取血液并返回患者的靜脈CRRT模式SCUF緩慢連續(xù)性超濾CVVH連續(xù)性靜脈-靜脈血液濾過CVVHD連續(xù)性靜脈-靜脈血液透析CVVHDF連續(xù)性靜脈-靜脈血液透析濾過BellomoRet.al.NomenclatureforContinuousRenalReplacementTherapies.1996.CRRT模式流出液血液濾器注射泵患者血泵SCUFCRRT模式SCUFSCUF通過超濾清除液體SCUF可用于無尿毒癥或顯著電解質(zhì)失衡的液體超負(fù)荷SCUF可用于清除難治性心力衰竭患者的多余液體緩慢、連續(xù)的性質(zhì)可清除大量液體，同時(shí)盡量減少血流動(dòng)力學(xué)問題DaugirdasJet.al.HandbookofDialysis.5thed.2015.CRRT模式SCUFCRRT監(jiān)護(hù)儀設(shè)置半透膜的跨膜壓力梯度血液室中的壓力為正，超濾液室中的壓力為負(fù)凈效應(yīng)是清除血液中的血漿水至流出液中超濾壓力梯度超濾CRRT模式SCUF臨床實(shí)踐中的SCUF液體清除率約為100-300ml/hr12在流出液袋中收集超濾液不使用置換液置換超濾液不使用透析液KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.超濾壓力梯度超濾CRRT模式CVVH置換流出液置換PBP或抗凝劑之后

之前之后血液濾器注射泵患者血泵CRRT模式CVVHCVVH是連續(xù)性血液濾過使用的清除方法為超濾、對(duì)流和吸附血液濾過旨在清除中分子至大分子不使用透析液在流出液袋中收集超濾液DaugirdasJet.al.HandbookofDialysis.5thed.2015.CerdaJet.al.ModalitiesofContinuousRenalReplacementTherapy:TechnicalandClinicalConsiderations.2009.CRRT模式CVVH當(dāng)血液進(jìn)入濾器時(shí)，CRRT監(jiān)護(hù)儀設(shè)置半透膜的跨膜壓力梯度血液室中的壓力為正，超濾液室中的壓力為負(fù)凈效應(yīng)是清除血液中的血漿水至流出液中超濾壓力梯度超濾CRRT模式CVVHCVVH中超濾的量通常在1.5-2L/h之間在從血液中超濾出血漿水的同時(shí)向血液管路中加入置換液，以防止出現(xiàn)低血容量癥可在濾器前或?yàn)V器后輸注置換液KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.超濾壓力梯度超濾CRRT模式CVVH為什么之前……為什么之后？稀釋前可通過稀釋進(jìn)入濾器的血液降低濾器凝血風(fēng)險(xiǎn)，從而降低血濃縮。但是，稀釋進(jìn)入濾器的血液降低了清除效率稀釋后未稀釋進(jìn)入濾器的血液，因此可有效清除溶質(zhì)。但是，超濾率較高時(shí)濾器凝血的風(fēng)險(xiǎn)就會(huì)增加，尤其是當(dāng)血液流速較慢時(shí)GrootendorstAet.al.Practicalaspectsofhaemofiltration.2004.JoannidisMet.al.Clinicalreview:Patencyofthecircuitincontinuousrenalreplacementtherapy.2007.超濾CRRT模式CVVH隨著血漿水跨膜超濾，將拖拽所有大小的分子這被稱為對(duì)流或溶質(zhì)拖拽超濾流速越高，溶質(zhì)對(duì)流越大DaugirdasJet.al.HandbookofDialysis.5thed.2015BrunetSet.al.DiffusiveandConvectiveSoluteClearancesDuringContinuousRenalReplacementTherapyatVariousDialysateandUltrafiltrationFlowRates.1999.液體溶質(zhì)對(duì)流對(duì)流CRRT模式CVVH吸附是一些類型的膜的另一種溶質(zhì)清除機(jī)制吸附分子粘附在膜表面或內(nèi)部。發(fā)生吸附需要液體移動(dòng)那些太大而不能跨膜的分子可能發(fā)生吸附

AmlaniG.Continuousrenalreplacementtherapy.2012.DeVrieseAet.al.CytokineRemovalduringContinuousHemofiltrationinSepticPatients.1999.吸附吸附CRRT模式CVVH

6DoiKet.al.AssociationsofPolyethylenimine-CoatedAN69STMembraneinContinuousRenalReplacementTherapywiththeIntensiveCareOutcomes:ObservationsfromaClaimsDatabasefromJapan.2017.7ChanardJ.Biocompatiblemembranesmustbehemocompatible:theroleofheparinadsorptionontodialysismembranes.2003.8BoumanCet.al.CytokineFiltrationandAdsorptionduringPre-andPostdilutionHemofiltrationinFourDifferentMembranes.1998.9GoldfarbSet.al.ProinflammatoryCytokinesandHemofiltrationMembranes.1994.吸附CRRT模式CVVHD透析液流出液PBP或抗凝劑血液濾器注射泵患者血泵CRRT模式CVVHDCVVHD為連續(xù)性血液透析，并使用擴(kuò)散清除溶質(zhì)透析過程可清除小分子量溶質(zhì)，如尿素、肌酐和鉀分子越大，其通過擴(kuò)散清除的效率越低透析液與血液反向流動(dòng)通過濾器DaugirdasJet.al.HandbookofDialysis.5thed.2015.PannuNet.al.Renalreplacementtherapyintheintensivecareunit.2005.CerdaJet.al.ModalitiesofContinuousRenalReplacementTherapy:TechnicalandClinicalConsiderations.2009.CRRT模式CVVHD在濾器內(nèi)，血液沿著半透膜的一側(cè)流動(dòng)，而透析液沿著另一側(cè)流動(dòng)半透膜允許一定大小的分子跨膜血液中的溶質(zhì)（包括毒素）濃度高于透析液中的溶質(zhì)擴(kuò)散擴(kuò)散CRRT模式CVVHD溶質(zhì)從較高濃度區(qū)域移動(dòng)至較低濃度區(qū)域無需置換液CVVHD中透析液的流速通常在1.5-2L/h之間KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.擴(kuò)散擴(kuò)散CRRT模式CVVHDF流出液置換PBP或抗凝劑之后

之前血液濾器注射泵患者血泵透析液CRRT模式CVVHDFCVVHDF使用血液透析和血液濾過清除溶質(zhì)和多余液體使用的清除方法為透析、超濾、對(duì)流和吸附在流出液袋中收集用過的透析液和超濾液3SharfuddinAet.al.AcuteKidneyInjury.InBrenner&Rector’sTheKidney.9thed.2012.17CerdaJet.al.ModalitiesofContinuousRenalReplacementTherapy:TechnicalandClinicalConsiderations.2009.稀釋前置換液透析液稀釋后置換液CRRT模式CVVHDF當(dāng)血液進(jìn)入濾器時(shí)，CRRT監(jiān)護(hù)儀設(shè)置半透膜的跨膜壓力梯度血液室中的壓力為正，超濾液室中的壓力為負(fù)凈效應(yīng)是清除血液中的血漿水至流出液中超濾壓力梯度超濾CRRT模式CVVHDF超濾CVVHDF中超濾的量通常在1-1.5L/h之間在從血液中超濾出血漿水的同時(shí)向血液管路中加入置換液，以防止出現(xiàn)低血容量癥可在濾器前或?yàn)V器后輸注置換液KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.超濾壓力梯度CRRT模式CVVHDF超濾為什么之前……為什么之后？稀釋前可通過稀釋進(jìn)入濾器的血液降低濾器凝血風(fēng)險(xiǎn)，從而降低血濃縮。但是，稀釋進(jìn)入濾器的血液降低了清除效率稀釋后未稀釋進(jìn)入濾器的血液，因此可有效清除溶質(zhì)。但是，超濾率較高時(shí)濾器凝血的風(fēng)險(xiǎn)就會(huì)增加，尤其是當(dāng)血液流速較慢時(shí)GrootendorstAet.al.Practicalaspectsofhaemofiltration.2004.JoannidisMet.al.Clinicalreview:Patencyofthecircuitincontinuousrenalreplacementtherapy.2007.CRRT模式CVVHDF對(duì)流隨著血漿水跨膜超濾，將拖拽所有大小的分子。這被稱為對(duì)流或溶質(zhì)拖拽超濾流速越高，溶質(zhì)對(duì)流越大DaugirdasJet.al.HandbookofDialysis.5thed.2015BrunetSet.al.DiffusiveandConvectiveSoluteClearancesDuringContinuousRenalReplacementTherapyatVariousDialysateandUltrafiltrationFlowRates.1999.對(duì)流液體+溶質(zhì)CRRT模式CVVHDF吸附吸附是一些類型的膜的另一種溶質(zhì)清除機(jī)制吸附分子粘附在膜表面或內(nèi)部。發(fā)生吸附需要液體移動(dòng)那些太大而不能跨膜的分子可能發(fā)生吸附

AmlaniG.Continuousrenalreplacementtherapy.2012.DeVrieseAet.al.CytokineRemovalduringContinuousHemofiltrationinSepticPatients.1999.吸附CRRT模式CVVHDF

6DoiKet.al.AssociationsofPolyethylenimine-CoatedAN69STMembraneinContinuousRenalReplacementTherapywiththeIntensiveCareOutcomes:ObservationsfromaClaimsDatabasefromJapan.2017.7ChanardJ.Biocompatiblemembranesmustbehemocompatible:theroleofheparinadsorptionontodialysismembranes.2003.8BoumanCet.al.CytokineFiltrationandAdsorptionduringPre-andPostdilutionHemofiltrationinFourDifferentMembranes.1998.9GoldfarbSet.al.ProinflammatoryCytokinesandHemofiltrationMembranes.1994.吸附CRRT模式CVVHDF擴(kuò)散透析可清除小分子量溶質(zhì)，如尿素、肌酐和鉀分子越大，其通過擴(kuò)散清除的效率越低透析液與血液反向流動(dòng)通過濾器DaugirdasJet.al.HandbookofDialysis.5thed.2015.PannuNet.al.Renalreplacementtherapyintheintensivecareunit.2005..CRRT模式CVVHDF擴(kuò)散在濾器內(nèi)，血液沿著半透膜的一側(cè)流動(dòng)，而透析液沿著另一側(cè)流動(dòng)半透膜允許一定大小的分子跨膜血液中的溶質(zhì)（包括毒素）濃度高于透析液中的溶質(zhì)擴(kuò)散CRRT模式CVVHDF擴(kuò)散溶質(zhì)從較高濃度區(qū)域移動(dòng)至較低濃度區(qū)域CVVHDF中的透析液流速通常為1-1.5L/hKidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.擴(kuò)散CRRT模式總結(jié)SCUFCVVHCVVHDCVVHDF血泵有有有有流出液泵有有有有透析液泵無無有有置換液泵無有無有

主要轉(zhuǎn)運(yùn)機(jī)制超濾超濾對(duì)流吸附透析超濾對(duì)流吸附透析流速關(guān)系增加透析液和置換液流速透析液和置換前/后流速均對(duì)溶質(zhì)清除有影響置換液和/或透析液流速越高，溶質(zhì)清除越多BrunetSet.al.DiffusiveandConvectiveSoluteClearancesDuringContinuousRenalReplacementTherapyatVariousDialysateandUltrafiltrationFlowRates.1999.低流速高流速管路抗凝預(yù)防CRRT管路凝血的抗凝類型普通肝素（UFH）局部枸櫞酸局部肝素（肝素/魚精蛋白）低分子量肝素（LMWH）類肝素（如達(dá)那肝素鈉）重組人活化蛋白C（rhAPC）阿加曲班水蛭素（利匹盧定）前列環(huán)素蛋白酶抑制劑（萘莫司他）鹽水沖洗JoannidisMet.al.Clinicalreview:Patencyofthecircuitincontinuousrenalreplacementtherapy.2007.MarianoF,BergamoD,GangemiE,HolloZ,StellaM,TrioloG.CitrateAnticoagulationforContinuousRenalReplacementTherapyinCriticallyIllPatients:SuccessandLimits.InternationalJournalofNephrology.2011;2011:748320.doi:10.4061/2011/748320.Epub2011Mar16.血液濾過導(dǎo)管功能性血管通路對(duì)于充分的RRT至關(guān)重要導(dǎo)管的基本要求為：充分流動(dòng)持續(xù)流動(dòng)導(dǎo)管故障率低低患病率（感染、置入風(fēng)險(xiǎn)）KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.血液濾過導(dǎo)管位置選擇放置透析導(dǎo)管的血管選擇，考慮這些首選項(xiàng)：第一選擇：右頸內(nèi)靜脈第二選擇：股靜脈第三選擇：左頸內(nèi)靜脈最后選擇：鎖骨下靜脈提供充分血流和盡量減少再循環(huán)的理想導(dǎo)管長度：12-15cm（對(duì)于RIJ）15-20cm（對(duì)于LIJ）19-24cm（對(duì)于股靜脈）KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.頸內(nèi)靜脈通路鎖骨下靜脈通路股動(dòng)脈通路血液濾過導(dǎo)管流體動(dòng)力學(xué)主干靜脈靜脈血流方向血液濾過導(dǎo)管側(cè)孔導(dǎo)管血液濾過導(dǎo)管流體動(dòng)力學(xué)主干靜脈血液濾過導(dǎo)管高流量導(dǎo)管靜脈血流方向警告體外管路中的血液暴露于以下溫度較低處：房間濾器中的透析液輸注的置換液返回患者的血液溫度將低于其離開時(shí)的溫度。已證明返回血液比通路血液低1.9-5.5℃，血液流速越低和/或溶液劑流速越高，降幅越大因此，CRRT監(jiān)護(hù)儀使用加溫器防止熱損失RickardCet.al.Preventinghypothermiaduringcontinuousveno-venoushaemodiafiltration:arandomizedcontrolledtrial.2004.CRRT并發(fā)癥（1）低血壓-失血膜反應(yīng)液體清除過多熱損失/體溫過低酸/堿失衡血管通路并發(fā)癥容量管理錯(cuò)誤氣栓凝血套件管路反復(fù)失血導(dǎo)致的貧血

AmlaniG.Continuousrenalreplacementtherapy.2012.FinkelKet.al.ComplicationsofContinuousRenalReplacementTherapy.2009.CRRT并發(fā)癥（2）與抗凝治療無效、血液濾過器凝血、CRRT系統(tǒng)意外斷開、過度抗凝導(dǎo)致出血或血液濾過器泄漏相關(guān)的失血感染-靜脈通路部位、CRRT套件或CRRT液體污染與CRRT期間高UF率（高清除率）、電解質(zhì)補(bǔ)充不足或碳酸氫鹽損失補(bǔ)充不足相關(guān)的電解質(zhì)失衡彌散性血管內(nèi)凝血和血小板減少AmlaniG.Continuousrenalreplacementtherapy.2012.FinkelKet.al.ComplicationsofContinuousRenalReplacementTherapy.2009.參考文獻(xiàn)BellomoR,RoncoC,MehtaR.TechniqueofContinuousRenalReplacementTherapy:NomenclatureforContinuousRenalReplacementTherapies.AmericanJournalofKidneyDiseases.1996;28(5,suppl.3):S2-S7.DaugirdasJ,BlakeP,IngT,eds.HandbookofDialysis.5thed.Philadelphia,PA:LippincottWilliams&Wilkins;2015.Chapters3,4and15.SharfuddinA,WeisbordS,PalevskyP,MolitorisB.Chapter64.AcuteKidneyInjury.In:TaalM,ChertowG,MarsdenP,SkoreckiK,YuA,BrennerB.eds.Brenner&Rector’sTheKidney.9thed.PhiladelphiaPA:ElsevierSaunders;2012:1044-1099.AmlaniG.Continuousrenalreplacementtherapy.JournalofthePakistanMedicalAssociation.2012;62(3);276-280.DeVrieseA,ColardynF,PhillippeJ,VanholderR,DeDutterJ,LameireN.CytokineRemovalduringContinuousHemofiltrationinSepticPatients.JournalofAmericanSocietyofNephrology.1999:10;846-853.DoiK,IwagamiM,YoshidaE,MarshallM.AssociationsofPolyethylenimine-CoatedAN69STMembraneinContinuousRenalReplacementTherapywiththeIntensiveCareOutcomes:ObservationsfromaClaimsDatabasefromJapan.BloodPurification.2017;44:184-192.ChanardJ.Biocompatiblemembranesmustbehemocompatible:theroleofheparinadsorptionontodialysismembranes.PortugueseJournalofNephrologyandHypertension.2003;17(3):133-142.參考文獻(xiàn)BoumanC,vanOldenR,StoutenbeekC.CytokineFiltrationandAdsorptionduringPre-andPostdilutionHemofiltrationinFourDifferentMembranes.BloodPurification.1998;16:261-268.GoldfarbS,GolperT.ProinflammatoryCytokinesandHemofiltrationMembranes.JournalofAmericanSocietyofNephrology.1994;5:228-232.KierdorfH,LeueC,ArnsS.Lactate-orbicarbonate-bufferedsolutionsincontinuousextracorporealrenalreplacementtherapies.KidneyInternational.1999;56(Suppl.72):S32-S36).HeeringP,IvensK,ThumerO,BrauseM,GrabenseeB.Acid-basebalanceandsubstitutionfluidduringcontinuoushemofiltration.KidneyInternational.1999;56(Suppl.72):S37-S40.KidneyDisease:ImprovingGlobalOutcomes(KDIGO)AcuteKidneyInjuryWorkGroup.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury.KidneyIntSupplements.2012;2(1):1-138.AucelleaF,DiPaoloS,Gesua