高截留量血液透析对比高通量血液透析清除游离轻链一例并文献复习

摘要

Objective To compare the high cut-off hemodialysis with high flux hemodialysis for free light chain removal,and to review literatures concerned.Methods A male aged 59 was admitted due to "fatigue more than one year,aggravated two days".He felt fatigue one year ago and was diagnosed as multiple myeloma by bone marrow biopsy and increased free light chain.Then partial remission was achieved by thalidomide,adriamcin and dexamethasone.One week before,he felt weakness and chest pain,then a decrease in hemoglobin and acute renal failure were found,which was considered the recurrence of multiple myeloma.Cyclophosphamide,doxorubicin and dexamethasone chemotherapy was started.When the creatinine up to 611 μmol/L,the hemodialysis treatment began.He received two times high flux hemodialysis (Fresenius FX60) first,then three times high cut-off hemodialysis (HCO2100).Time was four h and ultrafiltration was set at 0.5 kg.Human albumin 10 g was replenished at high flux hemodialysis for 3.5 h.The levels of serum FLCλ were detected by particle enhanced turbidimetric immunoassay,and those of serum albumin by automatic biochemical immunoassay before and after treatment.Results After two times high flux hemodialysis,serum levels of FLCλ were decreased from 45.9 to 36.4 mg/L,and those of albumin changed from 31.9 to 32.7 mg/L respectively.After three times high cut-off hemodialysis,serum levels of FLC λ decreased from 42.3 to 32.1 mg/L,and those of albumin were decreased from 33 to 28 mg/L (10 g albumin was added in each high cut-off hemodialysis).Conclusions We didn't find the superiority of high cut-off hemodialysis over high flux hemodialysis for serum FLC removal in multiple myeloma on renal replacement therapy.During four hours of high cut-off hemodialysis,albumin loss can be effectively prevented by intravenous administration of 10 g albumin.%目的 报道应用高截留量血液透析(HCO-HO)对比高通量血液透析(HFHD)清除游离轻链(FLC)一例,并进行相关文献复习.方法 一例59岁的男性因“乏力1年余,加重伴气短2天”入院.患者1年前乏力,经骨髓细胞学检查诊断为多发性骨髓瘤,查血清FCLλ升高,应用沙利度胺+阿霉素+地塞米松化疗后达到部分缓解.入院前一周因乏力、胸痛,出现急性肾功能不全及贫血,考虑多发性骨髓瘤复发,予以环磷酰胺+阿霉素+地塞米松化疗,肌酐最高达611 μmol/L,遂开始血液透析治疗.患者规律血液透析后,先在Fresenius 4008S透析机上进行2次HFHD,后在Fresenius 5008透析机上行3次HCO-HD,时间均为4h,透析超滤量均设定为0.5 kg.HCO-HD时透析液采用超纯透析液.在行HCO-HD3.5 h予以补充人血白蛋白10 g.留取每次治疗前后及治疗0.Sh及2h血液标本,测定血中FLC及白蛋白水平.血清白蛋白检测应用全自动生化仪免疫比浊法;血清FLCκ和FLCλ检测采用乳粒增强免疫比浊法.结果 患者经过2次HFHD后FLCλ从45.9 mg/L降至36.4 mg/L,血清白蛋白从31.9 g/L到32.7 g/L;经过3次HCO-HD后FLCλ从42.3 mg/L降至32.1 mg/L,血清白蛋白从33 g/L降至28.4 g/L(每次透析中补充10 g人血白蛋白后).结论 本例患者治疗中HCO-HD及HFHD对FCL清除均有一定效果.在HCO-HD中,需要输入白蛋白以防止血清白蛋白的丢失.