腹透原理2HowPDWorks2

HowPDworks2腹透原理2MinSunPARK M D Ph D MedicalDirectorBaxterAsiaRenal Contentsoftalk內(nèi)容 Whatisperitonealmembrane PhysiologyofperitonealdialysisUremictoxinremovalFluidremovalSodiumremovalPDprescriptionAdequacyMembranetransport PETIndicationsandcontraindicationsofPDPreparingandperformingPDAPDComplicationsrelatedtoPDClinicaloutcomeofPDHowtoset upPDcenter 什么是腹膜 腹膜透析 peritonealdialysis PD 的生理學(xué)尿毒癥毒素的清除液體的清除鈉的清除腹膜透析處方充分性膜轉(zhuǎn)運(yùn) 腹膜平衡試驗(yàn) PET 腹膜透析的適應(yīng)癥和禁忌癥腹膜透析的準(zhǔn)備和實(shí)施自動(dòng)腹膜透析 automaticperitonealdialysis APD PD相關(guān)并發(fā)癥PD的臨床預(yù)后怎樣建立PD中心 GoalofDialysis透析目標(biāo) Maintainssymptom freebyreplacingsomeofthefunctionsperformedbythehealthykidneys ToremovesuremictoxinsaccumulatedinthebloodWaterElectrolytesUrea creatinine phosphate PTH etc H MinimizesmortalityandmorbidityPreventsshort andlong termcomplications通過(guò)替代正常腎臟的部分功能減輕腎衰時(shí)機(jī)體相關(guān)癥狀清除積聚在血液中的尿毒癥毒素水分電解質(zhì)尿素 肌酐 磷 甲狀旁腺激素等等氫離子發(fā)病率和死亡率最低化預(yù)防短期 長(zhǎng)期并發(fā)癥 Whatis adequate treatment 何謂 充分的 治療 Avoidanceoffluidoverload Bloodpressurecontrol Preservationofresidualrenalfunction Wellnourished Phosphoruscontrol Acid basebalance Correctionofanaemia Sufficientremovalofuremictoxins absenceofuremicsymptoms MDt P physiciantimeperpatient RamGokal2002 避免水負(fù)荷血壓良好控制保護(hù)殘存腎功能營(yíng)養(yǎng)良好控制血磷酸堿平衡糾正貧血清除足夠的尿毒癥毒素 沒(méi)有尿毒癥相關(guān)癥狀醫(yī)生治療每個(gè)病人的時(shí)間 醫(yī)生對(duì)每個(gè)病人的治療所付出的時(shí)間直接關(guān)系到病人的治療質(zhì)量 這是目前國(guó)際上公認(rèn)的概念 Howtoachieveit 如何達(dá)到治療目標(biāo) Sufficientfluidandtoxinremoval doseofdialysisItdependsonResidualrenalfunctionBodysizeCo morbidcondition充分清除水分和毒素 透析劑量有賴于 殘存腎功能體形大小合并癥情況 Howtomeasuretoxinremoval 如何評(píng)估毒素清除情況 SurrogatemarkersofuremiaCreatinineUreaNumericmeasurementofuremictoxinremovalRemovalofureaandcreatinineNormalizingfactor BodysizeTotalremoval Peritoneal Renal 尿毒癥的 應(yīng)用 指標(biāo)肌酐尿素尿毒癥毒素清除的量化評(píng)估尿素和肌酐的清除標(biāo)化因素 體形大小總的清除率 腹透清除 腎臟清除 Calculationofperitonealclearance腹透清除率計(jì)算 Calculationofrenalcreatinineclearancefor24hours TotalurinarycreatinineremovaldividedbyserumcreatininelevelU PcreatininexurinevolumeStandardizedbybodysurfaceareaCalculationofperitonealclearance Urea Creatinine for24hoursTotalperitonealremovaldividedbyserumlevelD PxtotaldialysatevolumeStandardizedbybodysurfacearea creatinine PeritonealcreatinineclearanceStandardizedbybodywatercontent urea Kt Vurea 計(jì)算24小時(shí)腎臟內(nèi)生肌酐清除率 尿中肌酐清除總量除以血清肌酐值尿肌酐 血肌酐 U P 尿量按體表面積標(biāo)化計(jì)算腹透24小時(shí)尿素 肌酐清除率腹透清除總量除以血清濃度腹透液濃度 血清濃度 D P 腹透液總量按體表面積標(biāo)化 肌酐 腹透肌酐清除率按體內(nèi)水分量標(biāo)化 尿素 Kt Vurea Kt V計(jì)算 總Kt V 殘腎Kt V 腹膜Kt V殘腎Kt V 腹膜Kt V 肌酐清除率 Ccr 計(jì)算 總Ccr 殘腎Ccr 腹膜Ccr殘腎Ccr L 周 腹膜Ccr L 周 體表面積校正的Ccr L 周 1 73m2 Importantfactorsdeterminingperitonealclearance決定腹膜清除率的重要因素 Dialysatetoplasmaconcentrationratio D P PeritonealtransportcharacteristicsDiffusionConvection MainlydependsonultrafiltrationDialysatevolumeTotalinfusionvolumeUltrafiltrationvolumePeritonealabsorptionBodysize 腹透液和血漿濃度比值 D P 腹膜轉(zhuǎn)運(yùn)特點(diǎn)彌散對(duì)流 主要依賴超濾透析液量總灌入量超濾量腹膜吸收量體形大小 SurvivalwasbetterwithhigherKt VureaandCCr較高的Kt Vurea和CCr伴隨較高的生存率Maiorcaetal ND12 2158 62SurvivalinuremiapatientscanbeasgoodasinpatientswithRRF有殘余腎功能的尿毒癥病人生存率較高SzetoCetal JAmSocNephrol12 355 360 2001 RecentKt V OutcomeData新近關(guān)于Kt V和預(yù)后的觀察 FluidandSodiumRemovalvsOutcome水鈉清除與預(yù)后的比較 Effectoffluidremova水清除的影響l Effectofsodiumremoval鈉清除的影響 Atesetal KidneyInt60 767 776 2001 Sodiumandfluidremoval hypertension creatinineandRRFwereindependentpredictorsofsurvival鈉及水分的清除 高血壓 肌酐以及殘余腎功能是生存率的獨(dú)立預(yù)測(cè)因子 232mmols96 181 231mmols89 130 180mmols73 130mmols60 RelevanceofFluidRemovalIndependentPredictorofSurvival水分清除的相關(guān)性生存率的獨(dú)立預(yù)測(cè)因子 Atesetal KidneyInt2001 60 767 776 Fluidremovalassociatedwithlowermortalityrisksbybothunivariateandmultivariateanalyses無(wú)論單因素或多因素分析中 水分清除都與較低的死亡風(fēng)險(xiǎn)相關(guān) Urineoutput 尿量 EAPOSPatientSurvivalbyBaselineUF基線超濾值與患者的存活情況 Brown etal JAmSocNephrol 2003 14 2948 2957 TotalSmallSoluteClearance 小分子溶質(zhì)總清除率 Probabilityofsurvival生存率 Rangeofsoluteclearanceinpreviousstudies以往研究中溶質(zhì)清除率變化范圍 Outcomemoreinfluencedbyothervariables BP phosphorous volume middlemolecule chronicinflammation 預(yù)后受其他的一些變量如 血壓 血磷 容量負(fù)荷 中分子物質(zhì)及慢性炎癥等的影響更多 NewerTechnologies 新技術(shù) MinimalTarget 1 7 最低目標(biāo) BurkartARRT2000 Smallsoluteclearanceandoutcome小分子溶質(zhì)的清除與預(yù)后 DeterminationofPeritonealMembraneCharacteristics腹膜轉(zhuǎn)運(yùn)特性 WatertransportNetultrafiltrationvolume TranscapillaryUF PeritonealabsorptionSolutetransportDiffusion Convectivetransport Peritonealabsorption水轉(zhuǎn)運(yùn)凈超濾量 跨毛細(xì)血管的超濾量 腹膜吸收量溶質(zhì)轉(zhuǎn)運(yùn)彌散 對(duì)流轉(zhuǎn)運(yùn) 腹膜吸收 Methodstoevaluateperitonealmembranefunction腹膜功能評(píng)估方法 ParametersusedinresearchMasstransportareacoefficient MTAC Diffusivetransportcoefficient KBD ParameterscommonlyusedinclinicPeritonealequilibrationtest PET D Pcreatinine D D0glucose UltrafiltrationvolumePeritonealclearance D PratioxUFvolume unittime ml minD Psodiumat2hoursofdwellPET ClearanceandD Psodiumcanbeaffectedbyresidualvolumeofdialysateafterdrainage 研究中應(yīng)用的參數(shù)溶質(zhì)轉(zhuǎn)運(yùn)面積系數(shù) Masstransportareacoefficient MTAC 彌散轉(zhuǎn)運(yùn)系數(shù) KBD 臨床常用的參數(shù)腹膜平衡試驗(yàn) Peritonealequilibrationtest PET 透析液肌酐濃度 血漿肌酐D P 葡萄糖濃度透析液 血漿 D D0 超濾量腹膜清除率 D P 超濾量ml 時(shí)間min ml min留腹2小時(shí)的透析液鈉濃度 血漿鈉濃度 D P 腹膜平衡試驗(yàn) 清除率及鈉濃度透析液 血漿可以受到引流腹透液后殘余在腹腔內(nèi)透析液的量的影響 WhatisPET Basedonequilibrationofsoluteconcentrationindialysatetoplasmaandperitonealglucoseabsorption Dialysatetoplasmaconcentrationratioofsolutessuchascreatinine urea potassium D Psolutes Dialysatecreatinineconcentrationincreasesascreatininediffusesintotheperitonealcavityduetotheconcentrationgradient Dialysateglucoseconcentrationdecreasesasperitonealglucoseabsorbsduringadwelltime Drainvolumeisinverselycorrelatedtosolutetransportrate PET建立在血漿與透析液中溶質(zhì)濃度的平衡以及腹膜對(duì)葡萄糖吸收作用的基礎(chǔ)上 透析液和血漿中溶質(zhì)濃度的比值 D P 如肌酐 尿素 鉀離子 隨著血液中肌酐順著濃度梯度彌散入腹腔內(nèi) 透析液中肌酐濃度逐漸增加 留腹期間透析液中葡萄糖的濃度隨著腹膜對(duì)葡萄糖的吸收而降低 引流量和溶質(zhì)轉(zhuǎn)運(yùn)率負(fù)相關(guān) PeritonealEquilibrationTest腹膜平衡試驗(yàn) IntraperitonealVolumeinDifferentTransportGroups不同轉(zhuǎn)運(yùn)的腹膜在腹透時(shí)超濾量的變化 Wangetal NephrolDialTransplant13 1242 49 1998 2250 2500 2750 3000 3250 Intraperitonealvolume ml腹腔內(nèi)液體容量 0 60 120 180 240 300 360 Time min L低轉(zhuǎn)運(yùn) L A低平均 H A高平均 H高轉(zhuǎn)運(yùn) 1 Drainforatleast20min ideallyafteran8 to12 hourovernightdwellusing2Lof2 5 dextrosesolution2 Weigh2 Lbagofwarmed2 5 dextrosesolution3 Infuseover10min atarateof200ml min Aftereach400 mlinfused rollthepatientfromsidetoside 4 Indwellfor4hours Ambulatoryduringdwelltime 5 Drainover20min 6 Afterdrainage thebagisagainweighed 最好在使用2 5 葡萄糖腹透液留腹過(guò)夜8 12小時(shí)后 充分排放透析液至少20分鐘秤量袋裝2升規(guī)格的已加溫的2 5 葡萄糖腹膜透析液3 十分鐘以上灌入腹內(nèi) 速度200ml min 每灌入400ml時(shí)讓患者翻轉(zhuǎn)身體 4 留腹4小時(shí) 留腹期間要求不臥床 5 排液時(shí)間20分鐘以上 6 排液后再次秤量腹透液袋 PET ProtocolPET 操作程序 Bloodsample 0 2 4hourDialysatesample 200mlofdialysissolutionisdrainedintothebag mixedwell a10mlsampleistaken andtheremaining190mlisreinfusedbackafter2and4hours anothersampleistaken CalculateD Pcreatitineat2and4hoursD D0glucoseat2and4hoursthevolumeofUFinthedrainagebag血標(biāo)本 0 2 4小時(shí)透析液標(biāo)本 將200ml的透析液排至袋中 充分混勻 取10ml樣本 剩下的190ml液體重新灌入腹腔 計(jì)算2h 4h的肌酐濃度透析液 血漿 D Pcr 2h 4h的葡萄糖濃度透析液 血漿 D D0 引流袋凈超濾量 PET SamplingPET 取樣 PETcalculationPET 計(jì)算 Thecorrectionfactorforcreatininebyhighglucoseindialysissolutionsisbestdeterminedbyindividuallab ThecorrectionfactorusedbytheUniversityofMissouri 0 000531415 Correctedcreatininemg dl creatininemg dl glucoseX0 000531415 mg dl由于透析液中高濃度葡萄糖影響 肌酐測(cè)定需要的校正因子最好由每個(gè)實(shí)驗(yàn)室確定 密蘇里大學(xué)使用的校正因子 0 000531415 校正的肌酐mg dl 肌酐mg dl 葡萄糖 0 000531415 mg dl PET InterpretationPET評(píng)估 D PforUr CrandNaandD DoforGluat0 2 and4hrsarecalculatedPatientsareclassifiedonbasisof4hrD PCraslow lowaverage highaverageorhightransportersIngeneral hightransportersdialyzewell butabsorbGlurapidly havelessUF greaterdialysateproteinlossesandlowerserumalbuminLowtransportersaretheoppositeandaveragetransportersareinbetween計(jì)算0 2 4小時(shí)的尿素 肌酐 鈉的透析液濃度 血漿濃度 D PUr D PCr D PNa 以及葡萄糖透析液濃度 血漿濃度 D Do 按照4h時(shí)肌酐透析液濃度 血漿濃度 D PCr 分為低 低平均 高平均或高轉(zhuǎn)運(yùn)患者總的來(lái)說(shuō) 高轉(zhuǎn)運(yùn)患者透析好但是葡萄糖的吸收快 超濾量少 透析液丟失蛋白多 血清白蛋白也較低低轉(zhuǎn)運(yùn)患者與上述相反 平均轉(zhuǎn)運(yùn)者在兩者之間 CategorizationofperitonealtransportinPETPET中腹膜轉(zhuǎn)運(yùn)特性的分類 我國(guó)患者腹膜轉(zhuǎn)運(yùn)功能分布有所不同 H15 HA50 LA40 L6 Membranetransporttype腹膜轉(zhuǎn)運(yùn)類型 Blakedatabase TwardowskiZJ ASAIOTrans1990 36 8 Rapid high vsslow low transportersinPD高轉(zhuǎn)運(yùn)與低轉(zhuǎn)運(yùn)比較 由于病人的轉(zhuǎn)運(yùn)功能不同 應(yīng)進(jìn)行個(gè)體化處方 Importantfactorsdeterminingsoluteandfluidremoval決定水和溶質(zhì)清除的重要因素 Dialysatetoplasmaconcentrationratio D P PeritonealtransportcharacteristicsDiffusionConvectivetransport MainlydependsonultrafiltrationDialysatevolumeTotalinfusionvolumeUltrafiltrationvolumePeritonealabsorptionBodysize 透析液血漿濃度比值 D P 腹膜轉(zhuǎn)運(yùn)特點(diǎn) 彌散對(duì)流轉(zhuǎn)運(yùn) 主要依賴超濾透析液劑量 灌腹總量超濾量腹膜吸收量體形大小 Empiricprescription經(jīng)驗(yàn)處方 3 5exchangesof2LdialysisbagConsideringmainlyfluidbalance2升袋裝透析液交換3 5次注意保持大致液體平衡 TheweightsatwhichtheweeklyKt Vureaequalstheminimumtargetof1 7每周尿素Kt V最少達(dá)到1 7的患者體重水平NolphKdetal PeritDialInt1994 14 261 264 Contentsoftalk內(nèi)容 Whatisperitonealmembrane PhysiologyofperitonealdialysisUremictoxinremovalFluidremovalPDprescriptionAdequacyMembranetransport PETIndicationsandcontraindicationsofPDPreparingandperformingPDAPDComplicationsrelatedtoPDClinicaloutcomeofPDHowtoset upPDcenter 什么是腹膜 腹膜透析 peritonealdialysis PD 的生理學(xué)尿毒癥毒素的清除液體的清除鈉的清除腹膜透析處方充分性膜轉(zhuǎn)運(yùn) 腹膜平衡試驗(yàn) PET 腹膜透析的適應(yīng)癥和禁忌癥腹膜透析的準(zhǔn)備和實(shí)施自動(dòng)化腹膜透析 automaticperitonealdialysis APD PD相關(guān)并發(fā)癥PD的臨床預(yù)后怎樣建立PD中心 腹膜透析適應(yīng)癥大部分病人都適合做腹膜透析164 病人既可以腹透也可以血透2 中國(guó)維持性腹膜透析專家共識(shí)JagarKJet AJKD2004 StrongmedicalindicationforPD腹膜透析絕對(duì)適應(yīng)癥 DifficultieswithvascularaccessLeftventricularhypertrophyCongestiveheartfailureProstheticvasculardiseaseIntoleranceofHDFrequentepisodesofhypotensionHeadacheandastheniaafterHDsessionChildren 血管通路建立困難左心室肥厚充血性心衰人造血管病變不能耐受血液透析經(jīng)常出現(xiàn)低血壓事件血透后頭痛和乏力兒童 PDpreferred適合PD Bleedingdiathesis noneedofheparinization Diabetes statusofvessels insulini p Chronicinfections preventionofthenosocomialspread hepatitisB C HIV Futuretransplantation improvedinitialgraftfunctionrate Multiplemyeloma improvesthechancesofrenalrecovery removessomelight chainsproteins 出血傾向 不需要肝素化 糖尿病 血管條件 腹腔內(nèi)使用胰島素 慢性傳染病 預(yù)防乙肝 丙肝及艾滋病的院內(nèi)感染 將來(lái)準(zhǔn)備腎移植 改善術(shù)后移植物成功率 多發(fā)性骨髓瘤 增加腎功能恢復(fù)機(jī)會(huì) 清除一些小的輕鏈蛋白 PDandHDequallypreferred可以選擇PD或HD PolycystickidneydiseaseScleroderma otherconectivetissuediseases e g SLE Patientslivinginnursinghomes多囊腎疾病硬皮病及其他結(jié)締組織疾病 系統(tǒng)性紅斑狼瘡等 居住在護(hù)理院的患者 TheoreticallynottochoosePDinitially BUTPDmaybefeasiblewithaddedadjustments理論上不宜首選腹透治療 但是進(jìn)行某些改進(jìn)后腹透也可以實(shí)行的情況 LargebodysizeDiverticulosis diverticulitisSeverebackacheNIPDHerniasNIPDMultipleabdominalsurgeryPoormanualdexterityBlindnessNocompliance 體形較大 腸 憩室病 憩室炎重度背痛NIPD疝氣NIPD腹部多次手術(shù)史操作不便失明依從性差 PsychosocialsituationsinwhichPDismoreappropriate更適合腹透的心理狀態(tài) PDpreferredIndependentLifeFrequenttravelsTendencytowardsPDGreatneedofindependencebythepatientNeedtomaintainworkDistancetotheHDcenter 優(yōu)先選腹透獨(dú)立生活經(jīng)常旅行傾向于腹透患者有強(qiáng)烈獨(dú)立生活的愿望需要繼續(xù)工作遠(yuǎn)離血透中心 PreparationforPD腹透的準(zhǔn)備 Pre dialysiscounselingPeritonealdialysisequipmentsandaccessoriesPeritonealcatheterinsertionBreak inperiodDialysisprocedures透前咨詢腹透裝備及配套品準(zhǔn)備埋置腹透導(dǎo)管導(dǎo)管修整期透析培訓(xùn) Pre dialysiscounseling透析前的咨詢 Motivation complianceandhomeenvironmentareimportantfactorsforthesuccessofthetherapy asPDishomebasedselftreatment ThebetterunderstandingofESRDanddialysistherapy thebettermotivationandcompliance Canbedonebynephrologist dialysiscounselororBaxtercoordinator腹透是以家庭自我治療為主透析方式 所以患者的動(dòng)力 依從性及家庭環(huán)境是治療能否獲得成功至關(guān)重要的因素 對(duì)ESRD和透析的理解越好 患者的動(dòng)力及依從性越好 可以由腎病專科醫(yī)師 透析顧問(wèn)或百特公司協(xié)作者進(jìn)行 DifferentPDcatheters不同腹透管路 Straight1cuff Straight2cuffs CoiledTenckhoffcatheters卷曲管 Coiled1cuff Coiled2cuffs SwanNeckTenckhoffcatheters鵝頸管 Straight Coiled DownwardsdirectedexitsitePermanentbendbetween2cuffs 180 Rightorleft SwanNeckMissouri鵝頸Missouri管 Straight Coiled BeadplacedIP FlangeextraP StraightTenckhoffcatheters直管 Variations演變 O Z T W TenckhoffCatheter O Z T W MissouriTenckhoffCatheter Moncrief popovichCatheter Pediatric Presternal T Fluted DiPoaloSelflocating Accessories Titaniumadaptor配件 鈦接頭 SecureSealLockingsleeveprovidesasnugcompressionfit LongerTailanddualreversebarbsmeanbettercathetergrip Patenteddoublelockingsealincreasessecurityoftransfersetconnection ReducedPeritonitisRiskSeamlessmachiningavoidsroughsurfacesthatcantearcathetersandcatchdebris Titanium withtwicethestrengthofsteelandonlyhalftheweight willnotcracklikeplastic 安全密封連接套管保證緊密的壓縮接合 加長(zhǎng)的尾部及雙道反向的溝槽使得連接更緊 專利的雙連接密封技術(shù)增加了體外傳輸裝置連接時(shí)的安全性 減少腹膜炎的風(fēng)險(xiǎn)無(wú)縫加工技術(shù)避免了因粗糙表面劃割導(dǎo)管或粘粘碎屑 鈦金屬 硬度是鋼的兩倍而質(zhì)量是其一半 不會(huì)象塑料那樣容易破裂 NursingConvenienceThelockingsleevegripsawiderrangeofcathetersizes Titaniumstandsuptodisinfectantsandresistscorrosion PatientComfortHighlypolishedbulletshapefeelssmoothagainsttheskin Superiormachiningminimizessizeandweight 護(hù)理方便連接套管可以緊連各種規(guī)格導(dǎo)管 鈦金屬可抗菌及抗腐蝕 患者舒適高度磨光的子彈型的外表對(duì)皮膚而言很平滑 精細(xì)加工使其最輕最小 PDCatheterimplantation腹透置管術(shù) PeritonealCatheterimplantationmustbeperformedbyacompetentandexperiencedsurgeonornephrologist Optimallongtermperitonealcatheterfunctionandexitsitehealingaredirectlyrelatedtotheskillsandthecompetenceofthecatheterinsertionteam 腹透導(dǎo)管埋置術(shù)必需由熟練有經(jīng)驗(yàn)的外科醫(yī)生或