中國腹透發(fā)展現(xiàn)狀與挑戰(zhàn)教學(xué)內(nèi)容

中國腹透發(fā)展(fāzhǎn)現(xiàn)狀與挑戰(zhàn)余學(xué)清中山大學(xué)附屬第一(dìyī)醫(yī)院第一頁，共45頁。中國腹透發(fā)展(fāzhǎn)現(xiàn)狀中國腹透未來發(fā)展(fāzhǎn)內(nèi)容提要(nèirónɡtíyào)第二頁，共45頁。廣州CKD的患病率:12.1%北京(běijīnɡ)CKD的患病率:11.3%上海CKD的患病率:11.8%鄭州CKD的患病率:13.5%ChenW,…YuXQ.etal.NDT2009;24:1205-12ZhangL,…WangH.etal.AJKD,2008;51(3):373-84ChenN,…FanQ.etal.NDT2009;24:2117-23LiuZS,….etal.ChinJofNephrol.2008;24(8):524CKD是中國重要(zhòngyào)的公共健康問題第三頁，共45頁?！?50,000dialysispatientsinChina中國ESRD患者(huànzhě)數(shù)量快速增長第四頁，共45頁。中國(zhōnɡɡuó)腹膜透析的需求增加人口數(shù)量激增，特別是老年(lǎonián)群體比例增加CKD患病率高,越來越多的ESRD患者隨著經(jīng)濟(jì)的發(fā)展，醫(yī)療保障覆蓋更多透析患者有限的資源和基礎(chǔ)設(shè)施（空間，設(shè)備，技術(shù)人員）家庭透析逐漸普及和接受第五頁，共45頁。腹膜(fùmó)透析在中國的優(yōu)勢安全，方便以及容易掌握有益于遠(yuǎn)離透析中心居住的患者中國大多數(shù)人民居住在農(nóng)村大部分縣級(jí)醫(yī)院沒有血液透析設(shè)備(shèbèi)適合患有具傳染性疾病的患者第六頁，共45頁。ESRD患者(huànzhě)：100多萬HD：20萬PD：2.3萬中國透析登記(dēngjì)資料中國不同透析方式(fāngshì)現(xiàn)狀第七頁，共45頁。2006—2010中國(zhōnɡɡuó)腹透病人數(shù)*年份20062007200820092010病人數(shù)量10000～1200013000～1500016000～1800019000～2100021000～23000*由于目前尚未得到(dédào)全國腹透病人的數(shù)據(jù)，此數(shù)據(jù)僅為百特工作人員的推測數(shù)據(jù)中國腹透的發(fā)展(fāzhǎn)情況第八頁，共45頁。Dialysismodalitychoicevarieswidelyaroundtheworld9USRDSADR2008Table12.dNAmLAmAsiaPacW.EuropeECEMEA全球(quánqiú)各地不同透析方式構(gòu)成第九頁，共45頁。衛(wèi)生部腹膜(fùmó)透析專家組會(huì)議第十頁，共45頁。腹膜(fùmó)透析方式的政府支持衛(wèi)辦醫(yī)政函2011－549號(hào)頒布,文件中詳細(xì)闡述了提高我國腹膜透析水平，擴(kuò)大腹膜透析覆蓋面的管理要求制定了逐級(jí)開展腹透培訓(xùn)，提高醫(yī)療機(jī)構(gòu)腹透治療能力的路徑部署了按照《腹膜透析標(biāo)準(zhǔn)操作流程》進(jìn)行系列培訓(xùn)的實(shí)施辦法要求各省級(jí)衛(wèi)生行政部門在制定醫(yī)療質(zhì)量考核和醫(yī)院評(píng)審、評(píng)價(jià)指標(biāo)時(shí)，腹透液費(fèi)用不計(jì)入藥品收入(shōurù)，按照醫(yī)用耗材進(jìn)行統(tǒng)計(jì)“關(guān)于(guānyú)做好腹膜透析相關(guān)工作的通知”,衛(wèi)辦醫(yī)政函2011－549號(hào),衛(wèi)生部辦公廳,2011年6月13日第十一頁，共45頁。腹膜透析數(shù)量與腹透質(zhì)量同步提高腹透臨床和腹透科研齊頭并進(jìn)不同級(jí)別醫(yī)院腹透中心(zhōngxīn)共同發(fā)展中國腹透未來(wèilái)發(fā)展的方向第十二頁，共45頁。0102030405060708090100198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003病人生存率(%)90Days1Year2Year3Year5Year10YearHDPD根據(jù)年齡、性別、種族和原發(fā)病進(jìn)行校正USRDSAnnualDataReport2007不同(bùtónɡ)治療年限的腹透病人生存率均顯著提高第十三頁，共45頁。不可調(diào)控的危險(xiǎn)因素可調(diào)控的危險(xiǎn)因素年齡殘余腎功能(RRF)性別腹膜功能人種/種族感染：腹膜炎糖尿病透析中心規(guī)模ESRD病因病人教育遺傳JessicaKendrickandIsaacTeitelbaum,ClinJAmSocNephrol5:1123-1131,2010影響患者(huànzhě)生存率的因素第十四頁，共45頁。中心(zhōngxīn)規(guī)模>50與<50比較，腹透病人臨床預(yù)后較好HD=hemodialysis;pt-yr=patient-year;RH=relativehazard;CI=confidenceinterval;ref.=referencevaluea

p<0.05bDemographics:age,sex,andrace;Clinical:IndexofCoexistentDiseasescore,diabeticstatus,andbodymassindex;Laboratory:albuminandcreatinineLauraal:PDI,Vol.29,pp.285–291中心規(guī)模與腹透患者(huànzhě)臨床預(yù)后密切相關(guān)第十五頁，共45頁。退出(tuìchū)率DOR%治療(zhìliáo)持續(xù)時(shí)間TOT（月）BigisBeautifulinPD!-Prof.PeterBlake*百特中國(zhōnɡɡuó)數(shù)據(jù)腹透中心的規(guī)模與治療質(zhì)量成正相關(guān)*第十六頁，共45頁。腹透臨床和腹透科研(kēyán)齊頭并進(jìn)中國(zhōnɡɡuó)腹透未來發(fā)展的方向第十七頁，共45頁。2012.2.311009RapidincreaseinPDpatientnumberatSYSU第十八頁，共45頁。PatientSurvivalforPrevalentPatientsn12mo36mo60moAge＜64ys37796±0.01%86±0.02%79±0.03%Age≥65ys13188±0.03%62±0.05%38±0.06%Total50894±0.01%79±0.02%66±0.03%DatafromSYSUPDregistrationsystem第十九頁，共45頁。TechniqueSurvivalforPrevalentPatientsn12mo36mo60moAge＜64ys37799±0.00%96±0.01%86±0.03%Age≥65ys13197±0.03%88±0.05%80±0.03%Total50899±0.02%94±0.03%85±0.06%DatafromSYSUPDregistrationsystem第二十頁，共45頁。KPIApproachinSYSU2010IndicatorsKPIApproach%Hemoglobin(110-130g)≥70%65%SerumPhosphate(≤1.78mmol/L)≥70%66%WeeklyKt/V≥1.7≥90%91%SBP105-140mmHg≥70%73%PeritonitisRate≥1:301:76ExitInfectionRate≥1:501:87TechnicalSurvival(1year)≥85%98%CatheterSurvival(1year)≥80%94%Johnson,DW,etal.ISPDACM2010,8:2-3第二十一頁，共45頁。TheroleofTGF-/smadsinthemechanismofperitonealfibrosisNieJ,…YuXQ*..PeritDialInt.2007;27(5):580-8.

NieJ,…YuXQ*.KidneyInt.2007;72(11):1336-44.

SunYY,…YuXQ*.AmJNephrol.2009;18;30(1):84-94.

LiuQH,…YuXQ*.PeriDialInt.2008,28:S88-95.WuJ,…YuXQ*.

InflammRes.2009;March7Epubaheadofprint.Smad7Smad4CellmembraneNucleusIIISmad2/3TGF-βpSmad2/3EMTandFibrosisSmad7TF第二十二頁，共45頁。TheRegulatingMechanismofTGF-β/SmadsonEMTWangXY,…YuXQ*.BiochimBiophysActa.2008,1782:51-59.NieJ,…YuXQ*.BiochimBiophysActa.2009;1792:122-31.

MaoH,…YuXQ*.AmJPhysiol-RenalPhysiol.2008;295(1):F202-14.ZhangHY,…YuXQ*.Nephrology.2009;14(3):302-10ZhouY,…YuXQ*.JASN2010;21:598-609ZhuFX,etal.AmJPathol2010;176:650-9.ZhouQ,etal.JBiolChem.2010;285(51):40019-27Smad4CellmembraneNucleusEMTandFibrosisSmad7TFIIISmad2/3TGF-βpSmad2/3HSP72HSP72第二十三頁，共45頁。ClinicalResearchPrograminPDPreservationofPeritonealfunctionPreservationofresidualrenalfunctionPreventionofCVDinPDpatientsBio-makerfortheearlydiagnosisSatelliteCenterforoutofGuangzhou第二十四頁，共45頁。TheOngoingPrograminSYSUACEI,ARBandcombinationinthepreservationofperitonealandRRF.RestricteddietproteinplusketoacidinthepreservationofperitonealandRRFThemolecularmechanismofpathogeninthePDrelatedperitonitisandpreventivestrategyfortherelapseperitonitis.第二十五頁，共45頁。AnExcellentPDTeam第二十六頁，共45頁。不同地區(qū)腹透中心(zhōngxīn)共同發(fā)展中國(zhōnɡɡuó)腹透未來發(fā)展的一些思考第二十七頁，共45頁。HigherdropoutofPDpatientsinSuburbanPatientNo’sPercentageGuangzhou20239.6%OutofGuangzhou30860.4%Total510100%2008.6.第二十八頁，共45頁。MajorityofpatientsliveinsuburbanareasNumberPercentageInsideofGuangzhou23741.9%OutsideofGuangzhou32958.1%Total566100%Datafrom2008第二十九頁，共45頁。Satellitecenter●★★★★★★★★★★★★27doctorsandnursestrainedinourcenterPDsatelliteCenterPrograminGuangzhouThisprogramwassupportedbytheBaxterClinicalEvidenceCouncil(CEC)grant2008第三十頁，共45頁。BackgroundforPDsatellitecenter50%patientsneedtogotothedifferentareasinGuangdongprovinceforfollowupThereexistsomeproblemsinthoseregionsSmallscaleandhaven’thadaPDteamPoorPDtechniqueandcentermanagementWeak/poortraining,teachingandfollowupprogramHighperitonitisanddropoutrates,poorpatientsurvival第三十一頁，共45頁。PurposeoftheprogramToestablishadvancedPDsatellitecentersinGuangdongprovincewithwelleducationandtrainingsystemUsingstandardPDprograminpatient’straining,educationandfollow-upproceduresTosetupagoodmodeltoimprovePDoutcome(i.e.patientandtechnicalsurvival)andQOI第三十二頁，共45頁。PDSatelliteCenterRunningProcedureThePDcenterinSunYat-SenUniversityinitiatedandrunningthisprogramEachsatellitePDcenterneedtohavefull-timePDdoctorandnurses,and,usethesameprogramfortraining,education,followupandforalltreatmentprotocols.AllthecentersreporttheirworktotheSunYat-senuniversityPDcentereverymonthandjointheregularmeetingevery6monthsRegularsiteobservationandfeedbackourcomments第三十三頁，共45頁。RegulardatacollectionIncidencepatientsandcausesPDadequacyandanalysisNutritionalstatusComplicationincidencePatient-andtechnical-survivalPatientdrop-outsandreasons第三十四頁，共45頁。SummaryofthesatellitePDcenter12PDcentersjoinedthisprogram26doctorsand32nursestrainedPDptsincreasedfrom1010to1860第三十五頁，共45頁。ClinicaldataofPDpatients20072009BloodPressureNormalBP38.4%39.3hypotension1.1%1.7%Mild-mediumhypertension52.5%51.8%Serioushypertension10.3%7.1%SerumAlbumin<35g/L28.8%25.0%≥35g/L71.2%75.0%Kt/V>2.041.0%40.6%1.7-2.032.1%34.8%<1.727.2%24.6%第三十六頁，共45頁。SomeIndexeshaveshownimprovementIndex20072009Patientsurvivor(1year)82.0%84.2%TechnicalSurvivor(1year)88.7%93.0%Patientdropout28.217.6TOT17.818.1Peritonitisrate44.343.8第三十七頁，共45頁。ThefutureplanforthisprogramExpandourexperienceinthePDsate