腎內(nèi)科教學(xué)課件：腹膜透析

腹膜透析終末期腎病治療方式的選擇血液透析腹膜透析腎移植Transplantation

移植AdvantagesMostlikeyourownkidneyNodialysisneededNoaccessneededNormalDiet(-sodium)More“normal”lifestyle優(yōu)點(diǎn)與自己的腎臟功能相似不需透析不需要通路正常飲食（鈉）生活方式更接近正常DisadvantageRisksofmajorsurgeryRiskofbodyrejectingkidneyPossiblesideeffectsofdrugsLowerresistancetoillnessBodyimagechanges.缺點(diǎn)手術(shù)風(fēng)險(xiǎn)排異反應(yīng)藥物的副作用抵抗力低下體形改變Patient's

KidneyTransplant

Kidney(extra-peritoneally)Bladder病腎移植腎膀胱Who

cannot

donateakidney?

哪些人不可捐獻(xiàn)腎？HIVorAIDS-relatedinfectionHepatitisBorCinfectionMajorheartorbreathingproblemsDiabetesExtremeobesitySignificantkidneydiseaseMostcancersIVdrugabusePregnancyHighBPHavingonlyonekidneyEvidenceoffinancialornon-financialcoercionInabilitytogiveinformedconsent/psychiatricdisordersHIV或AIDS相關(guān)感染乙肝或丙肝感染嚴(yán)重心肺疾病糖尿病過(guò)度肥胖明顯的腎臟疾病大多數(shù)癌癥靜脈吸毒妊娠高血壓僅有一個(gè)腎有經(jīng)濟(jì)或非經(jīng)濟(jì)利益企圖的證據(jù)無(wú)法做到知情同意或有精神障礙Indicationsfordialysisinitiation

開(kāi)始透析的指征腎小球?yàn)V過(guò)率10-15ml/min/1.73m2尿毒癥癥狀尿毒癥導(dǎo)致?tīng)I(yíng)養(yǎng)不良有計(jì)劃地開(kāi)始透析對(duì)于患者非常重要，應(yīng)盡量避免“急診透析”！GFR10-15ml/min/1.73m2UremicsymptomsMalnutritionHemodialysis

血液透析Theprocessofseparatingchemicalsubstancesfrombloodthroughasemi-permeablemembrane通過(guò)透析器半透膜從血液中分離化學(xué)物質(zhì)的過(guò)程ToxinRemoval

清除毒素Removaloftoxinsfromthebloodisaccomplishedby:清除血液中毒素是通過(guò)：Diffusion

彌散Convection

對(duì)流Adsorption

吸附Blood血Blood血液Dialysate透析液Salt鹽Toxin毒素Semi-permeableMembrane半透膜在血透治療中，絕大部分清除毒素作用是通過(guò)彌散實(shí)現(xiàn)彌散清除與下列因素相關(guān)：濃度梯度，分子大小，膜表面積ConcentrationGradient-FlowGeometry

濃度梯度-液流動(dòng)力影響B(tài)loodIn血液入口BloodOut血液出口DialysateIn透析液入口DialysateOut透析液出口CounterFlow

反向液流Temporaryvs.Permanent

臨時(shí)通路或永久通路TemporaryAccessUsedforafewhourstoseveralweeksUsuallypercutaneousinsertionofacannulaintoalargeveinSurgicalimplantationofpairedtubesintoanarteryandveinwereusedanumberofyearsago;fairlyobsoletenowForpatientswithacuterenalfailure,chronicrenalfailurewithoutpermanentaccess,peritonealdialysis(PD)ortransplantpatientsfortemporaryhemodialysisPermanentForperiodsrangingfrommonthstoyearsOptionsSub-cutaneousanastomosisofarterytoveinSub-cutaneouspositioningofa“tube”graftbetweenanarteryandveinImplantationofacuffeddual-lumencatheterintoavein臨時(shí)通路使用幾小時(shí)到數(shù)周通常經(jīng)皮穿刺大靜脈，留置導(dǎo)管。外瘺（動(dòng)靜脈各植入一根臨時(shí)導(dǎo)管）現(xiàn)在已經(jīng)基本不再使用急性腎衰、慢性腎衰尚未建立永久通路、腹透或移植患者進(jìn)行臨時(shí)血透時(shí)使用永久通路可以持續(xù)使用數(shù)月到數(shù)年選項(xiàng)內(nèi)瘺（動(dòng)脈與靜脈經(jīng)手術(shù)連接）人造血管連接動(dòng)脈和靜脈深靜脈植入帶滌綸套的雙腔導(dǎo)管ComplicationsofVascularAccess

血管通路相關(guān)并發(fā)癥InfectionThrombosisEarlyvs.latethrombosis“Thrombolysisvs.thrombectomy”

HemodynamiccomplicationCongestiveheartfailure:“Highoutputcardiacfailure”VascularinsufficiencyorarterialstealVenoushypertensionVascularaccessneuropathy“Carpaltunnelsyndrome”Aneurysms(trueorpseudo)

感染

栓塞早期和晚期栓塞血液動(dòng)力學(xué)改變相關(guān)并發(fā)癥充血性心力衰竭：“高輸出性”

血流不足或動(dòng)脈竊血癥

靜脈高壓造成肢體末端腫脹

血管通路相關(guān)的神經(jīng)損傷“腕管綜合癥”Aneurysms(trueorpseudo)“動(dòng)靜脈短路””造成心臟輸出量增加?！皠?dòng)靜脈短路”的靜脈動(dòng)脈化使得肢體遠(yuǎn)端血液回流受阻?！皠?dòng)靜脈短路”造成肢體遠(yuǎn)端（尤其是手部）供血不足。腹膜透析可以在任何地方進(jìn)行換液，便于旅行無(wú)需依賴(lài)機(jī)器治療時(shí)間可靈活安排學(xué)習(xí)簡(jiǎn)單無(wú)需穿刺獨(dú)立性強(qiáng)，生活自主優(yōu)點(diǎn)腹膜透析的臨床優(yōu)越性保護(hù)殘余的腎臟功能維持血壓的平穩(wěn)減輕心臟的負(fù)擔(dān)，減少心力衰竭的發(fā)生減少貧血的發(fā)生減少肝炎等交叉感染的機(jī)會(huì)移植腎功能延遲發(fā)生少飲食限制較少Whatarethebenefitsofpreservingresidualrenalfunction?

保護(hù)殘余腎功能的益處Contributestototalsoluteclearance(1ml/minCrCl=10literCrCl/week)增加總的溶質(zhì)清除Improves2-microglobulinandmiddlemoleculeclearance改善2-微球蛋白及中分子毒素的清除Providesendocrinefunctions內(nèi)分泌功能ReducesMortality降低死亡率Facilitatesvolumecontrol有利于容量控制Allowsformoreliberaldietandfluidintake允許較多的飲食和水分?jǐn)z入Improvesnutritionalstatus改善營(yíng)養(yǎng)狀況ImprovesQOL提高生活質(zhì)量IncreasestotalNaremoval增加總鈉清除Davies,S.2000Whatistheperitonealmembrane?

關(guān)于腹膜腹膜是被覆于腹腔的光滑漿膜臟層腹膜壁層腹膜腹膜凹陷腹腔和腹膜腔ThemesotheliumTheinterstitiumMacrophages/MonocytesPeritonealcapillariesPlaysimportantrolewaterandsoluteexchange間皮間質(zhì)巨噬細(xì)胞/單核細(xì)胞腹膜毛細(xì)血管在水和溶質(zhì)的轉(zhuǎn)換中起重要作用Componentsoftheperitoneum腹膜的結(jié)構(gòu)Diffusion

彌散Definition:Solutemovementduetoconcentrationgradientoftwosolutesbetweencomponentsacrossasemi-permeablemembraneMaindrivingforceforsmallsoluteremovalFactorsinvolvedindiffusionSizeofsolutePeritonealsurfaceareaHydrostaticpressureElectricalchargeofsolutes定義:溶質(zhì)依靠溶液之間濃度梯度透過(guò)半透膜（腹膜）進(jìn)行的轉(zhuǎn)運(yùn)彌散是小分子溶質(zhì)清除的主要機(jī)制影響彌散的因素

溶質(zhì)分子的大小

腹膜表面積靜水壓溶質(zhì)的電負(fù)荷腹膜轉(zhuǎn)運(yùn)機(jī)理小分子依靠彌散作用從毛細(xì)血管進(jìn)入腹膜間質(zhì)，再進(jìn)入透析液中透析液中的葡萄糖借助彌散作用從腹腔進(jìn)入腹膜間質(zhì)，加上彌散出來(lái)的小分子，使間質(zhì)晶體滲透壓升高，對(duì)毛細(xì)血管內(nèi)水分形成超濾，水就從毛細(xì)血管移出；毛細(xì)血管中水分的超濾對(duì)毛細(xì)血管中大分子又產(chǎn)生對(duì)流作用，大分子就進(jìn)入間質(zhì)，使局部膠體滲透壓升高，水被進(jìn)一步超濾，這樣，水和大分子然后分別進(jìn)入透析液當(dāng)中；葡萄糖不斷進(jìn)入間質(zhì)和毛細(xì)血管使?jié)B透梯度下降，水的超濾下降。

通過(guò)上述過(guò)程，毛細(xì)血管內(nèi)的水被超濾出來(lái)，小分子和大分子毒素通過(guò)彌散和對(duì)流作用也被排出，從而實(shí)現(xiàn)水和毒素的清除，同時(shí)伴隨著透析液葡萄糖被機(jī)體攝入。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(lài)于：殘存腎功能體形大小合并癥情況PET:Interpretation

PET評(píng)估

D/PforUr,CrandNaandD/DoforGluat0,2,and4hrsarecalculatedPatientsareclassifiedonbasisof4hrD/PCraslow,lowaverage,highaverageorhightransportersIngeneral,hightransportersdialyzewell,butabsorbGlurapidly,havelessUF,greaterdialysateproteinlossesandlowerserumalbuminLowtransportersaretheoppositeandaveragetransportersareinbetweenD/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（物質(zhì)清除較快），但是葡萄糖的吸收也快，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AuditingthePDProgram

評(píng)估腹透InfectionratesTechnicalproblemseg.catheterflowproblemsAdequacyindicesNutritionindicesTechniqueandpatientsurvivalAnaemiamanagement感染率技術(shù)問(wèn)題，如導(dǎo)管漂移等透析充分性營(yíng)養(yǎng)狀況技術(shù)生存率和病人生存率貧血的治療Globaltherapymix

全球治療方式APD= Automated Peritoneal Dialysis

自動(dòng)化腹膜透析CAPD: Continuous Ambulatory Peritoneal Dialysis

持續(xù)性不臥床腹膜透析我國(guó)目前約為1％AutomatedPeritonealDialysis

自動(dòng)化腹膜透析PeritonealdialysisusingautomatedexchangemachineDesignedtominimizetheburdenoffrequentexchangesofdialysatebagsAllowindividualizedprescriptionofperitonealdialysis使用自動(dòng)交換腹透機(jī)進(jìn)行腹膜透析減少透析液交換次數(shù),減輕腹透換液負(fù)擔(dān)允許個(gè)性化腹膜透析處方DifferentPDcatheters

不同腹透管路Straight1cuffStraight2cuffsCoiledTenckhoffcatheters卷曲管Coiled1cuffCoiled2cuffsSwanNeckTenckhoffcatheters鵝頸管StraightCoiledDow