腹膜透析原理1課件

BaxterAsiaRenalHowPDworks

腹透原理KidneyDisease

腎臟病基礎ImplicationsTherapyoptions包括治療選擇PrMaxDratwaH?pitalBrugmannBrusselsLearningobjectives

學習目的Understandnormalkidneyanatomy&functioningUnderstandkidneydisease:acuteandchronicKnowtheimplicationsofkidneydiseaseBeabletodiscussthedifferenttreatmentoptions理解腎臟正常的解剖和功能理解急性和慢性腎臟疾病了解腎臟病的并發(fā)癥討論不同的治療方式TheKidney腎臟腎解剖特征：1.腎外形似蠶豆，成年人腎約長12cm，寬6cm，厚3cm，重約120－160g；呈紅褐色，質(zhì)軟。TheKidney腎臟（續(xù)）腎解剖特征：2.冠狀面：外1/3皮質(zhì)，內(nèi)2/3髓質(zhì)

腎錐體的尖端形成腎乳頭，2－3個腎乳頭匯入腎小盞，腎小盞匯入腎盂

腎門：腎靜脈、腎動脈、輸尿管、神經(jīng)結締組織等

腎皮質(zhì)腎錐體腎盂輸尿管腎髓質(zhì)腎動脈腎靜脈腎小盞TheKidneybasicunit:thenephron

腎臟基本結構：腎單位每個腎臟由100萬個腎單位組成腎單位腎小球腎小管血管叢血小囊關鍵詞：原尿：終尿：Ureter輸尿管Urethra尿道Calyx腎盞Bladder膀胱Renalpelvis腎盂Functionsofthekidney

腎功能Homeostasis=maintenanceofequilibriumintermsof:Saltandwater(bloodpressure)Electrolytes(K,Mg,…)Acid-Basebalance(pH)MetabolismofwasteproductsHormoneproduction

ActiveformofVitaminD(healthybones)Erythropo?etin(RBCsynthesis)Renin-Angiotensin(bloodpressure)

內(nèi)環(huán)境穩(wěn)態(tài)水鹽平衡電解質(zhì)(K,Mg,…)酸堿平衡(pH)廢物的代謝激素生成

活性維生素D（健康骨）EPO(促進紅細胞生成)腎素－血管緊張素（調(diào)節(jié)血壓）

Thediseasedkidney

腎臟疾病TwotypesofkidneydiseaseAcutefailure…Classifiedaccordingtositeofproblem:pre-renalrenalpost-renalChronicdisease…Classifiedin5stagesofincreasingseriousness1:1:milddamage2:milddecreaseofrenalfunction3:moderaterenalinsufficiency4:severedamage5:endstagerenaldisease(ESRD)兩種類型急性:根據(jù)病變部位分類腎前性（腎臟供血障礙）腎性（腎本身疾病所致）腎后性（腎的排泄系統(tǒng)阻塞）慢性:嚴格按照疾病進展分5期1:輕微損害2:GRF輕度下降3:GRF中度下降4:GRF重度下降5:終末期腎臟疾病（ESRDClassificationofKidneyDisease

腎臟病分類1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,Guideline1:DefinitionandStagesofChronicKidneyDisease,

NKF,2002.腎功能急驟地、進行性地減退導致的臨床癥候群急性腎衰“Pre-renal”Usuallyduetodecreasedbloodflowtothekidneyshemorrhage,gastrointestinalbleedingleadingtoshockburnssepsisemboli,stenosis,occlusion,traumatorenalarterydecreasedcardiacoutputcongestiveheartfailure,myocardialinfarctionSurgery腎前性通常是因為腎臟血流灌注減少出血性疾病導致休克創(chuàng)傷敗血癥腎動脈狹窄、栓塞、硬化等心輸出量下降充血性心力衰竭、心肌梗塞手術CausesofAcuteKidneyFailure

急性腎功能衰竭的原因1ANNACoreCurriculumforNephrologyNursing,3rdEdition,Lancaster,L.;SectionIII,CausesofRenalDisease,pgs.53-62.CausesofAcute

KidneyFailure

急性腎功能衰竭的原因“Intra-renal”(continued)Inflammationfrombacteria/virusTraumaImmunologicalandvasculiticdiseasesAuto-antibodies(Goodpasture’s,LED,Wegener’s,…)TransfusionreactionsVasculardisordershypertension,diabetesPregnancydisorderspre-eclampsia,septicabortionTissueororgantransplantrejection腎性（續(xù)）細菌或病毒感染創(chuàng)傷自身免疫性疾病和血管疾病自身抗體(Goodpasture’s,LED,Wegener’s,…)輸血反應血管性疾病高血壓、糖尿病妊娠相關疾病子癇,敗血癥流產(chǎn)器官移植排異CausesofAcuteKidneyFailure4

急性腎功能衰竭的原因4“Post-renal”Theflowofurinefromthekidneystotheexteriorofthebodyisprevented,usuallyduetoanobstruction(stones,tumors,…)腎后性尿液從腎臟排出體外受阻，通常為尿路梗阻(結石,腫瘤等)XXAcute

KidneyFailure

急性腎功能衰竭AcuteKidneyFailureOccursoverhoursorfewdaysLastshourstoafewmonths,upto1yearCanbereversible50%mortalityratemajorcauseofdeathisinfection急性腎功能衰竭數(shù)小時或數(shù)天后出現(xiàn)持續(xù)數(shù)小時、數(shù)日，甚至一年可逆性死亡率高達50%通常死于感染DefiningCKD(Guidelines1&61)Kidneydamage,asdefinedbystructuralorfunctionalabnormalitiesofthekidney(withorwithoutdecreasedGFR)asmanifestedby:pathologicalabnormalitiesmarkersofkidneydamageProteinuria(canbeestimatedbytheratiourinaryproteins/creatinine)HematuriaandRBCcastsPyuria(WBCs)abnormalimagingstudiesGlomerularFiltrationRate(GFR)<60ml/min/1.73m2(withorwithoutkidneydamage)ChronicKidneyDisease(CKD)

慢性腎臟?。–KD）1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,Guideline1:DefinitionandStagesofChronicKidneyDiseaseandPart5EvaluationofLaboratoryMeasurementsforClinicalAssessmentofKidneyDisease,

Guideline6:MarkersofChronicKidneyDiseaseOtherthanProteinuria,

AJKD,February2002.CKD的定義(指南1&61)腎損害：腎臟結構或功能的損害(可以沒有GFR下降):病理改變損害指標蛋白尿血尿白細胞尿或膿尿影像學檢查異常GFR<60ml/min/1.73m2(可以伴有或不伴有腎損害，持續(xù)3個月以上）ChronicKidneyDisease

慢性腎臟病ClinicalfactorsassociatedwithanincreasedriskforCKDDiabetesHypertensionAutoimmunediseasesSystemicinfectionsUrinarytractinfectionsUrinarystonesLowerurinarytractobstructionNeoplasia(cancer)FamilyhistoryofCKDRecoveryfromacutekidneyfailureReductioninkidneymass(trauma,surgery)ExposuretocertaindrugsLowbirthweight1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,

Guideline3:IndividualsatIncreasedRiskforChronicKidneyDisease,

AJKDFebruary2002.IndividualsatIncreasedRiskforCKD(Guideline31)CKD易患人群（指南3）臨床因素糖尿病高血壓自身免疫性疾病系統(tǒng)性感染尿路感染尿路結石下尿路梗阻腫瘤CKD家族史急性腎功能衰竭恢復期腎臟容積減少（創(chuàng)傷，手術）服用某些腎毒性藥物低出生體重GlomerularFiltrationRate(GFR)isanindexofkidneyfunctionMostaccuratemeasurementisbyisotopicmethodsEstimatingGFRisaccomplishedbyusingthepatient’sserumcreatininevalueinanequation…othervaluesusedintheequationincludepatient’sage,sex,weight,race,etc.Equationsinclude:Foradults,theequationderivedfromtheMDRDStudyortheCockcroft-GaultformulaForpediatricpatients,SchwartzorCounahan-BarrattNoneedtodoa24hoururinecollectiontomeasureclearances(althoughaprecisemeasurementcanbemadebythemeanofureaandcreatinineclearances)Calculatorscanbefoundonthefollowingsite:/professionals/tools/腎小球濾過率（GFR）是反應腎功能的一項指標是單位時間內(nèi)腎小球濾出地腎血漿流量，正常值為120－160ml/min最精確的方法是應用同位素測定估計GFR的公式需要考慮血肌酐、年齡、性別、種族、體重、身高等因素的影響:成人可以運用MDRD研究或Cockcroft-Gault方程兒童可以運用Schwartz或Counahan-Barratt方程無需留取24小時尿測定清除率（雖然測定尿素和肌酐清除率較準確）計算方程式可以參閱網(wǎng)站:/professionals/tools/

K/DOQIGuidelinesforClassification1

K/DOQI指南－估計GFR11

K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part5EvaluationofLaboratoryMeasurementsforClinicalAssessmentofKidneyDisease,

Guideline4:EstimationofGFR,

AJKDFebruary2002.CKD:Classification1

CKD分期StageDescriptionGFRmL/min/1.73m2Actions1KidneydamagewithnormalorincreasedGFR腎損害，GRF正?；蛟黾?070%ofnormalfunction70%腎功能正常）Diagnose&treatcause,comorbidconditions

診斷和治療Trytoslowprogression

延緩進展ReduceCKDrisk

減少CKD患病因素2KidneydamagewithmilddecreaseinGFR腎損害，GFR輕度下降60–8955–70%Estimateprogressionofdisease

評估進展IdemStage1

同Stage13ModeratedecreaseinGFRGFR中度下降30–5925–55%Assessanemia,nutritionandbonestatus

評價貧血、營養(yǎng)和骨病Treatcomplications

治療并發(fā)癥IdemStage1&2

同Stage1&24SeveredecreaseinGFRGFR重度下降15–2915–25%Referraltonephrologist

腎臟?？圃\治PrepareforRRT(Predialysiseducation)

準備腎臟替代治療（透析前教育）StartRRTearlierifelderly,diabetes,CVD,othercomorbidconditions老年、糖尿病、CVD、及其他合并癥者早期腎臟替代治療5Kidneyfailure腎衰竭<15(dialysis)<15%Uremicsymptoms,marked

inurea,creatinine,K+,P+&fluid

尿毒癥癥狀，尿素，肌酐升高，高鉀高磷，容量過多StartRRT

開始腎臟替代治療1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,Guideline2:EvaluationandTreatment,AJKDFebruary2002.CausesofChronicKidneyDisease

CKD病因DiabetesHypertension/LargeVesselDiseaseRenalArteryStenosisorOcclusionCholesterolEmboli,RenalEmboliGlomerulonephritisInterstitialNephritis/PyelonephritisAnalgesicAbuseMiscellaneousConditions(includesunknown)ComplicationPostBoneMarroworOtherTransplantSickleCellDiseaseAIDSNephropathyTraumatic/SurgicalLossofKidneyHepatorenalSyndromeTubularNecrosiswithNoRecoveryIncidenceofTreatedESRDbyPrimaryDisease,1999-2002DescriptionofDiseasestakenfromtheUSRDS2004AnnualDataReport糖尿病高血壓/大血管病變腎動脈狹窄或梗阻動脈粥樣硬化腎小球腎炎間質(zhì)性腎炎/腎盂腎炎止痛劑成癮不明原因骨髓移植或其他器官移植后鐮狀細胞病AIDS相關性腎病腎臟外傷或手術肝腎綜合征腎小管不可逆性壞死SecondaryGlomerulonephritis/VasculitisLupusSclerodermaHemolyticUremicSyndromeNephropathyfromHeroin/RelatedAbuseNeoplasms/TumorsMultipleMyelomaAmyloidosis繼發(fā)性腎小球腎炎/血管炎狼瘡硬皮病溶血尿毒綜合征海洛因或其它毒品成癮性腎病新生物/腫瘤多發(fā)性骨髓瘤淀粉樣變性

CausesofChronicKidneyDisease

CKD病因（續(xù)）ConsequencesofCKD

慢性腎臟病的預后When75-80%ofrenalfunctionislost,everyorgansystemisaffected1EndStageRenalDisease(ESRD)isirreversible

kidneydisease<10-15%ofrenalfunctionremainingPatientmustreceivedialysisortransplant,ortheywilldie!75-80%的腎功能喪失后，各個系統(tǒng)都會受到影響ESRD是不可逆

的腎臟疾病殘余腎功能<10-15%必須接受透析或移植，否則將死亡！1

ANNACoreCurriculumforNephrologyNursing,3rdEdition,Lancaster,L.;SectionIV,SystemicManifestationsofRenalFailure,pg.75.ConsequencesofCKD2

慢性腎臟病的預后2UremicSyndrome1–acollectionofsignsandsymptomsthatoccurwithCKDfluidandelectrolytedisordersdisorderedregulatoryfunctionsanemiahypertensionbonediseaseaccumulationofuremictoxinsalterationinallbodysystems尿毒癥（一系列癥狀和體征）水電解質(zhì)紊亂調(diào)節(jié)功能異常貧血高血壓骨病尿毒癥毒素蓄積影響全身各個系統(tǒng)1

ANNACoreCurriculumforNephrologyNursing,3rdEdition,Lancaster,L.;SectionIV,SystemicManifestationsofRenalFailure,pg.76.ManifestationsofCKD

慢性腎臟病的臨床表現(xiàn)ChronicKidneyDiseasecanaffecteveryorgansysteminthebody慢性腎臟病可以影響全身各個系統(tǒng)（由于毒素不能清除而導致各系統(tǒng)癥狀）AlterationsinBodySystems1

各系統(tǒng)癥狀1Gastrointestinalsystem(stomachandintestines)anorexia,nausea,vomitinghighuremictoxins“urinebreath”intestinalbleedingHeparinduringdialysistreatmentirritatingmedicationsclottingabnormalities1

ANNACoreCurriculumforNephrologyNursing,3rdEdition,Lancaster,L.;SectionIV,SystemicManifestationsofRenalFailure,pg.76-108.胃腸道系統(tǒng)食欲不振，惡心，嘔吐尿毒癥毒素呼吸有尿味腸道出血透析時肝素應用刺激性藥物凝血功能異常AlterationsinBodySystems2

各系統(tǒng)癥狀2Gastrointestinalsystem(continued)diarrheaintestinalirritationconstipationphosphatebindermedications胃腸道（續(xù)）腹瀉腸道激惹便秘磷結合劑AlterationsinBodySystems3

各系統(tǒng)癥狀3Neuromuscularsystem(nervesandmuscles)encephalopathyheadache,sleepproblems,inabilitytoconcentratetremors,twitching,seizures,comaneuropathy“restlesslegsyndrome”burningfeetweaknessoflowerextremities神經(jīng)肌肉系統(tǒng)腦病頭痛、失眠、注意力不集中震顫、抽搐、驚厥、昏迷神經(jīng)病變“不安腿綜合征”燒灼感肌無力

Bothencephalopathyandneuropathyaredueto

uremictoxins,electrolyte

imbalancesandmetabolicacidosis腦病和神經(jīng)病變都是由于尿毒癥毒素、電解質(zhì)紊亂和代謝性酸中毒引起AlterationsinBodySystems4

各系統(tǒng)癥狀4Cardio-vascularsystem(heartandvessels)arythmiashyperkalemiaatherosclerosisandcoronaryarterydiseasehyperlipidemiahypertensionretentionofsodiumandwaterRenin-AngiotensindysfunctionHypertensioninRenalFailure心血管系統(tǒng)心律失常高鉀動脈硬化和冠心病高脂血癥（脂質(zhì)代謝異常所致）高血壓水鈉潴留腎素－血管緊張素紊亂AlterationsinBodySystems

5

各系統(tǒng)癥狀5Cardio-vascularsystem(continued)pericarditis/effusion/tamponadeitissuspectedthaturemiacausesinflammationinpericardiuminadequatedialysisHeparinuse心血管系統(tǒng)（續(xù)）心包炎/心包積液/心包填塞尿毒癥引起心包炎癥透析不適當肝素應用Pericarditis

11IllustrationfromNKFNephrology101Course:PathophysiologybyS.Mujais,2004.AlterationsinBodySystems

6

各系統(tǒng)癥狀6Skingray-yellowcolorretainedpigmentspalloranemiadryness

decreasedactivityofsweatandsebaceousglandspruritus(itching)depositionofcalciumphosphatecrystalsintheskin皮膚

灰黃色色素沉著蒼白貧血干燥皮脂腺和汗腺分泌減少瘙癢鈣磷結晶沉積AlterationsinBodySystems7

各系統(tǒng)癥狀

7Skin(continued)bleeding/infection

scratchingtorelieveitchingbruisingabnormalbloodclottingfragilecapillaries“uremicfrost”awhite,powderydepositofureacrystalsthatisleftbehindafterperspirationdriesusuallyseenonlyinadvancedrenalfailureorifthepatientisnotbeingadequatelydialyzed

常見于進展期腎功能衰竭和不適當透析的病人皮膚（續(xù)）出血/感染

瘙抓淤斑凝血功能異常毛細血管脆性尿素霜結晶出汗后留下的白色粉狀結晶常見于進展期腎功能衰竭和不適當透析的病人AlterationsinBodySystems

8

各系統(tǒng)癥狀8Pulmonarysystem(lungs)pulmonaryedemaandpleuralrubsvolumeoverloadtenacioussputumincreasedrespiratoryrateanddepthcompensationformetabolicacidosis肺肺水腫和胸腔積液體液過多粘痰呼吸深而長代謝性酸中毒AlterationsinBodySystems9

各系統(tǒng)癥狀9Hematologicsystem(blood)anemiadecreasedRBC(redbloodcell)productionlossoffunctioningrenaltissue(decreasedEPOproduction)vitamindeficienciesirondeficiencyaluminumtoxicitybloodlossabnormalbleedinglabsamplinglossindialyzerredbloodcell(RBC)destructionhemolysisduringdialysistreatmenthemolyticanemiaLupus,sicklecell血液系統(tǒng)貧血RBC生成減少EPO減少維生素缺乏鐵缺乏鋁中毒失血出血實驗室檢查抽血透析失血RBC破壞透析時溶血溶血性貧血狼瘡，鐮狀細胞AlterationsinBodySystems

10

各系統(tǒng)癥狀10Hematologicsystem(continued)anemia(continued)bleedingabnormalities;prolongedbleedingdecreasednumberofplateletsandplateletdefectssevereanemiaHeparintherapyduringhemodialysismedicationsthatdecreaseplateletadhesiveness血液系統(tǒng)（續(xù)）凝血功能異常血小板數(shù)量和功能下降嚴重貧血透析時應用肝素影響血小板聚集、粘附的藥物IronStudiesSerumIron25-170mcg/dL.normalDialysispatients:>60mcg/dL.%TransferrinSaturationavailableIron25-45%normalDialysispatients:>25%SerumFerritinstoredIron12-300ng/mL.NormalDialysispatients:100-600ng/mL.AnemiaStatus

貧血鐵血清鐵正常值：25-170mcg/dL透析病人：>60mcg/dL.轉鐵蛋白飽和度可利用的鐵正常值：25-45%透析病人：>25%血清鐵蛋白儲存鐵正常值：12-300ng/mL透析病人：100-600ng/mL.注意：多數(shù)患者鐵的指標并不低IndicatorsofIronDeficiency

鐵缺乏指標

CausesresultingdecreaseinHblevels

導致血紅蛋白下降AnemiaStatus

貧血（續(xù)）AnemiaTreatment貧血治療Recombinanthumanerythropoietin(Eprex,Neo-Recormon)ordarbepoietin(Aranesp)withincreasedhalf-lifeandactivityGivensub-cut.(pre-DandPD)orIV(HD)StimulatesRBCproductionbybonemarrowPtmustbeironrepletedforthesedrugstoworkefficiently:majorcauseofresistancetoEPOtherapyOthercausesofresistance:-inflammation(infection,cancer,…)

-PureRedCellAplasia(antibodiesagainstEPOseenwithSCEprex)重組人紅細胞生成素（EPO）皮下(透析前和PD)或靜脈(HD)刺激骨髓造血補鐵:缺鐵是EPO反應不佳的主要原因其他原因:感染、腫瘤、純紅細胞再障（EPO抗體形成）AlterationsinBodySystems11

各系統(tǒng)癥狀11Fluidbalance/imbalanceretentionofwatervolumeoverloadserumalbuminlevelislowhypertensionshortnessofbreathedemaoftissuesororgans體液平衡水潴留體液過多低蛋白血癥高血壓呼吸短促水腫IllustrationfromNKFNephrology101Course:PathophysiologybyS.Mujais,2004.AlterationsinBodySystems12

各系統(tǒng)癥狀12Electrolytebalance/imbalancesodiumpotassiumcalcium/phosphorusglucosemagnesiumhydrogen/bicarbonateAluminum電解質(zhì)平衡/失衡鈉（GFR↓、排鈉↓、血鈉↑）鉀鈣磷葡萄糖鎂（GFR↓、排鈉↓、血鈉↑）H+/HCO3-鋁AlterationsinBodySystems

13

各系統(tǒng)癥狀13Acid/basebalance(alterationinpH)patientsusuallyexhibitmetabolicacidosisretentionofhydrogenionsdecreasedreabsorptionofbicarbonatedecreasedexcretionofammoniumchlorideretentionofacidendproductsofmetabolismCatabolism酸堿平衡（PH改變）常有代謝性酸中毒H+潴留HCO3-重吸收減少泌H+減少酸性代謝產(chǎn)物潴留分解代謝Acid/basebalance(continued)signsandsymptomsincreasedrateanddepthofrespirationsplasmabicarbonatelevel<22mEq/L.arterialpH<7.4tachycardiainmildacidosis;bradycardiainsevereacidosisalteredmentalstatuslowbloodpressurehyperkalemiavariousothercomplaints…nausea,vomiting,headacheAlterationsinBodySystems

14

各系統(tǒng)癥狀14酸堿平衡（續(xù)）癥狀和體征呼吸深長HCO3-<22mEq/L.pH<7.4輕度酸中毒時出現(xiàn)心動過速;嚴重酸中毒時則出現(xiàn)心動過緩精神癥狀低血壓高鉀其他如惡心、嘔吐、頭痛等AlterationsinBodySystems

15

各系統(tǒng)癥狀15Endocrinesystem(hormones)decreasedsomatotropin(exertseffectongrowthhormone)inchildrengoodamountsofdietaryprotein,controlanemia,controlacidosishumanrecombinantgrowthhormone(somatropin)decreasedreproductiveability/sexualdesiretestosterone,zincformalescounselinganemiatherapy內(nèi)分泌系統(tǒng)（激素）兒童生長激素減少增加膳食蛋白,糾正貧血和酸中毒人重組生長激素生育能力和性欲下降男性睪丸素、鋅下降心理咨詢糾正貧血AlterationsinBodySystems

16

各系統(tǒng)癥狀

16Immunesystemsuppressionofimmunesystemhighlevelofcirculatinguremictoxinsabnormalintakeofnutrientsforwhitebloodcell(WBC)functionCKDpatientshavesubnormaltemperaturesureaisaknownantipyretic免疫系統(tǒng)免疫抑制（T細胞、B細胞功能均受到抑制）循環(huán)中毒素水平高不適當?shù)娘嬍秤绊懓准毎δ蹸KD病人體溫常較低尿素氮降體溫作用CalciumPhosphorusImbalanceandBoneDisease

鈣磷平衡失調(diào)和腎性骨病17RenalFailure/HighPhosphorusIntake腎功能衰竭/高磷攝入

PhosphorusIncreases/VitaminDsynthesisDecreases血磷升高/VitD合成減少CalciumAbsorbtionfromIntestinesDecreases/SerumCalciumandPhosphorusBind腸道吸收鈣減少/血鈣磷乘積

LowSerumCalciumStimulatesIncreasedPTHSecretion低血鈣刺激PTH分泌

CalciumisPulledfromtheBonestoIncreaseSerumCalcium腎鈣動員以升高血鈣FurtherBindingofCalciumandPhosphorusFormingCalciumPhosphateComplexes鈣磷乘積升高MetastaticCalcification軟組織鈣化AlterationsinBodySystems

各系統(tǒng)癥狀17AlterationsinBodySystems18

各系統(tǒng)癥狀18骨病-“腎性骨病”高轉運性骨病纖維性骨炎骨痛和骨折骨鈣磷丟失血鈣降低，血磷升高，血PTH升高，血維生素D降低低轉運性骨病

血鈣正?；蛏?，血磷升高，PTH降低

微骨折

（可能與高鈣攝入和維生素D的不適當應用有關）骨軟化骨痛，骨折，畸形骨脫礦質(zhì)(“woven”bone)高血鋁，影響成骨細胞活性Calcium,phosphorus,PTH,VitaminDandtheircontributionstobonediseasearediscussedinfurtherdetailinthe“BloodChemistriesandNutritioninKidneyDiseasePatients”presentationBoneproblems-“renalosteodystrophy”O(jiān)steitis

Fibrosa

bonepainandfracturescalciumandphosphateareremovedfromthebonespatienthaslowcalcium,highphosphorus,highPTH,lowvitaminDlevelsAdynamicbonediseasepatienthashighnormalcalcium,highphosphate,lowPTH

microfractures,calcificationsmaybeduetohighdosesofCasalts,inappropriateuseofVit.Osteomalaciabonepain,fractures,deformitiesdemineralizationofbone(“woven”bone)highaluminumlevels;alteredosteoblastactivityDisordersofmineralandbonemetabolismareassociatedwithexcessmorbidityandmortalityTheexcessmortalitylinkedtoabnormalitiesofmineralmetabolism(Ca≥10,P≥5,PTH≥600)(17.5%)supersedesthatduetoanemia[Hb<11](11.3%)andtounder-dialysis[URR<65%](5.1%)鈣磷代謝紊亂和骨病的發(fā)生與死亡率相關鈣磷等礦物質(zhì)代謝紊亂引起的死亡率[Ca≥10,P≥5,PTH≥600]

(17.5%)要高于貧血[Hb<11](11.3%)和透析不充分[URR<65%](5.1%)

BlockGAetal.AmJKidneyDis1998;31:601BlockGAetalJASN2004;15:2208GaneshSKetal.JASN2001;12:2131InfactparametersofmineralmetabolismcanbemodulatedbytherapeuticinterventionsHencethepublicationoftherapeutictargetsforthoseparameterssuchasthe“DOQIGuidelines”Therationalefortheserecommendationsisthehopeofreducingmortality

事實上，礦物質(zhì)代謝參數(shù)能夠由治療干預來調(diào)節(jié)因此，出版了有關這些參數(shù)的治療目標，如DOQI指南等制定這些指南的根本目的是為了降低相關的死亡率

TissueCalcification

組織鈣化SlidecourtesyofD.Sherrard.Femoralarterycalcification

股動脈鈣化Calcificationofcoronaryarteriesinadialyzedpatient

透析病人冠狀動脈鈣化ScancourtesyofP.Raggi.Calciphylaxis

or“calcifyingarteriolopathy”mostlyinoverweight,diabetic,

femalesonperitonealdialysiswithahighCaXPproduct.

Highmortality:50%!

鈣化防御

或“小動脈鈣化癥”，多見于肥胖，糖尿病，女性

的腹膜透析病人，CaXP乘積高，死亡率高達50%

FineAdrian&Zacharias,James

Calciphylaxisisusuallynon-ulcerating:Riskfactors,outcomeandtherapy.

KidneyInternational

61(6),

2210-2217Whatmeasures/drugscanwepropose?

鈣磷代謝紊亂的管理和治療DietaryPhophateRestriction

限制飲食中磷的攝入Badcompliance依從性差Riskofdecreasingproteinintake蛋白質(zhì)攝入不足的危險

MartinezIetal.AmJKidneyDis1997;29:496AparicioMetal.Nephron1993;63:122

Phosphatebinders

磷結合劑Sevelamer:BadG-ItoleranceLessefficient,moreexpensiveMetabolicacidosis(4mEqacidfor800mg)Calciumsalts:BadG-ItoleranceHypercalcemiaVascularcalcifications?Sevelamer:胃腸道耐受性差療效差，價格貴代謝性酸中毒(800mg

含4mEq酸)鈣鹽:胃腸道耐受性差高鈣血癥血管鈣化MetabolitesofvitaminD

VitD的代謝InhibitPTHsecretionBUTincreaseCa,PandCaxPLimiteduseifonewantstomeettheguidelinesintermsofcalcemiaandphosphoremiaNoIVpresentationsonthemarketinEurope抑制PTH分泌但是增加Ca,P和CaxP在PTH、Ca、P同時達到治療指征如果要達到血鈣和血磷的目標，其應用受限歐洲市場沒有注射劑型

SummaryPoints

總結KidneyDiseasemaybeAcuteorChronicAcuteKidneyFailuremaybereversibleChronicKidneyDiseasemeanspermanentlossofrenalfunctionTherearemultiplecausesofbothtypesofkidneydiseaseChronicKidneyDiseaseaffectsmostsystemsandfunctionsinthebody腎臟病可以是急性的或是慢性的急性腎功能衰竭是可逆的慢性腎臟病將致腎功能永久性損害急慢性腎衰各自有不同的原因慢性腎臟疾患造成全身各系統(tǒng)改變和功能損害TreatmentoptionsforESRD

ESRD治療PrMaxDratwaH?pitalBrugmannBrusselsTherapyoptionsofEndStageRenalDisease

終末期腎衰治療ConservativeManagementHemo-dialysis,-diafiltration,-filtrationIn-center,LowcareandHomehemodialysisPeritonealDialysis-CAPD,APD(orCCPD),NIPD,OCPDTransplantationNoTreatment保守治療血透、血濾、血液透濾中心血透、低護理血透和家庭血透腹透CAPD,APD(或CCPD),NIPD,OCPD腎移植不進行治療Indicationsfordialysisinitiation

開始透析的指征GFR10-15ml/min/1.73m2UremicsymptomsMalnutritionGFR10-15ml/min/1.73m2尿毒癥癥狀營養(yǎng)不良有計劃地開始透析對于患者非常重要，應盡量避免“急診透析”！Indicationsfor‘emergency’dialysisinitiation

急診透析的指征PericarditisHyperkaliemiaSevereacidosisLungoedemaIntractablehypertensionUremiccoma心包炎高鉀血癥嚴重酸中度肺水腫難治性高血壓尿毒癥昏迷DialysisProcess

透析替代作用WhatYourKidneysDo腎臟功能RemovesMetabolicWasteFluidBalanceElectrolyteBalanceAcidBaseBalanceHormoneProductionParathyroidHormoneErythropoietinVitaminDMetabolism清除代謝產(chǎn)物體液平衡電解質(zhì)平衡酸堿平衡產(chǎn)生激素PTHEPO維生素DDialysisXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

腎臟本身功能XXXXXXXXXXDisadvantagesPhysicalupsanddownsVascularaccessUseofneedlesRiskofinfectionsDietaryrestrictionsTraveltoCenterHighcost缺點內(nèi)環(huán)境波動大血管通路需要穿刺感染機會飲食限制需要到透析中心治療費用高Haemodialysis

血液透析AdvantagesEffectivemethodtoremovewasteproductsPerformedbytrainedprofessionalsProvidessocializationforpatientsOnlyneeddialysis3timesperweek.Noequipmentinthehome (UnlessHomeHD)優(yōu)點有效清除代謝產(chǎn)物專業(yè)人員實行操作提供病人社會化

一周僅需治療3次

家庭不需要購置設備 (除非家庭HD)AdvantagesManageyourowncareathomeGreaterindependenceandcontrolFlexibletreatmentscheduleLessrestricteddietNoneedlesLessstressonbodyBloodpressurecontrolLowercost優(yōu)點在家中自我管理自主性更高治療計劃可以更改飲食限制較少不需穿刺減少機體應激血壓控制費用降低DisadvantagesDialysiseverydayPermanentcatheterBodyimagechangesRiskofinfectionPossibleweightgainStoragespaceneededforsupplies.PeritonealDialysis

腹膜透析缺點每日透析植入腹透管體形改變感染機會體重可能增加需要一定的儲物空間Transplantation

移植AdvantagesMostlikeyourownkidneyNodialysisneededNoaccessneededNormalDiet(-sodium)More“normal”lifestyle優(yōu)點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.缺點手術風險排異反應藥物的副作用抵抗力低下體形改變Patient's

KidneyTransplant

Kidney(extra-peritoneally)Bladder病腎移植腎膀胱縮略詞GFR：GlomerularFiltrationRate腎小球濾過率ESRD:EndStageRenalDisease終末期腎臟病CKD：ChronicKidneyDisease慢性腎臟病HD:Hemodialysis

血液透析PD:PeritonealDialysis腹膜透析CAPD:ContinuousAmbulatoryPD連續(xù)性不臥床腹膜透析APD:AutomatedPD自動化腹膜透析CCPD:ContinuousCyclicPD持續(xù)循環(huán)腹膜透析NIPD:NocturnalIntermittentPD夜間間歇性腹膜透析Goodpasture’s?。嚎够啄た贵w腎小球腎炎HIV：艾滋病病毒CMV：巨細胞病毒HepatitisB&C乙肝或丙肝EPO：促紅細胞生產(chǎn)素PTH：甲狀旁腺素MMF:驍悉KDOQI:KidneyDiseaseOutcomeQualityInitiative

SuggestedReadingandReferenceMaterial

推薦閱讀和參考文獻OxfordHandbookofDialysisbyJ.Levy,J.MorganandE.Brown,2ndedition2004,OxfordUniversityPressK/DOQIGuidelines(allpublishedintheAmericanJournalofKidneyDisease):NutritioninCRF(06/00),Vascularaccessupdate(01/01),Anemiaupdate(01/01),PDadequacyupdate(01/01),HDadequacyupdate(01/01),ClinicalPracticeGuidelinesforChronicKidneyDisease(02/02),DyslipidemiasinCRF(04/03),HypertensioninCKD(05/04),BonediseaseinCKD(10/04)USRDSAnnualDataReport,UnitedStatesRenalDataSystem,2004.Nephrology101CourseMaterials;AnatomyandPhysiologybyDr.Salim

Mujais,CNNTDivisionoftheNationalKidneyFoundation,SpringClinicalMeetings.2004.

Contents內(nèi)容Whatisperitonealmembrane?PhysiologyofperitonealdialysisUremictoxinremovalFluidremovalSodiumRemovalPreparingandperformingPDPDprescriptionIndicationsandcontraindicationsofPDAPDComplicationsrelatedtoPDClinicaloutcomeofPDHowtoset-upPDcenter

什么是腹膜？

腹膜透析(peritonealdialysis,PD)的生理學尿毒癥毒素的清除液體的清除鈉的清除PD的準備和實施PD處方PD的適應癥和禁忌癥

自動化腹膜透析PD相關并發(fā)癥PD的臨床預后

怎樣建立PD中心?Whatistheperitonealmembrane?

關于腹膜Theperitoneumistheserosalmembranethatcoverstheperitonealcavity.ThevisceralperitoneumTheparietalperitoneum腹膜是被覆于腹腔的光滑漿膜臟層腹膜壁層腹膜ThemesotheliumTheinterstitiumMacrophages/MonocytesPeritonealcapillariesPlaysimportantrolewaterandsoluteexchange間皮間質(zhì)

巨噬細胞/單核細胞腹膜毛細血管

在水和溶質(zhì)的轉換起著重要作用Componentsoftheperitoneum腹膜的結構Roleoftheperitoneum

腹膜的功能ProtectperitonealorgansPreventfrictionofmovingorgansHostdefensemechanisms:Mesothelialcells,monocytesmacrophages,opsonins保護腹腔臟器防止臟器移動時的摩擦宿主的防御機制:間皮細胞、單核巨噬細胞、調(diào)理素GoalofDialysis

透析目標Maintainssymptom-freebyreplacingsomeofthefunctionsperformedbythehealthykidneys.ToremovesuremictoxinsaccumulatedinthebloodWaterElectrolytesUrea,creatinine,phosphate,PTH,etc.H+通過替代正常腎臟的部分功能減輕腎衰時機體相關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、甲狀旁腺素等等氫離子Thetransportofsolutesandwateracrossa“membrane”thatseparatestwofluidcontainingcompartments.ThebloodintheperitonealcapillariesDialysissolutionintheperitonealcavity腹膜將下列兩種液體分隔，水分和溶質(zhì)進行跨膜轉運腹膜毛細血管中的血液循環(huán)腹腔中的透析液ABasicConceptofPeritonealDialysis腹透基本概念PERITONEALTISSUEBLOOD腹膜組織血液Membrane腹膜PERITONEALCAVITY

DIALYSATE腹腔透析液Membranemodel腹膜模型Removalofuremictoxins

尿毒癥毒素清除

SmallsolutesDiffusion:

Convec