腹膜透析講訴

1、腹 膜 透 析六安市中醫(yī)院腎病二科 鄭昌志,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,AdvantagesMost like your own kidneyNo dialysis neededNo access neededNormal Diet (-sodium)More “normal” life style優(yōu)點與自己的腎臟功能相似不需透析不需要通路

2、正常飲食（鈉）生活方式更接近正常,DisadvantageRisks of major surgeryRisk of body rejecting kidneyPossible side effects of drugsLower resistance to illnessBody image changes.缺點手術(shù)風險排異反應(yīng)藥物的副作用抵抗力低下體形改變,病腎,移植腎,膀胱,Who cannot dona

3、te a kidney?哪些人不可捐獻腎？,HIV or AIDS-related infectionHepatitis B or C infectionMajor heart or breathing problemsDiabetesExtreme obesitySignificant kidney diseaseMost cancersIV drug abusePregnancyHigh BPHaving on

4、ly one kidneyEvidence of financial or non-financial coercionInability to give informed consent/psychiatric disorders,HIV 或AIDS相關(guān)感染乙肝或丙肝感染嚴重心肺疾病糖尿病過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腎有經(jīng)濟或非經(jīng)濟利益企圖的證據(jù)無法做到知情同意或有精神障礙,I

5、ndications for dialysis initiation開始透析的指征,腎小球濾過率 10-15 ml /min /1.73m²尿毒癥癥狀尿毒癥導致營養(yǎng)不良,有計劃地開始透析對于患者非常重要，應(yīng)盡量避免“急診透析”！,GFR 10-15 ml /min /1.73m²Uremic symptomsMalnutrition,Hemodialysis血液透析,The process of sep

6、arating chemical substances from blood through a semi-permeable membrane通過透析器半透膜從血液中分離化學物質(zhì)的過程,Toxin Removal 清除毒素,Removal of toxins from the blood is accomplished by:清除血液中毒素是通過：Diffusion 彌散Convection 對流Ad

7、sorption 吸附,,在血透治療中，絕大部分清除毒素作用是通過彌散實現(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,Concentration Gradient - Flow Geometry 濃度梯度 - 液流動力影響,,,,Blood In血液入口,Blood Out血液出口,Dialysate In透析液入口,Dialysate Out透析液出口,,,,,,Counter Flow

8、反向液流,Temporary vs. Permanent臨時通路或永久通路,Temporary AccessUsed for a few hours to several weeksUsually percutaneous insertion of a cannula into a large veinSurgical implantation of paired tubes into an artery and vein we

9、re used a number of years ago; fairly obsolete nowFor patients with acute renal failure, chronic renal failure without permanent access, peritoneal dialysis (PD) or transplant patients for temporary hemodialysisPermane

10、ntFor periods ranging from months to yearsOptionsSub-cutaneous anastomosis of artery to veinSub-cutaneous positioning of a “tube” graft between an artery and veinImplantation of a cuffed dual-lumen catheter into a v

11、ein,臨時通路使用幾小時到數(shù)周通常經(jīng)皮穿刺大靜脈，留置導管。外瘺（動靜脈各植入一根臨時導管）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、腹透或移植患者進行臨時血透時使用,永久通路可以持續(xù)使用數(shù)月到數(shù)年選項內(nèi)瘺（動脈與靜脈經(jīng)手術(shù)連接）人造血管連接動脈和靜脈深靜脈植入帶滌綸套的雙腔導管,Complications of Vascular Access血管通路相關(guān)并發(fā)癥,Infection Thrombos

12、isEarly vs. late thrombosis“Thrombolysis vs. thrombectomy” Hemodynamic complicationCongestive heart failure: “High output cardiac failure” Vascular insufficiency or arterial steal Venous hypertension Vascular acce

13、ss neuropathy“Carpal tunnel syndrome” Aneurysms (true or pseudo),感染 栓塞早期和晚期栓塞血液動力學改變相關(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 (true or pseudo),,,,,腹膜透析,,優(yōu)點,,,腹膜透析的臨床優(yōu)越性,,保護殘余的腎臟功

14、能,維持血壓的平穩(wěn),減輕心臟的負擔，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會,移植腎功能延遲發(fā)生少,飲食限制較少,What are the benefits of preserving residual renal function?保護殘余腎功能的益處,Davies, S. 2000,,What is the peritoneal membrane ?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

15、膜凹陷腹腔和腹膜腔,The mesotheliumThe interstitiumMacrophages/MonocytesPeritoneal capillariesPlays important role water and solute exchange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(zhuǎn)換中起重要作用,,,,Components of the peritoneum腹膜的結(jié)構(gòu),Diffusi

16、on 彌散,Definition:Solute movement due to concentration gradient of two solutes between components across a semi-permeable membraneMain driving force for small solute removalFactors involved in diffusion Size of solut

17、e Peritoneal surface area Hydrostatic pressure Electrical charge of solutes定義:溶質(zhì)依靠溶液之間濃度梯度透過半透膜（腹膜）進行的轉(zhuǎn)運彌散是小分子溶質(zhì)清除的主要機制影響彌散的因素 溶質(zhì)分子的大小 腹膜表面積 靜水壓 溶質(zhì)的電負荷,,腹膜轉(zhuǎn)運機理,小分子依靠彌散作用從毛細血管進入腹膜間質(zhì)，再進入透析液中透析液中的葡萄糖借助彌散作用從腹腔進入

18、腹膜間質(zhì)，加上彌散出來的小分子，使間質(zhì)晶體滲透壓升高，對毛細血管內(nèi)水分形成超濾，水就從毛細血管移出；毛細血管中水分的超濾對毛細血管中大分子又產(chǎn)生對流作用，大分子就進入間質(zhì)，使局部膠體滲透壓升高，水被進一步超濾，這樣，水和大分子然后分別進入透析液當中；葡萄糖不斷進入間質(zhì)和毛細血管使?jié)B透梯度下降，水的超濾下降。 通過上述過程，毛細血管內(nèi)的水被超濾出來，小分子和大分子毒素通過彌散和對流作用也被排出，從而實現(xiàn)水和毒素的清除，同時伴隨

19、著透析液葡萄糖被機體攝入。,How to achieve it ? 如何達到治療目標？,Sufficient fluid and toxin removal: dose of dialysisIt depends onResidual renal functionBody sizeCo-morbid condition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,D/P for Ur, Cr an

20、d Na and D/Do for Glu at 0, 2, and 4 hrs are calculatedPatients are classified on basis of 4 hr D/P Cr as low, low average, high average or high transportersIn general, high transporters dialyze well, but absorb Glu ra

21、pidly, have less UF, greater dialysate protein losses and lower serum albuminLow transporters are the opposite and average transporters are in between,D/P for Ur, Cr and Na and D/Do for Glu at 0, 2, and 4 hrs are calcul

22、atedPatients are classified on basis of 4 hr D/P Cr as low, low average, high average or high transportersIn general, high transporters dialyze well, but absorb Glu rapidly, have less UF, greater dialysate protein loss

23、es and lower serum albuminLow transporters are the opposite and average transporters are in between,計算0、2、4小時的尿素、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)運患者總的來說，高

24、轉(zhuǎn)運患者透析好（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)運患者與上述相反，平均轉(zhuǎn)運者在兩者之間,Auditing the PD Program評估腹透,Infection ratesTechnical problems eg. catheter flow problemsAdequacy indicesNutrition indicesTechnique and patient

25、survivalAnaemia management,感染率技術(shù)問題，如導管漂移等透析充分性營養(yǎng)狀況技術(shù)生存率和病人生存率貧血的治療,Global therapy mix全球治療方式,APD = AutomatedPeritonealDialysis自動化腹膜透析CAPD:ContinuousAmbulatoryPeritonealDialysis持續(xù)性不臥床腹膜透析,我國目前約為1％,

26、Automated Peritoneal Dialysis 自動化腹膜透析,Peritoneal dialysis using automated exchange machineDesigned to minimize the burden of frequent exchanges of dialysate bagsAllow individualized prescription of peritoneal dialysis

27、使用自動交換腹透機進行腹膜透析減少透析液交換次數(shù),減輕腹透換液負擔允許個性化腹膜透析處方,Different PD catheters 不同腹透管路,Straight 1 cuff,Straight 2 cuffs,Coiled Tenckhoff catheters 卷曲管,Coiled 1 cuff,Coiled 2 cuffs,Swan Neck Tenckhoff catheters 鵝頸管,Straight,Coil

28、ed,Downwards directed exit sitePermanent bend between 2 cuffs (180°)Right or left,Swan Neck Missouri 鵝頸Missouri管,Straight,Coiled,Bead placed IP, Flange extraP,Straight Tenckhoff catheters 直管,廣泛腸粘連及腸梗阻腹部皮膚廣泛感染無法

29、植管者腹部大手術(shù)3天以內(nèi)，腹部有外科引流管嚴重肺功能不全腹腔內(nèi)血管疾患晚期妊娠或腹內(nèi)巨大腫瘤、多囊腎高分解代謝者長期不能攝入足夠的蛋白質(zhì)及熱量者疝未修補者不合作者或有精神病,腹膜透析相對禁忌證,腹膜透析的并發(fā)癥（急性）,腹腔臟器損傷出血導管功能障礙 1）隧道內(nèi)導管扭曲 2）導管移位 3）大網(wǎng)膜包裹使引流不暢 4）纖維蛋白凝塊堵塞腹透管腹透液外漏腹痛腹透管皮膚出口處感染,

30、腹膜透析的并發(fā)癥（慢性）,腹膜炎腹膜超濾功能減退蛋白質(zhì)、氨基酸和維生素的丟失糖負荷增加高脂血癥心血管系統(tǒng)并發(fā)癥呼吸系統(tǒng)并發(fā)癥腰背痛腹疝,腹膜炎的診斷與防治,,,,,,,,,,,,,,,第一代頭孢菌素（頭孢唑啉）或萬古霉素；聯(lián)用第三代頭孢菌素或氨基糖甙類藥物， 氨曲南，喹喏酮類肝素500－1000U/L留腹以防止纖維蛋白凝塊形成單藥治療：亞胺培南、西司他丁500mg留腹6h，繼以100mg/2L；頭孢吡肟2g留腹

31、6h，繼以1g/d連用9天。,經(jīng)驗療法,ISPD Guidelines/ Recommendations. Perit Dial Int 25:107-131,2005,,,人有了知識，就會具備各種分析能力，明辨是非的能力。所以我們要勤懇讀書，廣泛閱讀，古人說“書中自有黃金屋?！蓖ㄟ^閱讀科技書籍，我們能豐富知識，培養(yǎng)邏輯思維能力；通過閱讀文學作品，我們能提高文學鑒賞水平，培養(yǎng)文學情趣；通過閱讀報刊，我們能增長見識，擴大自