腹膜透析(6).ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Confidential,Not for distribution,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,终末期肾病治疗方式的选择,血液透析,腹膜透析,肾移植,Transplantation,移植,Advantages,Most like your own kidney,No dialysis needed,No access needed,Normal Diet(-sodium),More,“,normal,”,life style,优点,与自己的肾脏功能相似,不需透析,不需要通路,正常饮食（钠）,生活方式更接近正常,Disadvantage,Risks of major surgery,Risk of body rejecting kidney,Possible side effects of drugs,Lower resistance to illness,Body image changes.,缺点,手术风险,排异反应,药物的副作用,抵抗力低下,体形改变,P,a,t,i,e,n,t,s,K,i,d,n,e,y,T,r,a,n,s,p,l,a,n,t,K,i,d,n,e,y,(,e,x,t,r,a,-,p,e,r,i,t,o,n,e,a,l,l,y,),B,l,a,d,d,e,r,病肾,移植肾,膀胱,Who,cannot,donate a kidney?,哪些人不可捐献肾？,HIV or AIDS-related infection,Hepatitis B or C infection,Major heart or breathing problems,Diabetes,Extreme obesity,Significant kidney disease,Most cancers,IV drug abuse,Pregnancy,High BP,Having only one kidney,Evidence of financial or non-financial coercion,Inability to give informed consent/psychiatric disorders,HIV,或,AIDS,相关感染,乙肝或丙肝感染,严重心肺疾病,糖尿病,过度肥胖,明显的肾脏疾病,大多数癌症,静脉吸毒,妊娠,高血压,仅有一个肾,有经济或非经济利益企图的证据,无法做到知情同意或有精神障碍,Indications for dialysis initiation,开始透析的指征,肾小球滤过率 10-15,ml/min/1.73m,尿毒症症状,尿毒症导致营养不良,有计划地开始透析对于患者非常重要，应尽量避免,“,急诊透析,”,！,GFR,10-15 ml/min/1.73m,Uremic symptoms,Malnutrition,Hemodialysis,血液透析,The process of,separating chemical substances,from blood through a,semi-permeable membrane,通过透析器半透膜从血液中,分离化学物质的过程,Toxin Removal,清除毒素,Removal of toxins from the blood is accomplished by:,清除血液中毒素是通过：,Diffusion,弥散,Convection,对流,Adsorption,吸附,Blood,血,Blood,血液,Dialysate,透析液,Salt,盐,Toxin,毒素,Semi-permeable Membrane,半透膜,在血透治疗中，绝大部分清除毒素作用是通过弥散实现,弥散清除与下列因素相关：浓度梯度，分子大小，膜表面积,Concentration Gradient-Flow Geometry,浓度梯度-,液流动力影响,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,反向液流,Temporary vs.Permanent,临时通路或永久通路,Temporary Access,Used for a few hours to several weeks,Usually percutaneous insertion of a cannula into a large vein,Surgical implantation of paired tubes into an artery and vein were used a number of years ago;fairly obsolete now,For patients with acute renal failure,chronic renal failure without permanent access,peritoneal dialysis(PD)or transplant patients for temporary hemodialysis,Permanent,For periods ranging from months to years,Options,Sub-cutaneous anastomosis of artery to vein,Sub-cutaneous positioning of a,“,tube,”,graft between an artery and vein,Implantation of a cuffed dual-lumen catheter into a vein,临时通路,使用几小时到数周,通常经皮穿刺大静脉，留置导管。,外瘘（动静脉各植入一根临时导管）现在已经基本不再使用,急性肾衰、慢性肾衰尚未建立永久通路、腹透或移植患者进行临时血透时使用,永久通路,可以持续使用数月到数年,选项,内瘘（动脉与静脉经手术连接）,人造血管连接动脉和静脉,深静脉植入带涤纶套的双腔导管,Complications of Vascular Access,血管通路相关并发症,Infection,Thrombosis,Early vs.late thrombosis,“Thrombolysis vs.thrombectomy”,Hemodynamic complication,Congestive heart failure:,“High output cardiac failure”,Vascular insufficiency or arterial steal,Venous hypertension,Vascular access neuropathy,“Carpal tunnel syndrome”,Aneurysms(true or pseudo),感染,栓塞,早期和晚期栓塞,血液动力学改变相关并发症,充血性心力衰竭：“,高输出性”,血流不足或动脉窃血症,静脉高压造成肢体末端肿胀,血管通路相关的神经损伤,“,腕管综合症”,Aneurysms(true or pseudo),“,动静脉短路,”,造成心脏输出量增加。,“,动静脉短路,”,的静脉动脉化使得肢体远端血液回流受阻。,“,动静脉短路,”,造成肢体远端（尤其是手部）供血不足。,腹膜透析,可以在任何地方进行换液，便于旅行,无需依赖机器,治疗时间可灵活安排,学习简单,无需穿刺,独立性强，生活自主,优点,腹膜透析,的临床优越性,保护残余的肾脏功能,维持血压的平稳,减轻心脏的负担，减少心力衰竭的发生,减少贫血的发生,减少肝炎等交叉感染的机会,移植肾功能延迟发生少,饮食限制较少,What are the benefits of preserving residual renal function?,保护残余肾功能的益处,Contributes to total solute clearance,(1 ml/min CrCl=10 liter CrCl/week),增加总的溶质清除,Improves,2-microglobulin,and middle molecule clearance,改善,2-,微球蛋白及中分子毒素的清除,Provides endocrine functions,内分泌功能,Reduces Mortality,降低死亡率,Facilitates volume control,有利于容量控制,Allows for more liberal diet and fluid intake,允许较多的饮食和水分摄入,Improves nutritional status,改善营养状况,Improves QOL,提高生活质量,Increases total Na removal,增加总钠清除,Davies,S.2000,What is the peritoneal membrane?,关于腹膜,腹膜是被覆于腹腔的光滑,浆,膜,脏层腹膜,壁层腹膜,腹膜凹陷,腹腔和腹膜腔,The mesothelium,The interstitium,Macrophages/Monocytes,Peritoneal capillaries,Plays important role water and solute exchange,间皮,间质,巨噬细胞,/,单核细胞,腹膜毛细血管,在水和溶质的转换中起重要作用,Components of the peritoneum,腹膜的结构,Diffusion,弥散,Definition:,Solute movement due to concentration gradient of two solutes between components across a semi-permeable membrane,Main driving force for small solute removal,Factors involved in diffusion,Size of solute,Peritoneal surface area,Hydrostatic pressure,Electrical charge of solutes,定义,:,溶质依靠溶液之间浓度梯度透过半透膜（腹膜）进行的转运,弥散是小分子溶质清除的主要机制,影响弥散的因素,溶质分子的大小,腹膜表面积,静水压,溶质的电负荷,腹膜转运机理,小分子依靠弥散作用从毛细血管进入腹膜间质，再进入透析液中,透析液中的葡萄糖借助弥散作用从腹腔进入腹膜间质，加上弥散出来的小分子，使间质晶体渗透压升高，对毛细血管内水分形成超滤，水就从毛细血管移出；,毛细血管中水分的超滤对毛细血管中大分子又产生对流作用，大分子就进入间质，使局部胶体渗透压升高，水被进一步超滤，这样，水和大分子然后分别进入透析液当中；,葡萄糖不断进入间质和毛细血管使渗透梯度下降，水的超滤下降。,通过上述过程，毛细血管内的水被超滤出来，小分子和大分子毒素通过弥散和对流作用也被排出，从而实现水和毒素的清除，同时伴随着透析液葡萄糖被机体摄入。,How to achieve it?,如何达到治疗目标？,Sufficient fluid and toxin removal:dose of dialysis,It depends on,Residual renal function,Body size,Co-morbid condition,充分清除水分和毒素：透析剂量,有赖于：,残存肾功能,体形大小,合并症情况,PET:Interpretation,PET,评估,D/P for Ur,Cr and Na and D/Do for Glu at 0,2,and 4 hrs are calculated,Patients are classified on basis of 4 hr D/P Cr as low,low average,high average or high transporters,In general,high transporters dialyze well,but absorb Glu rapidly,have less UF,greater dialysate protein losses and lower serum albumin,Low 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 calculated,Patients are classified on basis of 4 hr D/P Cr as low,low average,high average or high transporters,In general,high transporters dialyze well,but absorb Glu rapidly,have less UF,greater dialysate protein losses and lower serum albumin,Low transporters are the opposite and average transporters are in between,计算,0,、,2,、,4,小时的尿素、肌酐、钠的透析液浓度,/,血浆浓度,(D/PUr,D/PCr,D/PNa),以及葡萄糖透析液浓度,/,血浆浓度,(,D/Do,),按照,4h,时肌酐透析液浓度,/,血浆浓度,(D/PCr),分为低、低平均、高平均或高转运患者,总的来说，高转运患者透析好（物质清除较快），但是葡萄糖的吸收也快，超滤量少，透析液丢失蛋白多，血清白蛋白也较低,低转运患者与上述相反，平均转运者在两者之间,Auditing the PD Program,评估腹透,Infection rates,Technical problems eg.catheter flow problems,Adequacy indices,Nutrition indices,Technique and patient survival,Anaemia management,感染率,技术问题，如导管漂移,等,透析充分性,营养,状况,技术生存率和病人生存率,贫血的,治疗,Global therapy mix,全球治疗方式,APD=,Automated,Peritoneal,Dialysis,自动化腹膜透析,CAPD:,Continuous,Ambulatory,Peritoneal,Dialysis,持续性不卧床腹膜透析,我国目前约为,1,Automated Peritoneal Dialysis,自动化腹膜透析,Peritoneal dialysis using automated exchange machine,Designed to minimize the burden of frequent exchanges of dialysate bags,Allow individualized prescription of peritoneal dialysis,使用,自动,交换腹透,机,进行,腹膜透析,减少透析液交换次数,减轻腹透换液负担,允许,个性化腹膜透析处方,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,鹅颈管,Straight,Coiled,Downwards directed exit site,Permanent bend between 2 cuffs(180),Right or left,Swan Neck Missouri,鹅颈,Missouri,管,Straight,Coiled,Bead placed IP,Flange extraP,Straight Tenckhoff catheters,直管,广泛肠粘连及肠梗阻,腹部皮肤广泛感染无法植管者,腹部大手术3天以内，腹部有外科引流管,严重肺功能不全,腹腔内血管疾患,晚期妊娠或腹内巨大肿瘤、多囊肾,高分解代谢者,长期不能摄入足够的蛋白质及热量者,疝未修补者,不合作者或有精神病,腹膜透析相对禁忌证,腹膜透析的并发症（急性）,腹腔脏器损伤,出血,导管功能障碍,1,）隧道内导管扭曲,2,）导管移位,3,）大网膜包裹使引流不畅,4,）纤维蛋白凝块堵塞腹透管,腹透液外漏,腹痛,腹透管皮肤出口处感染,腹膜透析的并发症（慢性）,腹膜炎,腹膜超滤功能减退,蛋白质、氨基酸和维生素的丢失,糖负荷增加,高脂血症,心血管系统并发症,呼吸系统并发症,腰背痛,腹疝,腹膜炎的诊断与防治,第一代头孢菌素（头孢唑啉）或万古霉素；联用第三代头孢菌素或氨基糖甙类药物，,氨曲南，喹喏酮类,肝素,500,1000U/L,留腹以防止纤维蛋白凝块形成,单药治疗：亚胺培南、西司他丁,500mg,留腹,6h,，继以,100mg/2L,；头孢吡肟,2g,留腹,6h,，继以,1g/d,连用,9,天。,经验疗法,ISPD Guidelines/Recommendations.Perit Dial Int 25:107-131,2005,