腹膜透析ESRD治疗.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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。,How PD works,腹 透 原 理,What is the peritoneal membrane?,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,Role of the peritoneum,腹膜的功能,Protect peritoneal organs,Prevent friction of moving organs,Host defense mechanisms:,Mesothelial cells,monocytesmacrophages,opsonins,支持、保护腹腔脏器,分泌滑液防止脏器移动时的摩擦,宿主的防御机制,:,间皮细胞、单核巨噬细胞、调理素,Components of the peritoneum as a dialysis membrane,腹膜（做为透析膜）的组成,The mesothelium,The stagnant fluid film,The interstitium,Peritoneal capillaries,Stagnant capillary fluid,The capillary endothelium itself,The endothelial basement membrane,间皮,滞留液体层（阻力）,间质,腹膜毛细血管,毛细血管滞留液体,毛细血管内皮,内皮基底膜,The transport of solutes and water across a“membrane”that separates two fluid containing compartments.,The blood in the peritoneal capillaries,Dialysis solution in the peritoneal cavity,腹膜将下列两种液体分隔，水分和溶质进行跨膜转运,腹膜毛细血管中的血液,腹腔中的透析液,A Basic Concept of Peritoneal Dialysis,腹透基本概念,PERITONEAL,TISSUE,BLOOD,腹膜组织,血液,Membrane,腹膜,PERITONEAL,CAVITY,DIALYSATE,腹腔,透析液,Membrane model,腹膜模型,Removal of uremic toxins,尿毒症毒素清除,Small solutes,Diffusion:,Convective transport,Middle or large solutes,Peritoneal leak,小分子溶质,弥散,:,对流转运：,中等或大分子溶质,腹膜渗漏,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,Convective transport,对流转运,Solute transport along with fluid movement,High during active ultrafiltration,Terms used in convective transport,Sieving coefficient:,Ratio of solute being passed the barrier,Reflection coefficient,Ratio of solute being rejected by the barrier,Sieving coefficient=1-reflection coefficient,Factors involved in convective transport,Size of solute,Electrical charge of solutes,定义：水分转运时伴随的溶质清除,高效超滤过程中对流作用大,对流转运应用的参数,筛选系数（,Sieving coefficient,）：溶质通过膜屏障的比例,反射系数（,Reflection coefficient,）：溶质被膜屏障阻挡的比例,筛选系数,1,反射系数,影响对流转运的因素,溶质分子的大小,溶质的电负荷,Osmotic Ultrafiltration,Movement of water from a chamber with lower osmotic pressure to higher one across a semi-permeable membrane,渗透超滤,水分通过半透膜从低渗透压的腔室转移到高渗透压的腔室，静水压和渗透压的矢量和决定水分渗透的方向。,Removal of Water in PD:,Crystalloid Osmosis,PD,水分清除：晶体渗透压,H,2,O,High glucose-High osmolality,Peritoneal Space,高糖高渗,腹膜部位,Capillary space,毛细血管,Normal osmolality,正常渗透压,Small pore:50%,小孔：,50,Aquaporin mediated:50%,水孔蛋白介导：,50,，,（只能使水通过，也叫水通道）,Pathways for Peritoneal Transport,腹膜转运途径,Endothelium,内皮,Capillaries,毛细血管,Mesothelium,间皮,Peritoneal Cavity(Dialysate),腹腔（透析液）,Small solutes,小分子溶质,Glucose,葡萄糖,Macro molecules,大分子溶质,Crystalloidosmosis,晶体渗透压,Colloidosmosis,胶体渗透压,Water,水,Interstitium,间质,Peritoneal tissue layer,腹膜组织层,Ultrafiltration,超滤,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。,Solutes from the circulation to dialysis solutions,从血循环到透析液中的溶质,Solutes from dialysis solutions to the circulation,从透析液到血循环的溶质,Protein,What is PET?,Based on equilibration of solute concentration in dialysate to plasma and peritoneal glucose absorption.,Dialysate to plasma concentration ratio of solutes such as creatinine,urea,potassium(D/P solutes):Dialysate,creatinine concentration increases as creatinine diffuses into the peritoneal cavity due to the concentration gradient.,Dialysate glucose concentration decreases as peritoneal glucose absorbs during a dwell time.,Drain volume is inversely correlated to solute transport rate.,PET,建立在血浆与透析液中溶质浓度的平衡以及腹膜对葡萄糖吸收作用的基础上,.,透析液和血浆中溶质浓度的比值,(D/P),如肌酐、尿素、钾离子：随着血液中肌酐顺着浓度梯度弥散入腹腔内，透析液中肌酐浓度逐渐增加,.,留腹期间透析液中葡萄糖的浓度随着腹膜对葡萄糖的吸收而降低,.,引流量和溶质转运率负相关,.,Peritoneal Equilibration Test,腹膜平衡试验,Intraperitoneal Volume in Different Transport Groups,不同转运的腹膜在腹透时超滤量的变化,Wang et al.Nephrol Dial Transplant 13:1242-49,1998,2250,2500,2750,3000,3250,Intraperitoneal volume,ml,腹腔内液体容量,0,60,120,180,240,300,360,Time,min,L,低转运,L-,A,低平均,H-,A,高平均,H,高转运,1.Drain for at least 20min,ideally after an 8-to 12-hour overnight dwell using 2L of 2.5%dextrose solution,2.Weigh 2-L bag of warmed 2.5%dextrose solution,3.Infuse over 10min(at a rate of 200 ml/min).,After each 400-ml infused,roll the patient from side to side.,4.Indwell for 4 hours.Ambulatory during dwell time.,5.Drain over 20 min.,6.After drainage,the bag is again weighed.,最好在使用,2.5,葡萄糖腹透液留腹过夜,8,12,小时后，充分排放透析液至少,20,分钟,秤量袋装,2,升规格的已加温的,2.5,葡萄糖腹膜透析液,3.,十分钟以上灌入腹内,(,速度,200ml/min),每灌入,400ml,时让患者翻转身体,.,4.,留腹,4,小时，留腹期间要求不卧床,.,5.,排液时间,20,分钟以上,.,6.,排液后再次秤量腹透液袋,.,PET:Protocol,PET,：,操作程序,Blood sample:0,2,4 hour,Dialysate sample:,200 ml of dialysis solution is drained into the bag,mixed well,a 10 ml sample is taken,and the remaining 190 ml is reinfused back,after 2 and 4 hours,another sample is taken.,Calculate D/P creatitine at 2 and 4 hours,D/D,0,glucose at 2 and 4 hours,the volume of UF in the drainage bag,血标本,:0,2,4,小时,透析液标本,:,将,200ml,的透析液排至袋中，充分混匀，取,10ml,样本，剩下的,190ml,液体重新灌入腹腔,.,计算,2h,、,4h,的肌酐浓度透析液,/,血浆,(D/Pcr),2h,、,4h,的葡萄糖浓度透析液,/,血浆,(D/D,0,),引流袋净超滤量,PET:Sampling,PET,：取样,PET calculation,PET,：计算,The correction factor for creatinine by high glucose in dialysis solutions is best determined by individual lab.,The correction factor used by the University of Missouri 0.000531415.,Corrected creatinine mg/dl=creatinine mg/dl(glucose X 0.000531415)mg/dl,由于透析液中高浓度葡萄糖影响，肌酐测定需要的校正因子最好由每个实验室确定,.,密苏里大学使用的校正因子,0.000531415,.,校正的肌酐,mg/dl=,肌酐,mg/dl-(,葡萄糖,0.000531415)mg/dl,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,计算,0,、,2,、,4,小时的尿素、肌酐、钠的透析液浓度,/,血浆浓度,(D/P,Ur,D/P,Cr,D/P,Na,),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/P,Cr,),分为低、低平均、高平均或高转运患者,总的来说，高转运患者透析好但是葡萄糖的吸收快，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,Categorization of peritoneal transport in PET,PET,中腹膜转运特性的分,类,D/P creatinine,肌酐,D/D,0,glucose,葡萄糖,Drain volume,引流量,High,高转运,Mean+1SD and above,Mean-1SD and below,Mean-1SD and below,High average,高平均,Mean+1 SD,Mean-1 SD,Low average,低平均,Mean-1 SD,Mean+1SD,Mean+1SD,Low,低转运,Mean-1SD and below,Mean+1SD and above,Mean+1SD and above,患者比例,膜的类型,4h,时肌酐腹透液血清比,(D/P),特性,10%,高转运,0.82,1.03,膜效率很高,溶质转运快,葡萄糖的吸收快,达到超滤目标可能较难,有低白蛋白血症的危险,53%,高平均,0.65,0.81,膜效率高,溶质转运好,超滤好,31%,低平均,0.50,0.64,膜的效率较低,溶质转运有点慢,超滤好,6%,低转运,0.34,0.49,膜的效率很低,溶质转运慢,没有残肾功能时很难达到目标肌酐清除率,超滤非常好,我国患者腹膜转运功能分布有所不同：,H15，HA50，LA40，L6,Membrane transport type,腹膜转运类型,Blake database,Twardowski ZJ,ASAIO Trans 1990;36:8,Rapid(high)vs slow(low)transporters in PD,高转运与低转运比较,由于病人的转运功能不同，应进行个体化处方。,Important factors determining solute and fluid removal,决定水和溶质清除的重要因素,Dialysate to plasma concentration ratio(D/P):,Peritoneal transport characteristics,Diffusion,Convective transport:Mainly depends on ultrafiltration,Dialysate volume,Total infusion volume,Ultrafiltration volume,Peritoneal absorption,Body size,透析液血浆浓度比值,(D/P):,腹膜转运特点：,弥散,对流转运：主要依赖超滤,透析液剂量,:,灌腹总量,超滤量,腹膜吸收量,体形大小,Indications for dialysis initiation,开始透析的指征,GFR,10-15 ml/min/1.73m,Uremic symptoms,Malnutrition,GFR,10-15 ml/min/1.73m,尿毒症症状,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”！,Indications for emergency dialysis initiation,急诊透析的指征,Pericarditis,Hyperkaliemia,Severe acidosis,Lung oedema,Intractable hypertension,Uremic coma,心包炎,高钾血症,严重酸中毒,肺水肿,难治性高血,压,尿毒症昏迷,Dialysis Process,透析替代作用,What Your Kidneys Do,肾脏功能,清除代谢产物,体液平衡,电解质平衡,酸碱平衡,产生激素,PTH,EPO,维生素,D,肾脏本身功能,XXXXXXXXXX,缺点,内环境波动大,血管通路,需要穿刺,感染机会,饮食限制,需要到透析中心治疗,费用高,Haemodialysis,血液透析,优点,有效清除代谢产物,专业人员实行操作,提供病人社会化,一周仅需治疗3次,家庭不需要购置设备,(除非家庭,HD,),优点,在家中自我管理,自主性更高,治疗计划可以更改,饮食限制较少,不需穿刺,减少机体应激,血压控制,费用降低,Peritoneal Dialysis,腹膜透析,缺点,每日透析,植入腹透管,体形改变,感染机会,体重可能增加,需要一定的储物空间,Transplantation,移植,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,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,Strong medical indication for PD,腹膜透析绝对适应症,Difficulties with vascular access,Left ventricular hypertrophy,Congestive heart failure,Prosthetic vascular disease,Intolerance of HD,Frequent episodes of hypotension,Headache and asthenia after HD session,Children,血管通路建立困难,左心室肥厚,充血性心衰,人造血管病变,不能耐受血液透析,经常出现低血压事件,血透后头痛和乏力,儿童,PD preferred,适合,PD,Bleeding diathesis(no need of heparinization),Diabetes(status of vessels,insulin i.p.),Chronic infections(prevention of the nosocomial spread hepatitis B,C,HIV),Future transplantation(improved initial graft function rate),Multiple myeloma(improves the chances of renal recovery,removes some light-chains proteins),出血倾向,(,不需要肝素化,),糖尿病,(,血管条件，腹腔内使用胰岛素,),慢性传染病,(,预防乙肝、丙肝及艾滋病的院内感染,),将来准备肾移植,(,改善术后移植物成功率,),多发性骨髓瘤,(,增加肾功能恢复机会，清除一些小的轻链蛋白,),PD and HD equally preferred,可以选择,PD,或,HD,Polycystic kidney disease,Scleroderma,other conective tissue diseases(,e.g.,SLE),Patients living in nursing homes,多囊肾疾病,硬皮病及其他结缔组织疾病（系统性红斑狼疮等）,居住在护理院的患者,Theoretically not to choose PD initially,BUT,PD may be feasible with added adjustments,理论上不宜首选腹透治疗，但是进行某些改进后腹透也可以实行的情况,Large body size,Diverticulosis/diverticulitis,Severe backache,NIPD,Hernias,NIPD,Multiple abdominal surgery,Poor manual dexterity,Blindness,No compliance,体形较大,(,肠,),憩室病,/,憩室,炎,重度背痛,NIPD,疝气,NIPD,腹部多次手术史,操作不便,失明,依从性差,Psychosocial situations in which PD is more appropriate,更适合腹透的心理状态,PD preferred,Independent Life,Frequent travels,Tendency towards PD,Great need of independence by the patient,Need to maintain work,Distance to the HD center,独立生活,经常旅行,优先选腹透,倾向于腹透,患者有强烈独立生活的愿望,需要继续工作,远离血透中心,Suggested Reading and Reference Material,推荐阅读和参考文献,Oxford Handbook of Dialysis,by J.Levy,J.Morgan and E.Brown,2,nd,edition 2004,Oxford University Press,K/DOQI Guidelines(,all published in the American Journal of Kidney Disease):,Nutrition in CRF(06/00),Vascular access update(01/01),Anemia update(01/01),PD adequacy update(01/01),HD adequacy update(01/01),Clinical Practice Guidelines for Chronic Kidney Disease(02/02),Dyslipidemias in CRF(04/03),Hypertension in CKD(05/04),Bone disease in CKD(10/04),USRDS Annual Data Report,United States Renal Data System,2004.,Nephrology 101 Course Materials;,Anatomy and Physiology,by Dr.Salim Mujais,CNNT Division of the National Kidney Foundation,Spring Clinical Meetings.2004.,Empiric prescription,经验处方,3-5 exchanges of 2 L dialysis bag,Considering mainly fluid balance,2,升袋装透析液交换,3-5,次,注意保持大致液体平衡,The weights at which the weekly Kt/Vurea equals the minimum target of 1.7,每周尿素,Kt/V,最少达到,1.7,的患者体重水平,Nolph Kd et al.Perit Dial Int 1994.14:261-264,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,Variations,演变,O-Z(T-W)Tenckhoff,Catheter,O-Z(T-W)Missouri,Tenckhoff Catheter,Moncrief-popovich,Catheter,Pediatric,Presternal,T-Fluted,Di Poalo,Self locating,PD Catheter implantation,腹透置管术,Peritoneal Catheter implantation must be performed by a competent and,experienced surgeon or nephrologist,.Optimal long term peritoneal catheter function and exit site healing are directly related to the skills and the competence of the catheter insertion team.,腹透导管埋置术必需由熟练有经验的外科医生或肾病专科医师施行。腹透导管长期保持最佳功能及体外段的愈合，直接与手术医生的技术和能力相关,Gokal et al.Peritoneal catheter and exit site practices.Toward optimal peritoneal access,Perit Dial Int,1998;18:11-33,Impact of Catheter insertion by Nephrologists on PD utilization,腹膜透析应用上肾病医师对置管的影响,Non-Nephrologists,无肾病医师,Nephrlogists,肾病医师,Non-Nephrologists,无肾病医师,Canter 1,1993-2001,38-45 pts(16%),2001,101 pts(32%),Center 2,1988-1990,70-78 pts(17%),1991,125 pts(22%),Center 3,1988-1991,20-30 pts(18%),1991-2000,97 pts(27%),2001,25 pts(6%),Seminar Dial 2005 18:157-60,Break-in period,导管修整期,To allow a sufficient time to heal surgical wound(exit site):2-4 weeks,Aseptic dressing with minimum opening is recommended,Immobilization is important,Temporary HD should be considered in this period in patients with advanced kidney failure,Some centers start PD training for patients at this period,给予足够的时间让手术伤口愈合（体外段）：,2-4,周,建议使用无菌敷料覆盖并减少伤口暴露,导管固定（体外段）很重要,此期，若患者肾衰持续进展，可以考虑暂时血液透析过渡,有些中心在此期开始腹透患者培训,Peritoneal Dialysis Technique,腹透技术,Basic procedures,Infusion,Dwell time(variable),Drainage of dialysis solution(effluent),Volume describes the amount of dialysis solution used in each exchange,Dose depicts the amount of solution used over a specified time period,Intermittent PD and continuous PD describe the regimens or plans of the therapy over a period of time,基本操作,灌注,留腹时间（可变）,引流腹透液,(,流出液,),容量每次交换所用的腹透液的量,剂量某一时间段内用的透析液总量,间歇性腹透及连续性腹透一段时期内用的腹透方案或用法,2-2.5 L dialysis solutions,4-5 exchanges/day,Each exchange may take 30-50 min.,2-2.5 L,透析液，每天交换,4,5,次，每次交换时间约,30,50,分钟,“,Flush before Fill”Design,Ultra transfer set.With roller clamp,Disconnect system,Using standard spike Solution.,Prefilled,Minicap Disconnect cap.,“,灌注前冲洗”的设计,带有滚轴夹子的体外导管设置,分离系统,使用标准接口溶液,.,预备分离小帽,Drain Flush Fill-Dwell,引流冲洗灌注留腹,Common complications in PD,腹透并发症,Peritonitis,Exit site infection,Fluid overload,腹膜炎,出口感染,容量过多,The impact of Peritonitis on CAPD Results,腹膜炎对,CAPD,影响,Causes,Catheter loss in 8.2%of cases,Catheter infection in 10.8%of cases,Accounts for,24.2%of hospitalization cases,6.7%of death,30.0%of drop-out,Viglio et al.Adv.Perit Dial 1992.8:269-275,原因,导管故障,8.2%,导管感染,10.8%,导致,住院率,24.2%,死亡率,6.7%,患者退出腹透,30.0%,30,！,管理腹膜炎对于成功腹透的重要性！,374,个病人中腹膜炎的发生率,（1991年1998年）,Peritonitis Rate CAPD and APD,CAPD,和,APD,的腹膜炎发生率,Early 80:6.3 episodes/yr,Late 90,Japan 1 episode in 53.4 patient mths,Korea 1 episode in 25-33.3 patient mths,Hong Kong 1 episode in 33.5 patient,mths,80,年代早期：每年,6.3,次,90,年代晚期：,日本,53.4,病人月,韩国,25,-33.3,病人月,香港,33,.5病人月,Y.Kawaguchi.Han DS.Lai KN and Lo WK.PDI Vol19,Supp 3,1999,污染,围手术期,腹泻,/,便秘,败血症,不明原因,导管相关,腹膜炎来源,肠道损伤,41%!,提示无菌操作的重要性,Peritonitis,腹膜炎,Identification of peritonitis,Turbid PDF,PDF WCC100/mm3,Abdominal pain,fever,腹膜炎的确诊,腹透液混浊,腹透液中白细胞数,100/,mm3,腹痛，发热,以上条件中具备两条即可确诊，有一条时应引起高度重视。,Quality Management of peritonitis,控制腹膜炎,Ensure prompt diagnosis,Ensure prompt treatment,Ensure appropriate treatment,Ensure timely adjustment of antibiotics,Identification of cause of peritonitis,Prevention of recurrence of peritonitis,Minimization of peritonitis rate,及时诊断,及时治疗,恰当的治疗,及时调整抗生素,明确腹膜炎的原因,预防腹膜炎的复发,减少腹膜炎的发生率,Ensure prompt diagnosis,及时诊断,Send PDF WCC,Do not