肾内科教学课件：腹膜透析

腹膜透析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AdvantagesMostlikeyourownkidneyNodialysisneededNoaccessneededNormalDiet(-sodium)More“normal”lifestyle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DisadvantageRisksofmajorsurgeryRiskofbodyrejectingkidneyPossiblesideeffectsofdrugsLowerresistancetoillnessBodyimagechanges.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Patient's

KidneyTransplant

Kidney(extra-peritoneally)Bladder病肾移植肾膀胱Who

cannot

donateakidney?

哪些人不可捐献肾？HIVorAIDS-relatedinfectionHepatitisBorCinfectionMajorheartorbreathingproblemsDiabetesExtremeobesitySignificantkidneydiseaseMostcancersIVdrugabusePregnancyHighBPHavingonlyonekidneyEvidenceoffinancialornon-financialcoercionInabilitytogiveinformedconsent/psychiatricdisordersHIV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Indicationsfordialysisinitiation

开始透析的指征肾小球滤过率10-15ml/min/1.73m²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”！GFR10-15ml/min/1.73m²UremicsymptomsMalnutritionHemodialysis

血液透析Theprocessofseparatingchemicalsubstancesfrombloodthroughasemi-permeablemembrane通过透析器半透膜从血液中分离化学物质的过程ToxinRemoval

清除毒素Removaloftoxinsfromthebloodisaccomplishedby: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-permeableMembrane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ConcentrationGradient-FlowGeometry

浓度梯度-液流动力影响BloodIn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

临时通路或永久通路TemporaryAccessUsedforafewhourstoseveralweeksUsuallypercutaneousinsertionofacannulaintoalargeveinSurgicalimplantationofpairedtubesintoanarteryandveinwereusedanumberofyearsago;fairlyobsoletenowForpatientswithacuterenalfailure,chronicrenalfailurewithoutpermanentaccess,peritonealdialysis(PD)ortransplantpatientsfortemporaryhemodialysisPermanentForperiodsrangingfrommonthstoyearsOptionsSub-cutaneousanastomosisofarterytoveinSub-cutaneouspositioningofa“tube”graftbetweenanarteryandveinImplantationofacuffeddual-lumencatheterintoavein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ComplicationsofVascularAccess

血管通路相关并发症InfectionThrombosisEarlyvs.latethrombosis“Thrombolysisvs.thrombectomy”

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

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(trueorpseudo)“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Whatarethebenefitsofpreservingresidualrenalfunction?

保护残余肾功能的益处Contributestototalsoluteclearance(1ml/minCrCl=10literCrCl/week)增加总的溶质清除Improves2-microglobulinandmiddlemoleculeclearance改善2-微球蛋白及中分子毒素的清除Providesendocrinefunctions内分泌功能ReducesMortality降低死亡率Facilitatesvolumecontrol有利于容量控制Allowsformoreliberaldietandfluidintake允许较多的饮食和水分摄入Improvesnutritionalstatus改善营养状况ImprovesQOL提高生活质量IncreasestotalNaremoval增加总钠清除Davies,S.2000Whatistheperitonealmembrane?

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ThemesotheliumTheinterstitiumMacrophages/MonocytesPeritonealcapillariesPlaysimportantrolewaterandsoluteexchange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Componentsoftheperitoneum腹膜的结构Diffusion

弥散Definition:Solutemovementduetoconcentrationgradientoftwosolutesbetweencomponentsacrossasemi-permeablemembraneMaindrivingforceforsmallsoluteremovalFactorsinvolvedindiffusionSizeofsolutePeritonealsurfaceareaHydrostaticpressureElectricalchargeofsolutes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。Howtoachieveit?

如何达到治疗目标？Sufficientfluidandtoxinremoval:doseofdialysisItdependsonResidualrenalfunctionBodysizeCo-morbidcondition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/PforUr,CrandNaandD/DoforGluat0,2,and4hrsarecalculatedPatientsareclassifiedonbasisof4hrD/PCraslow,lowaverage,highaverageorhightransportersIngeneral,hightransportersdialyzewell,butabsorbGlurapidly,havelessUF,greaterdialysateproteinlossesandlowerserumalbuminLowtransportersaretheoppositeandaveragetransportersareinbetweenD/PforUr,CrandNaandD/DoforGluat0,2,and4hrsarecalculatedPatientsareclassifiedonbasisof4hrD/PCraslow,lowaverage,highaverageorhightransportersIngeneral,hightransportersdialyzewell,butabsorbGlurapidly,havelessUF,greaterdialysateproteinlossesandlowerserumalbuminLowtransportersaretheoppositeandaveragetransportersareinbetween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AuditingthePDProgram

评估腹透InfectionratesTechnicalproblemseg.catheterflowproblemsAdequacyindicesNutritionindicesTechniqueandpatientsurvivalAnaemiamanagement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Globaltherapymix

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％AutomatedPeritonealDialysis

自动化腹膜透析PeritonealdialysisusingautomatedexchangemachineDesignedtominimizetheburdenoffrequentexchangesofdialysatebagsAllowindividualizedprescriptionofperitonealdialysis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DifferentPDcatheters

不同腹透管路Straight1cuffStraight2cuffsCoiledTenckhoffcatheters卷曲管Coiled1cuffCoiled2cuffsSwanNeckTenckhoffcatheters鹅颈管StraightCoiledDow