腹膜透析原理1课件

BaxterAsiaRenalHowPDworks

腹透原理KidneyDisease

肾脏病基础ImplicationsTherapyoptions包括治疗选择PrMaxDratwaHôpitalBrugmannBrusselsLearningobjectives

学习目的Understandnormalkidneyanatomy&functioningUnderstandkidneydisease:acuteandchronicKnowtheimplicationsofkidneydiseaseBeabletodiscussthedifferenttreatmentoptions理解肾脏正常的解剖和功能理解急性和慢性肾脏疾病了解肾脏病的并发症讨论不同的治疗方式TheKidney肾脏肾解剖特征：1.肾外形似蚕豆，成年人肾约长12cm，宽6cm，厚3cm，重约120－160g；呈红褐色，质软。TheKidney肾脏（续）肾解剖特征：2.冠状面：外1/3皮质，内2/3髓质

肾锥体的尖端形成肾乳头，2－3个肾乳头汇入肾小盏，肾小盏汇入肾盂

肾门：肾静脉、肾动脉、输尿管、神经结缔组织等

肾皮质肾锥体肾盂输尿管肾髓质肾动脉肾静脉肾小盏TheKidneybasicunit:thenephron

肾脏基本结构：肾单位每个肾脏由100万个肾单位组成肾单位肾小球肾小管血管丛血小囊关键词：原尿：终尿：Ureter输尿管Urethra尿道Calyx肾盏Bladder膀胱Renalpelvis肾盂Functionsofthekidney

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

ActiveformofVitaminD(healthybones)Erythropoïetin(RBCsynthesis)Renin-Angiotensin(bloodpressure)

内环境稳态水盐平衡电解质(K,Mg,…)酸碱平衡(pH)废物的代谢激素生成

活性维生素D（健康骨）EPO(促进红细胞生成)肾素－血管紧张素（调节血压）

Thediseasedkidney

肾脏疾病TwotypesofkidneydiseaseAcutefailure…Classifiedaccordingtositeofproblem:pre-renalrenalpost-renalChronicdisease…Classifiedin5stagesofincreasingseriousness1:1:milddamage2:milddecreaseofrenalfunction3:moderaterenalinsufficiency4:severedamage5:endstagerenaldisease(ESRD)两种类型急性:根据病变部位分类肾前性（肾脏供血障碍）肾性（肾本身疾病所致）肾后性（肾的排泄系统阻塞）慢性:严格按照疾病进展分5期1:轻微损害2:GRF轻度下降3:GRF中度下降4:GRF重度下降5:终末期肾脏疾病（ESRDClassificationofKidneyDisease

肾脏病分类1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,Guideline1:DefinitionandStagesofChronicKidneyDisease,

NKF,2002.肾功能急骤地、进行性地减退导致的临床症候群急性肾衰“Pre-renal”Usuallyduetodecreasedbloodflowtothekidneyshemorrhage,gastrointestinalbleedingleadingtoshockburnssepsisemboli,stenosis,occlusion,traumatorenalarterydecreasedcardiacoutputcongestiveheartfailure,myocardialinfarctionSurgery肾前性通常是因为肾脏血流灌注减少出血性疾病导致休克创伤败血症肾动脉狭窄、栓塞、硬化等心输出量下降充血性心力衰竭、心肌梗塞手术CausesofAcuteKidneyFailure

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

KidneyFailure

急性肾功能衰竭的原因“Intra-renal”(continued)Inflammationfrombacteria/virusTraumaImmunologicalandvasculiticdiseasesAuto-antibodies(Goodpasture’s,LED,Wegener’s,…)TransfusionreactionsVasculardisordershypertension,diabetesPregnancydisorderspre-eclampsia,septicabortionTissueororgantransplantrejection肾性（续）细菌或病毒感染创伤自身免疫性疾病和血管疾病自身抗体(Goodpasture’s,LED,Wegener’s,…)输血反应血管性疾病高血压、糖尿病妊娠相关疾病子痫,败血症流产器官移植排异CausesofAcuteKidneyFailure4

急性肾功能衰竭的原因4“Post-renal”Theflowofurinefromthekidneystotheexteriorofthebodyisprevented,usuallyduetoanobstruction(stones,tumors,…)肾后性尿液从肾脏排出体外受阻，通常为尿路梗阻(结石,肿瘤等)XXAcute

KidneyFailure

急性肾功能衰竭AcuteKidneyFailureOccursoverhoursorfewdaysLastshourstoafewmonths,upto1yearCanbereversible50%mortalityratemajorcauseofdeathisinfection急性肾功能衰竭数小时或数天后出现持续数小时、数日，甚至一年可逆性死亡率高达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)

慢性肾脏病（CKD）1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,Guideline1:DefinitionandStagesofChronicKidneyDiseaseandPart5EvaluationofLaboratoryMeasurementsforClinicalAssessmentofKidneyDisease,

Guideline6:MarkersofChronicKidneyDiseaseOtherthanProteinuria,

AJKD,February2002.CKD的定义(指南1&61)肾损害：肾脏结构或功能的损害(可以没有GFR下降):病理改变损害指标蛋白尿血尿白细胞尿或脓尿影像学检查异常GFR<60ml/min/1.73m2(可以伴有或不伴有肾损害，持续3个月以上）ChronicKidneyDisease

慢性肾脏病ClinicalfactorsassociatedwithanincreasedriskforCKDDiabetesHypertensionAutoimmunediseasesSystemicinfectionsUrinarytractinfectionsUrinarystonesLowerurinarytractobstructionNeoplasia(cancer)FamilyhistoryofCKDRecoveryfromacutekidneyfailureReductioninkidneymass(trauma,surgery)ExposuretocertaindrugsLowbirthweight1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,

Guideline3:IndividualsatIncreasedRiskforChronicKidneyDisease,

AJKDFebruary2002.IndividualsatIncreasedRiskforCKD(Guideline31)CKD易患人群（指南3）临床因素糖尿病高血压自身免疫性疾病系统性感染尿路感染尿路结石下尿路梗阻肿瘤CKD家族史急性肾功能衰竭恢复期肾脏容积减少（创伤，手术）服用某些肾毒性药物低出生体重GlomerularFiltrationRate(GFR)isanindexofkidneyfunctionMostaccuratemeasurementisbyisotopicmethodsEstimatingGFRisaccomplishedbyusingthepatient’sserumcreatininevalueinanequation…othervaluesusedintheequationincludepatient’sage,sex,weight,race,etc.Equationsinclude:Foradults,theequationderivedfromtheMDRDStudyortheCockcroft-GaultformulaForpediatricpatients,SchwartzorCounahan-BarrattNoneedtodoa24hoururinecollectiontomeasureclearances(althoughaprecisemeasurementcanbemadebythemeanofureaandcreatinineclearances)Calculatorscanbefoundonthefollowingsite:/professionals/tools/肾小球滤过率（GFR）是反应肾功能的一项指标是单位时间内肾小球滤出地肾血浆流量，正常值为120－160ml/min最精确的方法是应用同位素测定估计GFR的公式需要考虑血肌酐、年龄、性别、种族、体重、身高等因素的影响:成人可以运用MDRD研究或Cockcroft-Gault方程儿童可以运用Schwartz或Counahan-Barratt方程无需留取24小时尿测定清除率（虽然测定尿素和肌酐清除率较准确）计算方程式可以参阅网站:/professionals/tools/

K/DOQIGuidelinesforClassification1

K/DOQI指南－估计GFR11

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

Guideline4:EstimationofGFR,

AJKDFebruary2002.CKD:Classification1

CKD分期StageDescriptionGFRmL/min/1.73m²Actions1KidneydamagewithnormalorincreasedGFR肾损害，GRF正常或增加9070%ofnormalfunction70%肾功能正常）Diagnose&treatcause,comorbidconditions

诊断和治疗Trytoslowprogression

延缓进展ReduceCKDrisk

减少CKD患病因素2KidneydamagewithmilddecreaseinGFR肾损害，GFR轻度下降60–8955–70%Estimateprogressionofdisease

评估进展IdemStage1

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

评价贫血、营养和骨病Treatcomplications

治疗并发症IdemStage1&2

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

肾脏专科诊治PrepareforRRT(Predialysiseducation)

准备肾脏替代治疗（透析前教育）StartRRTearlierifelderly,diabetes,CVD,othercomorbidconditions老年、糖尿病、CVD、及其他合并症者早期肾脏替代治疗5Kidneyfailure肾衰竭<15(dialysis)<15%Uremicsymptoms,marked

inurea,creatinine,K+,P+&fluid

尿毒症症状，尿素，肌酐升高，高钾高磷，容量过多StartRRT

开始肾脏替代治疗1K/DOQIClinicalPracticeGuidelinesforChronicKidneyDisease:Evaluation,Classification,andStratification;Part4DefinitionandClassificationofStagesofChronicKidneyDisease,Guideline2:EvaluationandTreatment,AJKDFebruary2002.CausesofChronicKidneyDisease

CKD病因DiabetesHypertension/LargeVesselDiseaseRenalArteryStenosisorOcclusionCholesterolEmboli,RenalEmboliGlomerulonephritisInterstitialNephritis/PyelonephritisAnalgesicAbuseMiscellaneousConditions(includesunknown)ComplicationPostBoneMarroworOtherTransplantSickleCellDiseaseAIDSNephropathyTraumatic/SurgicalLossofKidneyHepatorenalSyndromeTubularNecrosiswithNoRecoveryIncidenceofTreatedESRDbyPrimaryDisease,1999-2002DescriptionofDiseasestakenfromtheUSRDS2004AnnualDataReport糖尿病高血压/大血管病变肾动脉狭窄或梗阻动脉粥样硬化肾小球肾炎间质性肾炎/肾盂肾炎止痛剂成瘾不明原因骨髓移植或其他器官移植后镰状细胞病AIDS相关性肾病肾脏外伤或手术肝肾综合征肾小管不可逆性坏死SecondaryGlomerulonephritis/VasculitisLupusSclerodermaHemolyticUremicSyndromeNephropathyfromHeroin/RelatedAbuseNeoplasms/TumorsMultipleMyelomaAmyloidosis继发性肾小球肾炎/血管炎狼疮硬皮病溶血尿毒综合征海洛因或其它毒品成瘾性肾病新生物/肿瘤多发性骨髓瘤淀粉样变性

CausesofChronicKidneyDisease

CKD病因（续）ConsequencesofCKD

慢性肾脏病的预后When75-80%ofrenalfunctionislost,everyorgansystemisaffected1EndStageRenalDisease(ESRD)isirreversible

kidneydisease<10-15%ofrenalfunctionremainingPatientmustreceivedialysisortransplant,ortheywilldie!75-80%的肾功能丧失后，各个系统都会受到影响ESRD是不可逆

的肾脏疾病残余肾功能<10-15%必须接受透析或移植，否则将死亡！1

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

慢性肾脏病的预后2UremicSyndrome1–acollectionofsignsandsymptomsthatoccurwithCKDfluidandelectrolytedisordersdisorderedregulatoryfunctionsanemiahypertensionbonediseaseaccumulationofuremictoxinsalterationinallbodysystems尿毒症（一系列症状和体征）水电解质紊乱调节功能异常贫血高血压骨病尿毒症毒素蓄积影响全身各个系统1

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

慢性肾脏病的临床表现ChronicKidneyDiseasecanaffecteveryorgansysteminthebody慢性肾脏病可以影响全身各个系统（由于毒素不能清除而导致各系统症状）AlterationsinBodySystems1

各系统症状1Gastrointestinalsystem(stomachandintestines)anorexia,nausea,vomitinghighuremictoxins“urinebreath”intestinalbleedingHeparinduringdialysistreatmentirritatingmedicationsclottingabnormalities1

ANNACoreCurriculumforNephrologyNursing,3rdEdition,Lancaster,L.;SectionIV,SystemicManifestationsofRenalFailure,pg.76-108.胃肠道系统食欲不振，恶心，呕吐尿毒症毒素呼吸有尿味肠道出血透析时肝素应用刺激性药物凝血功能异常AlterationsinBodySystems2

各系统症状2Gastrointestinalsystem(continued)diarrheaintestinalirritationconstipationphosphatebindermedications胃肠道（续）腹泻肠道激惹便秘磷结合剂AlterationsinBodySystems3

各系统症状3Neuromuscularsystem(nervesandmuscles)encephalopathyheadache,sleepproblems,inabilitytoconcentratetremors,twitching,seizures,comaneuropathy“restlesslegsyndrome”burningfeetweaknessoflowerextremities神经肌肉系统脑病头痛、失眠、注意力不集中震颤、抽搐、惊厥、昏迷神经病变“不安腿综合征”烧灼感肌无力

Bothencephalopathyandneuropathyaredueto

uremictoxins,electrolyte

imbalancesandmetabolicacidosis脑病和神经病变都是由于尿毒症毒素、电解质紊乱和代谢性酸中毒引起AlterationsinBodySystems4

各系统症状4Cardio-vascularsystem(heartandvessels)arythmiashyperkalemiaatherosclerosisandcoronaryarterydiseasehyperlipidemiahypertensionretentionofsodiumandwaterRenin-AngiotensindysfunctionHypertensioninRenalFailure心血管系统心律失常高钾动脉硬化和冠心病高脂血症（脂质代谢异常所致）高血压水钠潴留肾素－血管紧张素紊乱AlterationsinBodySystems

5

各系统症状5Cardio-vascularsystem(continued)pericarditis/effusion/tamponadeitissuspectedthaturemiacausesinflammationinpericardiuminadequatedialysisHeparinuse心血管系统（续）心包炎/心包积液/心包填塞尿毒症引起心包炎症透析不适当肝素应用Pericarditis

11IllustrationfromNKFNephrology101Course:PathophysiologybyS.Mujais,2004.AlterationsinBodySystems

6

各系统症状6Skingray-yellowcolorretainedpigmentspalloranemiadryness

decreasedactivityofsweatandsebaceousglandspruritus(itching)depositionofcalciumphosphatecrystalsintheskin皮肤

灰黄色色素沉着苍白贫血干燥皮脂腺和汗腺分泌减少瘙痒钙磷结晶沉积AlterationsinBodySystems7

各系统症状

7Skin(continued)bleeding/infection

scratchingtorelieveitchingbruisingabnormalbloodclottingfragilecapillaries“uremicfrost”awhite,powderydepositofureacrystalsthatisleftbehindafterperspirationdriesusuallyseenonlyinadvancedrenalfailureorifthepatientisnotbeingadequatelydialyzed

常见于进展期肾功能衰竭和不适当透析的病人皮肤（续）出血/感染

瘙抓淤斑凝血功能异常毛细血管脆性尿素霜结晶出汗后留下的白色粉状结晶常见于进展期肾功能衰竭和不适当透析的病人AlterationsinBodySystems

8

各系统症状8Pulmonarysystem(lungs)pulmonaryedemaandpleuralrubsvolumeoverloadtenacioussputumincreasedrespiratoryrateanddepthcompensationformetabolicacidosis肺肺水肿和胸腔积液体液过多粘痰呼吸深而长代谢性酸中毒AlterationsinBodySystems9

各系统症状9Hematologicsystem(blood)anemiadecreasedRBC(redbloodcell)productionlossoffunctioningrenaltissue(decreasedEPOproduction)vitamindeficienciesirondeficiencyaluminumtoxicitybloodlossabnormalbleedinglabsamplinglossindialyzerredbloodcell(RBC)destructionhemolysisduringdialysistreatmenthemolyticanemiaLupus,sicklecell血液系统贫血RBC生成减少EPO减少维生素缺乏铁缺乏铝中毒失血出血实验室检查抽血透析失血RBC破坏透析时溶血溶血性贫血狼疮，镰状细胞AlterationsinBodySystems

10

各系统症状10Hematologicsystem(continued)anemia(continued)bleedingabnormalities;prolongedbleedingdecreasednumberofplateletsandplateletdefectssevereanemiaHeparintherapyduringhemodialysismedicationsthatdecreaseplateletadhesiveness血液系统（续）凝血功能异常血小板数量和功能下降严重贫血透析时应用肝素影响血小板聚集、粘附的药物IronStudiesSerumIron25-170mcg/dL.normalDialysispatients:>60mcg/dL.%TransferrinSaturationavailableIron25-45%normalDialysispatients:>25%SerumFerritinstoredIron12-300ng/mL.NormalDialysispatients:100-600ng/mL.AnemiaStatus

贫血铁血清铁正常值：25-170mcg/dL透析病人：>60mcg/dL.转铁蛋白饱和度可利用的铁正常值：25-45%透析病人：>25%血清铁蛋白储存铁正常值：12-300ng/mL透析病人：100-600ng/mL.注意：多数患者铁的指标并不低IndicatorsofIronDeficiency

铁缺乏指标

CausesresultingdecreaseinHblevels

导致血红蛋白下降AnemiaStatus

贫血（续）AnemiaTreatment贫血治疗Recombinanthumanerythropoietin(Eprex,Neo-Recormon)ordarbepoietin(Aranesp)withincreasedhalf-lifeandactivityGivensub-cut.(pre-DandPD)orIV(HD)StimulatesRBCproductionbybonemarrowPtmustbeironrepletedforthesedrugstoworkefficiently:majorcauseofresistancetoEPOtherapyOthercausesofresistance:-inflammation(infection,cancer,…)

-PureRedCellAplasia(antibodiesagainstEPOseenwithSCEprex)重组人红细胞生成素（EPO）皮下(透析前和PD)或静脉(HD)刺激骨髓造血补铁:缺铁是EPO反应不佳的主要原因其他原因:感染、肿瘤、纯红细胞再障（EPO抗体形成）AlterationsinBodySystems11

各系统症状11Fluidbalance/imbalanceretentionofwatervolumeoverloadserumalbuminlevelislowhypertensionshortnessofbreathedemaoftissuesororgans体液平衡水潴留体液过多低蛋白血症高血压呼吸短促水肿IllustrationfromNKFNephrology101Course:PathophysiologybyS.Mujais,2004.AlterationsinBodySystems12

各系统症状12Electrolytebalance/imbalancesodiumpotassiumcalcium/phosphorusglucosemagnesiumhydrogen/bicarbonateAluminum电解质平衡/失衡钠（GFR↓、排钠↓、血钠↑）钾钙磷葡萄糖镁（GFR↓、排钠↓、血钠↑）H+/HCO3-铝AlterationsinBodySystems

13

各系统症状13Acid/basebalance(alterationinpH)patientsusuallyexhibitmetabolicacidosisretentionofhydrogenionsdecreasedreabsorptionofbicarbonatedecreasedexcretionofammoniumchlorideretentionofacidendproductsofmetabolismCatabolism酸碱平衡（PH改变）常有代谢性酸中毒H+潴留HCO3-重吸收减少泌H+减少酸性代谢产物潴留分解代谢Acid/basebalance(continued)signsandsymptomsincreasedrateanddepthofrespirationsplasmabicarbonatelevel<22mEq/L.arterialpH<7.4tachycardiainmildacidosis;bradycardiainsevereacidosisalteredmentalstatuslowbloodpressurehyperkalemiavariousothercomplaints…nausea,vomiting,headacheAlterationsinBodySystems

14

各系统症状14酸碱平衡（续）症状和体征呼吸深长HCO3-<22mEq/L.pH<7.4轻度酸中毒时出现心动过速;严重酸中毒时则出现心动过缓精神症状低血压高钾其他如恶心、呕吐、头痛等AlterationsinBodySystems

15

各系统症状15Endocrinesystem(hormones)decreasedsomatotropin(exertseffectongrowthhormone)inchildrengoodamountsofdietaryprotein,controlanemia,controlacidosishumanrecombinantgrowthhormone(somatropin)decreasedreproductiveability/sexualdesiretestosterone,zincformalescounselinganemiatherapy内分泌系统（激素）儿童生长激素减少增加膳食蛋白,纠正贫血和酸中毒人重组生长激素生育能力和性欲下降男性睾丸素、锌下降心理咨询纠正贫血AlterationsinBodySystems

16

各系统症状

16Immunesystemsuppressionofimmunesystemhighlevelofcirculatinguremictoxinsabnormalintakeofnutrientsforwhitebloodcell(WBC)functionCKDpatientshavesubnormaltemperaturesureaisaknownantipyretic免疫系统免疫抑制（T细胞、B细胞功能均受到抑制）循环中毒素水平高不适当的饮食影响白细胞功能CKD病人体温常较低尿素氮降体温作用CalciumPhosphorusImbalanceandBoneDisease

钙磷平衡失调和肾性骨病17RenalFailure/HighPhosphorusIntake肾功能衰竭/高磷摄入

PhosphorusIncreases/VitaminDsynthesisDecreases血磷升高/VitD合成减少CalciumAbsorbtionfromIntestinesDecreases/SerumCalciumandPhosphorusBind肠道吸收钙减少/血钙磷乘积

LowSerumCalciumStimulatesIncreasedPTHSecretion低血钙刺激PTH分泌

CalciumisPulledfromtheBonestoIncreaseSerumCalcium肾钙动员以升高血钙FurtherBindingofCalciumandPhosphorusFormingCalciumPhosphateComplexes钙磷乘积升高MetastaticCalcification软组织钙化AlterationsinBodySystems

各系统症状17AlterationsinBodySystems18

各系统症状18骨病-“肾性骨病”高转运性骨病纤维性骨炎骨痛和骨折骨钙磷丢失血钙降低，血磷升高，血PTH升高，血维生素D降低低转运性骨病

血钙正常或升高，血磷升高，PTH降低

微骨折

（可能与高钙摄入和维生素D的不适当应用有关）骨软化骨痛，骨折，畸形骨脱矿质(“woven”bone)高血铝，影响成骨细胞活性Calcium,phosphorus,PTH,VitaminDandtheircontributionstobonediseasearediscussedinfurtherdetailinthe“BloodChemistriesandNutritioninKidneyDiseasePatients”presentationBoneproblems-“renalosteodystrophy”Osteitis

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%)钙磷代谢紊乱和骨病的发生与死亡率相关钙磷等矿物质代谢紊乱引起的死亡率[Ca≥10,P≥5,PTH≥600]

(17.5%)要高于贫血[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

事实上，矿物质代谢参数能够由治疗干预来调节因此，出版了有关这些参数的治疗目标，如DOQI指南等制定这些指南的根本目的是为了降低相关的死亡率

TissueCalcification

组织钙化SlidecourtesyofD.Sherrard.Femoralarterycalcification

股动脉钙化Calcificationofcoronaryarteriesinadialyzedpatient

透析病人冠状动脉钙化ScancourtesyofP.Raggi.Calciphylaxis

or“calcifyingarteriolopathy”mostlyinoverweight,diabetic,

femalesonperitonealdialysiswithahighCaXPproduct.

Highmortality:50%!

钙化防御

或“小动脉钙化症”，多见于肥胖，糖尿病，女性

的腹膜透析病人，CaXP乘积高，死亡率高达50%

FineAdrian&Zacharias,James

Calciphylaxisisusuallynon-ulcerating:Riskfactors,outcomeandtherapy.

KidneyInternational

61(6),

2210-2217Whatmeasures/drugscanwepropose?

钙磷代谢紊乱的管理和治疗DietaryPhophateRestriction

限制饮食中磷的摄入Badcompliance依从性差Riskofdecreasingproteinintake蛋白质摄入不足的危险

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

Phosphatebinders

磷结合剂Sevelamer:BadG-ItoleranceLessefficient,moreexpensiveMetabolicacidosis(4mEqacidfor800mg)Calciumsalts:BadG-ItoleranceHypercalcemiaVascularcalcifications?Sevelamer:胃肠道耐受性差疗效差，价格贵代谢性酸中毒(800mg

含4mEq酸)钙盐:胃肠道耐受性差高钙血症血管钙化MetabolitesofvitaminD

VitD的代谢InhibitPTHsecretionBUTincreaseCa,PandCaxPLimiteduseifonewantstomeettheguidelinesintermsofcalcemiaandphosphoremiaNoIVpresentationsonthemarketinEurope抑制PTH分泌但是增加Ca,P和CaxP在PTH、Ca、P同时达到治疗指征如果要达到血钙和血磷的目标，其应用受限欧洲市场没有注射剂型

SummaryPoints

总结KidneyDiseasemaybeAcuteorChronicAcuteKidneyFailuremaybereversibleChronicKidneyDiseasemeanspermanentlossofrenalfunctionTherearemultiplecausesofbothtypesofkidneydiseaseChronicKidneyDiseaseaffectsmostsystemsandfunctionsinthebody肾脏病可以是急性的或是慢性的急性肾功能衰竭是可逆的慢性肾脏病将致肾功能永久性损害急慢性肾衰各自有不同的原因慢性肾脏疾患造成全身各系统改变和功能损害TreatmentoptionsforESRD

ESRD治疗PrMaxDratwaHôpitalBrugmannBrusselsTherapyoptionsofEndStageRenalDisease

终末期肾衰治疗ConservativeManagementHemo-dialysis,-diafiltration,-filtrationIn-center,LowcareandHomehemodialysisPeritonealDialysis-CAPD,APD(orCCPD),NIPD,OCPDTransplantationNoTreatment保守治疗血透、血滤、血液透滤中心血透、低护理血透和家庭血透腹透CAPD,APD(或CCPD),NIPD,OCPD肾移植不进行治疗Indicationsfordialysisinitiation

开始透析的指征GFR10-15ml/min/1.73m²UremicsymptomsMalnutritionGFR10-15ml/min/1.73m²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”！Indicationsfor‘emergency’dialysisinitiation

急诊透析的指征PericarditisHyperkaliemiaSevereacidosisLungoedemaIntractablehypertensionUremiccoma心包炎高钾血症严重酸中度肺水肿难治性高血压尿毒症昏迷DialysisProcess

透析替代作用WhatYourKidneysDo肾脏功能RemovesMetabolicWasteFluidBalanceElectrolyteBalanceAcidBaseBalanceHormoneProductionParathyroidHormoneErythropoietinVitaminDMetabolism清除代谢产物体液平衡电解质平衡酸碱平衡产生激素PTHEPO维生素DDialysisXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

肾脏本身功能XXXXXXXXXXDisadvantagesPhysicalupsanddownsVascularaccessUseofneedlesRiskofinfectionsDietaryrestrictionsTraveltoCenterHighcost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AdvantagesEffectivemethodtoremovewasteproductsPerformedbytrainedprofessionalsProvidessocializationforpatientsOnlyneeddialysis3timesperweek.Noequipmentinthehome (UnlessHomeHD)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)AdvantagesManageyourowncareathomeGreaterindependenceandcontrolFlexibletreatmentscheduleLessrestricteddietNoneedlesLessstressonbodyBloodpressurecontrolLowercost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DisadvantagesDialysiseverydayPermanentcatheterBodyimagechangesRiskofinfectionPossibleweightgainStoragespaceneededforsupplies.PeritonealDialysis

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病肾移植肾膀胱缩略词GFR：GlomerularFiltrationRate肾小球滤过率ESRD:EndStageRenalDisease终末期肾脏病CKD：ChronicKidneyDisease慢性肾脏病HD:Hemodialysis

血液透析PD:PeritonealDialysis腹膜透析CAPD:ContinuousAmbulatoryPD连续性不卧床腹膜透析APD:AutomatedPD自动化腹膜透析CCPD:ContinuousCyclicPD持续循环腹膜透析NIPD:NocturnalIntermittentPD夜间间歇性腹膜透析Goodpasture’s病：抗基底膜抗体肾小球肾炎HIV：艾滋病病毒CMV：巨细胞病毒HepatitisB&C乙肝或丙肝EPO：促红细胞生产素PTH：甲状旁腺素MMF:骁悉KDOQI:KidneyDiseaseOutcomeQualityInitiative

SuggestedReadingandReferenceMaterial

推荐阅读和参考文献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内容Whatisperitonealmembrane?PhysiologyofperitonealdialysisUremictoxinremovalFluidremovalSodiumRemovalPreparingandperformingPDPDprescriptionIndicationsandcontraindicationsofPDAPDComplicationsrelatedtoPDClinicaloutcomeofPDHowtoset-upPDcenter

什么是腹膜？

腹膜透析(peritonealdialysis,PD)的生理学尿毒症毒素的清除液体的清除钠的清除PD的准备和实施PD处方PD的适应症和禁忌症

自动化腹膜透析PD相关并发症PD的临床预后

怎样建立PD中心?Whatistheperitonealmembrane?

关于腹膜Theperitoneumistheserosalmembranethatcoverstheperitonealcavity.ThevisceralperitoneumTheparietalperitoneum腹膜是被覆于腹腔的光滑浆膜脏层腹膜壁层腹膜ThemesotheliumTheinterstitiumMacrophages/MonocytesPeritonealcapillariesPlaysimportantrolewaterandsoluteexchange间皮间质

巨噬细胞/单核细胞腹膜毛细血管

在水和溶质的转换起着重要作用Componentsoftheperitoneum腹膜的结构Roleoftheperitoneum

腹膜的功能ProtectperitonealorgansPreventfrictionofmovingorgansHostdefensemechanisms:Mesothelialcells,monocytesmacrophages,opsonins保护腹腔脏器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GoalofDialysis

透析目标Maintainssymptom-freebyreplacingsomeofthefunctionsperformedbythehealthykidneys.ToremovesuremictoxinsaccumulatedinthebloodWaterElectrolytesUrea,creatinine,phosphate,PTH,etc.H+通过替代正常肾脏的部分功能减轻肾衰时机体相关症状清除积聚在血液中的尿毒症毒素水分电解质尿素、肌酐、磷、甲状旁腺素等等氢离子Thetransportofsolutesandwateracrossa“membrane”thatseparatestwofluidcontainingcompartments.ThebloodintheperitonealcapillariesDialysissolutionintheperitonealcavity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循环腹腔中的透析液ABasicConceptofPeritonealDialysis腹透基本概念PERITONEALTISSUEBLOOD腹膜组织血液Membrane腹膜PERITONEALCAVITY

DIALYSATE腹腔透析液Membranemodel腹膜模型Removalofuremictoxins

尿毒症毒素清除

SmallsolutesDiffusion:

Convec