肾透析医疗技术基础课件

肾透析医疗技术基础MedicalandTechnicalBasics

相关医学和技术基础29/09/2024肾透析医疗技术基础肾脏生理生成尿液，排除代谢终末产物、毒物和药物调节体内水、电解质、渗透压和酸碱平衡调节血压分泌肾素、促红细胞生成素、1,25-(OH)2D3、前列腺素等29/09/2024肾透析医疗技术基础血液透析的作用清除体内的毒素（弥散、对流、吸附）纠正酸碱平衡紊乱（弥散）清除体内过多的水份（超滤）纠正电解质失衡（弥散）29/09/2024肾透析医疗技术基础

Diffusion弥散Start开始时:Different

Concentrations膜两侧浓度有差别End结束时:Equal

Concentrations膜两侧浓度相同time弥散是微分子物质随机的运动可导致均匀分布的结果

Diffusionisaconsequenceoftherandommovement

ofallmolecules(BrownianMovement).29/09/2024肾透析医疗技术基础Ultrafiltration超滤TimePressureStart:End:Exertionofpressureononesideofthemembraneproducesfiltrationofwaterwithsolutes,aslongastheycanpassthemembrane.运用压力的作用将水份从膜一侧推到另一侧，膜孔够大时溶质也可以被挤出29/09/2024肾透析医疗技术基础dialysateside透析液侧bloodside血液侧Adsorption

吸附afterchemicaldisinfection?hollowfiverendotoxins内毒素-contactspace接触空间Virus病毒29/09/2024肾透析医疗技术基础H2OwatersolublemoleculesHFFmmHgmmHgBBHDBDBDHDFmmHgBmmHgDBDlow-flux低通透析器high-flux高通透析器high-flux高通透析器diffusionconvectionadsorptiondiffusion/convectionadsorptionTherapytypes治疗模式Hemodialysis血液透析Hemofiltration血液滤过Hemodiafiltration血液透析滤过弥散原理对流吸附弥散对流吸附29/09/2024肾透析医疗技术基础Hemodialysis血液透析利用血液和透析液中溶质的浓度差别使溶质在弥散作用下通过半透膜随透析液排出Diffusivemetabolictransportthroughsemi-permeablemembraneswithbalanceofaconcentrationdifferencebetweenbloodanddialysisfluid.

小分子物质可有效的被清除Smallmolecularsubstanceswillessentiallymoreeffective.diffusiveconvectiveadsorptiveclearanceBmmHgDBDhigh-fluxHemodialysis血液透析andHemofiltration血液透析滤过Hemofiltration血液透析滤过可溶物质随着通过高通透性半透膜的液体流动而被清除（对流）。对流依靠跨膜压和膜的物理性质（面积、密度、质量、孔径）来实现。

Solublesubstancesaresweptalonginafluidstreamthroughhighpermeablemembranes(convection).Theconvectiondependsonthetransmembranepressureandonmembranefeatureslikesize,density,andqualityofthepores(„cut-off-value“).清除高分子量物质（只要是低于膜孔的筛选值的物质）的有效方法Highmolecularesubstances,aslongastheyarebelowthe„cut-off-value“,willbeeliminatedinabetterway.

29/09/2024肾透析医疗技术基础HDF–Hemodiafiltration血液透析滤过结合两种治疗模式：血液透析和血液滤过结合由弥散产生的小分子物质的高清除率和由对流产生的中大分子物质的高清除率两种方式的优点。Combinationoftwodialysistechnics,hemodialysisandhemofiltration:highclearanceofconventionelsmallmoleculesbydiffusionlinkedwithhighclearanceofmiddlemoleculesbyconvection.mmHgBmmHgDBDDiffusion+Convection+Adsorptionhigh-flux高通滤器29/09/2024肾透析医疗技术基础ReplacementSolutionforHFandHDF置换液常规离子范围常用配方29/09/2024肾透析医疗技术基础RheaterheparinVVPVPAUFBLDSADPostdilution后稀释Predilution前稀释HDF-Online在线透析滤过–Medical医学29/09/2024肾透析医疗技术基础Clearance

inHD,HFandHDF各治疗模式的清除率0408012010102103104105Urea尿素氮Creatinine肌酐Vit.B12ß2-Microglob.AlbumineClearance清除率ml/minMGDalton道尔顿（质量单位）HFHDHDFKidney肾脏29/09/2024肾透析医疗技术基础SemipermeableMembrane半透膜Virus病毒Bacteria细菌Mediumsized

molecules,e.g.

b2-MicroglobulinWaterflowis

easilypossible水最容易通过Erythrocyte,

redbloodcell红血球Albumin,as

exampleofabig

proteinmolecule白蛋白等大蛋白分子Electrolytes电解质Thesemipermeablemembranefunctionssimilartoafinesieve,

onlymoleculesthataresmallenoughcanpass.半透膜就是性能良好的筛网，仅有小于筛孔的物质可以通过29/09/2024肾透析医疗技术基础PressureDroponDialyser-LowFlux透析器内的压力分布示意图200250300350400bloodsidepressuredropdialysatesidepressuredropfiltration=netUF净超滤450PBEPVPDAUltrafiltration超滤作用mediumTMPpressureinthefilter29/09/2024肾透析医疗技术基础AdvantagesoftheDialogBalanceChamberControlDialog机器的改良的容量平衡控制系统的优点permanentmonitoringofthemembraneposition持续监测平衡腔膜片位置

continuouscontrol连续控制nopressurespikesatthedialyser透析器内没有压力尖峰

smoothUFandpreventionofreverseUFintheswitching moment超滤平稳并且避免了液流切换时产生反超continuousdialysateflowevenintheswitchingmoment

透析液持续不断（包括液流切换时刻）

bettertherapyresults(K*t/V)bymaintainingthediffussion pressure维持住弥散压力可带来更好的治疗效果(K*t/V值)protectionofthemembranematerial,valvesandpumps

对膜片、阀门和泵都有保护作用。

extendedlifetime延长配件寿命Dialog+competitor29/09/2024肾透析医疗技术基础

TheAccessPoints-onPatient

病人血管通路CiminoFistulaV.jugularisinternaV.subclaviaV.cubitalisV.femoralisThebloodflowinthefistulamustbeatleastthedoubledfromtherequiredbloodflowattherapytominimizetherecirculation.29/09/2024肾透析医疗技术基础TheSievingCoefficientoftheDialyser透析器的筛选系数Albumine69000DaUrea60DaCreatinin113DaPhosphat96DaVitaminB121355DaInulin5200Da

ß2-Microglobuline

Membranepores

0,003µmErythozyt8,5*2µm29/09/2024肾透析医疗技术基础UFFactor–SubstanceTransportFactor超滤系数

Diacap®HE1400-factor7,47,4ml/hpermmHgPressuredifference300mmHg*7,4ml/h/mmHg=2220ml/h200mmHg-100mmHgTMP300mmHgfactor7,4Cuprophan®CE2000factor8,6transportUF1500perhourvenouspressure220mmHgTMP=PDA=1500:8,6=174,4mmHgTMP-PV=-45,6mmHgvenouspressurePDAcalculationofUFremovalpressurecalculationmemorize:thefactorofthefiltercaneveninonechargedupto±15%changed.29/09/2024肾透析医疗技术基础DialyserTypes透析器类型Syntheticmembrane

Cellulosemembrane

modifiedcelluloseregeneratedcellulose

Polysulfone(PSU)Polyamide(PA)Polycarbonate(PC)

Ethyl-vinyl-alcoholcopolymer(EVAL)

Polyacrylonitrile(PAN)

Polymethylmethacrylate(PMMA)High-fluxandLow-flux Low-fluxSyntheticmodifiedcellulose(SMC)Celluloseacetate(CA)Cellulosediacetate(CDA)

Cellulosetriacetate(CTA)Hemophan(HE)Cuprophan(CU)Cuprammonium29/09/2024肾透析医疗技术基础DialyserTypeshighbiocompatiblebutmoreheparinnecessaryhighclearanceatmiddlemolecularsubstancesmoreeffectiveon

smallmolecularsubstancesmembranewithhighadsorptioneffectDiacap®PolysulfoneDiacap®

SMCSyntheticmodifiedCelluloseexcellentbalancedbiocompatibleprofile

29/09/2024肾透析医疗技术基础10²10³104105106107108ExotoxicfragmentsExotoxicsMuramylpeptidPeptidoglykaneEndotoxicfragmentsLipidAEndotoxicsVirusBacteriaverificationCISCISCISCISCISLALLALCut-OffPointofDialyserMolecularweight/Daltonlowfluxhighflux29/09/2024肾透析医疗技术基础MicrobiologicRequest微生物要求AAMI=AmericanAssociationfortheAdvancementofMedicalInstrumentationPh.Eur.=EuropäischePharmacopoeiaCFU=ColonyFormingUnitsEU=EndotoxinUnits29/09/2024肾透析医疗技术基础QualityofWaterandDialysate反渗水和透析液水质Theusermustensurethatthewaterqualityiscontinuousmonitored.Thefollowingrequirementsmustbefulfilled:•TheincomingwatermustbefreefromMg++andCa++.•pHvalueofbetween5and7Wateranddialysatemustcomplywiththecountryspecificstandards,i.e.:•ISO13959:2002Waterforhemodialysisandrelatedtherapies•DINVDE0753-4,issue:1986-09Applicationregulationsforhemodialysismachines•ANSI/AAMIRD5-03Hemodialysissystems•ANSI/AAMIRD61:2001Concentratesforhemodialysis•ANSI/AAMIRD62:2001Watertreatmentequipmentforhemodialysisapplications29/09/2024肾透析医疗技术基础QualityofWaterandDialysateFluid反渗水和透析液水质29/09/2024肾透析医疗技术基础ContextpHValue,HCO3-andpCO2Normalvalueonblood pH 7,36–7,45 pCO2 33–45mmHg HCO3- 21–26mmol/LIncreasingordropthepHvalueintheblood,overorunderacriticalvalueisnonphysological.Consequenceslikeheadaches,cramps,hypotension,hypertensionoratotalcollapseofthebloodcircuitarepossible.pHvalue>7.45alkalosespHvalue<7.36acidosisThenormalvalueforpCO2isbetween33-45mmHg,i.e.,thepCO2increase(alkaloses)-automaticallythepatientstartsahypervitalisation.ThepatientstartsCO2

dismantleasacontrareaction.29/09/2024肾透析医疗技术基础ContextpHValue,HCO3-andpCO2H++HCO3-↔H2CO3↔H2O+CO2hydrogen–bicarbonate–carbondioxide-buffersystempCO2(mmHg)HCO3-(mmol/LpH7,450403530242016121098712141620253040506070pH7,3AzidosepH7,5Alkalosestandardrange

H+=24________pCO2

HCO3-

29/09/2024肾透析医疗技术基础BicarbonateTherapy碳酸盐治疗–Technical技术方面

ImportantforthefactorspecificationorrechecktackthesamplecarefullyonlyonthebluecouplingwithasyringeasecurespecificationonlywithtitrationpossiblePHvaluerecheckmeasurementinstrumentondialysatemodus.SchalterSendeelektrodenVerstärkerGleichrichterTiefpaß+5VoltRef.4kHzLFSignalEmpfangselktrodeconductivitycell29/09/2024肾透析医疗技术基础BicarbonateTherapy–CalcificationNormalvalueinblood24mmol/L(attheendoftherapy26-28mmol/L).Thedirectmeasurementofthebicarbonateisnotpossible,wemeasureonlythesodiumonthebiccell.Normallytheproportionis1:1.Thegrainsofthepowder(2Na+HCO³-)inthecartridgearecoatedwithcarbonate.Thiscoatingisdissolvedfirst,thepHincreasesandtheunitcangetcalcified.Followup:proportionisnotmore1:1strongercalcification(frompH>7,5critical)pHmovementondialysate,bloodandbuddyfluidblockofdialysatefiltercoatingonconductivitycells(ratioalarm,sodiumnotcorrect)bloodleakalarm29/09/2024肾透析医疗技术基础BicarbonateTherapy–MedicalAcetatemustbemetabolizedintheliverandkidneyfirsttobicarbonate,sothattheacid/basebalance(pHvalue)iscorrected.Duetothedelayintheconversionthepatientcanbecomeacidotic.Thiscanleadtocramps,hypotensionandvomitingofthepatient.Thisisevenworseifthepatienthasaliverdysfunction.Todayismostlyonlybicarbonateused.WiththattreatmentthepHvalueismorestable.Thepatientfeelsbetterandhisbodyisnotsoheavilyused.Thefluidtransportandexchangeofionsstartdirectlyafterthestartofthetherapy.Normalvalueinblood:24-28mmol/L29/09/2024肾透析医疗技术基础AtomsBasicnucleus

protonelectronelectronelectronnucleus

proton/neutronhydrogenhelium29/09/2024肾透析医疗技术基础ElectrolytesandIonsH2

O

Na+Cl-

Na+Cl-dissolvertDefinition Electrolytesaresubstanceswheretheelectricalcurrent isguidedviaions

Definition

Ionsareatomswithelectronabsence(cations)

orelectronexcess(anions)

Forinstance NaCldissociateinwater inNa+cationsandCl-anions29/09/2024肾透析医疗技术基础Conductivity电导率Theconductivityisbasedonelectrolytesandtemperature.ThephysicalunitismS/cm(milleSiemenspercm).

ThisisanAmericannotationfortheelectricalresistanceandthisisareciprocalvaluetoEuropewithOhm(

).

Cl-

Na+currentquellcurrentmeasurementmS/cmMinuspole负极Pluspole正极29/09/2024肾透析医疗技术基础CellconstantsoftheConductivityCell电导度传感器的传感器系数Thecellconstantsarechangingdifferencewiththecoating传感器敏感系数会随附着层增加而变化82,5=3,2165,5=2,9183=2,666166=2,666cellconstants传感器系数

Distance距离diameter直径distanceholderflowdirection透析液流向referenceelectrodetransmitter-electrodereceiver-electrodemeasurementcell2measurementcell10,5mmcoatingtransmitter-electrode=29/09/2024肾透析医疗技术基础QualityofWaterandDialysateFluid

水质与透析液0,5mmcoating附着层MagnesiumCarbonate碳酸镁CalciumCarbonate

碳酸钙Thecellconstantsarechangingdifferencewiththecoating传感器敏感系数会随附着层增加而变化Damagetothemachineduetocalciumdepositionsduringbicarbonatedialysis!钙质沉淀物将会损坏机器！Decalcifythemachineaftereachbicarbonatedialysis.每次碳酸盐透析治疗后都需要脱钙Warning29/09/2024肾透析医疗技术基础ReasonsforCalcification生成沉淀的原因2Na+HCO-3

Na2CO3+H2O+CO2bicarbonatesoda+water+carbondioxideNa2CO3+MgCl2MgCO3+2NaClmagnesiumcarbonateNa2CO3+CaCl2CaCO3+2NaClandcalciumcarbonate-frequently(often,chemicalresolvable)2Na2CO3+CaCl2+MgCl2CaMg(CO3)2+4NaClmarble(seldom,andnoteasydissolvable)Thecalciumandmagnesiumoftheacidconcentratereactchemicallywiththecarbonateandprecipitatestonon-dissolvableMgCO3+CACO3.沉淀物质是A液中的钙镁离子和B液中的碳酸根离子产生的碳酸钙和碳酸镁29/09/2024肾透析医疗技术基础AccommodationSystemfortwoMachinesmainsupplycentralacidconnectorsinletconnectoroutletconnectorwithfreefallgrounding29/09/2024肾透析医疗技术基础IonExchanger-Softener离子交换罐—软化29/09/2024肾透析医疗技术基础microbiologicdebitofthepermeatecircuitwaternetreverseosmo