HowPDWorksCH腹透原理课件.ppt

1、How PD works 2腹透原理 2Min Sun PARK, M.D., Ph. D.,Medical DirectorBaxter Asia Renal,Contents of talk 内容,What is peritoneal membrane ?Physiology of peritoneal dialysisUremic toxin removalFluid removalSodium removalPD prescriptionAdequacyMembrane transport: PETIndications and contraindications of PDPrepa

2、ring and performing PDAPDComplications related to PDClinical outcome of PDHow to set-up PD center,什么是腹膜？腹膜透析(peritoneal dialysis, PD)的生理学尿毒症毒素的清除液体的清除钠的清除腹膜透析处方充分性膜转运：腹膜平衡试验(PET)腹膜透析的适应症和禁忌症腹膜透析的准备和实施自动腹膜透析（automatic peritoneal dialysis, APD)PD相关并发症PD的临床预后怎样建立PD中心?,Goal of Dialysis 透析目标,Maintains sy

3、mptom-free by replacing some of the functions performed by the healthy kidneys.To removes uremic toxins accumulated in the bloodWaterElectrolytesUrea, creatinine, phosphate, PTH, etc.H+Minimizes mortality and morbidityPrevents short- and long-term complications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

4、分电解质尿素、肌酐、磷、甲状旁腺激素等等氢离子发病率和死亡率最低化预防短期、长期并发症,What is “adequate” treatment? 何谓“充分的”治疗,Avoidance of fluid overload + Blood pressure control+ Preservation of residual renal function+ Well nourished+ Phosphorus control+ Acid-base balance + Correction of anaemia+ Sufficient removal of uremic toxins - abse

5、nce of uremic symptoms+ MDt/P - physician time per patient,Ram Gokal 2002,避免水负荷血压良好控制保护残存肾功能营养良好控制血磷酸碱平衡纠正贫血清除足够的尿毒症毒素没有尿毒症相关症状医生治疗每个病人的时间,医生对每个病人的治疗所付出的时间直接关系到病人的治疗质量，这是目前国际上公认的概念,How to achieve it ? 如何达到治疗目标？,Sufficient fluid and toxin removal: dose of dialysisIt depends onResidual renal functionB

6、ody sizeCo-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,How to measure toxin removal ?如何评估毒素清除情况？,Surrogate markers of uremiaCreatinineUreaNumeric measurement of uremic toxin removalRemoval of urea and creatinine Normalizing factor: Body sizeTotal removal=Peritoneal + Renal,尿毒症的“应用”指标肌酐尿素尿毒症毒素清除

7、的量化评估尿素和肌酐的清除标化因素：体形大小总的清除率=腹透清除肾脏清除,Calculation of peritoneal clearance腹透清除率计算,Calculation of renal creatinine clearance for 24 hours:Total urinary creatinine removal divided by serum creatinine levelU/Pcreatinine x urine volumeStandardized by body surface areaCalculation of peritoneal clearance (U

8、rea/Creatinine) for 24 hoursTotal peritoneal removal divided by serum levelD/P x total dialysate volumeStandardized by body surface area (creatinine)-Peritoneal creatinine clearanceStandardized by body water content (urea): Kt/Vurea,计算24小时肾脏内生肌酐清除率:尿中肌酐清除总量除以血清肌酐值尿肌酐/血肌酐(U/P)尿量 按体表面积标化计算腹透24小时尿素/肌酐清

9、除率腹透清除总量除以血清浓度腹透液浓度/血清浓度(D/P) 腹透液总量按体表面积标化(肌酐)腹透肌酐清除率按体内水分量标化(尿素)： Kt/Vurea,Kt/V计算：总Kt/V=残肾Kt/V+腹膜Kt/V 残肾Kt/V=腹膜Kt/V=,肌酐清除率(Ccr)计算：总Ccr = 残肾Ccr+腹膜Ccr残肾Ccr(L/周)=腹膜Ccr (L/周) = 体表面积校正的Ccr （L/周/1.73m2）=,Important factors determining peritoneal clearance决定腹膜清除率的重要因素,Dialysate to plasma concentration rati

10、o (D/P) : Peritoneal transport characteristics DiffusionConvection : Mainly depends on ultrafiltrationDialysate volumeTotal infusion volumeUltrafiltration volumePeritoneal absorptionBody size,腹透液和血浆浓度比值(D/P)：腹膜转运特点弥散 对流：主要依赖超滤透析液量总灌入量超滤量腹膜吸收量体形大小,Survival was better with higher Kt/Vurea and CCr 较高的K

11、t/V urea 和CCr伴随较高的生存率Maiorca et al., ND 12:2158-62Survival in uremia patients can be as good as in patients with RRF 有残余肾功能的尿毒症病人生存率较高 Szeto C et al. J Am Soc Nephrol 12: 355 360, 2001,Recent Kt/V & Outcome Data新近关于Kt/V和预后的观察,Fluid and Sodium Removal vs Outcome水钠清除与预后的比较,Effect of fluid remova水清除的影响

12、l,Effect of sodium removal钠清除的影响,Ates et al., Kidney Int 60:767-776, 2001,Sodium and fluid removal, hypertension, creatinine and RRF were independent predictors of survival钠及水分的清除、高血压、肌酐以及残余肾功能是生存率的独立预测因子,232 mmols96% 181-231 mmols89% 130-180 mmols73% 130 mmols60%,Relevance of Fluid RemovalIndepende

13、nt Predictor of Survival水分清除的相关性生存率的独立预测因子,Ates et al. Kidney Int 2001;60:767-776,Fluid removal associated with lower mortality risks by both univariate and multivariate analyses无论单因素或多因素分析中，水分清除都与较低的死亡风险相关,*Urine output.尿量,EAPOS Patient Survival by Baseline UF基线超滤值与患者的存活情况,Brown, et al. J Am Soc Ne

14、phrol. 2003;14:2948-2957.,Total Small Solute Clearance? 小分子溶质总清除率？,Probability of survival 生存率,Range of solute clearancein previous studies以往研究中溶质清除率变化范围,Outcome more influenced by other variables; BP, phosphorous, volume, middle molecule, chronic inflammation?预后受其他的一些变量如:血压、血磷、容量负荷、中分子物质及慢性炎症等的影响更多

15、,Newer Technologies ?新技术？,Minimal Target: 1.7 ?最低目标,Burkart ARRT 2000,Small solute clearance and outcome小分子溶质的清除与预后,Determination of Peritoneal Membrane Characteristics腹膜转运特性,Water transportNet ultrafiltration volume: Transcapillary UF-Peritoneal absorptionSolute transportDiffusion + Convective tran

16、sport-Peritoneal absorption水转运净超滤量：跨毛细血管的超滤量腹膜吸收量溶质转运弥散对流转运腹膜吸收,Methods to evaluate peritoneal membrane function腹膜功能评估方法,Parameters used in researchMass transport area coefficient (MTAC)Diffusive transport coefficient (KBD)Parameters commonly used in clinicPeritoneal equilibration test (PET)D/P crea

17、tinine, D/D0 glucose, Ultrafiltration volumePeritoneal clearance: D/P ratio x UF volume/unit time= ml/minD/P sodium at 2 hours of dwellPET, Clearance and D/Psodium can be affected by residual volume of dialysate after drainage.,研究中应用的参数溶质转运面积系数 (Mass transport area coefficient ,MTAC)弥散转运系数 (KBD)临床常用

18、的参数腹膜平衡试验 (Peritoneal equilibration test ,PET)透析液肌酐浓度/血浆肌酐D/P ,葡萄糖浓度透析液/血浆( D/D0),超滤量腹膜清除率：D/P超滤量ml/时间min= ml/min留腹2小时的透析液钠浓度/血浆钠浓度 (D/P)腹膜平衡试验、清除率及钠浓度透析液/血浆可以受到引流腹透液后残余在腹腔内透析液的量的影响.,What is PET?,Based on equilibration of solute concentration in dialysate to plasma and peritoneal glucose absorption.

19、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 abso

20、rbs 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 Differen

21、t 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%

22、 dextrose solution2. Weigh 2-L bag of warmed 2.5% dextrose solution3. 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

23、葡萄糖腹透液留腹过夜812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 hourDialysate sample:200 ml of dialysis solution is drained into the bag, mixed well, a 10 ml sample is taken,

24、and the remaining 190 ml is reinfused backafter 2 and 4 hours, another sample is taken.Calculate D/P creatitine at 2 and 4 hours D/D0 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/

25、血浆(D/D0 ) 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

26、.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 calculatedPatients are classified on basis of 4 hr D/P Cr as low, low average, high aver

27、age or high transportersIn general, high transporters dialyze well, but absorb Glu rapidly, have less UF, greater dialysate protein losses and lower serum albuminLow 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(

28、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,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

29、) 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 DiffusionConvective transport : Mainly depends on ultrafiltrationDialysate volume

30、Total infusion volumeUltrafiltration volumePeritoneal absorptionBody 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,Empiric prescription经验处方,3-5 exchanges of 2 L dialysis bagConsidering mainly fluid balance2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 m

31、inimum 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,Contents of talk 内容,What is peritoneal membrane ?Physiology of peritoneal dialysisUremic toxin removalFluid removalPD prescriptionAdequacyMembrane transport: PETIndications and contraindications of PD Prepar

32、ing and performing PDAPDComplications related to PDClinical outcome of PDHow to set-up PD center,什么是腹膜？腹膜透析(peritoneal dialysis, PD)的生理学尿毒症毒素的清除液体的清除钠的清除腹膜透析处方充分性膜转运：腹膜平衡试验(PET)腹膜透析的适应症和禁忌症腹膜透析的准备和实施自动化腹膜透析（automatic peritoneal dialysis, APD)PD相关并发症PD的临床预后怎样建立PD中心?,腹膜透析适应症大部分病人都适合做腹膜透析164病人既可以腹透也可以血

33、透2,中国维持性腹膜透析专家共识Jagar KJ et, AJKD2004,Strong medical indication for PD腹膜透析绝对适应症,Difficulties with vascular accessLeft ventricular hypertrophyCongestive heart failureProsthetic vascular diseaseIntolerance of HDFrequent episodes of hypotensionHeadache and asthenia after HD sessionChildren,血管通路建立困难左心室肥

34、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

35、(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 diseaseScleroderma, other conective tissue diseases (e.g. SLE)Patien

36、ts 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 sizeDiverticulosis / diverticulitisSevere backacheNIPDHerniasNIPDMultiple abdominal surgeryPoor manual dexte

37、rityBlindnessNo 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 LifeFrequent travelsTendency towards PD Great need of independence by the patient Need to maintain workDistance to the HD center,优先选腹透独立

38、生活经常旅行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,Preparation for PD 腹透的准备,Pre-dialysis counselingPeritoneal dialysis equipments and accessoriesPeritoneal catheter insertionBreak-in periodDialysis procedures透前咨询腹透装备及配套品准备埋置腹透导管导管修整期透析培训,Pre-dialysis counseling透析前的咨询,Motivation, compliance and home environment are

39、 important factors for the success of the therapy, as PD is home based self treatment.The better understanding of ESRD and dialysis therapy, the better motivation and compliance.Can be done by nephrologist , dialysis counselor or Baxter coordinator 腹透是以家庭自我治疗为主透析方式，所以患者的动力，依从性及家庭环境是治疗能否获得成功至关重要的因素.对

40、ESRD和透析的理解越好，患者的动力及依从性越好.可以由肾病专科医师，透析顾问或百特公司协作者进行.,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 sitePermanent bend between 2 cuffs (180)Right or lef

41、t,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-popovichCatheter,Pediatric,Presternal,T-Fluted,Di PoaloSelf locating,Accessories: Titanium adaptor 配

42、件：钛接头,Secure SealLocking sleeve provides a snug compression fit.Longer Tail and dual reverse barbs mean better catheter grip.Patented double locking seal increases security of transfer set connection.Reduced Peritonitis RiskSeamless machining avoids rough surfaces that can tear catheters and catch d

43、ebris.Titanium, with twice the strength of steel and only half the weight, will not crack like plastic.安全密封连接套管保证紧密的压缩接合.加长的尾部及双道反向的沟槽使得连接更紧.专利的双连接密封技术增加了体外传输装置连接时的安全性.减少腹膜炎的风险无缝加工技术避免了因粗糙表面划割导管或粘粘碎屑.钛金属，硬度是钢的两倍而质量是其一半，不会象塑料那样容易破裂.,Nursing Convenience The locking sleeve grips a wider range of cathet

44、er sizes.Titanium stands up to disinfectants and resists corrosion.Patient ComfortHighly polished bullet shape feels smooth against the skin.Superior machining minimizes size and weight.护理方便连接套管可以紧连各种规格导管.钛金属可抗菌及抗腐蚀.患者舒适高度磨光的子弹型的外表对皮肤而言很平滑.精细加工使其最轻最小.,PD Catheter implantation 腹透置管术,Peritoneal Cathet

45、er 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

46、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,Seminar Dial 2005 18: 157-60,Break-in period 导管修整期,To allow a sufficient time to heal sur

47、gical wound (exit site): 2-4 weeksAseptic dressing with minimum opening is recommendedImmobilization is importantTemporary HD should be considered in this period in patients with advanced kidney failureSome 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

48、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 proceduresInfusionDwell time (variable)Drainage of dialysis solution (effluent)Volume describes the amount of dialysis solution used in each exchangeDose depicts the amount of solution used over a specified time periodIntermittent 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,