腹膜透析讲诉.ppt

1、Confidential Not for distribution腹 膜 透 析六安市中医院肾病二科 郑昌志Confidential Not for distribution终末期肾病治疗方式的选择血液透析腹膜透析 肾移植Confidential Not for distributionTransplantation移植Advantages Most like your own kidney No dialysis needed No access needed Normal Diet (-sodium) More “normal” life style优 点与自己的 肾脏 功能相似不需透析不

2、需要通路正常 饮 食（ 钠 ）生活方式更接近正常Disadvantage Risks of major surgery Risk of body rejecting kidney Possible side effects of drugs Lower resistance to illness Body image changes.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Patients KidneyTransplant Kidney(extra-peritoneally)Bladder病 肾移植 肾膀胱Confidential Not for distributionWh

3、o cannot donate a kidney?哪些人不可捐献肾？v HIV or AIDS-related infectionv Hepatitis B or C infectionv Major heart or breathing problemsv Diabetesv Extreme obesityv Significant kidney diseasev Most cancersv IV drug abusev Pregnancyv High BPv Having only one kidneyv Evidence of financial or non-financial coe

4、rcionv Inability to give informed consent/psychiatric disorders HIV 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Confidential Not for distributionIndications for dialysis initiation开始透析的指征v肾小球滤过率 10-15 ml /min /1.73mv尿毒症症状v尿毒症导致营养不良

5、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 ”！ GFR 10-15 ml /min /1.73m Uremic symptoms MalnutritionConfidential Not for distributionHemodialysis血液透析The process of separating chemical substances from blood through a semi-permeable membrane通 过 透析器半透膜从血液中分离化学物 质 的 过 程Confidential Not for distributionToxin Re

6、moval 清除毒素v Removal of toxins from the blood is accomplished by:v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-permeable Membrane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Confidential Not for distributionConcentration Gradient - Flow Geomet

7、ry 浓度梯度 - 液流动力影响Blood In血液入口Blood Out血液出口Dialysate In透析液入口Dialysate Out透析液出口Counter Flow 反向液流Confidential Not for distributionTemporary vs. Permanent临时通路或永久通路Temporary Accessv Used for a few hours to several weeksv Usually percutaneous insertion of a cannula into a large veinv Surgical implantation

8、of paired tubes into an artery and vein were used a number of years ago; fairly obsolete nowv For patients with acute renal failure, chronic renal failure without permanent access, peritoneal dialysis (PD) or transplant patients for temporary hemodialysisPermanentv For periods ranging from months to

9、 yearsv Options Sub-cutaneous anastomosis of artery to vein Sub-cutaneous positioning of a “tube” graft between an artery and vein Implantation of a cuffed dual-lumen catheter into a vein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

10、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Confidential Not for distributionComplications of Vascular Access血管通路相关并发症v Infectionv Thrombosis Early vs. late thrombosis“Thrombolysis vs. thrombectomy”v Hemodynamic complication Congestive heart failure: “High output cardia

11、c failure”v Vascular insufficiency or arterial stealv Venous hypertensionv Vascular access neuropathy“Carpal tunnel syndrome”v Aneurysms (true or pseudo) 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 (true or pseudo)“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。