1、血液透析介紹,新光醫院 腎臟科方昱偉,腎臟功能,全年無休24小時工作Filtration and reabsorption function: 把身體裡過多的水份、電解質及新陳代謝後的廢物，經由尿液排出身體外Endocrine and metabolism function: 分泌腎素、紅血球生成素及活性維生素D3的功能,Renal Replacement Therapy,Renal Replacement Therapy,透析俗稱洗腎HD (hemodialysis)血液透析PD (peritoneal dialysis)腹膜透析Kid/Trans (kidney transplantati
2、on)腎臟移植,優缺點,衛生署 CKD 照護計畫,半年追蹤一次,半年追蹤一次,三個月追蹤一次,三個月追蹤一次,二至四週追蹤一次,Estimated GFR (I),Ccr: overestimates GFR (proximal tubular secretion in advanced RF)Curea: underestimates GFR (urea is reabsorbed in the distal nephron)When measurement of GFR by a direct test is not available, the average of the sum of
3、 the creatinine and urea clearance is recommended.Ccr (ml/min)= Ucr X V (24-hr urine, ml) - Pcr X 1440 (min),Estimated GFR (II),Cockcroft-Gault equationIn men:Ccr= (140- Age) X Body weight in kg - 72 X serum CreatinineIn women: men Ccr X 0.85,In Taiwan 中央健康保險局,一、長期透析適應症：（請勾選） （一）絕對適應症：肌酐酸廓清率 Ccr 100
4、 mg/dl) 10.其他 （請說明）：,Preparation for dialytic treatment,Explain the timing of complete renal failure and provide forms of available therapy 提早準備 HD: create an AV fistula in advancePD: implantation of peritoneal catheter減少尿毒所引發不適的症狀與徴後及合併症減少雙腔導管放置時的危險。,Principles of Hemodialysis,透析用血管通路,Blood flow of
5、 200 to 400 ml/min are necessaryBlood from veins is inadequate & repeated puncture of a large artery is not feasible暫時性 vascular access (by Nep Dr.)femoral, int. jugular vein, subclavian veinA double lumen catheter: temporary or semipermanent with cuffs永久性 vascular access (by CVS Dr.)A fistula is cr
6、eated (surgically anastamosing a superficial artery and nearby vein)A prosthetic graft (PTFE: polytetrafluoroethylene), if a native vein is not available because of vessel fibrosis and atrophy (due to prior needling, phlebitis, or other injury),Standard of A-V Fistula,arterialization of the vein,Mec
7、hanism of HD,Diffusion (擴散)bi-directionally across a semipermeable membrane與濃度差、膜表面積大小、膜之擴散係數有關 Ultrafiltration (超過濾)因幫浦推動而產生壓力，另外透析液流動製造出負的壓力Convection (對流): solvent dragAbsorption (吸附): some of the dialyzers,透析用水水處理,積層過濾器軟水器活性碳過濾器逆滲透機 (reverse osmosis) 5及0.2Microfilter紫外線定期水處理機器維修定期透析用水水質檢驗及細菌培養,W
8、ater source,Multi-media filter,Cartridge filter 5 mm,Dialyzer (hollow fiber),Membrane material is spun into fine capillaries, thousands of which are packed into bundles with blood flowing through capillaries while dialysate is circulated on the outside of the fiber bundle.,Types of Artificial Kidney
9、 (1),Adequacy of HD,Measure the delivered dose of dialysisBy use of a pre- and post-dialysis urea sampleUrea reduction ratio (URR) or KT/V (K = clearance,T = dialysis time, & V = volume of distribution of the patient)A URR of 65% and a KT/V of 1.2 per treatment are minimal standards for adequacyLowe
10、r levels of dialysis treatment are associated with increased morbidity and mortality,Complications of vascular access,Intimal hyperplasiastenosis thrombosisInfection (Staphylococcus aureus)Aneurysm formation, particularly in the prosthetic graft,Critical Care Nephrology-continuous renal replacement therapy,
