透析方式醫(yī)學(xué)課件

1、血液透析治療模式血液透析治療模式的選擇和評價(jià)的選擇和評價(jià)基本原理基本原理溶質(zhì)清除機(jī)制溶質(zhì)清除機(jī)制彌散彌散diffusion 溶質(zhì)濃度梯度溶質(zhì)濃度梯度成正比成正比 溶質(zhì)分子大小溶質(zhì)分子大小成反比成反比 對流對流convectconvection 隨溶劑的跨膜運(yùn)動(dòng)而轉(zhuǎn)運(yùn)隨溶劑的跨膜運(yùn)動(dòng)而轉(zhuǎn)運(yùn) 溶質(zhì)分子大小成反比溶質(zhì)分子大小成反比 超濾率及篩選系數(shù)決定轉(zhuǎn)運(yùn)速率超濾率及篩選系數(shù)決定轉(zhuǎn)運(yùn)速率 吸附吸附absorption水份清除機(jī)制水份清除機(jī)制超濾系數(shù)超濾系數(shù)Kuf跨膜壓跨膜壓(TMP)(TMP) Water permeability Solute permeability Biocompatibili

2、ty Material/Polymer Regenerated cellulose Modified cellulose Synthetic Low- fluxKuf 15 ml/mmHghr For small solute KoA e.g. BUNScrUA For larger solute SC e.g. 2-MG Qualitative measures1970s was on enhancing the solute diffusive and water removing properties of the membranes1980s the emphasis has been

3、 on convective transport, absorption, and biocompatibilityEFFICIENCYBIOCOMPATIBILITY ConvectionDiffusionDiffusion+ConvectionModified CelluloseCelluloseSynthetic(Relationship between membranes,technologies,efficiency and biocompatibility)continuous ambulatory peritoneal dialysis (CAPD)continuous cycl

4、ical peritoneal dialysis (CCPD)slow continuous ultrafiltration (SCUF)continuous arterio-venous hemofiltration (CAVH)continuous arterio-venous hemodialysis (CAVHD)continuous arterio-venous hemodiafiltration (CAVHDF)continuous vono-venous hemofiltration (CVVH)continuous vono-venous hemodialysis (CVVHD

5、)continuous veno-venous high-flux dialysis (CVVHFD)continuous vono-venous hemodiafiltration (CVVHDF)continuousintermittentintermittent peritoneal dialysis (IPD)hemoperfusion (HP)hemoconcentrationplasmapheresishemodialysis (HD)hemofiltration (HF)hemodiafiltration (HDF) 水分迅速減少水分迅速減少 組織器官血供障礙組織器官血供障礙 血

6、漿滲量驟然下降血漿滲量驟然下降 血壓不平穩(wěn)或誘發(fā)肺水腫血壓不平穩(wěn)或誘發(fā)肺水腫 生理代償機(jī)制生理代償機(jī)制 加重或誘發(fā)心衰加重或誘發(fā)心衰 血血/膜反應(yīng)膜反應(yīng) SIRS IRRTIRRT對血流動(dòng)力學(xué)影響對血流動(dòng)力學(xué)影響CRRT與IRRT比較 改善心血管穩(wěn)定性改善心血管穩(wěn)定性 維持腦灌注維持腦灌注 控制高分解代謝控制高分解代謝 維持水電解質(zhì)和酸堿平衡維持水電解質(zhì)和酸堿平衡 為營養(yǎng)支持創(chuàng)造條件為營養(yǎng)支持創(chuàng)造條件 重癥重癥ARF已首選已首選CRRTH2Owater soluble moleculesBBDBDmmHgBBF,Dlow-fluxFilterhigh-flux or FiltermmHgBmm

7、HgmmHgFDmmHgmmHgTelTel：8542234185422341 85422339854223399、 人的價(jià)值，在招收誘惑的一瞬間被決定。2022-3-172022-3-17Thursday, March 17, 202210、低頭要有勇氣，抬頭要有低氣。2022-3-172022-3-172022-3-173/17/2022 8:38:22 AM11、人總是珍惜為得到。2022-3-172022-3-172022-3-17Mar-2217-Mar-2212、人亂于心，不寬余請。2022-3-172022-3-172022-3-17Thursday, March 17, 202

8、213、生氣是拿別人做錯(cuò)的事來懲罰自己。2022-3-172022-3-172022-3-172022-3-173/17/202214、抱最大的希望，作最大的努力。2022年3月17日星期四2022-3-172022-3-172022-3-1715、一個(gè)人炫耀什么，說明他內(nèi)心缺少什么。2022年3月2022-3-172022-3-172022-3-173/17/202216、業(yè)余生活要有意義，不要越軌。2022-3-172022-3-17March 17, 202217、一個(gè)人即使已登上頂峰，也仍要自強(qiáng)不息。2022-3-172022-3-172022-3-172022-3-17HFHDHDF

9、Kidney1042-MGC3a、C5aIT-1TNFVit. B12LipidABunCrUAclearance ml/min12080400 10 103 102 0MWDa105AlbLpsMethodologiesPatientMaterials“Ancillary”therapyCost？heparinAVPVPA評價(jià)評價(jià) good elimination of middle and large molecules good filtration complex machinery expensive fluid balance complicated 特點(diǎn)特點(diǎn) 高通量透析器或?yàn)V過器

10、高通量透析器或?yàn)V過器 對流清除為主對流清除為主 QB =250 ml/min Qi =250 ml/min QD =500 ml/min 不需要置換液不需要置換液 評價(jià)評價(jià) elimination of a wide molecular range simpler and cheaper fresh and purity dialysate fluid balance complicated systemic inflammatory response RheaterheparinVVPVPADUFDBLDSADhigh-flux特點(diǎn)特點(diǎn) 高通量透析器高通量透析器 對流對流+彌散清除為主彌散清

11、除為主 QB =250 ml/min QD .= 500 ml/min Qi 1長長固定固定高高無需無需低低小小抗抗 Xa:IIa 活性比值活性比值血漿半衰期血漿半衰期清除率清除率生物利用度生物利用度需需 aPTT 監(jiān)測監(jiān)測對對 PF4 的敏感性的敏感性對血小板抑制作用對血小板抑制作用普通肝素普通肝素=1短短不固定不固定低低需要需要高高大大 低分子肝素對血透中的影響低分子肝素對血透中的影響I nterm i ttent1. Hypotensi on2. Arrhythm i a3. Hem ol ysi s4. M uscl e Cram ps5. Ai r Em bol i sm6. Dys

12、equi l i bri um Syndrom7. Fl ui d Lung8. Hyperkal i em i a9. Hypertensi onConti nuous1. Fl ui d Bal ance Error2. Fi l ter Cl otti ng3. Low Tem perature4. Access Probl em s5. Coagul ati on Probl em s6. Hypotensi on7. I nfecti on/Sepsi s8. Ai r Em bol i sm9. Di sconnecti onVCKd+KrCG堆積產(chǎn)生清除堆積產(chǎn)生清除攝入攝入產(chǎn)生產(chǎn)

13、生堆積堆積分布分布其中: G -尿素產(chǎn)生的速率 V -體內(nèi)尿素的分布容積 C -血液尿素的濃度 Kd -透析器的廓清率 Kr -殘存腎功能的廓清率 清除清除PCRnPCRBUNKt/ VURR80 60 40 20 0120100SUN MON TUE WEN TUE FRI SAT SUN/dLnPCRKtV TACDelivered: 3 times/ week Td4hrs U.F. 0.05WtTarge:Kt/ V1.2 nPCR1.1g/day TAC50/dLSurvivalMorbidityNutritional StatusMetabolic AlterationsHospi

14、talization Time MemberaneMemberane SubstitutionSubstitution Sub./Dia. FlowSub./Dia. Flow Blood FlowBlood Flow HDHD Low-Flux Lac./Bic. as Dialysate Dia. 500 ml/min 200-300 ml/min H HF FD D High-Flux Bic. as Dialysate Dia. 500-800 ml/min 250ml/min HFHF High-Flux or Filter Bic. Sub. 5000 ml/h 250ml/min

15、 HDFHDF High-Flux Bic. Sub. 5000 ml/h 250ml/min SCUFSCUF High-Flux - - 100-150 ml/min CVVHCVVH High-Flux or Filter Bic. Sub. 500-2000 ml/h 100-150 ml/min CVVHDCVVHD Dialyzer or Filter Lac./Bic. as Dialysate Dia. 500-2000 ml/h 100-150 ml/min CVVHDFCVVHDF High-Flux or Filter Bic. Both 500-2000 ml/h 10

16、0-150 ml/min HPHP Whole Blood Adsorber - - 100-150 ml/min PEPE Plasma Filter Albumin Sol., FFP, Plasma Expander 30% of BF 60-150 ml/min PAPA Plasma Adsorber - - 60-150 ml/min TelTel：8542234185422341 85422339854223399、 人的價(jià)值，在招收誘惑的一瞬間被決定。2022-3-172022-3-17Thursday, March 17, 202210、低頭要有勇氣，抬頭要有低氣。2022-3-172022-3-172022-3-173/17/2022 8:38:23 AM11、人總是珍惜為得到。2022-3-172022-3-172022-3-17Mar-2217-Mar-2212、人亂于心，不寬余請。2022-3-172022-3-172022-3-17Thursday, March 17, 202213、生氣是拿別人做錯(cuò)的事來懲罰自己。2022-3-172022-3-17