腹膜透析基礎(chǔ)PPT幻燈片課件

1、 腹膜透析ESRD治療1 How PD works 腹 透 原 理 2腹膜透析的定義腹膜透析（peritoneal dialysis，PD）是通過(guò)體內(nèi)自身膜結(jié)構(gòu)腹膜，作為濾器進(jìn)行血液凈化，清除多余的水份和廢物腹膜透析主要是在家中進(jìn)行治療。腹膜透析前，先通過(guò)簡(jiǎn)單的手術(shù)，將約0.7厘米直徑的軟管（稱為導(dǎo)管）通過(guò)腹壁置于腹腔。透析液可以通過(guò)此管道進(jìn)入腹腔。3 腹膜結(jié)構(gòu)腹膜是被覆于腹腔的光滑漿膜臟層腹膜壁層腹膜腹膜凹陷腹腔和腹膜腔4間皮間質(zhì)巨噬細(xì)胞/單核細(xì)胞腹膜毛細(xì)血管在水和溶質(zhì)的轉(zhuǎn)換中起重要作用腹膜組成5 腹膜轉(zhuǎn)運(yùn)途徑Endothelium內(nèi)皮Capillaries 毛細(xì)血管Mesothelium間

2、皮Peritoneal Cavity (Dialysate)腹腔（透析液）Small solutes小分子溶質(zhì)Glucose葡萄糖Macro molecules大分子溶質(zhì)Crystalloidosmosis晶體滲透壓Colloidosmosis膠體滲透壓Water水Interstitium間質(zhì)Peritoneal tissue layer腹膜組織層Ultrafiltration超濾6腹膜將下列兩種液體分隔，水分和溶質(zhì)進(jìn)行跨膜轉(zhuǎn)運(yùn)腹膜毛細(xì)血管中的血液腹腔中的透析液腹膜工作原理PERITONEAL TISSUEBLOOD腹膜組織血液Membrane腹膜PERITONEAL CAVITY DIALY

3、SATE腹腔透析液Membrane model腹膜模型7腹膜轉(zhuǎn)運(yùn)機(jī)理小分子依靠彌散作用從毛細(xì)血管進(jìn)入腹膜間質(zhì)，再進(jìn)入透析液中透析液中的葡萄糖借助彌散作用從腹腔進(jìn)入腹膜間質(zhì)，加上彌散出來(lái)的小分子，使間質(zhì)晶體滲透壓升高，對(duì)毛細(xì)血管內(nèi)水分形成超濾，水就從毛細(xì)血管移出；毛細(xì)血管中水分的超濾對(duì)毛細(xì)血管中大分子又產(chǎn)生對(duì)流作用，大分子就進(jìn)入間質(zhì)，使局部膠體滲透壓升高，水被進(jìn)一步超濾，這樣，水和大分子然后分別進(jìn)入透析液當(dāng)中；葡萄糖不斷進(jìn)入間質(zhì)和毛細(xì)血管使?jié)B透梯度下降，水的超濾下降。 通過(guò)上述過(guò)程，毛細(xì)血管內(nèi)的水被超濾出來(lái)，小分子和大分子毒素通過(guò)彌散和對(duì)流作用也被排出，從而實(shí)現(xiàn)水和毒素的清除，同時(shí)伴隨著透析液葡

4、萄糖被機(jī)體攝入。814至6小時(shí)之后，代謝廢物及多余的水分會(huì)停止移動(dòng)至透析液中然后你必須流出舊的透析液并灌入另一袋新的透析液當(dāng)透析液中的濃度相當(dāng)于血液中的濃度時(shí)，水分和代謝廢物則不會(huì)再移動(dòng)。當(dāng)你注入新鮮的透析液，廢物和多余的水分又會(huì)再度移動(dòng)。1249腹膜透析操作10Indications for dialysis initiation 開始透析的指征GFR 10-15 ml /min /1.73mUremic symptomsMalnutritionGFR 10-15 ml /min /1.73m尿毒癥癥狀營(yíng)養(yǎng)不良有計(jì)劃地開始透析對(duì)于患者非常重要，應(yīng)盡量避免“急診透析”！11 Indicatio

5、ns for emergency dialysis initiation 急診透析的指征PericarditisHyperkaliemiaSevere acidosisLung oedemaIntractable hypertensionUremic coma心包炎高鉀血癥嚴(yán)重酸中毒肺水腫難治性高血壓尿毒癥昏迷12 Dialysis Process 透析替代作用What Your Kidneys Do腎臟功能清除代謝產(chǎn)物體液平衡電解質(zhì)平衡酸堿平衡產(chǎn)生激素PTHEPO維生素D 腎臟本身功能 XXXXXXXXXX13缺點(diǎn)內(nèi)環(huán)境波動(dòng)大血管通路 需要穿刺感染機(jī)會(huì)飲食限制需要到透析中心治療費(fèi)用高Haem

6、odialysis 血液透析優(yōu)點(diǎn)有效清除代謝產(chǎn)物專業(yè)人員實(shí)行操作提供病人社會(huì)化 一周僅需治療3次 家庭不需要購(gòu)置設(shè)備(除非家庭 HD)14優(yōu)點(diǎn)在家中自我管理自主性更高治療計(jì)劃可以更改飲食限制較少不需穿刺減少機(jī)體應(yīng)激血壓控制費(fèi)用降低Peritoneal Dialysis 腹膜透析缺點(diǎn)每日透析植入腹透管體形改變感染機(jī)會(huì)體重可能增加需要一定的儲(chǔ)物空間15 Transplantation 移植優(yōu)點(diǎn)與自己的腎臟功能相似不需透析不需要通路正常飲食（鈉）生活方式更接近正常缺點(diǎn)手術(shù)風(fēng)險(xiǎn)排異反應(yīng)藥物的副作用抵抗力低下體形改變Patients KidneyTransplant Kidney(extra-perit

7、oneally)Bladder病腎移植腎膀胱16Strong medical indication for PD腹膜透析絕對(duì)適應(yīng)癥Difficulties with vascular accessLeft ventricular hypertrophyCongestive heart failureProsthetic vascular diseaseIntolerance of HDFrequent episodes of hypotensionHeadache and asthenia after HD sessionChildren血管通路建立困難左心室肥厚充血性心衰人造血管病變不能耐受

8、血液透析經(jīng)常出現(xiàn)低血壓事件血透后頭痛和乏力兒童17PD preferred 適合PDBleeding 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 (improves the c

9、hances of renal recovery, removes some light-chains proteins)出血傾向(不需要肝素化)糖尿病(血管條件，腹腔內(nèi)使用胰島素)慢性傳染病(預(yù)防乙肝、丙肝及艾滋病的院內(nèi)感染)將來(lái)準(zhǔn)備腎移植(改善術(shù)后移植物成功率)多發(fā)性骨髓瘤(增加腎功能恢復(fù)機(jī)會(huì)，清除一些小的輕鏈蛋白)18 PD and HD equally preferred可以選擇PD或HDPolycystic kidney diseaseScleroderma, other conective tissue diseases (e.g. SLE)Patients living in n

10、ursing homes多囊腎疾病硬皮病及其他結(jié)締組織疾病（系統(tǒng)性紅斑狼瘡等）居住在護(hù)理院的患者19 Theoretically not to choose PD initially BUT PD may be feasible with added adjustments 理論上不宜首選腹透治療，但是進(jìn)行某些改進(jìn)后腹透也可以實(shí)行的情況Large body sizeDiverticulosis / diverticulitisSevere backacheNIPDHerniasNIPDMultiple abdominal surgeryPoor manual dexterityBlindnes

11、sNo compliance體形較大(腸)憩室病/憩室炎重度背痛NIPD疝氣NIPD腹部多次手術(shù)史操作不便失明依從性差20 Psychosocial situations in which PD is more appropriate更適合腹透的心理狀態(tài)PD preferred Independent LifeFrequent travelsTendency towards PD Great need of independence by the patient Need to maintain workDistance to the HD center獨(dú)立生活經(jīng)常旅行優(yōu)先選腹透傾向于腹透患者

12、有強(qiáng)烈獨(dú)立生活的愿望需要繼續(xù)工作遠(yuǎn)離血透中心21Empiric prescription 經(jīng)驗(yàn)處方3-5 exchanges of 2 L dialysis bagConsidering mainly fluid balance2升袋裝透析液交換3-5次注意保持大致液體平衡2223The weights at which the weekly Kt/Vurea equals the minimum target of 1.7 每周尿素Kt/V最少達(dá)到1.7的患者體重水平 Nolph Kd et al. Perit Dial Int 1994. 14: 261-26424Different PD

13、 catheters 不同 腹透管路Straight 1 cuffStraight 2 cuffsCoiled Tenckhoff catheters 卷曲管Coiled 1 cuffCoiled 2 cuffsSwan Neck Tenckhoff catheters 鵝頸管StraightCoiledDownwards directed exit sitePermanent bend between 2 cuffs (180)Right or leftSwan Neck Missouri 鵝頸Missouri管StraightCoiledBead placed IP, Flange ext

14、raPStraight Tenckhoff catheters 直管25PD Catheter implantation 腹透置管術(shù)Peritoneal Catheter 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 t

15、he catheter insertion team.腹透導(dǎo)管埋置術(shù)必需由熟練有經(jīng)驗(yàn)的外科醫(yī)生或腎病專科醫(yī)師施行。腹透導(dǎo)管長(zhǎng)期保持最佳功能及體外段的愈合，直接與手術(shù)醫(yī)生的技術(shù)和能力相關(guān)Gokal et al. Peritoneal catheter and exit site practices.Toward optimal peritoneal access,Perit Dial Int, 1998;18:11-33262728Peritoneal Dialysis Technique 腹透技術(shù)Basic proceduresInfusionDwell time (variable)Drai

16、nage 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基本操作灌注留腹時(shí)間（可變）引流腹透液 (流出液)容量每次交換所用的腹透液的量劑量某一時(shí)間段內(nèi)用的透析液總量間歇性腹透及連續(xù)性腹透一段時(shí)期內(nèi)用的腹透方案或用法29“Flush before Fill” DesignUltra transfer set. With roll