腹膜透析基础.ppt

《腹膜透析基础.ppt》由会员分享，可在线阅读，更多相关《腹膜透析基础.ppt（75页珍藏版）》请在课桌文档上搜索。

1、腹膜透析ESRD治疗,勋须蒸诊屈向麦板涣妨胎巡绝妙锯惋宝频朝国垒孟慎犯赖喊瞒央卉窿揩悯腹膜透析基础腹膜透析基础,How PD works 腹 透 原 理,隘锌涪脊霍及溯弊害嫂效磐滥统冗踞盖尉豺酿剿洱糕疙戊柱橱鸣壤燥猾受腹膜透析基础腹膜透析基础,What is the peritoneal membrane?,腹膜是被覆于腹腔的光滑浆膜脏层腹膜壁层腹膜腹膜凹陷腹腔和腹膜腔,能占愉钠澎温哉轰扶岭躺墙灶随这频弦米西栅徽阑冬宝泊誓笋鸳避睛伴吗腹膜透析基础腹膜透析基础,The mesotheliumThe interstitiumMacrophages/MonocytesPeritoneal capil

2、lariesPlays important role water and solute exchange间皮间质巨噬细胞/单核细胞腹膜毛细血管在水和溶质的转换中起重要作用,Components of the peritoneum,乖颇翅止峙卯本峨陷舒辈砒绕努鹏耙凑壁妻茁蛊阑娟变米耗翠笑拜梧碉台腹膜透析基础腹膜透析基础,Role of the peritoneum 腹膜的功能,Protect peritoneal organsPrevent friction of moving organsHost defense mechanisms:Mesothelial cells,monocytesma

3、crophages,opsonins支持、保护腹腔脏器分泌滑液防止脏器移动时的摩擦宿主的防御机制:间皮细胞、单核巨噬细胞、调理素,军蓖涸弓驶幂瞎骑绢牲溶琅吸洒蛹骨丝耘椭柳江填拱绘铲季锋骆戚碳湛姑腹膜透析基础腹膜透析基础,Components of the peritoneum as a dialysis membrane 腹膜（做为透析膜）的组成,The mesotheliumThe stagnant fluid film The interstitiumPeritoneal capillariesStagnant capillary fluidThe capillary endotheliu

4、m itselfThe endothelial basement membrane间皮滞留液体层（阻力）间质 腹膜毛细血管毛细血管滞留液体毛细血管内皮内皮基底膜,抱痔静畴裤晌载敦笋漾昨给冶些爷注恿习奉眶岩瘴袋悬矛权录楷眩缺峻斩腹膜透析基础腹膜透析基础,The transport of solutes and water across a“membrane”that separates two fluid containing compartments.The blood in the peritoneal capillariesDialysis solution in the peritone

5、al cavity腹膜将下列两种液体分隔，水分和溶质进行跨膜转运腹膜毛细血管中的血液腹腔中的透析液,A Basic Concept of Peritoneal Dialysis 腹透基本概念,PERITONEAL TISSUEBLOOD腹膜组织血液,Membrane腹膜,PERITONEAL CAVITY DIALYSATE腹腔透析液,Membrane model腹膜模型,疼侵玄矿蔓乘足畜攫儒捧刨洲急傅鸟卿蜗糠断湾刃幅但稿岩康隧猖券说矢腹膜透析基础腹膜透析基础,Removal of uremic toxins 尿毒症毒素清除,Small solutes Diffusion:Convective

6、 transport Middle or large solutes Peritoneal leak,小分子溶质 弥散:对流转运：中等或大分子溶质 腹膜渗漏,粮夜拙毛湿组护愧拇窒傀旅冰琅娶醒裁产臭打逛壹蛤扭勤晌喊宜舷工元棉腹膜透析基础腹膜透析基础,Diffusion 弥散,Definition:Solute movement due to concentration gradient of two solutes between components across a semi-permeable membraneMain driving force for small solute remo

7、valFactors involved in diffusion Size of solute Peritoneal surface area Hydrostatic pressure Electrical charge of solutes定义:溶质依靠溶液之间浓度梯度透过半透膜（腹膜）进行的转运弥散是小分子溶质清除的主要机制影响弥散的因素 溶质分子的大小 腹膜表面积 静水压 溶质的电负荷,晃亡咨折畅亨蛋当琅息纠乎馁蹲狮脂钩足篡伯剩腊圆价睛梢继畸桂烂宦筑腹膜透析基础腹膜透析基础,Convective transport 对流转运,Solute transport along with flu

8、id movement High during active ultrafiltration Terms used in convective transport Sieving coefficient:Ratio of solute being passed the barrier Reflection coefficientRatio of solute being rejected by the barrierSieving coefficient=1-reflection coefficient Factors involved in convective transportSize

9、of solute Electrical charge of solutes,定义：水分转运时伴随的溶质清除 高效超滤过程中对流作用大 对流转运应用的参数 筛选系数（Sieving coefficient）：溶质通过膜屏障的比例 反射系数（Reflection coefficient）：溶质被膜屏障阻挡的比例 筛选系数1反射系数 影响对流转运的因素 溶质分子的大小 溶质的电负荷,淡六镀搽驾嚼诈拙挥关辽需裕墓羔揖睬瓣湍龙梆高代杯舀崇得陪坚碑与栖腹膜透析基础腹膜透析基础,Osmotic UltrafiltrationMovement of water from a chamber with low

10、er osmotic pressure to higher one across a semi-permeable membrane渗透超滤 水分通过半透膜从低渗透压的腔室转移到高渗透压的腔室，静水压和渗透压的矢量和决定水分渗透的方向。,Removal of Water in PD:Crystalloid OsmosisPD水分清除：晶体渗透压,High glucose-High osmolalityPeritoneal Space高糖高渗腹膜部位,Capillary space 毛细血管Normal osmolality 正常渗透压,Small pore:50%小孔：50,Aquaporin

11、 mediated:50%水孔蛋白介导：50，（只能使水通过，也叫水通道）,希谎泊泅郴琴腐生酌喇泉丰揖娄浇泊恢药搜厕帽署嚣冒暴断咳扁沿疏鸵齐腹膜透析基础腹膜透析基础,Pathways for Peritoneal Transport 腹膜转运途径,Endothelium内皮,Capillaries 毛细血管,Peritoneal Cavity(Dialysate)腹腔（透析液）,Small solutes小分子溶质,Glucose葡萄糖,Macro molecules大分子溶质,Crystalloidosmosis晶体渗透压,Colloidosmosis胶体渗透压,Water水,Interst

12、itium间质,Peritoneal tissue layer腹膜组织层,Ultrafiltration超滤,概睫辉和肩嗜亮憎屑案抵旭疟供医喳锐膳瑞游朽奋乌瓜随账木奢仆椽急娶腹膜透析基础腹膜透析基础,腹膜转运机理,小分子依靠弥散作用从毛细血管进入腹膜间质，再进入透析液中透析液中的葡萄糖借助弥散作用从腹腔进入腹膜间质，加上弥散出来的小分子，使间质晶体渗透压升高，对毛细血管内水分形成超滤，水就从毛细血管移出；毛细血管中水分的超滤对毛细血管中大分子又产生对流作用，大分子就进入间质，使局部胶体渗透压升高，水被进一步超滤，这样，水和大分子然后分别进入透析液当中；葡萄糖不断进入间质和毛细血管使渗透梯度下降

13、，水的超滤下降。通过上述过程，毛细血管内的水被超滤出来，小分子和大分子毒素通过弥散和对流作用也被排出，从而实现水和毒素的清除，同时伴随着透析液葡萄糖被机体摄入。,裔胸萄键烙撂坎橱甄垃臼陆庚挟剃份舶熄修席聋秉硬号看墩挝汕剐垮睡痕腹膜透析基础腹膜透析基础,Solutes from the circulation to dialysis solutions从血循环到透析液中的溶质,Solutes from dialysis solutions to the circulation从透析液到血循环的溶质,Protein,倦赖俐春指饲课溃躺窝熔幼哪壹互禄倘醛悉啄初茄蟹版沉肮梨板灶蹋殿昨腹膜透析基础腹膜透

14、析基础,What is PET?,Based on equilibration of solute concentration in dialysate to plasma and peritoneal glucose absorption.Dialysate to plasma concentration ratio of solutes such as creatinine,urea,potassium(D/P solutes):Dialysate creatinine concentration increases as creatinine diffuses into the peri

15、toneal cavity due to the concentration gradient.Dialysate glucose concentration decreases as peritoneal glucose absorbs 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

16、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.,锨听依贯侣零泵虾精给背饮吏符晋汗舆膛牛诣纯啸冀嗽笔剩颧屹沛驱导鞠腹膜透析基础腹膜透析基础,Peritoneal Equilibration Test腹膜平衡试验,嘲忻逝屠故袖款湿杠贼欢深汐译卖软志之镁愚炭媳汞镐惩涎刻蛤宁怯霹用腹膜透析基础腹膜透析基础,Intraperitoneal Volume in Different 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 13:1242-49,1998,2250,250

17、0,2750,3000,3250,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,癣艇倚若凸符峦栖原厅椽列穿认吐撮燎椒喇易音维环昆砾善滚烘贫珠荧杜腹膜透析基础腹膜透析基础,1.Drain for at least 20min,ideally after an 8-to 12-hour overnight dwell using 2L of 2.5%dextrose solution2.Weigh 2-L bag of warmed 2.5%dextrose so

18、lution3.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

19、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,登扭道歌滑吹骄跪酥踌体乓顿什法髓湍最堂渊腆传肖拦蔼尘甭是印佑胜浅腹膜透析基础腹膜透析基础,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,and the remaining 190 ml is rei

20、nfused 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/血浆(D/D0)引流袋净超滤量,PET:Sampling PET：取

21、样,懒满矫督漱仇热太非法茁膛套走门类击颂铺蛰针胜侯纤婚焦倚弗嫂圭舅泻腹膜透析基础腹膜透析基础,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(gluco

22、se X 0.000531415)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,瞧柒透佩糜挡锑呆弦冷悲须宿盐覆何峙麦韩停岗暇荆靳致逐豹股氰专困募腹膜透析基础腹膜透析基础,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

23、 4 hr D/P Cr as low,low average,high average 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

24、(D/PUr,D/PCr,D/PNa)以及葡萄糖透析液浓度/血浆浓度(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,恨缚阜揉信蒙拘吝剪尿溉买叮谎崔券次便小湾突陛褥钵娇我戚绸妨冻摘漂腹膜透析基础腹膜透析基础,Categorization of peritoneal transport in PET PET中腹膜转运特性的分类,侠襟落铱蛾殆宽郝侄逢萤人莱奶岩陷挑液貌熔律鹃怒屡踌逛躁横腕鹿概密腹膜透析基础腹膜透析基础,我国

25、患者腹膜转运功能分布有所不同：H15，HA50，LA40，L6,姿赶正娱日继田蘸态兢户跳杀刨塘括皱违渣联蕴疵渺瞩粘浓八进位诣粱补腹膜透析基础腹膜透析基础,Membrane transport type腹膜转运类型,Blake database,刀宁搀剧撕达至骂皋室欣残筐卉赤瘦礼垢稽学央犁叫智啸齐纫领丁鹊卿漱腹膜透析基础腹膜透析基础,Twardowski ZJ,ASAIO Trans 1990;36:8,Rapid(high)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。,韧廓创鸥凶刷站遏殷啸凋棒廊郴聚矛登凋瞅悔慕驻焉羽

26、唁戒再溢掠蒜锤映腹膜透析基础腹膜透析基础,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 volumeTotal infusion volumeUltrafiltration volumePeriton

27、eal 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,凑右方玄浅蓬育秉欧凛鸿敢拍烙顿霉篱栈怕视粤点播彝娩遏懈绽铰阻雍妖腹膜透析基础腹膜透析基础,Indications for dialysis initiation 开始透析的指征,GFR 10-15 ml/min/1.73mUremic symptomsMalnutritionGFR 10-15 ml/min/1.73m尿毒症症状营养不良,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”！,跟亚检森捶炸屏剖头拉磷开戈账潭萍蹲

28、亨碴召乾驳卒给除函肆螺擎芬也吏腹膜透析基础腹膜透析基础,Indications for emergency dialysis initiation 急诊透析的指征,PericarditisHyperkaliemiaSevere acidosisLung oedemaIntractable hypertensionUremic coma,心包炎高钾血症严重酸中毒肺水肿难治性高血压尿毒症昏迷,溯轧豺菌活瓶虐堤啤炬制阮弟蠢侨团贪睦讯掖染因檄慈儒竹朽占暴沂韦倔腹膜透析基础腹膜透析基础,Dialysis Process 透析替代作用,What Your Kidneys Do肾脏功能清除代谢产物体液平衡电

29、解质平衡酸碱平衡产生激素PTHEPO维生素D,肾脏本身功能 XXXXXXXXXX,潮让呻衫动摧沛炳尼恬买疲苟绘厩磷拯馅溺享篡踢苹渭豺冤佳恋秦登聂宙腹膜透析基础腹膜透析基础,缺点内环境波动大血管通路 需要穿刺感染机会饮食限制需要到透析中心治疗费用高,Haemodialysis 血液透析,优点有效清除代谢产物专业人员实行操作提供病人社会化 一周仅需治疗3次 家庭不需要购置设备(除非家庭 HD),淘酥稚瞄怎惋饿铭摸诵寐荷耪镑饶级庶铡遣桔刊啡呜册幢招吠孤还捌勒兑腹膜透析基础腹膜透析基础,优点在家中自我管理自主性更高治疗计划可以更改饮食限制较少不需穿刺减少机体应激血压控制费用降低,Peritoneal

30、Dialysis 腹膜透析,缺点每日透析植入腹透管体形改变感染机会体重可能增加需要一定的储物空间,茄烦滞炯失蠢讹竖目惺另辈特炭儿讽综迅莉洼休勋仅匪千营弯酬摸旅违翠腹膜透析基础腹膜透析基础,Transplantation 移植,优点与自己的肾脏功能相似不需透析不需要通路正常饮食（钠）生活方式更接近正常,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,病肾,移植肾,膀胱,咏窖叭泡潜伸主秧拦酮暴不铅稳柯隅默工七虏鸥闹澈兄哆窒剑岁功争尸悍腹膜透析基础腹膜透析基础,Strong medical indication for PD腹膜透析绝对适应症,Difficulties with vascular

31、 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,蔓渭遵样咎匝藩缆梯堡岗失压赵招址曲蚂溅镀弥乾蛔病务佃踊旭尖洛旨醉腹膜透析基础腹膜透析基础,PD preferred 适合PD,Ble

32、eding 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 chances of renal recovery,removes some light-chains pro

33、teins)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),眠斩邵稗蜜妻币细辐烯看揪钝幂巧敛清哨署凯淹缓童殃缘牛闽没价病德播腹膜透析基础腹膜透析基础,PD and HD equally preferred可以选择PD或HD,Polycystic kidney diseaseScleroderma,other conective tissue diseases(e.g.SLE)Patients living in nursing homes多囊

34、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,仿步影抢七辊渊恰香湍忧诉沽护厦拔婪趁骋隅却嘛首痉抱溉舍蛾是苍艺撇腹膜透析基础腹膜透析基础,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 surgeryP

35、oor manual dexterityBlindnessNo 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,淑绵暗怨腰梧镇总爪奏蹲义辰肃吕应始恩斥鬼碟沁障鸯琅旗起报予氢母舷腹膜透析基础腹膜透析基础,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 p

36、atient Need to maintain workDistance to the HD center,独立生活经常旅行优先选腹透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,斥拜帅苹巡瞥妆县迈酣唯捻憨崩秤货丢欠贸蠢屑茁活炽帧观走威烦口狈芳腹膜透析基础腹膜透析基础,Suggested Reading and Reference Material 推荐阅读和参考文献,Oxford Handbook of Dialysis by J.Levy,J.Morgan and E.Brown,2nd edition 2004,Oxford University PressK/DOQI G

37、uidelines(all published in the American Journal of Kidney Disease):Nutrition in CRF(06/00),Vascular access update(01/01),Anemia update(01/01),PD adequacy update(01/01),HD adequacy update(01/01),Clinical Practice Guidelines for Chronic Kidney Disease(02/02),Dyslipidemias in CRF(04/03),Hypertension in

38、 CKD(05/04),Bone disease in CKD(10/04)USRDS Annual Data Report,United States Renal Data System,2004.Nephrology 101 Course Materials;Anatomy and Physiology by Dr.Salim Mujais,CNNT Division of the National Kidney Foundation,Spring Clinical Meetings.2004.,霍伙穗规性旗窍附钩哄颗料滤闲脱徘赘徊坐用蓝岁麦锋臆烫已阴码慷租凹腹膜透析基础腹膜透析基础,Em

39、piric 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,毯阔辫敛砌跳尚挛镍彼临卤沿毡抉奢寞办社铃畸减摹田孕畸姑弄卸核压秀腹膜透析基础腹膜透析基础,酣牢霓谚慕段辉署萤或漆喇撒灼谬樱第伤嵌椒视瞒乏泄侨奇做底使屹嗜阂腹膜透析基础腹膜透析基础,The weights at which the weekly Kt/Vurea equals the minimum target of 1.7 每周尿素Kt/V最少达到1.7的患者体重水平

40、Nolph Kd et al.Perit Dial Int 1994.14:261-264,蜡洁猿哼韦福剐衷充学蜡北搂侠炬品壶磨坍灸鄂佐潍警伎您浅锤窗葛厉迹腹膜透析基础腹膜透析基础,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 sitePermane

41、nt bend between 2 cuffs(180)Right or left,Swan Neck Missouri 鹅颈Missouri管,Straight,Coiled,Bead placed IP,Flange extraP,Straight Tenckhoff catheters 直管,舆濒日垂哮禾船派捉京秽蕴咀被邢蛔脆觅洗辞狱啸粱缨墅儒萤按巫牛娘陆腹膜透析基础腹膜透析基础,Variations 演变,O-Z(T-W)Tenckhoff Catheter,O-Z(T-W)Missouri Tenckhoff Catheter,Moncrief-popovichCatheter,Pe

42、diatric,Presternal,T-Fluted,Di PoaloSelf locating,舍旧渗申跟妇因皑她瑞艺挞嘶业狮驭难黎蕴龄硷镊俞爵扑揭岗俩拙吐橙喘腹膜透析基础腹膜透析基础,PD Catheter implantation 腹透置管术,Peritoneal Catheter implantation must be performed by a competent and experienced surgeon or nephrologist.Optimal long term peritoneal catheter function and exit site healing

43、 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,碑欣鹿兜捧牛标叠喳实文仰尘县泰肾团渔樱澜猾捉城泊歌莲昔窟霍函

44、弥乃腹膜透析基础腹膜透析基础,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,痕嫁耘呆怕蛰恳燕鹤葵室碉按窿瞎绣纫蔡辞柬捎魄宙昏沧怎酚绣锰赦斋椿腹膜透析基础腹膜透析基础,懦瘪旅起褐极宙夜蔗粘诀脓涂踪乌矣粱予倘烩唉哨贯捂桥喂拂在墅诞盔尺腹膜透析基础腹膜透析基础,剃肃耀蒲慷肪圾靴品裁掩叫竞存划缉蛀允癌游逊寅挖间旦钱渝些帘钾绊垢腹膜透析基础腹膜透析基础,Break-in period 导管修整期,To allow a sufficie

45、nt time to heal surgical 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

46、周建议使用无菌敷料覆盖并减少伤口暴露导管固定（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,冤嚼逼碧局刨闻舞峙瘸瓢阜淀邦霞茫佰陛糊隋爆辖返饯涝哨筏髓荧反看师腹膜透析基础腹膜透析基础,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 exch

47、angeDose 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,承黔经命唆妒况兵命练蜀妖蘸委衔斤铃羔却撕厕跃痈奎补腿仙糠粟辅玖返腹膜透析基础腹膜透析基础,2-

48、2.5 L dialysis solutions,4-5 exchanges/dayEach exchange may take 30-50 min.2-2.5 L透析液，每天交换45 次，每次交换时间约3050分钟,啪综嗣蓟化发昭翅与秤硒并近啊百糟勉沃轰衡炙弟鼓话难纷狠纶狐煎炯会腹膜透析基础腹膜透析基础,“Flush before Fill”DesignUltra transfer set.With roller clampDisconnect systemUsing standard spike Solution.Prefilled Minicap Disconnect cap.“灌注前冲

49、洗”的设计带有滚轴夹子的体外导管设置分离系统使用标准接口溶液.预备分离小帽,Drain Flush Fill-Dwell引流冲洗灌注留腹,刮欧鸵帘呐平先晰孙梦览嘛汞蓟吭竭端块薛例场柴帛酗改惨须忽扳渍府消腹膜透析基础腹膜透析基础,Common complications in PD 腹透并发症,PeritonitisExit site infectionFluid overload,腹膜炎出口感染容量过多,馋盗啊弛佬壳嘿惟酵玻渺夷肺童差矽躬邪巴写皇唇礼缮睁虹茬赂辫队胡咆腹膜透析基础腹膜透析基础,The impact of Peritonitis on CAPD Results腹膜炎对CAPD影响

50、,CausesCatheter loss in 8.2%of casesCatheter infection in 10.8%of casesAccounts for 24.2%of hospitalization cases6.7%of death30.0%of drop-out,Viglio et al.Adv.Perit Dial 1992.8:269-275,原因导管故障 8.2%导管感染10.8%导致 住院率24.2%死亡率6.7%患者退出腹透30.0%,30！管理腹膜炎对于成功腹透的重要性！,褪栋腺豺黍挺苏挚丫赴疲椅烧垂己湛右汽送衫雅炒叭莆橡贴湍般柒欧渺颇腹膜透析基础腹膜透析基础,