高通量血液透析的临床应用实践PPT课件.ppt

高通量血液透析的临床应用实践,提要,高通量透析器历史为什么应用高通量透析器高通量透析技术要求临床实践中的高通量透析,EU,USA,巴西,中国,日本,世界人口与透析患者,人口：约亿人透析患者：约万人,出典（Table4)改編2005年EDTA開催時報告,USA,24%（HD22%,PD2%）,EU,18%,日本,18%（HD17%,PD1%）,其他,40%,世界整体透析患者约137万人,世界透析患者的比例,出典（Table4)改編2005年EDTA開催時報告,透析患者所占的人口比例,出典（Table4)改編2005年EDTA開催時報告,世界人口与透析患者,出典（Table4)改編2005年EDTA開催時報告,透析器膜的历史,MembranesforMedicalApplications,regeneratedcellulose,modifiedcellulose,hydrophilizedcopolymers,hydrophobic/hydrophilicblend,syntheticmembranes,cellulosicmembranes,AN69(Hospal)PMMA(Toray)EVAL(Kuraray)PEPA(Nikkiso)SPAN(Akzo/Asahi),PA/PAES/PVP(Gambro)PAES/PVP(Hospal)PSU/PVP(Fresenius/Minntech/BraunKawasumi,Toray,Asahi)PES/PVP(Membrana-Bellco-BaxterNipro),Cuprophan(Membrana)RC(Asahi)RG(Tejin,Terumo),Hemophan(Membrana)CA,CTA(Membrana/Toyobo)SMC(Membrana)PEG(Asahi)SCE(Membrana/Tejin),MembraneVlassaraetal1996;Miyateetal,1997,高通量透析:降低LMWAGEs,Makitaetal,1994,为什么应用高通量血液透析？,保存残余肾功能减少炎症反应减少血管性病变改善脂质代谢延迟透析相关淀粉样变性改善营养降低住院率,并发症和死亡率,Improvementoflipidprofile,*p0.05vstime0and4weeks,timeweeks,ModifiedCellulose,PolyfluxS,0,20,40,60,80,100,120,0,4,12,20,28,lipidconcentrationmg/dl,0,0.5,1.0,1.5,2.0,2.5,3.0,3.5,4.0,ratioLDL/HDL,*,*,*,LDL,HDL,LDL/HDL,PitoneJetal,ISBP,2003,ModifiedcelluloseversusPolyfluxS43patientsPolyflux:Improvementsinlipidprofilemayhelptoreducethelipidloweringmedications,为什么应用高通量血液透析？,保存残余肾功能减少炎症反应减少血管性病变改善脂质代谢延迟透析相关淀粉样变性改善营养降低住院率,并发症和死亡率,1,2,3,4,5,6,7,8,9,10,11,12,HF80S,P170H,0,5,10,15,20,25,30,35,40,Ratio(%),b2m/Albumin,Patients,HF80S,P170H,Selectivity2M/AlbuminHDFPost-Dilution,Polyflux170H:1.7mPS(HF80S):1.8m,Souidetal.ISBP2003,膜通量和膜材料对淀粉样变性的影响(HemoStudy),Schiffletal.NephrolDialTransplant15:1399-1409,2000,b2mMD=11,800D,Preventionofb2m-relatedamyloidosisbyhigh-fluxtherapies,0,0,2,0,4,0,6,0,8,1,Relativeamyloidosisrisk,Low-fluxHD,High-fluxHD,HDF,Riskofaworsetherapeuticeffect,JapaneseDialysisPatientRegistry(N=1196)Ref:NakaietalAJKD2001,为什么应用高通量血液透析？,保存残余肾功能减少炎症反应减少血管性病变改善脂质代谢延迟透析相关淀粉样变性改善营养降低住院率,并发症和死亡率,高通量透析对血清白蛋白的影响(HEMOstudy),Marcusetal.AmJKidneyDis31:491-494,1998,Increasedlossofvitalsolutesnotconfinedtohighfluxtreatments,营养不良患者的治疗策略,充分透析避免或尽量减少急慢性的炎症反应选用血液生物相容性好的膜排除任何外源性的潜在刺激，诸如透析液的污染,为什么应用高通量血液透析？,保存残余肾功能减少炎症反应减少血管性病变改善脂质代谢延迟透析相关淀粉样变性改善营养降低住院率,并发症和死亡率,透析膜和死亡率,(Woodsetal.),提要,高通量透析器历史为什么应用高通量透析器高通量透析技术要求临床实践中的高通量透析,0,1000,2000,3000,4000,5000,0,1,2,3,4,细菌计数(CFU/ml),内毒素(IU/ml),软化后,滤芯后,未净化的水,1st滤器后,0,1,2,3,4,5,6,7,8,9,10,碳缸后,反渗后,机器入口,透析液,透析液滤器后,水处理和透析液制备的细菌污染情况,100,1.000,10.000,0,50,100,150,200,Molweight,D,清除率(ml/min),High-flux膜(反向滤过),Low-flux膜(反向弥散),内毒素片断,尿素,肌酐,磷,Vit.B,12,菊酚,2-m,白蛋白,清除率:双向,5200dal.,1355dal.,11800dal.,60dal.,113dal.,高通量透析需要高质量的透析液,Weberetal.1996,High-fluxdialyzersandbackfiltration,压力,反向弥散,反向滤过,High-flux,Low-flux,LengthalongDialyser,血液,透析液,Dialysate,血液,膜,透析液,血液,滤过,反向滤过,PDo,PBi,PDi,PBo,MorphologicalCharacteristics,Polyflux,Polysulfonebased,HomogeneousSponge-like-Structure,Novel3-layer-Structure,3-LayerStructure,InnerSelectiveLayer(Skin)-narrowporesize-separationlayer-0.1-0.5mStabilizationlayer-supportfunction-25mFingerTypeStructure-highvoidfraction-lowdiffusiveresistance-4045m,MosteffectiveandstableremovalcharacteristicsEndotoxinsretention,透析膜对提高清除率的2个重要原因,Lessmaterielhighpermeability,Tri-dimensionalconfigurationofthehollowfiberbundle,透析液侧,血侧,从透析液侧到血侧无内毒素的转移:透析液侧泡沫状膜，血液侧膜光滑、表面大吸附能力强仅有1/百万单位的内毒素能跨过膜!,高通量聚砜膜:内毒素截留能力,超纯透析液对细胞因子和2-微球蛋白的影响,提要,高通量透析器历史为什么应用高通量透析器高通量透析技术要求临床实践中的高通量透析,Removalofuremictoxins,*P0.01,GongDehua,etal.JNephrolDialyTransplant,2002,Removalofuremictoxins,*,P0.05,*,P0.01,GongDehua,etal.JNephrolDialyTransplant,2002,Reductionratepost-dialysis(%),EffectofMHDonrenalosteopathyinESRD,ComparisonbetweenHFHDandLFHDinserumPTH,CaandP,GongDehua,etal.JNephrolDialyTransplant,2001,EffectofMHDonrenalosteopathyinESRD,SerumiPTHlevelsinpatientsbetweenHFHDandLFHD*,P0.01,MaitainencetimeonHD(years),GongDehua,etal.JNephrolDialyTransplant,2001,EffectofMHDonrenalosteopathyinESRD,ClinicalandbonebiopsydatafrompatientstreatedbyLFHDandHFHD,GongDehua,etal.JNephrolDialyTransplant,2001,EffectofreusingofHFHDontheperformance,Usenumberofdialyser,Solutesclearancechangesduringreuseofahighfluxdialyser(BLS627),GongDehua,etal.BulletinofMedicalPostgraduate,2000,EffectofreusingofHFHDontheperformance,Usenumberofdialyser,ReductionrateofMMSandbeta2-MafterHDduringreuseofahighfluxdialyser(BLS627),*,*,*,Comparedwithfirstuse,*,P0.05,*,P0.01,GongDehua,etal.BulletinofMedicalPostgraduate,2000,ChangesofendotoxinsduringMHD,SerumendotoxinslevelchangeduringHFHDandLFHD,HDtime(min),GongDehua,etal.ChineseCriticalCareMedicine,2001,SerumIL-1levelchangeduringHFHDandLFHD,HDtime(min),GongDehua,etal.ChineseCriticalCareMedicine,2001,Cha