【持续性肾脏替代治疗crrt英文精品课件】separation technology in dialysis

SeparationTechnologyinDialysis AllanP TurnerM D February17 2006 KidneyFunction KidneyFunction TermsUsedinDialysis DiffusionConvectionUltrafiltrationClearance 100ml min100mg dl 100ml min50mg dl Clearance 50ml min 100ml min100mg dl 100ml min10mg dl Clearance 90ml min OptionsforRRT Hemodialysis3Xaweekfor3 4hoursdiffusiveclearancewithultrafiltrationofwaterfasterbloodflowrates lesshemodynamicstabilityCRRT Hemodiafiltration acontinuousprocessusedoncriticallyillpatientsinUSmoreconvectiveclearancelowerbloodflowratesandsmallerfilter greaterhemodynamicstabilityPeritonealDialysisperitonealmembraneusedassemipermeablemembranebatchprocess DescriptionofHemodialysis PrimarilydiffusionDialysatelookslikebloodofhealthypatient3Xweekfor3 4hoursBloodanddialysateflowsarefastQB 500ml minQD 800ml min Membrane Dialyzer HollowFiberDesignBiologicvssyntheticReuseTermsBiocompatibilityHighefficiencyHighflux Access DifficultTradeOffsrapidityofusechanceofinfectionpatientcomfortneedforaddlprocedures Access PermCath UseimmediatelyNoneedlesticksHighinfectionrateHighrecirculation Access AVGraft Usein2 3weeksSomeinfectionrisk2needlestickslowrecirculationnumerousinterventionstokeepopen Access AVFistula 3 18monthstouseMinimalinfectionriskCanlastalifetime Anticoagulation BloodclotsHeparindiscoveredin1926PartialclottinglimitsdiffusionreducessurfaceareaAccessmuststopbleedingCalciumrequiredforclotting DialysisMachine BloodCircuitanticoagulatedeliverbloodtomembranesafelyreturnbloodtopatientDialysateCircuitdeliverdialysateatpropertemperature concentration andpHcontrolultrafiltration DialysisMachine BloodCircuit RollerpumpHeparinsyringepump2airtrapsAirdetectorVenouslineclamp DialysisMachine DialysateCircuit Warm deaerate mixconcentrates monitorconductivityandpH pumpDetectbloodleaksGenerateandmonitorultrafiltration DialysisMachine DialysisMachine Dialysate UreaClearance Urea uremictoxin DiffusionUrea MW 60 small KoAClearanceofureaof250ml minNativekidneysprovideureaclearanceofabout90 110ml min UreaClearance ClearanceofOtherSolutes Urea MW60 creatinine MW113 B12 MW 1355 2microglobulin MW 11 800 albumin MW 80 000 MiddlemoleculesDiffusionnoteffective Hemofiltration ConvectiontoclearlargermoleculesReplacementfluidswithoutremovedsoluteCostly ContinuousRenalReplacementTherapy CRRT CriticallyillICUpatientslowBPcan ttoleratelargeQBorlargefilteroftencan tbesystemicallyanticoagulatedContinuouslowclearancesbutruns24 7AnticoagulationregionalanticoagulationinsteadofsystemicCombinehemodialysisandhemofiltrationhemodiafiltrationincreasesclearancesevenofmiddlemoleculescontinuousvenovenoushemodiafiltration CVVHDF CRRTvsHemodialysis QB150ml hr Dialysate Ultrafiltration Replacementfluid Replacementfluid1000ml hr Dialysate40ml min 2500ml hr QB500ml hr Dialysate Ultrafiltration CRRT Hemodialysis Dialysate800ml min 48 000ml hr CRRTCitrateAnticoagulation D I A L Y Z E R Blood From patient Blood To patient C C C C C C Calcium C C C C C C C C C Liver CitrateHCO3 Tri SodiumCitrate CRRT V Q B Q E Q R Q FR Q D 100 150 mL min actualQ B Q B machine Q R Patient iCa 2 1 1 1 3 mmol L GambroPrisma GambroPrisma with with M60AN69Filter M60AN69Filter V CRRT PeritonealDialysis PD SalmondialysisPeritonealmembraneCapillariesDiffusion ultrafiltration ieosmosis convection andabsorption PDMembrane PdMembranesurfacearea BSA 1 2m2heteroporus heterogeneoussemipermeablemembranewithcomplexphysiologyBloodFlowapprox 50 100ml min3poremodellargepores macromoleculeslikeproteins smallpores smallsolutes ultrapores aquaporins waterwithoutsolute PDUltrafiltration Dextrose 3concentrations addedtoprovidegradientforUF osmosis GlucosediffusesintobloodanddiminishesgradientAbsorptionofdialysateoccurslimitingUFNeweragents PDClearance HighTransportersdialyzewellultrafilterpoorly Icodextran bestwithfreq shortdwellsHighAvg LowAVGtransportersLowTranspor