透析机功能组件的临床使用

2017/12/21,Dialysate Safety,1,透析机功能组件的临床使用,北京大学第一医院肾内科, 100034左力,透析机功能组件的临床使用,背景血容量监测透析充分性监测血温监测血压监测总结,2017/12/21,Dialysate Safety,2,低温保存盘管透析器,Br Med J 1:5347:17161717, 1963,2017年12月21日,血液透析原理,4,最早的人工肾,2017年12月21日,血液透析原理,5,改进后的早期人工肾,2017年12月21日,血液透析原理,6,转鼓式人工肾,2017年12月21日,血液透析原理,7,早期的血泵,2017年12月21日,血液透析原理,8,平板式人工肾,透析器的化学消毒,JAMA 207:20872088, 1969,Dial Transplant 2:1416, 32, 1973,透析患者死亡率高,HFD,10,Am J Kidney Dis. 1998; 32 (5 Suppl. 3):S112119,中国ESRD的患病和发病情况,2017/12/21,CSBP, ESRD Registration,11,中国血液净化. 2010; 9: 47-49,ESRD的病因构成,2017/12/21,CSBP, ESRD Registration,12,中国血液净化. 2010; 9: 47-49,死因构成,2017/12/21,CSBP, ESRD Registration,13,中国血液净化. 2010; 9: 47-49,我国香港/台湾/日本的ESRD患病率,ESRD Challenge,14,大陆,北京市血液透析患病率,ESRD Challenge,15,透析机功能组件的临床使用,背景血容量监测透析充分性监测血温监测血压监测总结,2017/12/21,Dialysate Safety,16,血容量监测方法,标志物稀释法Hct蛋白胶体渗透压自动监测超声法光电原理,2017年12月21日,血液透析原理,17,Hct1BV1= HCT2 BV2BV=(Hct2-HCT1)/Hct2,HYPOTENSION !,Possible causes of Hypotension during dialysis,Drugs,Incorrect weight,Sodium Influences,Eating,Temperature related,Fluid removal,Acetate Dialysate,Autonomous nervous system dysfunction,Intracellular volume (ICV) 63% TBW,Extracellular volume (ECV) 37% TBW,Lean body mass,Fat,Total body water (60-65% BW),Plasma ( 7%), 35-40% BW,人体组成,透析过程中的体液重分布,Intracellular water (without blood cell water),Interstitial water,Blood,circulating BV,peripheral BV,ultrafiltrationdialysate osmolaritydialysate temperature,Model of BV response to UF,Biofeedback based on detection of change in (relative) blood volume,Measuring Solid density of blood,Sound Speed for Blood Volume Measurement,Control System,Pulse, now!,Start counting!,Sound transmitter,t = 0,Sound receiver,Control System,Stop counting!,t = t1,Pulse detected!,Sound transmitter,Sound receiver,Sound Speed, Hematocrit and Temperature,25,30,35,40,45,1500,1520,1540,1560,1580,1600,1620,Sound speed m/s,Temperature C,water,saline,Hct = 10%,Hct = 20%,Hct = 30%,Hct = 40%,Hct = 50%,Blood,KRAEMER M, 1995,Water(84.7%),Proteins(12.5%),Other(2.8%),Typical blood composition (in mass-%, for HCT=35%),Start of dialysisRBV = 100%HCT = 30%v=1573.1 m/sec,End of dialysisRBV = 80% HCT = 37.5% v=1580.4 m/sec,Example:,Typical Sound Speed Range,KRAEMER M, 1995,Pulse Transit Time,Blood temperature,From Ultrasound to Blood Data,Sound speed in blood,Blood water concentration, blood protein concentration,Relative datarelative blood volume (RBV),Absolute datahematocrit (HCT), hemoglobin (Hb),Different blood volume monitors,FMC Ultrasonic Blood Volume Monitor (1),Transmitter,Temperature sensor,Receiver,Pulse transit time: 10.8 sTime resolution:20 ps,FMC Ultrasonic Blood Volume Monitor (2),Sensor head with cuvette disposable,BVM electronics compartment,On-line detection of the dry weight end point,RBV %,88,90,92,94,96,98,100,102,UFR = 1.1l/hr,Change rate of RBV= increase vascular refilling,Change rate of RBV= stop/reduce vascular refilling,UF Stress Test - overloaded patient,Time mins,0,15,30,45,60,75,90,105,120,135,150,165,180,195,210,225,240,255,270,RBV %,86,88,90,92,94,96,98,100,102,104,UF Stress Test - “dry” patient,ART,VEN,UFcontrol,Heatercontrol,Patient,BTM,BVM,Dialyzer,Hydraulic system,BVM in feedback loop,UFR = x x (UF.goal / UF.time),Automatic BV Control (1),Step 0:BVM Calibration-calibration is performed automatically during thepriming procedure-calibration time: depends on system conditions, not less than 4 minutes, typical 5 minutesStep 1:Parameter Input-UF Goal & UF Time from HD machine-minimum allowed RBV (critical RBV, patient individual)-maximum allowed UFR (1000 to 2800 ml/h)Step 2:Start-start control program with “BV Control” button-green LED indicates active control mode-BVM enters control cycle (see overview chart) and measures initial BV data,Automatic BV Control (2),UF volume,time,UF goal,Remaining UF volume,Remaining UF time,Current time t,Total UF time t end,UF (t),Step 3:Calculate average UFR(UFR m) for remaining UF volume,UFR m,=,Remaining UF volume,Remaining UF time,UFR m,=,UF goal - UF(t),t end - t,Automatic BV Control (3),Step 4:Calculate actual UFR set point,77.5,85,92.5,100,1.0,0.6,0.4,0.2,0,0.8,Reduction factor ,RBV %,UFR set= * * UFR m,:constant intensity factor(currently = 2):RBV dependent reduction factor,Feedback (algorithm) control of UF,BV response to UF modeling,Existing Automatic Devices: BTM, BVM,Dialysate temperature,Ultrafiltration rate,FMC 4008H with- body temperature control- blood volume control-non-invasive recirculation measurement,透析机功能组件的临床使用,背景血容量监测透析充分性监测血温监测血压监测总结,2017/12/21,Dialysate Safety,43,44,reference,#,#,#,#,#,*,*p0.05#p0.01,Nephrol Dial Transplant (1997) 12: 884888,Kt/Vurea与生存率相关,日本，13万HD病人，1年随访结果,试验设计：病人和分组,1846例在透患者，分布于72个透析中心随机分到四组平均随访观察2.8年（16）,N Engl J Med 2002;347:2010-9.,45,HFD,过高透析剂量不能进一步改善预后,N Engl J Med 2002;347:2010-9.,46,HFD,47,关于Kt/V的指南,Kt/Vurea 至少1.2 (single-pool）”.血液透析的处方剂量应使Kt/V达到 1.3”,K/DOQI,尿毒症患者，每周3次血液透析治疗，目标eKt/V至少1.2. 女性和合并症的患者可考虑更高，到1.4。,ERA-EDTA,Ref: Tattersall et al, NDT 2007,Kt/V目标实现过程中的临床变化,48,目标实现,透析不充分,透析资源浪费,US Clinic Example 美国临床案例,临床如何评估Kt/V？,49,读取处方,抽血检查,处方更新,每次治疗，156次/年,每次治疗，156 次/年,1次/月，12次/年,实施治疗,透析过程并非一帆风顺,50,透析过程并非一帆风顺,各种警报,血管通路,各类患者事件,各种延误,所有这些缺陷会导致,仅仅每月检查Kt/V的局限性,51,无法及时评估每次治疗传递的透析剂量的有效性Kt/V减低却不能发现，直到下一次验血很难判定改善治疗的最佳投入方案,实时监测和控制透析剂量,AK96的Diascan提供在线尿素清除率测量装置，实时在线检测尿素清除率/Kt/V了解所有治疗、每次治疗、每一个患者透析剂量是否合适 即便在某些无法验血的情况,52,Am J Kidney Dis. 2008 Jul;52(1):85-92,53,AK96的Diascan在线尿素清除率测量装置实时在线检测尿素清除率/Kt/V了解所有治疗、每次治疗、每一个患者透析剂量是否合适， 即便在某些无法验血的时间,Conductivity,如何实时监测并控制透析剂量？,透析机功能组件的临床使用,背景血容量监测透析充分性监测血温监测血压监测总结,2017/12/21,Dialysate Safety,54,Its the temperature that matters,The physiology of body temperature control,Resting EnergyExpenditure (REE)300 kJ / hour heat generation,Radiation 60%Evaporation 22%Conduction 18% heat dissipation,MechanismsVasodilatation/VasoconstrictionSweatingShivering,Thalamic temperaturecontrol centre,0,20,40,60,80,100,0,5,10,15,Cardiac Output,l/min,Diastolic Blood,Pressure,mmHg,Total Peripheral,Resistance rel.,units,Wezler et al., 1943,CO increasing,Incomplete BP,compensation,TPR decreasing,Effects of HD and UF on Thermal Balance,Heat exchange at the dialyser and ECCthermal gain or loss depending upon dialysate temperature, length of blood tubing etcVascular response to UFreduced capacity to dissipate heat due to peripheral vasoconstrictionheat gainCatabolic effects of interaction with membrane and dialysate contaminantstendency to generate excess heat,Net effect of standard dialysis at dialysate temperature 37C and moderate UF is for a rise in body core temperature,Ultrafiltration BV Skin perfusion TPR,REE Core T Skin perfusion TPR,Physiological conflict in HD / UF - control of total peripheral vascular resistance,Conflict,Temperature rise caused by vasoconstriction,Vasoconstriction,MG960426,Hypotensionwarm shock?,Why not just use cooler dialysate?,TB ini C,35.5,36.0,36.5,37.0,37.5,38.0,0,5,10,15,20,patient no.,25,# treatments: 81,Tattersall 1993,Body temperature variance,Tatterasall et al., 1993,Standard dialysate temperature = 36.5C,Body temperature response to HD,Yu et al., Kidney Int., 48(1995), 237-243,Vascular resistance is critical,Argumentation for biofeedback control of thermal energy balance,Body T is normally distributedT response to HD / UF variableHD raises core body T UF impairs T dissipation at the skinUF and T induce conflicting effects on peripheral vascular resistance T induces hemodynamic instability,ART,VEN,UFcontrol,Heatercontrol,Patient,BTM,BVM,Dialyzer,Hydraulic system,BTM in feedback loop, = * c * Qb(Tven - Tart),Options for BTM in control mode,Thermal controlSet gainlossstablecore body T,Energy balance controlSetgainlossstablethermal energy exchange,BTM in Temperature control mode,Wizemann and Kraemer, 1993, unpublished,BTM - monitoring mode,Wizemann and Kraemer, 1993, unpublished,BTM - temperature control mode,Body temperature and Energy transfer during HD (measured by BTM),van der Sande et al Am J Kidney Dis 1999 33 1115-1121,BP responses to dialysis-induced Energy transfer,van der Sande et al Am J Kidney Dis 1999 33 1115-1121,Thermal dynamics of iso-UF,van der Sande et al ISBP Prague 1999 (Blood Purif 1999; 17: 213,Thermal balance and vascular resistance,van der Sande et al ISBP Prague