最新血液透析治疗模式的选择及评价课件PPT文档

1、基本原理基本原理溶质清除机制溶质清除机制弥散弥散diffusion 溶质浓度梯度溶质浓度梯度成正比成正比 溶质分子大小溶质分子大小成反比成反比 对流对流convectconvection 随溶剂的跨膜运动而转运随溶剂的跨膜运动而转运 溶质分子大小成反比溶质分子大小成反比 超滤率及筛选系数决定转运速率超滤率及筛选系数决定转运速率 吸附吸附absorption水份清除机制水份清除机制超滤系数超滤系数kuf跨膜压跨膜压(tmp)(tmp) water permeability solute permeability biocompatibility material/polymer regenera

2、ted cellulose modified cellulose synthetic low- fluxkuf 15 ml/mmhghr for small solute koa e.g. bunscrua for larger solute sc e.g. 2-mg qualitative measures1970s was on enhancing the solute diffusive and water removing properties of the membranes1980s the emphasis has been on convective transport, ab

3、sorption, and biocompatibilityefficiencybiocompatibility convectiondiffusiondiffusion+convectionmodified cellulosecellulosesynthetic(relationship between membranes,technologies,efficiency and biocompatibility)continuous ambulatory peritoneal dialysis (capd)continuous cyclical peritoneal dialysis (cc

4、pd)slow continuous ultrafiltration (scuf)continuous arterio-venous hemofiltration (cavh)continuous arterio-venous hemodialysis (cavhd)continuous arterio-venous hemodiafiltration (cavhdf)continuous vono-venous hemofiltration (cvvh)continuous vono-venous hemodialysis (cvvhd)continuous veno-venous high

5、-flux dialysis (cvvhfd)continuous vono-venous hemodiafiltration (cvvhdf)continuousintermittentintermittent peritoneal dialysis (ipd)hemoperfusion (hp)hemoconcentrationplasmapheresishemodialysis (hd)hemofiltration (hf)hemodiafiltration (hdf) 水分迅速减少水分迅速减少 组织器官血供障碍组织器官血供障碍 血浆渗量骤然下降血浆渗量骤然下降 血压不平稳或诱发肺水肿血

6、压不平稳或诱发肺水肿 生理代偿机制生理代偿机制 加重或诱发心衰加重或诱发心衰 血血/膜反应膜反应 sirs irrtirrt对血流动力学影响对血流动力学影响crrt与irrt比较 改善心血管稳定性改善心血管稳定性 维持脑灌注维持脑灌注 控制高分解代谢控制高分解代谢 维持水电解质和酸碱平衡维持水电解质和酸碱平衡 为营养支持创造条件为营养支持创造条件 重症重症arf已首选已首选crrth2owater soluble moleculesbbdbdmmhgbbf,dlow-fluxfilterhigh-flux or filtermmhgbmmhgmmhgfdmmhgmmhghfhdhdfkidne

7、y1042-mgc3a、c5ait-1tnfvit. b12lipidabuncruaclearance ml/min12080400 10 103 102 0mwda105alblpsmethodologiespatientmaterials“ancillary”therapycost？heparinavpvpadufdbldsadheaterlow-fluxstandard surface 1.21.5 m2 qb 250 ml/min qd 500 ml/min td 4 hr 高高效效血血液液透透析析 surface 1.5 m2 qb 300400 ml/min qd 600800

8、ml/min td 23 hr heparinavpvpa评价评价 good elimination of middle and large molecules good filtration complex machinery expensive fluid balance complicated 特点特点 高通量透析器或滤过器高通量透析器或滤过器 对流清除为主对流清除为主 qb =250 ml/min qi =250 ml/min qd =500 ml/min 不需要置换液不需要置换液 评价评价 elimination of a wide molecular range simpler a

9、nd cheaper fresh and purity dialysate fluid balance complicated systemic inflammatory response rheaterheparinvvpvpadufdbldsadhigh-flux特点特点 高通量透析器高通量透析器 对流对流+弥散清除为主弥散清除为主 qb =250 ml/min qd .= 500 ml/min qi 1长长固定固定高高无需无需低低小小抗抗 xa:iia 活性比值活性比值血浆半衰期血浆半衰期清除率清除率生物利用度生物利用度需需 aptt 监测监测对对 pf4 的敏感性的敏感性对血小板抑制作

10、用对血小板抑制作用普通肝素普通肝素=1短短不固定不固定低低需要需要高高大大 低分子肝素对血透中的影响低分子肝素对血透中的影响i nterm i ttent1. hypotensi on2. arrhythm i a3. hem ol ysi s4. m uscl e cram ps5. ai r em bol i sm6. dysequi l i bri um syndrom7. fl ui d lung8. hyperkal i em i a9. hypertensi onconti nuous1. fl ui d bal ance error2. fi l ter cl otti ng3.

11、 low tem perature4. access probl em s5. coagul ati on probl em s6. hypotensi on7. i nfecti on/sepsi s8. ai r em bol i sm9. di sconnecti onvckd+krcg堆积产生清除堆积产生清除摄入产生摄入产生堆积分布堆积分布其中: g -尿素产生的速率 v -体内尿素的分布容积 c -血液尿素的浓度 kd -透析器的廓清率 kr -残存肾功能的廓清率 清除清除pcrnpcrbunkt/ vurr80 60 40 20 0120100sun mon tue wen tue

12、 fri sat sun/dlnpcrktv tacdelivered: 3 times/ week td4hrs u.f. 0.05wttarge:kt/ v1.2 npcr1.1g/day tac50/dlsurvivalmorbiditynutritional statusmetabolic alterationshospitalization time memberanememberane substitutionsubstitution sub./dia. flowsub./dia. flow blood flowblood flow hdhd low-flux lac./bic.

13、as dialysate dia. 500 ml/min 200-300 ml/min h hf fd d high-flux bic. as dialysate dia. 500-800 ml/min 250ml/min hfhf high-flux or filter bic. sub. 5000 ml/h 250ml/min hdfhdf high-flux bic. sub. 5000 ml/h 250ml/min scufscuf high-flux - - 100-150 ml/min cvvhcvvh high-flux or filter bic. sub. 500-2000 ml/h 100-150 ml/min cvvhdcvvhd dialyzer or filter lac./bic. as dialysate dia. 500-2000 ml/h 100-150 ml/min cvvhdfcvvhdf high-flu