血液透析治疗模式的选择和评价课件

此ppt下载后可自行编辑血液透析治疗模式的选择和评价

基本原理

溶质清除机制

弥散﹙diffusion﹚

溶质浓度梯度—成正比溶质分子大小—成反比

对流﹙convection﹚

随溶剂的跨膜运动而转运溶质分子大小成反比超滤率及筛选系数决定转运速率吸附﹙absorption﹚

水份清除机制

超滤系数﹙Kuf﹚

跨膜压(TMP)

Classificationofartificialmembranes

usedforbloodpurificationtherapyWaterpermeabilitySolutepermeabilityBiocompatibilityMaterial/PolymerRegeneratedcelluloseModifiedcelluloseSyntheticLow-flux﹙Kuf<15ml/mmHg·hr﹚High-flux﹙Kuf>15ml/mmHg·hr﹚Forsmallsolute→KoA﹙e.g.BUN﹑Scr﹑UA﹚Forlargersolute→SC﹙e.g.β2-MG﹚Qualitativemeasures1970s wasonenhancingthesolutediffusiveandwaterremovingpropertiesofthemembranes1980s theemphasishasbeenonconvectivetransport,absorption,andbiocompatibilityHistoricalOverviewEFFICIENCYBIOCOMPATIBILITY

TechnologiesConvectionDiffusionDiffusion+ConvectionMembranesModifiedCelluloseCelluloseSyntheticLong-termresultsinhaemodialysistherapy(Relationshipbetweenmembranes,technologies,efficiencyandbiocompatibility)CRRTcontinuousambulatoryperitonealdialysis(CAPD)continuouscyclicalperitonealdialysis(CCPD)slowcontinuousultrafiltration(SCUF)continuousarterio-venoushemofiltration(CAVH)continuousarterio-venoushemodialysis(CAVHD)continuousarterio-venoushemodiafiltration(CAVHDF)continuousvono-venoushemofiltration(CVVH)continuousvono-venoushemodialysis(CVVHD)continuousveno-venoushigh-fluxdialysis(CVVHFD)continuousvono-venoushemodiafiltration(CVVHDF)BloodPurificationProcedurescontinuousintermittentIRRTintermittentperitonealdialysis(IPD)hemoperfusion(HP)hemoconcentrationplasmapheresishemodialysis(HD)hemofiltration(HF)hemodiafiltration(HDF)

水分迅速减少组织器官血供障碍血浆渗量骤然下降血压不平稳或诱发肺水肿生理代偿机制加重或诱发心衰血/膜反应SIRSIRRT对血流动力学影响CRRT与IRRT比较改善心血管稳定性维持脑灌注控制高分解代谢维持水电解质和酸碱平衡为营养支持创造条件重症ARF已首选CRRTH2OwatersolublemoleculesHFBHDBDBDHDFmmHgBBF,Dlow-fluxFilterhigh-fluxorFilterdiffusionconvectiondiffusion/convectionmmHgBmmHgmmHgFDmmHgmmHgHFHDHDFKidney104ß2-MGC3a、C5aIT-1TNFVit.B12LipidABunCrUAclearance﹙ml/min﹚12080400101031020MW﹙Da﹚105AlbLpsMethodologiesPatientMaterials“Ancillary”therapyCost？FactorsaffectingrenaldialysistherapyresultsheparinAVPVPAUFBLDSADRheaterhigh-fluxHFPredilutionPostdilutionheparinAVPVPADUFDBLDSADheaterhigh-fluxHigh-fluxHDRheaterheparinVVPVPADUFDBLDSADhigh-fluxHDFPostdilutionPredilutionReplacementSolutionContinuousIntermittentDialysisTreatmentRRT的抗凝

方法

优点

问题

功效

监测全身

普通肝素低分子肝素抗凝良好↓血小板减少症出血、血小板减少出血良好良好PTT∕ACTAnti-Xaactivity局部

肝素化+鱼精蛋白中和枸橼酸前列腺环素+（低剂量肝素）减少出血出血危险最少降低出血危险过敏反应、不可靠代谢失调、需特殊透析液严重高血压良好特好不足PTT∕ACTPTT∕ACTThrombelastpgraph无肝素

盐水冲洗无出血危险滤过膜凝血不足

～低分子肝素的优势低分子肝素>1长固定高无需低小抗Xa:IIa活性比值血浆半衰期清除率生物利用度需aPTT监测对PF4的敏感性对血小板抑制作用普通肝素=1短不固定低需要高大

低分子肝素对血透中的影响UFHLMWH（Fraxiparine)ACT延长倍数1.7～2.01.1～1.3PTT延长倍数2.4～2.71.3～1.7血肌酐变化(1、4次)64.2%、64.1%62.7%、61.9%透析器无凝血例数15.9%21.6%管路滤网凝血20.5%22.3%穿刺点压迫时间8分钟6分钟透析器复用情况4次/个4次/个HeparinisationinRRTBleedingRiskInitial(IU∕㎏)Continuous(IU∕㎏∕h)PTT(sec.)ACT(sec.)NoRisk102.5～530<120SmallRisk15～255～1045160～180HighRisk5010～2060～250ComplicationsV×C﹙Kd+Kr﹚·CG堆积＝产生－清除摄入﹙产生﹚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PCRnPCRBUNKt/VURR血液透析动力学模型综合评价806040200

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SUNBUN﹙㎎/dL﹚weeknPCRKt∕VTACDelivered:3times/weekTd>4hrsU.F.≈0.05×WtTarge: