[精品]血液透析原理及临床适应症

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1、血液透析原理及臨床適應症台大醫院外科部護理師蔡壁如EvolutionofRenalReplacementTherapyAbel,1913FirstdialysisofanimalKolff,1945FirstdialysisinhumanTeschan,1950sDailydialysisinKoreanwarSince1960sChronic,intermittenthemodialysis(IHD)(24hrsq.w.10-16hrsb.i.w.-4-6hrst.i.w.)Dailydialysis?Kramer,1977FirstCRRT(CAVH

2、)1994AutomatedCRRTCRRTorSLEDD?BasicPrincipleofRenalReplacementTherapyDiffusionSolutefromhigherconcentrationtolowerconcentrationUltra-filtrationFluidtroughsemi-permeablemembranedrivenbypressuregradientConvectionSoluteandfluid(Dependingonmolecularweightandsize)byultra-filtrationAds

3、orptionMolecularadhesiontoinnersurfaceofsemi-membraneNEJM336:1303-1309DiffusionUltra-filtrationConvectionAdsorptionMolecularweightsMoleculessizesMoleculesSizeLow-FluxMembraneHighFluxMembrane20000IL-1,IL-8,TNF-aIL-6Molecularweightscut-offs<30000>IL-6,TNF-αIL-1,IL-8Clearance=QFxSCQ

4、F=filtrationamountSC=sievingcoefficientsHemodialysisNEJM336:1303-1309HemofiltrationNEJM336:1303-1309ComponentofrenalreplacementtherapyMembraneVascularaccessAnti-coagulantDialysateRenalreplacementfluidChoiceofmembraneSubstitutedcellulosedialyzers:hydroxylgroupCelluloseacetate,diac

5、etate,triacetateSyntheticdialyzers:Polysulfone(PS)Polyamide(PA)Polyacrylonitrile(PAN)Polymethylmethacrylate(PMMA)AmericanJournalofKidneyDisease,Vol35,NO5(May),2000:pp980-991ChoiceofmembraneBiocompatiblemembrane(activatelesscomplementandgreaterhigher2-microglobulinclearance,great

6、erhydraulicpermeability.lowandhigh-fluxsyntheticmembranes)HypotensionandprolongationofARFinbiocompatiblemembranesAdsorptivevs.nonadsorptivemembraneinCRRTAmericanJournalofKidneyDisease,Vol35,NO5(May),2000:pp980-991VascularaccessGradeC:avoidedsubclavianinadultsGradeD:avoidedfemoral

7、veininneonatesandyoung(femoralveinthrombosisisasignificantproblem)GradeC:InternaljugularveinLevelIIandIIIstudies:UltrasoundguidanceRe-circulationislikelytobesignificantforbloodflowinexcessof200c.c/min,butdependingoncatheterdesignandlocationThefirstinternationalconsensusconference

8、onCRRT,2002Doublelumen:Re-circulationrat