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1、長(zhǎng)時(shí)間血液透析的益處,盧方平 2009-4-30,病例報(bào)告,姓名 龐潔 性別 女 年齡25歲 民族 漢族 因維持性血液透析5年半，大量腹水1年3個(gè)月于2008年9月轉(zhuǎn)入我院繼續(xù)治療。,患者于2002年底因“肺結(jié)核”在外地抗結(jié)核治療（免費(fèi)藥）中出現(xiàn)腎損害，腎功能減退，伴腎性貧血與高血壓，用中藥治療無(wú)效后于2003年4月在北京某醫(yī)院接受血液透析治療（5次/2周3次/周，每次4小時(shí)）。血管通路為中心靜脈半永久導(dǎo)管。透析半年后殘余腎功能喪失（尿量為）2007年6月發(fā)現(xiàn)腹水。2007年8月中心靜脈半永久導(dǎo)管感染，而后改為左前臂動(dòng)靜脈內(nèi)瘺。雖經(jīng)抗感染治療與多次放腹水（最多放4000ml），此后腹水進(jìn)行性加

2、重，于2008年9月轉(zhuǎn)入我院。,既往史：9歲時(shí)曾患甲亢，已治愈。年前患乙型肝炎。對(duì)他巴唑過敏。無(wú)食物過敏史。有輸血史。,體 格 檢 查：慢性病容，貧血貌。營(yíng)養(yǎng)狀態(tài)差。未見肝掌、蜘蛛痣。全身淺表淋巴結(jié)未及。瞼結(jié)膜蒼白，鞏膜無(wú)黃染。無(wú)頸靜脈怒張。胸廓未見異常，雙側(cè)呼吸運(yùn)動(dòng)對(duì)稱，語(yǔ)顫雙側(cè)對(duì)稱，雙肺呼吸音粗，未聞及干濕羅音。心前區(qū)無(wú)隆起，心尖搏動(dòng)位于第五肋間左側(cè)鎖骨中線外側(cè)0.5cm處,搏動(dòng)范圍無(wú)彌散, 心率108次/分，律齊，未聞及病理性雜音。腹部平坦腹膨隆,無(wú)壓痛，肝脾觸診不滿意，全腹叩診呈濁音，移動(dòng)性濁音（+），腹水征（+），腸鳴音聽診不理想。雙下肢水腫（-）。,腹部B超：雙腎萎縮，雙腎彌漫性病

3、變，腹盆腔多量積液。盆腔深20cm。 腹部CT：肝臟外形規(guī)整，各葉比例正常范圍內(nèi)，肝實(shí)質(zhì)內(nèi)未見異常密度。肝內(nèi)外膽管未見擴(kuò)張及結(jié)石。,2008-4-7北京xx醫(yī)院 1.肝大:劍下5.4cm,肋下1.0cm,右肝斜徑16.7cm 2.肝靜脈增寬:左1.6cm,中1.2cm,右1.6cm 3.脾大:厚4.7cm,長(zhǎng)14.2cm,肋下3.9cm 4.腹腔大量積液:9.3cm,化驗(yàn)檢查提示有重度貧血（Hb57g/L）、 繼發(fā)性甲狀旁腺功能亢進(jìn)（PTH 155.7pmol/L）、 微炎癥狀態(tài)(CRP 43.7mg/L)、 低蛋白血癥（ALB 34.6g/L） 鐵負(fù)荷過多,腹水常規(guī),腹水生化,腹水培養(yǎng)陰性,

4、轉(zhuǎn)入我院后繼續(xù)行常規(guī)血液透析治療。每次透析最大超濾量3.2Kg，較多發(fā)生透析低血壓，患者體力、精神、食欲均較差。,存在的問題,透析不耐受 透析不充分 心功能不全 肝臟疾病 嚴(yán)重貧血 繼發(fā)性甲狀旁腺功能亢進(jìn) 微炎癥狀態(tài) 營(yíng)養(yǎng)不良 低蛋白血癥 大量腹水 鐵負(fù)荷過多,根據(jù)臨床癥狀、體征及輔助檢查，考慮腹水的原因?yàn)槟I性腹水（透析相關(guān)性腹水），可能與透析不充分有關(guān)。因此我們決定改變患者的透析方案。10月30日用高通量透析器（Fresenius FX60）做日間長(zhǎng)時(shí)間透析治療，透析頻率仍為每周3次，但每次透析延長(zhǎng)至8小時(shí)。,的變化,血紅蛋白的變化,鐵參數(shù)的變化,血白蛋白的變化,血磷變化,鈣磷乘積,腹水的變

5、化,腹部B超（2008.10.14） 20cm 2008.11.28 10.5cm 2008.12.26 14.9cm 2009.2.2 8.6cm,超濾量增加：一次透析最大超濾量.Kg，未發(fā)生低血壓 臨床狀況改善：患者精神、食欲、體力等均有明顯改善 干體重下降,毒素清除,URR 79.3 %-84.96% KT/V 1.63-1.76 2MG 16.10ug/ml（透前）- 12.9ug/ml（透后）,清華一付院.mpg,透析時(shí)間問題?,Blood Purif 2007;25:9098 Treatment Time and Ultrafiltration Rate Are More Impo

6、rtant in Dialysis Prescription than Small Molecule Clearance Zbylut J. Twardowski Department of Medicine, Division of Nephrology, University of Missouri, Columbia, Mo. , USA Kt/V urea Should Be Abandoned as a Measure of Dialysis Quality,DOPPS Background,(1) longer HD session duration is independentl

7、y associated with lower mortality, (2) a synergistic mortality-reducing interaction exists between Kt/V and TT (i.e., more pronounced RR reduction at higher Kt/V combined with longer TT), (3) a faster rate of fluid removal at dialysis as measured by UFR10 ml/h/kg body weight is associated with both

8、higher risk of mortality and increased odds of intradialytic hypotension.,長(zhǎng)時(shí)間血液透析的方式,長(zhǎng)時(shí)間常規(guī)血液透析(Long conventional hemodialysis,LHD) 長(zhǎng)時(shí)間夜間血液透析(Long nocturnal hemodialysis,LNHD),Increasing dialysis time enables the ultrafiltration rate to be decreased. Increasing session time enables better session tol

9、erance and reduces the risk of dialysis-induced hypotension. correction of hypertension, correction of left ventricularhypertrophy, improvement of ejection fraction in individuals with heart failure, reduction of peripheral resistance, improvement of the vasodilatory response, and reduction of sleep

10、 hypoxemia,長(zhǎng)時(shí)間血液透析對(duì)心血管系統(tǒng)的好處,長(zhǎng)時(shí)間血液透析對(duì)磷平衡的影響,Dialysis time seems to be the most important factor for phosphate clearance,first 2 h, the level of phosphatemia decreases and phosphate removal is maximal; during the next 3 h, both the level of phosphatemia and phosphate removal remain stable. the amount

11、of phosphate removed increased with session time and was significantly higher during the 8 h session than during the 4 h or 6 h sessions.,Chazot C and Jean G (2008) The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessions Nat Clin Pract Nephrol doi:10.1

12、038/ncpneph0979,Figure Achievement of the KDOQI targets for bone mineral metabolism among patients on conventional hemodialysis from the DOPPS (n = 6,864), and from the RhneAlpes area of France (n = 1,842; mean treatment time 4 h 30 min) and patients on long conventional hemodialysis at the Centre d

13、e Rein Artificiel, Tassin, France (n = 195; mean treatment time 6 h 20 min 1 h 15 min),Chazot C and Jean G (2008) The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessions Nat Clin Pract Nephrol doi:10.1038/ncpneph0979,Figure Use of phosphate binders amo

14、ng patients on conventional hemodialysis in the RhneAlpes area of France (n = 1,842; mean treatment time 4 h 30 min) and patients on long conventional hemodialysis at the Centre de Rein Artificiel, Tassin, France (n = 195; mean treatment time 6 h 20 min 1 h 15 min),EFFECTS OF DIALYSIS TIME AND FREQU

15、ENCY ON NUTRITION,Food intake, nPNA, body weight and serum albumin level remained stable for 5 years in prevalent hemodialysis patients who were treated with LHD. Improvements in amino acid profile,EFFECTS OF DIALYSIS TIME ON SURVIVAL,Chazot C and Jean G (2008) The advantages and challenges of incre

16、asing the duration and frequency of maintenance dialysis sessions Nat Clin Pract Nephrol doi:10.1038/ncpneph0979,Figure 4 Cumulative survival of patients who received hemodialysis (data obtained from the US Renal Data System 2005) and patients treated with short daily in-center or home hemodialysis

17、(data pooled from five centers in the US, Italy, France and the UK),Permission obtained from Oxford University Press Kjellstrand CM et al. (2008) Nephrol Dial Transplant doi:10.1093/ndt/gfn210,Causes of inflammation in HD Patient related underlying disease comorbidity, peripheral vascular disease ox

18、idative stress Ca x P metabolism (calcification, fetuin-A) infection (apparent and non- apparent) immunologic genetic nonfunctioning kidney transplants encapsulating peritoneal sclerosis anemia (hepcidin) heart failure obesity tumors physical exercise: sedentary lifestyle,Chazot C and Jean G (2008)

19、The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessions Nat Clin Pract Nephrol doi:10.1038/ncpneph0979,Table 2 Standardized mortality ratios68 for patients who received long conventional hemodialysis at the Centre de Rein Artificiel, Tassin, France, compared with US patients who received conventional hemodialysis,Dialysis technique related retention of inflammatory mediators oxidative imbalance acetate pyrogenic substances of the dialysate complement activation; membranes and other bioincompatible material,謝謝！,