血液透析介紹

1. 血液透析介紹 新光醫院 腎臟科 方昱偉

2. 腎臟功能 • 全年無休24小時工作 • Filtration and reabsorption function: 把身體裡過多的水份、電解質及新陳代謝後的廢物，經由尿液排出身體外 • Endocrine and metabolism function: 分泌腎素、紅血球生成素及活性維生素D3的功能

3. Renal Replacement Therapy

4. Renal Replacement Therapy 透析俗稱洗腎 • HD (hemodialysis)血液透析 • PD (peritoneal dialysis)腹膜透析 • Kid/Trans (kidney transplantation)腎臟移植

5. Transplantation Peritoneal Dialysis Hemodialysis

6. 優缺點

8. 衛生署 CKD 照護計畫 半年追蹤一次 半年追蹤一次 三個月追蹤一次 三個月追蹤一次 二至四週追蹤一次

9. Estimated GFR (I) • Ccr: overestimates GFR (proximal tubular secretion in advanced RF) • Curea: underestimates GFR (urea is reabsorbed in the distal nephron) • When measurement of GFR by a direct test is not available, the average of the sum of the creatinine and urea clearance is recommended. • Ccr (ml/min)= Ucr X V (24-hr urine, ml) ---------------------------------Pcr X 1440 (min)

10. Estimated GFR (II) • Cockcroft-Gault equationIn men:Ccr= (140- Age) X Body weight in kg ------------------------------------------72 X serum CreatinineIn women: men Ccr X 0.85

11. In Taiwan 中央健康保險局 一、長期透析適應症：（請勾選） □ （一）絕對適應症：肌酐酸廓清率 Ccr < 5 ml/min或血清肌酐酸 Cr ≧ 10.0 mg/dl （二）相對適應症： 糖尿病患者：重度慢性腎衰竭且Ccr* ≦15 ml/min或血清Cr ≧6.0 mg/dl 且伴有下列任何一種併發症者 【註：重度慢性腎衰竭之定義為慢性腎衰竭為期至少三個月且腎功能逐漸衰退者】 非糖尿病患者：重度慢性腎衰竭且Ccr* ≦10 ml/min或血清Cr ＞8.0 mg/dl 且伴有下列任何一種併發症者 【註：重度慢性腎衰竭之定義為兩側腎臟顯著萎縮(多囊腎例外)或慢性腎衰竭為期至少三個月且腎功能逐漸衰退者】 二、伴隨症狀：( 請務必勾選) □ 1.心臟衰竭或肺水腫 □ 2.心包膜炎 □ 3.出血傾向 □ 4.神經症狀：意識障礙，抽搐或末稍神經病變 □ 5.高血鉀（藥物難以控制） □ 6.嚴重酸血症(藥物難以控制) □ 7.噁心、嘔吐(藥物難以控制) □ 8.惡病體質(cachexia) □ 9.重度氮血症 (BUN > 100 mg/dl) □ 10.其他 （請說明）：

12. Preparation for dialytic treatment • Explain the timing of complete renal failure and provide forms of available therapy  提早準備 • HD: create an AV fistula in advance • PD: implantation of peritoneal catheter • 減少尿毒所引發不適的症狀與徴後及合併症 • 減少雙腔導管放置時的危險。

13. Principles of Hemodialysis

14. 透析用血管通路 • Blood flow of 200 to 400 ml/min are necessary • Blood from veins is inadequate & repeated puncture of a large artery is not feasible • 暫時性vascular access (by Nep Dr.) • femoral, int. jugular vein, subclavian vein • A double lumen catheter: temporary or semipermanent with cuffs • 永久性vascular access (by CVS Dr.) • A fistula is created (surgically anastamosing a superficial artery and nearby vein) • A prosthetic graft (PTFE: polytetrafluoroethylene), if a native vein is not available because of vessel fibrosis and atrophy (due to prior needling, phlebitis, or other injury)

15. V A Standard of A-V Fistula

16. arterialization of the vein

17. Mechanism of HD • Diffusion (擴散) • bi-directionally across a semipermeable membrane • 與濃度差、膜表面積大小、膜之擴散係數有關 • Ultrafiltration (超過濾) • 因幫浦推動而產生壓力，另外透析液流動製造出負的壓力 • Convection (對流): solvent drag • Absorption (吸附): some of the dialyzers

18. 透析用水水處理 • 積層過濾器 • 軟水器 • 活性碳過濾器 • 逆滲透機 (reverse osmosis) • 5μ及0.2μMicrofilter • 紫外線 • 定期水處理機器維修 • 定期透析用水水質檢驗及細菌培養

19. Carbon filter 2 Multi-media filter Carbon filter 1 0.2 mm filter Dialysis machine DI UV sterilizer Water softener RO purification unit Cartridge filter 5 mm UF filtration UF tank Water source

20. Dialyzer (hollow fiber) • Membrane material is spun into fine capillaries, thousands of which are packed into bundles with blood flowing through capillaries while dialysate is circulated on the outside of the fiber bundle.

21. Types of Artificial Kidney (1)

22. Adequacy of HD • Measure the delivered dose of dialysis • By use of a pre- and post-dialysis urea sample • Urea reduction ratio (URR) or KT/V (K = clearance,T = dialysis time, & V = volume of distribution of the patient) • A URR of 65% and a KT/V of 1.2 per treatment are minimal standards for adequacy • Lower levels of dialysis treatment are associated with increased morbidity and mortality

23. Complications of vascular access • Intimal hyperplasia→stenosis→ thrombosis • Infection (Staphylococcus aureus) • Aneurysm formation, particularly in the prosthetic graft

25. Critical Care Nephrology-continuous renal replacement therapy