1、長時間血液透析的益處盧方平2009-4-30長時間血液透析的益處盧方平病例報告姓名 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個月于2008年9月轉入我院繼續(xù)治療。病例報告姓名 龐潔 性別 女 年齡25歲 患者于2002年底因“肺結核”在外地抗結核治療（免費藥）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）。血管通路為中心靜脈半永久導管。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管感染，而后改為左前臂動靜脈內瘺。雖經抗感染

2、治療與多次放腹水（最多放4000ml），此后腹水進行性加重，于2008年9月轉入我院。 患者于2002年底因“肺結核”在外地抗結核治療（免費藥）中出既往史：9歲時曾患甲亢，已治愈。年前患乙型肝炎。對他巴唑過敏。無食物過敏史。有輸血史。既往史：9歲時曾患甲亢，已治愈。年前患乙型肝炎。對他巴唑過體 格 檢 查：慢性病容，貧血貌。營養(yǎng)狀態(tài)差。未見肝掌、蜘蛛痣。全身淺表淋巴結未及。瞼結膜蒼白，鞏膜無黃染。無頸靜脈怒張。胸廓未見異常，雙側呼吸運動對稱，語顫雙側對稱，雙肺呼吸音粗，未聞及干濕羅音。心前區(qū)無隆起，心尖搏動位于第五肋間左側鎖骨中線外側0.5cm處,搏動范圍無彌散, 心率108次/分，律齊，未聞

3、及病理性雜音。腹部平坦腹膨隆,無壓痛，肝脾觸診不滿意，全腹叩診呈濁音，移動性濁音（+），腹水征（+），腸鳴音聽診不理想。雙下肢水腫（-）。體 格 檢 查：慢性病容，貧血貌。營養(yǎng)狀態(tài)差。未見肝掌腹部B超：雙腎萎縮，雙腎彌漫性病變，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，肝實質內未見異常密度。肝內外膽管未見擴張及結石。腹部B超：雙腎萎縮，雙腎彌漫性病變，腹盆腔多量積液。盆腔深22008-4-7北京xx醫(yī)院1.肝大:劍下5.4cm,肋下1.0cm,右肝斜徑16.7cm2.肝靜脈增寬:左1.6cm,中1.2cm,右1.6cm3.脾大:厚4.7cm,長14.2cm,肋

4、下3.9cm4.腹腔大量積液:9.3cm2008-4-7北京xx醫(yī)院化驗檢查提示有重度貧血（Hb57g/L）、繼發(fā)性甲狀旁腺功能亢進（PTH 155.7pmol/L）、微炎癥狀態(tài)(CRP 43.7mg/L)、低蛋白血癥（ALB 34.6g/L）鐵負荷過多化驗檢查提示有重度貧血（Hb57g/L）、腹水常規(guī)日期 SG RBC WBC MONO COENO 2008.10.15 1.0401760 13025% 75% 2008.10.20 1.040滿視野 26 腹水常規(guī)日期 SG RBC WBC MONO COENO 2腹水生化日期 KNaCIGLuTPALBA/GLDH2008.10.15 .

5、2008.10.20 .腹水培養(yǎng)陰性腹水生化日期 KNaCIGLuTPALBA/GLDH2008轉入我院后繼續(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。轉入我院后繼續(xù)行常規(guī)血液透析治療。每次透析最大超濾量3.2K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重貧血繼發(fā)性甲狀旁腺功能亢進微炎癥狀態(tài)營養(yǎng)不良低蛋白血癥大量腹水鐵負荷過多存在的問題透析不耐受根據(jù)臨床癥狀、體征及輔助檢查，考慮腹水的原因為腎性腹水（透析相關性腹水），可能與透析不充分有關。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

6、日間長時間透析治療，透析頻率仍為每周3次，但每次透析延長至8小時。 根據(jù)臨床癥狀、體征及輔助檢查，考慮腹水的原因為腎性腹水（透析的變化的變化血紅蛋白的變化血紅蛋白的變化鐵參數(shù)的變化TF%Ferr2008.10.1669.415002008.11.1624.315002008.12.223.9995.72008.12.2336.7941.72009.1.826.41174.42009.2.329.3883.3鐵參數(shù)的變化TF%Ferr2008.10.1669.415血白蛋白的變化血白蛋白的變化血磷變化血磷變化鈣磷乘積鈣磷乘積腹水的變化腹部B超（2008.10.14） 20cm 2008.11.2

7、8 10.5cm 2008.12.26 14.9cm 2009.2.2 8.6cm腹水的變化腹部B超（2008.10.14） 20cm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 超濾量增加：一次透析最大超濾量.Kg，未發(fā)生低血壓毒素清除URR 79.3 %-84.96%KT/V 1.63-1.762MG 16.10ug/ml（透前）- 12.9ug/ml（透后） 毒素清除URR 79.3 %-84.96%長時間血液透析的益處課件長時間血液透析的益處課件長時間血液透析的益處課件長時間血液透析的益處課件清華一付院.mpg清華一付院.

8、mpg透析時間問題?透析時間問題?Blood Purif 2007;25:9098Treatment Time and Ultrafiltration Rate AreMore Important in Dialysis Prescription thanSmall Molecule ClearanceZbylut J. TwardowskiDepartment of Medicine, Division of Nephrology, University of Missouri, Columbia, Mo. , USAKt/V urea Should Be Abandoned as a Me

9、asure of Dialysis QualityBlood Purif 2007;25:9098長時間血液透析的益處課件長時間血液透析的益處課件DOPPS Background DOPPS Background 長時間血液透析的益處課件長時間血液透析的益處課件長時間血液透析的益處課件(1) longer HD session duration is independently associated with lower mortality,(2) a synergistic mortality-reducing interaction exists between Kt/V and TT (

10、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 higher risk of mortality and increased odds of intradialytic hypotension.(1) longer HD session durati長時間血液透析的方式長

11、時間常規(guī)血液透析(Long conventional hemodialysis,LHD)長時間夜間血液透析(Long nocturnal hemodialysis,LNHD)長時間血液透析的方式長時間常規(guī)血液透析(Long conveIncreasing dialysis time enables the ultrafiltration rate to be decreased.Increasing session time enables better session tolerance and reduces the risk of dialysis-induced hypotension

12、. 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 hypoxemia長時間血液透析對心血管系統(tǒng)的好處Increasing dialysis time enabl長時間

13、血液透析對磷平衡的影響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 of phosphate removed increased w

14、ith session time and was significantly higher during the 8 h session than during the 4 h or 6 h sessions. 長時間血液透析對磷平衡的影響Dialysis time seChazot C and Jean G (2008) The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessionsNat Clin Pract Nephrol doi:10.1038

15、/ncpneph0979Figure Achievement of the KDOQI targets for bone mineral metabolismamong patients on conventional hemodialysis from the DOPPS (n = 6,864), and from the RhneAlpes area of France (n = 1,842; mean treatment time4 h 30 min) and patients on long conventional hemodialysis at the Centre deRein

16、Artificiel, Tassin, France (n = 195; mean treatment time 6 h 20 min 1 h15 min)Chazot C and Jean G (2008) TheChazot C and Jean G (2008) The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessionsNat Clin Pract Nephrol doi:10.1038/ncpneph0979Figure Use of ph

17、osphate binders among 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) Chazot C and Je

18、an G (2008) TheEFFECTS OF DIALYSIS TIMEAND FREQUENCY ON NUTRITIONFood 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 profileEFFECTS OF DIALYSIS TIMEAND FEFFECTS OF DIALYSIS TIMEON S

19、URVIVALEFFECTS OF DIALYSIS TIMEON SUChazot C and Jean G (2008) The advantages and challenges of increasing the duration and frequency of maintenance dialysis sessionsNat Clin Pract Nephrol doi:10.1038/ncpneph0979Figure 4 Cumulative survival of patients who received hemodialysis (data obtained from t

20、he US Renal Data System 2005) and patients treated with short daily in-center or home hemodialysis (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 Chazot C

21、and Jean G (2008) The Causes of inflammation in HD Patient related underlying disease comorbidity, peripheral vascular disease oxidative stress Ca x P metabolism (calcification, fetuin-A) infection (apparent and non- apparent) immunologicgenetic nonfunctioning kidney transplants encapsulating peritoneal sclerosis anemia (hepcidin) heart failure obesity tumors physical exerci