1、Anatomy of The Peritoneum,The lining of the abdominal cavity Two layers: parietal(壁層） - lines the anterior wall and undersurface of the diaphragm - 20% of total SA; blood supply from abdominal wall visceral（臟層） - covers the abdominal organs - 80% of total SA; blood supply from mesenteric aa and port

2、al vv Gokal R, Textbook of PD, pp. 61-70,Anatomy of The Peritoneum,Size 1.5 2 m2; approximates BSA Highly Vascular Semi-permeable/bi-directional “Lymphatic” drainage through diaphragmatic stomata（腹膜孔） Continuous with Fallopian Tubes（輸卵管） in females,It is important to be aware of the continuity of th

3、e peritoneal cavity with the Fallopian tubes as retrograde menstruation（逆行性月經(jīng)）- which may occur in any woman but goes undetected- will cause bloody dialysate and create concern in the PD patient.,Transport Processes in PeritonealDialysis,Osmosis（滲透）- Movement of water from an area of higher concentr

4、ation (lower solute concentration) to an area of lower concentration (higher solute concentration),Diffusion（擴(kuò)散）-Movement of solute from an area of higher concentration to an area of lower concentration,Models of Peritoneal Transport,The three pore model The pore- matrix model The distributed model,

5、These models are not mutually exclusive; rather they should be viewed as complementary to one another.,Transport Across the Peritoneal Endothelium:The Three Pore Model, Large pores (100 - 200 ) few in number (3% of SA) transport macromolecules clefts between endothelial cells Small pores (40 - 60 )

6、most numerous (95% of SA) allow transport of small solutes and water postulated to be clefts in the endothelium; have not been demonstrated anatomically Based,Transport Across the Peritoneal Endothelium:The Three Pore Model (續(xù)),Ultrasmall (transcellular) pores (4 - 6 ) many in number (but only 2% of

7、 SA) transport water only (Na sieving) Demonstrated to be AQP 1 （水通道蛋白）,Water Transport in Aquaporin- 1Knockout Mice,Yang et al. AJP 276:C76, 1999,問(wèn)題：如果反復(fù)在90分鐘放出腹透液，對(duì)病人電解質(zhì)會(huì)產(chǎn)生什么影響？,Ultrafiltration in PD:The Pore-Matrix Model,多糖包被，細(xì)胞衣,Effective Peritoneal Surface Area,Increased “effective” peritoneal

8、surface area may occur: During peritonitis After prolonged exposure to high glucose-containing fluids,這就是為什么腹膜炎時(shí)和長(zhǎng)期透析后“PET高轉(zhuǎn)運(yùn)的原因！,Kt/V (HD) = ln(R.008xt)+(43.5xR)x0.55UF/W,Adequacy is a concept, not a number, and includes more than the issues listed above.,Fun fact: Urea was discovered by Hilaire Ro

9、uelle in 1773. It was the first organic compound to be artificially synthesized from inorganic starting materials, in 1828 by Friedrich Woehler.,殘腎GFR 計(jì)算,殘腎GFR=（腎尿素清除率+ 腎肌酐清除率）/2； 腎尿素清除率（ml/min）=（尿尿素血清尿素）24 h 尿量 1 440 腎肌酐清除率（ml/min）=（尿肌酐血清肌酐）24 h 尿量 1 440 尿尿素和血尿素的單位為mmol/L，尿肌酐和血肌酐的單位為mol/L，尿量單位 為ml。

10、,Kt/V 計(jì)算,每周總Kt/V （每日腹膜透析Kt/V+ 每日殘腎Kt/V） 每周透析天數(shù),男性成年：V=2.447-0.095 16 年齡（yr）+0.1704身高（cm）+0.336 2體重（kg） 女性成年：V=-2.097+0.106 9 身高（cm）+0.246 6 體重（kg）,Ccr 的計(jì)算,總Ccr= 殘腎Ccr+ 腹膜Ccr,何謂“充分的”治療,避免過(guò)量水負(fù)荷 血壓控制良好 保護(hù)殘存腎功能 營(yíng)養(yǎng)良好 控制血磷 酸堿平衡 糾正貧血 清除足夠的尿毒癥毒素沒(méi)有尿毒癥相關(guān)癥狀,However, Hong Kong Data suggest,46,Lo WK, et al, PDI

11、1996;16:S163-166,With a usual prescription of 3 x 2 liters, patients survival was excellent; Even accounting for body size i.e. use Kt/V, at lower dose of dialysis, results were superior,*,ADEMEX: Treatment CharacteristicsEffects of Intervention,47,Paniagua et al. JASN 2002; 13(5):1307-20,ADEMEX: Pr

12、imary Outcome,48,Paniagua et al. JASN 2002; 13(5):1307-20,Preservation of RRF provides a survival advantage in PD patients,Bargman, et al. JASN 2001;12:2158-2162,A reanalysis of the CANUSA Study,K/DOQI 2006 Kt/V urea 1.7 for all types of PD No Creatinine Clearance Target Continuous Therapy (middle m

13、olecule clearance) ISPD 2006 Kt/V urea 1.7 for CAPD and APD Creatinine Clearance 45L/wk for APD Continuous Therapy (middle molecule clearance) China PD Practice Guidelines - 中華腎臟病雜志 2006;22(8):513 - 516 - KtV urea 1.5-1.7 Creatinine Clearance 40-50L/wk Continuous Therapy for anurics,透析充分性的推薦PD Adequ

14、acy Targets,Kt/V與CrCl的差異,kt/V以V或尿素分布容積來(lái)校正， CrCl 以BSA來(lái)校正 通常 kt/V 1.7 相當(dāng)于每周CrCl 50 升 但是兩者常常并不匹配，甚至出現(xiàn)很明顯的差異 原因很多,Kt/V與CrCl的差異,殘余腎功能-對(duì)肌酐清除率的影響比對(duì)尿素清除率的影響大-小管分泌與小管重吸收 轉(zhuǎn)運(yùn)特性-低轉(zhuǎn)運(yùn)的病人肌酐清除率明顯低于尿素清除率，轉(zhuǎn)運(yùn)狀態(tài)對(duì)肌酐清除率的影響大,Kt/V與CrCl的差異（續(xù)）,短時(shí)留腹方案 （如APD） - 白天干腹APD的肌酐清除率相對(duì)低于尿素清除率 - 平衡時(shí)間短對(duì)肌酐清除影響更大 身體體積的增加使V的增加多于BSA 的增加，因而Kt

15、/V的減少比肌酐清除率的減少明顯,常用透析方式,持續(xù)性不臥床腹膜透析（CAPD） 持續(xù)循環(huán)式腹膜透析（CCPD） 間歇性腹膜透析（IPD）,經(jīng)驗(yàn)處方,根據(jù)患者體型、殘腎功能狀況 2升袋裝透析液每日交換3-5次 24小時(shí)，一周七天持續(xù)透析,決定腹膜清除率的重要因素,腹膜轉(zhuǎn)運(yùn)特性 總灌入量 總超濾量 腹透液留置時(shí)間 個(gè)體因素（體形、性別、年齡）,如何提高PD中的腹膜清除率,最大限度延長(zhǎng)PD時(shí)間(如保持濕腹) 最大限度增加濃度梯度 增加交換次數(shù)(如APD) 增加透析液量(如 2.5 L和3 L) 最大限度增加有效腹膜表面積 增大透析量(如 2.5 L和 3 L) 血管活性物質(zhì)？ 最大限度增加液體清除

16、量 最大限度增加超濾量 盡量減少液體吸收？,增加留腹液量,提高清除率的最有效的方法 彌散梯度保持較久,腹膜有效面積增加 2L的溶質(zhì)水平達(dá)到平衡時(shí)間比1.5L輕度延長(zhǎng) 腹內(nèi)壓力的增加為限制因素 機(jī)械副作用,增加交換的次數(shù),可以同時(shí)增加溶質(zhì)清除（劑量增加）和水分清除能力（留腹時(shí)間縮短） 由于留腹時(shí)間縮短，限制了溶質(zhì)達(dá)到平衡的時(shí)間，效能可能較低 患者順應(yīng)性下降、費(fèi)用上升,提高透析液張力,增加超濾量，繼而提高清除率 長(zhǎng)期高糖透析液應(yīng)用注意隨訪高血糖、高血脂、體重及腹膜功能 不是提高溶質(zhì)清除的最佳選擇,PD病人的小分子溶質(zhì)清除情況,清除率是指單位時(shí)間內(nèi)有多少（毫升）血漿中的某種溶質(zhì)被清除 腹透時(shí)它是腹膜

17、清除率和殘腎清除率的總和 腹膜清除率=溶質(zhì)彌散量+溶質(zhì)超濾量-液體吸收量，因此在腹透液留腹期間是變化的 每日腹膜清除率=每日透析液引流量 當(dāng)日溶質(zhì)D/P比值,PD病人的小分子溶質(zhì)清除情況,PD時(shí)殘腎清除率比HD時(shí)更重要，因?yàn)镻D時(shí)殘腎清除率占總清除率的比例更大，而且這種情況持續(xù)很長(zhǎng)時(shí)間 PD清除率根據(jù)病人的體積大小進(jìn)行校正 總體水量(V)校正尿素清除率 1.73 m體表面積(BSA)校正肌酐清除率 V 和 BSA 通常根據(jù)體重、身高、性別等因素用公式進(jìn)行估計(jì) PD 清除率通常每天測(cè)定，但用每周表示,腹膜透析中鈉的清除,鈉濃度 血清:135-145 mEq/L 透析液 : 132 mEq/L 鈉

18、清除 依賴濃度梯度的彌散作用 超濾伴隨的對(duì)流轉(zhuǎn)運(yùn) 鈉篩 水分轉(zhuǎn)運(yùn)：小孔和水孔蛋白 鈉的轉(zhuǎn)運(yùn): 小孔,留腹期間總鈉清除（鈉篩現(xiàn)象）,在留腹初期，因?yàn)樗值那宄^(guò)鈉的清除，透析液中鈉的濃度逐漸降低 留腹晚期，隨著超濾減少和彌散梯度增加，鈉的彌散清除逐漸增加 因此，留腹后期，血清鈉下降而透析液鈉增加 1.5% 葡萄糖 x 4 hrs 清除 5 mEq Na 4.25% 葡萄糖 x 4 hrs 清除鈉 70 mEq,0,100,200,300,400,500,115,120,125,130,135,140,7.5% D,3.86% G,1.36% G,Dialysate sodium, mmol/liter 透析液鈉濃度,Time, min 時(shí)間，分,計(jì)算機(jī)模擬透析液鈉濃度的模式,Rippe and Levin. Kidney Int 57(6): 2546-56, 2000,不同透析液中透析液/血漿(D/P)鈉平衡曲線,0,60,120,180,240,300,360,Time, min,0.80,0.85,0.90,0.95,1.00,D/P