如何透析才算足夠 - tsim.org.tw

1 * * (end-stage renal disease) (renal replacement therapy) (hemodialysis) (peritoneal dialysis) (kidney transplantation) (dialysis adequacy) (American National Kidney Foundation) 2000 (Dialysis Outcome Quality Initiative DOQI) (International Society of Peritoneal Dialysis, ISPD) 2000 / (European Renal Association/European Dialysis and Transplantation Association, ERA/EDTA) 1999 (best practice guidelines) ( Dialysis adequacy ) ( Hemodialysis ) ( Peritoneal dialysis ) ( living ) ( cadaveric ) ( uremic toxin ) ( blood urea nitrogen, BUN ) ( creatinine, Cre ) ( clearance ) ( minimal effective dose ) ( maximal effective dose ) ( optimal dose ) ( dialysis dose ) ( native kidney )

2 ( American National Kidney Foundation ) (Dialysis Outcome Quality Initiative, DOQI ) 80% DOQI 1 ( ) ( ) ( ) ( hernias ) ( ) ( ) (leaks); ( ) ( ) ( ) ( inflammatory or ischemic bowel diseases ) ( ) ( ) ( ) ( diverticulitis ) BUN / Cre ( ) DOQI 2 BUN (Kt/V ) BUN ( Urea reduction ratio, URR ) Kt/V ( single-pool, variable volume ) URR 65% Kt/V ( dynamic kinetic ) K BUN ml/min t Kt BUN V BUN URR ( static kinetic ) Kt/V ( Formal urea kinetic modeling ) Kt/V = - Ln ( R t ) + ( 4 R)

3 UF / W Ln R BUN BUN t UF ( net ultrafiltration ) W URR URR = 100 ( 1 Ct / C0 ) Ct BUN C0 BUN DOQI USRDS Kt/V 7% Kt/V URR 11% URR 3 URR ( ultrafiltration ) BUN ( BUN BUN ) Kt/V 18% URR Kt/V 4 Kt/V ( ) DOQI Kt/V Cre ( Wccr ) ( continuous ambulatory peritoneal dialysis, CAPD ) Kt/V Wccr 60 L/ ( ) 50 L/ ( ) ( continuous cycler-assisted peritoneal dialysis, CCPD ) ( nightly intermittent peritoneal dialysis, NIPD ) Kt/V Wccr 63 66 L/ CCPD NIPD Kt/V / Wccr CANUSA Kt/V 5% 5, Wccr CAPD CCPD NIPD ( opinion ) CAPD ( evidence ) Kt/V Wccr Kt/V = Kpt/V + Krt/V Kpt/V Krt/V Kpt/V = Dun Vd 7 / V Krt/V = Uun Vu 7 / V Dun 24 mg/dl Uun 24 mg/dl Vd 24 dl ( 1 L=10 dl ) Vu 24 dl V ( ) ( )

4 Wason 6 Hume 7 24 Wccr DOQI Kt/V Wccr Kt/V Wccr DOQI Kt/V Wccr Kt/V Kt/V Wccr ( somatic protein ) Kt/V ( albumin ) 8 ( dose-dependent ) g/dl 10-70% ( ) DOQI PNA ( protein nitrogen apperance ) ( protein catabolic rate PCR ) ( subjective global assessment, SGA ) PNA SGA SGA 5 PNA PNA (PCR) = UNA + V PNA = ( UNA + ) UNA ( urea nitrogen appearance ) g/d V Wason 6 Hume 7 PCR ( ) 15 PCR PNA PNA ( ) nPNA ( nPCR ) nPNA g/kg/d ( positive nitrogen balance ) SGA a.

5 B. c. d. 1 7 DOQI 5 SGA g/kg ( high biological value protein ) g/kg 35 cal/kg ( ) ( glomerular filtration rate ) ( interdialysis ) ( time-average body weight ) ( trail-and-error ) ( ) A.

6 50-60 % 30 % Maillous 9 ( comorbidity ) 150/90 mmHg < 130/85 mmHg < 120/80 mmHg B. ( ) ( ) ( sodium profile ) ( sequential dialysis ) ( autonomic dysfunction ) -agonist ( ) D3 1- -hydroxylase D3 ( receptors ) ( sensitivity ) ( high-turnover rate ) ( renal osteodystrophy ) ( mg/dl)

7 ( mg/dl ) 60-70 ( metastatic calcification ) mg/dl 10 ( phosphate binders ) ( calcium carbonate ) Ulcerin-P ( ) Caligel ( ) D3 100-300 pg/ml 11 30 ml/min ( normocytic normochromic anemia ) ( ) (erythropoietin EPO) EPO EPO ( peritubular cortical fibroblast ) EPO ( hyperdynamic state ) ( cardiac output ) EPO ( iron-overloaded ) ( hemochromatosis ) 1985 EPO EPO 12 13 14 15,16 17 EPO EPO Hct ( hematocrit, Hct ) 30% EPO Hct 30% EPO DOQI 18 EPO 80-120 U/kg/week ( 6000 U/week )

8 2-3 Hct 33% ( Hb 11 g/dl ) 36% ( Hb 12 g/dl ) Hct 42% Hct 30% 19 5-10% EPO ( EPO resistance ) ( iron deficiency ) EPO EPO ( functional iron deficiency ) ( ferritin ) ( iron ) ( transferrin or total iron binding capacity ) ( percent transferrin saturation, TSAT = iron / TIBC 100% ) ( percentage of hypochromic RBC ) DOQI Hct ( 33-36% ) TSAT 20% ferritin 100 ng/ml TSAT 50% / ferritin 800 ng/ml / ( European Renal Association/European Dialysis and Transplantation Association, ERA/EDTA ) 1999 ( best practice guidelines ) 20 ferritin 200-500 ng/ml ( TSAT 30-40% ) ERA/EDTA 100-200 mg EPO Hct 25-100mg 4-5 ( )

9 DOQI 21 ( ) ( peritonitis ) ( exit-site infection ) ( tunnel infection ) (1) (2) 100/mm3 50% (3) 22 2000 ( International Society of Peritoneal Dialysis, ISPD ) 22 ( purulent discharge ) ( granulation tissue ) ( )

10 2000 ISPD 23 Rifampin 300 mg 12 mupirocin 7 5 mupirocin 24 / two-cuff Tenckoff one-cuff Tenckoff swan-neck Tenckoff