医学课件自动化腹膜透析的临床应用.ppt

,*,*,内容,APD,治疗的现状和趋势,APD,和,CAPD,的比较及评价,APD,常见治疗模式,应用人群,展望,APD,：泛指所有以自动化机器代替手 工进行腹透操作的治疗方式,APD%,50%,Denmark,Ireland,Belgium,US,Portugal,Finland,Canada,Australia,Israel,Norway,Netherlands,France,New Zealand,UK,Slovenia,Germany,Spain,20%,HK,Korea,APD%,发达国家,(,依次）发展中国家,(,依次）,50%,Oman,UAE,Tunisia,Brazil,2050%,Poland,Saudi Arabia,Slovakia,Uruguay,Jordan,Turkey,Croatia,”:,好于,2003,1,1999200,1 USRDS,美国,30,000,1,年生存率和技 术生存率,APDCAPD,2006,2,2000200,3 Baxter,美国,40/869,技术生存率,APDCAPD,2008,4,1999200,4,ANZDATA,澳大利 亚,/,新西 兰,2393/173,5,5,生存率和技术 生存率,APD=CAPD,2009,3,1996200,4 USRDS,美国,42,942/23,439,210,生存率和技术,生存率,APD=CAPD,2009,5,1997200,6,NECOSAD,荷兰,562/87,5,生存率和技术 生存率,APD=CAPD,2011,6,20032008,单中心,英国,178/194,5,生存率和技术 生存率,APD=CAPD,1.Kidney Int Suppl2003;(88):S3-12 2.Kidney Int Suppl2006;(103):S133-7 3.Kideny Int 2009;76(1):97 107,-,观察性研究,4.Kidney Int 2008;73(4):480-8,Clin,J Am Soc Nephrol,2009;4(5):943-9,Nephrol,Dial Transplant,2011;26:17021708,Perit Dial Int.2011;31:301-307,Taiwan,19972008,FU 6.4yrs(mean),161APD,121CAPD,APD,组年龄更轻（,52.4 VS 56.3yrs,）,其他（,BMI,DM%,腹膜转运类 型，生化参数及透析充分性）均无差异,死亡率,技术失败率,Nephrol Dial Trans-plant.2010;25:1973-1979,ANZDATA,19992004,FU,6.4yrs(mean),高转运者（,142APD,486CAPD,）,APD,组年龄更轻，白种人更多,糖尿病更少，在大中心治疗的 比例更少；腹膜转运类型和,CAPD,组无差异,CAPD,APD,CAPD,APD,生存率,技术生存率,technique survival,Group,Patient survival,Technique survival,Univariate HR(95%CI),Multivariate HR(95%CI),Univariate HR(95%CI),Multivariate HR(95%CI),High,0.57(0.35-0.94),0.56(0.35-0.87),0.93(0.671.28),0.88(0.641.21),High-A,0.98(0.72-1.34),1.08(0.81-1.45),1.16(0.951.40),1.17(0.951.44),Low-A,0.70(0.46-1.07),0.98(0.66-1.45),0.99(0.751.33),1.02(0.771.35),Low,2.21(1.24-3.93),2.19(1.02-4.70),1.35(0.792.28),1.24(0.672.29),Nephrol Dial Trans-plant.2010;25:1973-1979,进一步的病例对照分析显示：在年龄，糖尿病和种族匹配后，,高,R,转,es,运,ults,患,o,者,f in,接,ten,受,tion-to-t,治,rea,疗,t C,仍,ox,然,pr,降,op,低,ort,了,ion,总,al,体,ha,死,zar,亡,ds,风,m,险,odel analyses,of the relative ha,A,za,P,r,D,d of APD versus CAPD for patient surv,(H,iva,R,l a,0,n,.,d,60,95%CI 0.360.96),合并症少者死亡率：,APD”,好,2005,1,1994199,7,USRDS,US,9190/2785,6mo-2yr,0.74 VS 0.70,次,/,病,人年,AC,2009,2,2002200,3,多中心,UK,538/325,2yr,0.81 VS 0.66,次,/,病,人年,AC,2009,3,1996200,5,多中心,Canad a,3180,1.03(0.91-1.16),No dif,2011,4,2003200,8,单中心,UK,178/194,5y,0.41 VS 0.32,次,/,病人年,AC,2011,5,1993200,7,单中心,Nether lands,112/93,14yr,0.65 VS 0.62,次,/,病,人年,No dif,2011,6,Am,Peri,1997200,J,8,Kidney Dis.2005;,t,单,Dia,中,l In,心,t.2009;29:2,Taiwa,45,n,:372-380,97-302,121/161,4.,5.,6.4yr,Ne,(M,ph,),rol Dia,Perit Dial In Perit Dial In,0.39 VS 0.24,次,/,病,l T,人,ra,年,nsplant.2011;26:1702-170,t.2011;31:39-47,t 2010;31(3):301-307,AC,8,3.Clin,2014,7,J Am Soc Nephrol.,2003201,1,2009;4:1195,Aus/N,Z,2761/419,7,8,.,Cl,in J Am S,oc,G,N,+,ep,:0,hr,.,o,9,l 2,0,0,(,1,0,4,.,;9,8,:,0,10,-,9,1,1,.0,10,),97,C-:0.81(0.69-0.94),AC AC,腹膜炎,CAPD VS APD-RCT,Netherlands,19881991,FU,to,1992 Aug,41 VS 41,patients,Ann Intern Med.,1994;120:264-271,评价,结果,CAPD VS APD,生存率,No difference,2 VS 4,死亡,技术生存率,No difference,平均技术失败时间,26 VS 30,月,腹膜炎,APD,好于,CAPD,0.94 VS 0.51,次,/,病人年,透析充分性,No difference,Kt/V,Ccr,贫血，高血磷，高血,压控制方面,并发症,No difference,外口感染，疝气，渗漏等,残余肾功能,No difference,4.0 to 2.8 mL/min/1.73 m2 VS 5.4 to 2.1 mL/min/1.73 m2,APD,对预防腹膜炎方面的作用？,益处,减少换液次数,腹透液存腹时间长短对,腹膜免疫功能的影响,白天体力活动增加利于,机体免疫功能,待解决,接头的保护装置,暂时管路分离的安全措施,研发生物相容性更好的透 析液,APD,和,CAPD,同样需要规范培训，减少操作污染；其他非操作污染导致的腹膜炎风险仍然存在,发表,来源,国家,样本量,(CAPD/APD),随访,结果,“”:,好于,2001,1,19932001,NECOSAD,Netherl,ands,59/37,APDCAPD,Metal health,less depression/anxiety,2010,2,Cross-sectional,Turkey,48/20,APD=CAPD,2011,3,20032008,Single-center,UK,178/194,5 yrs,APD=CAPD,2011,4,19972006,NECOSAD,Netherl ands,486/64,3mo3yr s,APD=CAPD,APD,对生活质量的影响,-,观察性研究,1.Perit Dial Int.2001;21:306-312,2.Hemodial Int.2010;14:515-522,Nephrol,Dial Transplant.,2011;26:1702-1708,Clin,J Am Soc Nephrol.,2011;6:,537-542,Full time,Full time,HK,retrospective cohort,FU,21.9,mo,CAPD VS APD:180:,90,CAPD:,6L/d,APD:,9.2,2.3L/d,Nephrology 2013;18:356364,APD,全职工作者更多,-,观察性研究,生活质量,CAPD VS APD-RCT,Denmark,CAPD VS,APD:,17:17,25,人完成研究,APD,(n=12),CAPD,(n=13),P value,More time for work,family,and social activities,3.2,1.2,1.2,0.5,0.00005,Discomfort,(physical),1.9,1.0,2.2,1.3,NS,倾向,+,Discomfort (emotional),1.8,1.0,2.2,1.4,NS,倾向,+,Appetite(reduced),2.8,1.3,2.9,0.6,NS,Sleep problems,2.3,0.9,1.8,1.3,NS,Perit Dial Int.1999;19:526-533,APD,的水钠清除和残肾丢失,Spain,，前瞻队列研究，,19982002,FU to 2003,53 CAPD,51,APD,基线年龄、性别、原发病、糖尿病、合并症、腹膜转,运类型和残余肾功能无差别,调整方案,Kt/V,，,Ccr,达标,容量控制,保护残肾,Am J Kidney Dis 2004;44(1):132-145,水分清除,钠清除,GFR,Am J Kidney Dis 2004;44(1):132-145,，,发表,来源,国家,样本量,CAPD/APD,随访,水钠清除,“”:,差于,容量状态,2004,1,19982,002,Spain,53/51,1224,APDCAPD,APD,血压控制更差,2007,2,Cross-,sectional,Turkey,32/30,APDCAPD,APD:BNP,和,LVM,更高，但血压无差 别,2009,3,Cross-,sectional,Canad,a,90/68,APD=CAPD,血压、水肿和降压,药无差别,2012,4,Cross-,sectional,Netherl,ands,24/20,2130,mo,APDCAPD,APD,血压控制更差,BNP,更高,1.Am J Kidney Dis.2004;44:132-145,2.Perit Dial Int.2007;27:663-668,3.Clin J Am Soc Nephrol.2009;4:1044-1050 4.ASAIO J.2012;58:132-136,-,观察性研究,YES,高龄,男性,糖尿病,低白蛋白血症,低,BMI,收缩压高,至少,使用,1,次,4,.2,5,%,透析液,NO,透析龄,PD,液类型,APD vs,CAPD,腹膜转运状态,尿量,HT,和,NYHA,分期,合并肝脏疾病,Europe6,国家，,28,中心，,639,例腹透病人，,BCM,测定容量状态（排除无,icodextrin,的区域）,组织水负荷,的危险因素,PLoS ONE 2011;6(2):e17148,交换频度和存腹时间调,整更灵活,配比不同浓度葡萄糖,对体型小者选择更适合 的灌入量，减少淋巴回 吸收,钠筛更明显，尤其短时大,量脱水时,腹膜功能低转运者无法受 益于夜间短频交换,平卧引流可能不如坐位,APD,内置设定尽量满足存 腹时间，引流可能不充分,利,弊,原发病不同,基础残余肾功能水平,容量负荷或不足,血压控制,心衰,APD,的治疗模式,超滤速度和量,透析液的不同,RAAS,阻断剂的使用,肾毒性药物,患者因素,治疗因素,残肾功能,CAPD VS APD-RCT,Netherlands,19881991,FU to 1992 Aug,41 VS 41 patients,Ann Intern Med.,1994;120:264-271,Total Kt/V,Total Ccr,Renal Ccr,CAPD,CCPD,CAPD,CCPD,CAPD,CCPD,Start,2.9,1.0,3.5,1.4,88.8,30.,2,97.9,35.,9,4.0,2.9,5.4,3.5,6 mo,3.0,1.2,3.4,1.6,92,36,99.4,45.,5,4.3,3.7,5.0,3.7,12 mo,2.6,0.8,3.2,1.3,78.7,27.,7,86.6,42.,5,2.7,2.7,4.1,3.9,18 mo,2.4,0.7,3.0,1.3,69.1,25.,9,81.8,44.,8,1.8,2.4,3.6,3.9,24 mo,2.7,0.9,2.7,0.7,82.5,33.,2,75.9,24.,3,2.8,3.3,2.1,2.3,没有区别,APD,和,CAPD,的比较,方面,比较,生存率和技术生存率,无差异,在非老年人，高转运和少合并,症者：,APD,优于,CAPD,腹膜炎,APD,优于,CAPD,生活质量和社会回归,APD,优于,CAPD,容量负荷,有争议,残肾保护,有争议,内容,APD,治疗的现状和趋势,APD,和,CAPD,的比较及评价,APD,常见治疗模式,应用人群,展望,NIPD/IPD,CCPD,TPD,CFPD,夜间,/,白天,间断腹透,持续循环,式腹透,潮式腹透,持续流,式腹透,NIPD/IPD,残余肾功能尚可,短期存腹可能达到 满意溶质和水分清 除的高转运者,丧失残肾后，配合,血透治疗,NIPD,经典方案,夜间连续,4-5,个循环,每个循环存腹,2-3,小时,总治疗时间,8-15,小时,腹透液,8-12L,其他灵活的,IPD,方案,白天或夜间连续,2-4,个循,环,每个循环,2-3,小时,总治疗,4-12,小时,腹透液量酌情,新置管手术后，过,渡透析,腹腔手术，疝气修 补后过渡,多囊肾等耐受腹腔,内压有限,连续,3,个循环,每个循环存腹,3-4,小时,总治疗时间,9-12,小时,腹透液,6-8L,设立末袋：高浓度或葡聚糖透析,液长存腹,设立末袋（普通）,+,白天手工换,CCPD,类 似 与 目 前,CAPD,治疗,几 乎 适 用 于 所,有患者,夜间,白天,全天,液,1,次,腹透液,2-4L,腹透液,8-12L,Clin J Am Soc Nephrol.2009;4:1044-1050,Canada,cross-sectional,20042006,168,pts,(90CAPD,78CCPD),CCPD,调整原则是尽量延长存腹时间，而传统,治疗是夜间高频交换：,夜间通过限制交换次数保证存腹时间,(,在,910,小时内,34,循环,),日间长存腹，酌情使用,icodextrin,对溶质和水分清除不足者在上机前,34,小时手,工交换,1,次,Variables,CAPD (n=90),CCPD (n=78),P,value,age,56.7(15.8),56.2(15.6),0.858,DM%,40,54.4,0.072,Time on PD (month),24.2(20.7),29.6(17.3),0.001,Daily prescription(L),8.26(1.08),9.49(1.62),0.001,Icodextrin user(%),55.6,77.9,0.002,D/Pcr,0.69(0.1),0.75(0.08),0.01,Tkt/V,2.2(0.45),2.24(0.48),0.58,Rcr(L/wk),39.8(30.2),38.2(32.9),0.822,Pcr(L/wk),43.8(8.4),43.9(7.8),0.924,Data from Clin J Am Soc Nephrol.2009;4:1044-1050,Variables,CAPD,(n=90),CCPD,(n=68),P,value,UF(ml/d),572(1013),811(661),0.092,UV(ml/d),654(498),682(673),0.76,Una(mmol),42.7(26.9),31.1(24.2),0.0006,Dna(mmol),66.1(127.5),98.7(82),0.069,Tna(mmol),109(124),130(75),0.232,E/T(%),51.9(4.4),51.8(5.7),0.929,SBP/DBP(mmHg),129.9(17.4)/76.,4(11.3),132.9(19.1)/78.,6(10.5),0.323/0.,223,BP medication use(%),58.8,69.3,0.174,Diuretic use(%),33.8,39.8,0.446,Peripheral edema(%),38.2,36.4,0.81,Data from Clin J Am Soc Nephrol.2009;4:1044-1050,腹膜高转运不能达到满意超滤者,不能耐受腹腔内压的增加,存在社会心理因素者,35,欧洲最佳实践指南：腹透,1,ISPD,腹透超滤问题专家委员会,2,Nephrol Dial,Transplant2005,Dec;20 Suppl,9:ix21-ix3.,Perit Dial Int2000;20 Suppl,4:S5-21,年龄段不限,需要坚持学习和工作的腹透患者，尤其儿童、中年轻人,因动作不协调或视力障碍、不能自行手工腹透者，尤其 是需要他人照料的老年人。,腹膜转运类型不定,高转运和高平均转运者适合，而对低转运或低平均转 运者也可通过调节透析方案达到治疗目标,有助于以下人群的水分和溶质清除达标,残余肾功能低,体表面积大,超滤衰竭,避免腹腔压力相关问题,腹腔容积小或耐受压力有限：体型小，多囊肾、腹疝,无法修补、严重胃食管返流或胃轻瘫,无以上情况者：有助于减少腹腔压力相关并发症,促进社会回归,增加工作、生活和社交时间,避免“疲劳”感,YES,评估可行性：,1.,经济状况可,2.,理解能力和言语沟通正常,3.,导管引流良好,订购,APD,机器,安装、调试及运行 正常,试用：,1.,夜间睡眠干扰小,2.,初始,APD,方案适应良好,3.,培训顺利完成,开始愉快的,APD,之旅！,随着我国经济水平的增长，腹透患者对正 常社会角色和生活自由度的需求增高，,APD,的使用率一定呈上升趋势,直观方便的操作系统,在线数据传输和管理,配置电话医疗系统,