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1、基本原理 溶质清除机制 弥散diffusion 溶质浓度梯度成正比 溶质分子大小成反比 对流convection 随溶剂的跨膜运动而转运 溶质分子大小成反比 超滤率及筛选系数决定转运速率 吸附absorption 水份清除机制 超滤系数Kuf 跨膜压(TMP),Classification of artificial membranes used for blood purification therapy,Water permeability,Solute permeability,Biocompatibility,Material/Polymer,Regenerated cellulose
2、 Modified cellulose Synthetic,Low- fluxKuf 15 ml/mmHghr,For small solute KoA e.g. BUNScrUA For larger solute SC e.g. 2-MG,Qualitative measures,1970s was on enhancing the solute diffusive and water removing properties of the membranes 1980s the emphasis has been on convective transport, absorption, a
3、nd biocompatibility,Historical Overview,EFFICIENCY BIOCOMPATIBILITY,Technologies Convection Diffusion Diffusion+Convection,Membranes Modified Cellulose Cellulose Synthetic,Long-term results in haemodialysis therapy,(Relationship between membranes,technologies,efficiency and biocompatibility),CRRT,co
4、ntinuous ambulatory peritoneal dialysis (CAPD) continuous cyclical peritoneal dialysis (CCPD) slow continuous ultrafiltration (SCUF) continuous arterio-venous hemofiltration (CAVH) continuous arterio-venous hemodialysis (CAVHD) continuous arterio-venous hemodiafiltration (CAVHDF) continuous vono-ven
5、ous hemofiltration (CVVH) continuous vono-venous hemodialysis (CVVHD) continuous veno-venous high-flux dialysis (CVVHFD) continuous vono-venous hemodiafiltration (CVVHDF),Blood Purification Procedures,continuous,intermittent,IRRT,intermittent peritoneal dialysis (IPD) hemoperfusion (HP) hemoconcentr
6、ation plasmapheresis hemodialysis (HD) hemofiltration (HF) hemodiafiltration (HDF),水分迅速减少 组织器官血供障碍 血浆渗量骤然下降 血压不平稳或诱发肺水肿 生理代偿机制 加重或诱发心衰 血/膜反应 SIRS,IRRT对血流动力学影响,CRRT与IRRT比较,改善心血管稳定性 维持脑灌注 控制高分解代谢 维持水电解质和酸碱平衡 为营养支持创造条件 重症ARF已首选CRRT,HF,B,HD,B,D,B,D,HDF,mmHg,B,B,F,D,low-flux,Filter,high-flux or Filter,di
7、ffusion,convection,diffusion/convection,mmHg,B,mmHg,mmHg,F,D,mmHg,mmHg,HF,HD,HDF,Kidney,104,2-MG C3a、C5a IT-1 TNF,Vit. B12 LipidA,Bun Cr UA,clearance ml/min,120,80,40,0,10,103,102,0,MWDa,105,Alb Lps,Methodologies,Patient,Materials,“Ancillary” therapy,Cost,?,Factors affecting renal dialysis therapy r
8、esults,A,V,PV,PA,low-flux,HD,heparin,A,V,PV,PA,high-flux,HF,Predilution,Postdilution,A,V,PV,PA,high-flux,High-flux HD,V,V,PV,PA,high-flux,HDF,Postdilution,Predilution,Replacement Solution,Continuous,Intermittent,Dialysis Treatment,RRT的抗凝,低分子肝素的优势,低分子肝素 1 长 固定 高 无需 低 小,抗 Xa:IIa 活性比值 血浆半衰期 清除率 生物利用度 需
9、 aPTT 监测 对 PF4 的敏感性 对血小板抑制作用,普通肝素 =1 短 不固定 低 需要 高 大,低分子肝素对血透中的影响,Heparinisation in RRT,Complications,VC,Kd+KrC,G,堆积产生清除,摄入产生,堆积分布,其中: G -尿素产生的速率 V -体内尿素的分布容积 C -血液尿素的浓度 Kd -透析器的廓清率 Kr -残存肾功能的廓清率,清除,PCR nPCR,BUN,Kt/ V URR,血液透析动力学模型综合评价,80 60 40 20 0,120 100,SUN MON TUE WEN TUE FRI SAT SUN,BUN/dL,week,nPCR,KtV,TAC,Delivered: 3 times/ week Td4hrs U.F. 0.05Wt,Targe:Kt/ V1.2 nPCR1.1g/day TAC50/dL,Survival Morbidity Nutritional Status Metabolic Alterations Hospitalization Time,Evaluation,Long-term results in haemodialysis therapy,summary,谢!,
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