1、 卢方平 2009-4-30病例报告 姓名 庞洁 性别 女 年龄25岁 民族 汉族 因维持性血液透析5年半，大量腹水1年3个月于2008年9月转入我院继续治疗。患者于2002年底因“肺结核”在外地抗结核治疗（免费药）中出现肾损害，肾功能减退，伴肾性贫血与高血压，用中药治疗无效后于2003年4月在北京某医院接受血液透析治疗（5次/2周3次/周，每次4小时）。血管通路为中心静脉半永久导管。透析半年后残余肾功能丧失（尿量为）2007年6月发现腹水。2007年8月中心静脉半永久导管感染，而后改为左前臂动静脉内瘘。虽经抗感染治疗与多次放腹水（最多放4000ml），此后腹水进行性加重，于2008年9月转入
2、我院。既往史：9岁时曾患甲亢，已治愈。年前患乙型肝炎。对他巴唑过敏。无食物过敏史。有输血史。体 格 检 查：慢性病容，贫血貌。营养状态差。未见肝掌、蜘蛛痣。全身浅表淋巴结未及。睑结膜苍白，巩膜无黄染。无颈静脉怒张。胸廓未见异常，双侧呼吸运动对称，语颤双侧对称，双肺呼吸音粗，未闻及干湿罗音。心前区无隆起，心尖搏动位于第五肋间左侧锁骨中线外侧0.5cm处,搏动范围无弥散,心率108次/分，律齐，未闻及病理性杂音。腹部平坦腹膨隆,无压痛，肝脾触诊不满意，全腹叩诊呈浊音，移动性浊音（+），腹水征（+），肠鸣音听诊不理想。双下肢水肿（-）。腹部腹部B超：超：双肾萎缩，双肾弥漫性病变，腹盆腔多量积液。盆腔
3、深20cm。腹部腹部CT：肝脏外形规整，各叶比例正常范围内，肝实质内未见异常密度。肝内外胆管未见扩张及结石。2008-4-7北京xx医院 1.肝大:剑下5.4cm,肋下1.0cm,右肝斜径16.7cm 2.肝静脉增宽:左1.6cm,中1.2cm,右1.6cm 3.脾大:厚4.7cm,长14.2cm,肋下3.9cm 4.腹腔大量积液:9.3cm 化验检查提示有重度贫血（Hb57g/L）、继发性甲状旁腺功能亢进（PTH 155.7pmol/L）、微炎症状态(CRP 43.7mg/L)、低蛋白血症（ALB 34.6g/L）铁负荷过多铁负荷过多腹水常规日期日期 SG RBC WBC MONO COEN
4、O 2008.10.15 1.0401760 13025%75%2008.10.20 1.040满视野 26 腹水生化日期日期 KNaCIGLuTPALBA/GLDH2008.10.15.2008.10.20.腹水培养阴性腹水培养阴性 转入我院后继续行常规血液透析治疗。每次透析最大超滤量3.2Kg，较多发生透析低血压，患者体力、精神、食欲均较差。存在的问题 透析不耐受透析不耐受 透析不充分透析不充分 心功能不全心功能不全 肝脏疾病肝脏疾病 严重贫血严重贫血 继发性甲状旁腺功能亢进继发性甲状旁腺功能亢进 微炎症状态微炎症状态 营养不良低蛋白血症营养不良低蛋白血症 大量腹水大量腹水 铁负荷过多铁负
5、荷过多 根据临床症状、体征及辅助检查，考虑腹水的原因为肾性腹水（透析相关性腹水），可能与透析不充分有关。因此我们决定改变患者的透析方案。10月30日用高通量透析器（Fresenius FX60）做日间长时间透析治疗，透析频率仍为每周3次，但每次透析延长至8小时。的变化血红蛋白的变化铁参数的变化TF%TF%FerrFerr2008.10.1669.415002008.11.1624.315002008.12.223.9995.72008.12.2336.7941.72009.1.826.41174.42009.2.329.3883.3血白蛋白的变化血磷变化钙磷乘积腹水的变化腹部腹部B超（超（20
6、08.10.14）20cm 2008.11.28 10.5cm 2008.12.26 14.9cm 2009.2.2 8.6cm超滤量增加：一次透析最大超滤量超滤量增加：一次透析最大超滤量.Kg，未发生低血压，未发生低血压临床状况改善：患者精神、食欲、临床状况改善：患者精神、食欲、体力等均有明显改善体力等均有明显改善干体重下降干体重下降 毒素清除 URR 79.3%-84.96%KT/V 1.63-1.76 2MG 16.10ug/ml（透前）（透前）-12.9ug/ml（透后（透后）清华一付院.mpg透析时间问题透析时间问题?Blood Purif 2007;25:9098 Treatmen
7、t Time and Ultrafiltration Rate Are More Important in Dialysis Prescription than Small Molecule ClearanceZbylut J.TwardowskiDepartment of Medicine,Division of Nephrology,University of Missouri,Columbia,Mo.,USA Kt/V urea Should Be Abandoned as a Measure of Dialysis QualityDOPPS Background (1)longer H
8、D session duration is independently associated with lower mortality,(2)a synergistic mortality-reducing interaction exists between Kt/V and TT(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 wei
9、ght is associated with both higher risk of mortality and increased odds of intradialytic hypotension.长时间血液透析的方式长时间血液透析的方式长时间常规血液透析(Long conventional hemodialysis,LHD)长时间夜间血液透析(Long nocturnal hemodialysis,LNHD)Increasing dialysis time enables the ultrafiltration rate to be decreased.Increasing sessio
10、n time enables better session tolerance and reduces the risk of dialysis-induced hypotension.correction of hypertension,correction of left ventricularhypertrophy,improvement of ejection fraction in individuals with heart failure,reduction of peripheral resistance,improvement of the vasodilatory resp
11、onse,and reduction of sleep hypoxemia长时间血液透析对心血管系统的好处长时间血液透析对心血管系统的好处长时间血液透析对磷平衡的影响长时间血液透析对磷平衡的影响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 phosphatem
12、ia and phosphate removal remain stable.the amount of phosphate removed increased with session time and was significantly higher during the 8 h session than during the 4 h or 6 h sessions.Chazot C and Jean G(2008)The advantages and challenges of increasing the duration and frequency of maintenance di
13、alysis sessionsNat Clin Pract Nephrol doi:10.1038/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 convent
14、ional hemodialysis at the Centre deRein Artificiel,Tassin,France(n=195;mean treatment time 6 h 20 min 1 h15 min)Chazot 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
15、phosphate 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)EFFECTS OF DIALYSIS TIMEA
16、ND FREQUENCY ON NUTRITION Food 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 TIMEON SURVIVALChazot C and Jean G(2008)The advantages and challenges of incre
17、asing 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 the US Renal Data System 2005)and patients treated with short daily in-center or home hemodialysis(data
18、 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 Causes of inflammation in HD Patient related underlying disease comorbidity,peripheral vascular disease oxidative str
19、ess Ca x P metabolism(calcification,fetuin-A)infection(apparent and non-apparent)immunologic genetic nonfunctioning kidney transplants encapsulating peritoneal sclerosis anemia(hepcidin)heart failure obesity tumors physical exercise:sedentary lifestyleChazot C and Jean G(2008)The advantages and chal
20、lenges of increasing the duration and frequency of maintenance dialysis sessionsNat Clin Pract Nephrol doi:10.1038/ncpneph0979Table 2 Standardized mortality ratios68 for patients who received long conventional hemodialysis at the Centre de Rein Artificiel,Tassin,France,compared with US patients who received conventional hemodialysis Dialysis technique related retention of inflammatory mediators oxidative imbalance acetate pyrogenic substances of the dialysate complement activation;membranes and other bioincompatible material谢谢！
