《腹透原理1how pd works 1》由会员分享，可在线阅读，更多相关《腹透原理1how pd works 1（32页珍藏版）》请在金锄头文库上搜索。
1、Min Sun PARK, M.D., Ph. D., Medical Director Baxter Asia Renal,How PD works 1 腹透原理 1,内 容,什么是腹膜？ 腹膜透析(peritoneal dialysis, PD)的生理学 尿毒症毒素的清除 液体的清除 钠的清除 PD的准备和实施 PD处方 PD的适应症和禁忌症 自动化腹膜透析（automatic peritoneal dialysis,APD) PD相关并发症 PD的临床预后 怎样建立PD中心?,What is the peritoneal membrane ? 关于腹膜,腹膜是被覆于腹腔的光滑浆膜 脏层腹
2、膜 壁层腹膜 腹膜凹陷 腹腔和腹膜腔,The mesothelium The interstitium Macrophages/Monocytes Peritoneal capillaries Plays important role water and solute exchange 间皮 间质 巨噬细胞/单核细胞 腹膜毛细血管 在水和溶质的转换中起重要作用,Components of the peritoneum 腹膜的结构,Role of the peritoneum 腹膜的功能,Protect peritoneal organs Prevent friction of moving o
3、rgans Host defense mechanisms: Mesothelial cells, monocytesmacrophages, opsonins 支持、保护腹腔脏器 分泌滑液防止脏器移动时的摩擦 宿主的防御机制: 间皮细胞、单核巨噬细胞、调理素,Physiology of peritoneal dialysis 腹透生理学,Goal of Dialysis 透析目标,Maintains symptom-free by replacing some of the functions performed by the healthy kidneys. To removes urem
4、ic toxins accumulated in the blood Water Electrolytes Urea, creatinine, phosphate, PTH, etc. H+ 通过部分替代正常肾脏功能减轻肾衰时机体相关症状 清除积聚在血液中的尿毒症毒素 水分 电解质 尿素、肌酐、磷、甲状旁腺素等等 氢离子,The transport of solutes and water across a “membrane” that separates two fluid containing compartments. The blood in the peritoneal capil
5、laries Dialysis solution in the peritoneal cavity 腹膜将下列两种液体分隔，水分和溶质进行跨膜转运 腹膜毛细血管中的血液 腹腔中的透析液,A Basic Concept of Peritoneal Dialysis 腹透基本概念,PERITONEAL TISSUE BLOOD 腹膜组织 血液,Membrane腹膜,PERITONEAL CAVITY DIALYSATE 腹腔 透析液,Membrane model 腹膜模型,Components of the peritoneum as a dialysis membrane 腹膜（做为透析膜）的组
6、成,The mesothelium The stagnant fluid film The interstitium Peritoneal capillaries Stagnant capillary fluid The capillary endothelium itself The endothelial basement membrane 间皮 滞留液体层（阻力） 间质 腹膜毛细血管 毛细血管滞留液体 毛细血管内皮 内皮基底膜,Removal of uremic toxins 尿毒症毒素清除,Small solutes Diffusion: Convective transport Mi
7、ddle or large solutes Peritoneal leak,小分子溶质 弥散 : 对流转运： 中等或大分子溶质 腹膜渗漏,Diffusion 弥散,Definition: Solute movement due to concentration gradient of two solutes between components across a semi-permeable membrane Main driving force for small solute removal Factors involved in diffusion Size of solute Peri
8、toneal surface area Hydrostatic pressure Electrical charge of solutes 定义: 溶质依靠溶液之间浓度梯度透过半透膜（腹膜）进行的转运 弥散是小分子溶质清除的主要机制 影响弥散的因素 溶质分子的大小 腹膜表面积 静水压 溶质的电负荷,Convective transport 对流转运,Solute transport along with fluid movement High during active ultrafiltration Terms used in convective transport Sieving coe
9、fficient: Ratio of solute being passed the barrier Reflection coefficient Ratio of solute being rejected by the barrier Sieving coefficient=1-reflection coefficient Factors involved in convective transport Size of solute Electrical charge of solutes,定义：水分转运时伴随的溶质清除 高效超滤过程中对流作用大 对流转运应用的参数 筛选系数（Sievin
10、g coefficient）： 溶质通过膜屏障的比例 反射系数（Reflection coefficient）： 溶质被膜屏障阻挡的比例 筛选系数1反射系数 影响对流转运的因素 溶质分子的大小 溶质的电负荷,Osmotic Ultrafiltration Movement of water from a chamber with lower osmotic pressure to higher one across a semi-permeable membrane 渗透超滤 水分通过半透膜从低渗透压的腔室转移到高渗透压的腔室，静水压和渗透压的矢量和决定水分渗透的方向。,Removal of
11、Water in PD : Crystalloid Osmosis PD水分清除：晶体渗透压,High glucose-High osmolality Peritoneal Space 高糖高渗 腹膜部位,Capillary space 毛细血管 Normal osmolality 正常渗透压,Small pore: 50% 小孔：50,Aquaporin mediated: 50% 水孔蛋白介导：50， （只能使水通过，也叫水通道）,Pathways for Peritoneal Transport 腹膜转运途径,Endothelium 内皮,Capillaries 毛细血管,Periton
12、eal Cavity (Dialysate) 腹腔（透析液）,Small solutes 小分子溶质,Glucose 葡萄糖,Macro molecules 大分子溶质,Crystalloid osmosis 晶体渗透压,Colloid osmosis 胶体渗透压,Water 水,Interstitium 间质,Peritoneal tissue layer 腹膜组织层,Ultrafiltration 超滤,腹膜转运机理,小分子依靠弥散作用从毛细血管进入腹膜间质，再进入透析液中 透析液中的葡萄糖借助弥散作用从腹腔进入腹膜间质，加上弥散出来的小分子，使间质晶体渗透压升高，对毛细血管内水分形成超滤
13、，水就从毛细血管移出； 毛细血管中水分的超滤对毛细血管中大分子又产生对流作用，大分子就进入间质，使局部胶体渗透压升高，水被进一步超滤，这样，水和大分子然后分别进入透析液当中； 葡萄糖不断进入间质和毛细血管使渗透梯度下降，水的超滤下降。 通过上述过程，毛细血管内的水被超滤出来，小分子和大分子毒素通过弥散和对流作用也被排出，从而实现水和毒素的清除，同时伴随着透析液葡萄糖被机体摄入。,Solutes from the circulation to dialysis solutions 从血循环到透析液中的溶质,Solutes from dialysis solutions to the circul
14、ation 从透析液到血循环的溶质,Protein,Dextrose concentration/osmolality/UF 葡萄糖浓度 / 渗透压 / 超滤,The higher the osmotic pressure difference, the higher the ultrafiltration UFR 484 mOsm/L,Ultrafiltration Rate in Different Solutions 不同浓度的超滤率,Ultrafiltration rae (ml/min),-5,0,5,10,15,20,25,30,0,60,120,180,240,300,360,T
15、ime, min,3.86% G (n = 25),2.27% G (n = 9),1.36% G (n = 9),Heimbrger et al. Kidney Int 38: 495-506, 1990,Intraperitoneal Dialysate Volume in Different Solutions 不同溶液在腹腔内容量,3.86% G (n=23),0,60,120,180,240,300,360,Time, min,3500,3000,2500,2000,Intraperitoneal dialysate volume, ml,2.27% G (n=9),1.36% G
16、(n=9),Heimbrger et al. Kidney Int 41: 1320-1332, 1992,Peritoneal UF = water movement associated to permeable solutes through the peritoneal membrane Osmotic pressure = depends on the number of osmotic active moleculesin the solution: 腹膜超滤由渗透压驱动的水的清除方式 渗透压=取决于溶液中渗透活性分子的数量，分晶体和胶体渗透压。,Osmotic crystalloid pressure (glucose) 晶体渗透压 (葡萄糖),Small molecular weight molecules Fast and important osmotic pressure at start, gradual absorption and
