腹膜透析基础.ppt

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1、 腹膜透析腹膜透析ESRD治疗治疗 How PD works 腹腹 透透 原原 理理 What is the peritoneal membrane?腹膜是被覆于腹腔的光腹膜是被覆于腹腔的光滑滑浆膜膜n脏层腹膜脏层腹膜n壁层腹膜壁层腹膜n腹膜凹陷腹膜凹陷n腹腔和腹膜腔腹腔和腹膜腔The mesotheliumThe interstitiumMacrophages/MonocytesPeritoneal capillariesPlays important role water and solute exchange间皮皮间质巨噬细胞/单核细胞腹膜毛细血管在水和溶质的转换中起重要作用Compon

2、ents of the peritoneum Role of the peritoneum 腹膜的功能腹膜的功能nProtect peritoneal organsnPrevent friction of moving organsnHost defense mechanisms:nMesothelial cells,monocytesmacrophages,opsoninsn支持、保护腹腔脏器n分泌滑液防止脏器移动时的摩擦n宿主的防御机制:n间皮细胞、单核巨噬细胞、调理素 Components of the peritoneum as a dialysis membrane 腹膜（做为透析膜

3、）的组成腹膜（做为透析膜）的组成The mesotheliumThe stagnant fluid film The interstitiumPeritoneal capillariesStagnant capillary fluidThe capillary endothelium itselfThe 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The transport of solutes and water across a“membrane”that separates two fluid c

4、ontaining compartments.The blood in the peritoneal capillariesDialysis 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n腹膜毛细血管中的血液n腹腔中的透析液A Basic Concept of Peritoneal Dialysis 腹透基本概念腹透基本概念PERITONEAL TISSUEBLOOD腹膜组织腹膜组织血液血液Membrane腹膜腹膜PERITONEAL CAVITY DIALYSATE腹腔腹腔透析液透析液Membrane model腹膜模型腹膜

5、模型Removal of uremic toxins 尿毒症毒素清除尿毒症毒素清除 Small solutes Diffusion:Convective transport Middle 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 弥散弥散Definition:Solute movement due to concentration gradient of two solutes between components across a semi-permeable membraneMain driv

6、ing force for small solute removalFactors involved in diffusion Size of solute Peritoneal 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 对流转运对流转运 Solute transport along with fluid movement

7、 High during active ultrafiltration Terms used in convective transport Sieving coefficient:Ratio of solute being passed the barrier Reflection coefficientRatio of solute being rejected by the barrierSieving coefficient=1-reflection coefficient Factors involved in convective transportSize of solute E

8、lectrical 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（Sieving 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 UltrafiltrationMovement of water from a chamber with lower osmotic pressure to higher one across a semi-permeable

9、 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 Water in PD:Crystalloid OsmosisPD水分清除：晶体渗透压水分清除：晶体渗透压H2OHigh glucose-High osmolalityPeritoneal Space高糖高渗高糖高渗腹膜部位腹膜部位Capillary space 毛细血管Normal osmolality 正常渗透压Small pore:50%小孔：50Aquaporin mediated:50%水孔蛋白介导：50，（只能使水通过，也叫水通道）Path

10、ways for Peritoneal Transport 腹膜转运途径腹膜转运途径Endothelium内皮Capillaries 毛细血管毛细血管Mesothelium间皮Peritoneal Cavity(Dialysate)腹腔（透析液）腹腔（透析液）Small solutes小分子溶质Glucose葡萄糖Macro molecules大分子溶质Crystalloidosmosis晶体渗透压Colloidosmosis胶体渗透压Water水Interstitium间质Peritoneal tissue layer腹膜组织层Ultrafiltration超滤腹膜转运机理腹膜转运机理n小分

11、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n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，水的小分子，使间质晶体渗透压升高，对毛细血管内水分形成超滤，水就从毛细血管移出；就从毛细血管移出；n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，水和就进入间质，使局部胶体渗透压升高

12、，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；大分子然后分别进入透析液当中；n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。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。萄糖被机体摄入。Solutes from the circulation to dialysis solutions从从血

13、循血循环环到透析液中的溶到透析液中的溶质质Solutes from dialysis solutions to the circulation从从透析液到血循透析液到血循环环的溶的溶质质ProteinWhat is PET?Based on equilibration of solute concentration in dialysate to plasma and peritoneal glucose absorption.Dialysate to plasma concentration ratio of solutes such as creatinine,urea,potassium

14、(D/P solutes):Dialysate creatinine concentration increases as creatinine diffuses into the peritoneal cavity due to the concentration gradient.Dialysate glucose concentration decreases as peritoneal glucose absorbs during a dwell time.Drain volume is inversely correlated to solute transport rate.PET

15、建立在血浆与透析液中溶质浓度的平衡以及腹膜对葡萄糖吸收作用的基础上.透析液和血浆中溶质浓度的比值(D/P)如肌酐、尿素、钾离子：随着血液中肌酐顺着浓度梯度弥散入腹腔内，透析液中肌酐浓度逐渐增加.留腹期间透析液中葡萄糖的浓度随着腹膜对葡萄糖的吸收而降低.引流量和溶质转运率负相关.Peritoneal Equilibration Test腹膜平衡试验腹膜平衡试验 Intraperitoneal Volume in Different Transport Groups不同转运的腹膜在腹透时超滤量的变化不同转运的腹膜在腹透时超滤量的变化Wang et al.Nephrol Dial Transplan

16、t 13:1242-49,199822502500275030003250Intraperitoneal volume,ml腹腔内液体容量腹腔内液体容量060120180240300360Time,minL低转运低转运L-A低平均低平均H-A高平均高平均H高转运高转运1.Drain for at least 20min,ideally after an 8-to 12-hour overnight dwell using 2L of 2.5%dextrose solution2.Weigh 2-L bag of warmed 2.5%dextrose solution3.Infuse over 10min(at a rate of 200 ml/min).After each 400-ml infused,roll the patient from side to side.4.Indwell for 4 hours.Ambulatory during dwell time.5.Drain over 20 min.6.After drainage,the bag is again we