iU TR THAY TH THN

PGS,TS,BS TRAN TH BCH HNG Bo mon Noi, ai hoc Y Dc, Tp Ho Ch Minh

Cc bin php iu tr thay th thn

Hemodialysis (Thm tch mu, thn nhn to) Peritoneal dialysis (Thm phn phc mc) Kidney transplantation (ghp thn)

iu tr thay th thn
iu tr thay th thn l thay th cho nhng chc nng ca thn mt i trn bn STMG cui, khi m vic iu tr ni khoa v tit ch khng cn hiu qu v tnh mng bn b e da

CAC CHC NANG CHNH CUA THAN

Cc chc nng ca thn

Lc mu :Ly b cht cn thi, sn phm azote (ur, cratinine) Lc, ti hp thu v bi tit cc cht (Protein huyt tng, H2O, Hng cu,aminoacid, glucose,urea, mui khang) Thng bng nc Thng bng in gii Thng bng acid base Chc nng ni tit (vitamine D, erythropoietin) n nh huyt p

CHI PH IEU TR THAY THE THAN

USRDS 2005

Tn sut STMG cui ti M

USRDS 2011

Giai on PREDIALYSIS (Tin lc mu)

Mc tiu
iu tr cc bin chng ca suy thn mn Bo tn chc nng thn cn li Gio dc hng dn bn chn la PP iu tr thch hp Chun b ng ly mu vnh vin Hc tp v rn luyn nhng thao tc trong PD

Li tch
Khi u lc mu trong iu kin tt nht Gim s bn nhp vin cp cu HD Gim s bn cp cu HD vi gi tr ur huyt cao Gim s bn dng ng ly mu tm thi ( lm tng nguy c t vong)

La chn hnh thc thay th thn

Chng ch nh ca thn nhn to (HD) CC tuyt i Khng c ng ly mu thch hp CC tng i S kim chch Suy tim nng Ri lan ng mu Chng ch nh ca TPPM nh k ( PD) CC tuyt i Mt han tan chc nng mng bng So dnh trong phc mc cn tr dch lu thng Dch lc d ln c hanh Khng th hoc khng c ngi gip thay dch lc CC tng i Mi m ghp M ch bng Shunt no tht- bng Khng dung np vi cha dch trong bng Suy dinh dng nng Bo ph Nhim trng da vng bng Bnh vng bng ( vim rut, ti tha)

Bin php iu tr thay th thn ti M

Eli A. Friedman

Bin php iu tr thay th thn mt s nc trn th gii- 2011

USRDS 2011 Eli A. Friedman

Thi im iu tr thay th thn

Thi im bt u iu tr thay th thn c chn la nhm ti u ha cht lng cuc sng ca bn, trn c s cn nhc gia vic ko di thi gian bn cha phi lc mu v trnh cc bin chng ca hi chng ur mu cao (lm gim thi gian sng v cht lng sng ca bn) XN: Cratinine HT 10mg%, BUN 100mg%
KDOQI 2002

Ch nh lc mu ngoi thn
Bn i tho ng :
TLcratinine 15ml/ph/1,73 m2 da hoc cratinine HT 6mg/dL

Bn khng i tho ng :
TLcratinine 10ml/ph/1,73m2 da hoc cratinine HT 8mg/dL

Chung: TLcratinine 9-14ml/ph/1,73 m2 da

Brenner BM, The kidney 2008

Thi im iu tr thay th thn

Sm: 10-14ml/ph/1,73 Tr: 5-7 ml/ph/1,73 N=828

Cooper B, et al, IDEAL study, NEJM, 2010, 363. p609

C th ch nh lc mu sm hn?
Bn c nhng ch nh cp cu e da tnh mng bn Bn c cc tr/c khng iu chnh ni khoa v tit ch c nn, bun nn, st cn suy tim khng kim sat, tng kali khng p ng iu tr ni khoa Toan chuyn ha nng m b HCO3 lm tng nguy c qu ti tun han Qu ti th tch tun han khng p ng li tiu Cc triu chng thn kinh do HC ur huyt cao Bt u theo di st bn nhng tr/c trn khi TLcratinine < 20ml/ph/1,73 m2 da
Brenner BM, The kidney 2008

Hemodialysis (HD)
Intermittent HemoDialysis (IHD) Standard HemoDialysis (SHD)

Cc nguyn tc c bn Hemodialysis
Hemodialysis (thm tch mu, thn nhn to): l s o thi cc sn phm azote ca c th, c cht ca HC ur huyt cao, v nc ra khi c th qua 2 c ch khuch tn v i lu, nh my TNT

Khuch tn (Diffusion): l s di chuyn ca cc cht ha tan t ni c nng cao sang ni c nng thp cho n khi t cn bng qua mng bn thm
Siu lc (ultrafiltration: convective transport) l s di chuyn ca nc di tc dng ca p lc thy tnh hoc p lc thm thu xuyn quan mng bn thm

Cc nguyn tc c bn

Khuch tn

Thm thu

Siu lc

Hemodialysis- Hemofiltration

Khuch tn Dch lc khng c cht ha tan Cht c kch thc phn t nh (ur) Khng thi b cht c kch thc ln

i lu ( y nc ra di p lc) Khng c dch lc Cht c kch thc phn t nh v ln

Cc thut ng dng trong TNT

High efficiency : Ly b cc cht c kch thc nh bng c ch khuch tn vi tc cao High flux : Ly b cc cht c kch thc trung bnh ( ln hn ur) bng c ch khuch tn vi tc cao Cc lai mng lc (dialyzer)
High efficiency- High Flux High efficiency- Low Flux Low efficiencey- High Flux Low efficiency- Low Flux ( conventional dialysis)

Cc k thut dng trong TNT

Hemodialysis (HD)
Conventional HD: vi mng Low efficiency- Low flux, diffusion High-efficiency HD: vi mng High efficiency, c din tch ln ly nhiu cht kch thc nh nh ur bng khuch tn High- Flux HD: vi mng c l ln- middle molecule Slow or sustained slow-efficiency HD: continuous HD+ low efficiency HD+ low blood flow rate + low dialysate flow rate

Hemofiltration (HF) CAVHF/CVVHF: continuous HD+ mng high fluxconvection, thay v diffusion Intermittent HF: HF + fluid replacement

Hemodiafiltration: kt hp HD+ HF
Hemoperfusion (HP)

So snh hiu qu lc TNT v thn bnh thng Hai thn bnh thng: GFR 90-120 ml/ph clearance 130- 173L /ngy lc 24h x 7=168h/ tun hoc clearance 1008 L mu /tun Mng lc high efficiency : clearance180-240ml/ph, or >200ml/ph chy TNT 3-4 ln/tun, mi ln 3-4h = 9-12h/tun hoc clearance 108- 144 L/tun Mng lc low efficiency: clearance <150ml/ph clearance 81- 108 L/ tun
Nu bn cn RRF: Clcre 1ml/ph or 1440ml/ngy or 10L/tun 2ml/ph or 20L/tun

H s siu lc TNT Ultrafiltration coefficient Mng lc low flux: UF coefficient 2-5ml/h/mmHg

Transmembrane pressure: 200mmHg Nc rt c 0,5L/h x4h =2L

Mng lc high flux: UF coefficient >12-60ml/h/mmHg

Transmembrane pressure 200mmHg Nc rt c cn ty thuc khuch tn xuyn mao mch

ng ly mu (vascular access)
ng lay mau tam thi - TM ui : lu 3-4 ngay , - TM canh trong, TM di on: lu 3tuan ng lay mau ban vnh vien (Catheter co nut chan bang Silastic - Cuffed tunneled dialysis catheter) ng lay mau vnh vien - ng do ong- tnh mach, - mnh ghep PTFE

Catheter tnh mch trung tm

Cuffed tunneled dialysis catheter

patient hate to live with them, but couldnt live without them

Chun b m v chm sc AVFistula

Trc m AVF Thi im m AVF: Sm trc HD (ti u khong 6 thng), hn ch dng cc catheter lm HD cp cu (B) Khng chch vo cc TM ca tay d tnh lm u tin lm ti tay khng thun V tr lm bt u t mch mu c tay ln dn cnh tay Siu m nh gi h thng M, v TM trc m (B) nh gi TM trung tm nu trc bn c t pacemaker hoc t catheter TM trung tm cng bn (A)

KDOQI 2006

Tiu chun ng ly mu vnh vin

ng ly mu vnh vin l tng l ng ly mu: - Cung cp mu lc mu - C th chch c d dng Quy tc 6 ( rule of 6s) ca ng ly mu vnh vin l tng Cho lu lng mu khong 600ml/pht Khong cch t da n AVF 6 mm ( 5-10mm) ng knh ca AVF ti thiu t 0,6cm ng ly mu vnh vin l GN GT ACHILLES ca HD
KDOQI 2006

Tiu chun ng ly mu vnh vin

AV fistula c gi l trng thnh (mature) khi Ch m gim ph n Ch ni kt dnh vo mch mu Thi gian AV trng thnh thng cn ti thiu 3 tun, v thi im bt u dng ti u : 6-8 tun sau m V tr u tin chn l c tay khng thun ( M quay v TM u) D m Bo tn kh nhiu v tr m khc t c bin chng Nhc im: mch mu nh hn tay thun
KDOQI 2006

Tiu chun ng ly mu vnh vin

Nghim php Allen nh gi cung ng mch bn tay KDOQI 2006

Tiu chun ng ly mu vnh vin

H tnh mch u H tnh mch nn ng mch quay ng mch cnh tay KDOQI 2006

Thng ng tnh mch dng tnh mch t nhin (= AVF)

Chn la u tin l ti Tnh mch u ca tay khng thun ng knh ng mch quay ti thiu l 1,6 mm ng knh tnh mch ti thiu l 2,2 mm nh gi lm sng nh gi trn siu m nhng bnh nhn mp ph, i tho ng T l thnh cng khong 70%

Richard Allen

AVF chn la th hai

To D M cnh tay v TM u
TM u nm su c th to phnh mch

1 tun sau phu thut

Richard Allen

AVF chn la th ba

To d M tr v TM nn

Richard Allen

AVF chn la th t
2 bc to d M cnh tay-TM nn

Bc 1 : to d ni M cnh tay v TM nn Richard Allen

Bc 2 : nng ha tnh mch fistula - (sau 2-3 months)

Richard Allen

Dng TM fistula chy thn sau 6 to 8 tun

Richard Allen

AVF th nm
ghp TM hin ln to quai TM cnh tay

L thuc vo ng TM tt t nht 50% khng trng thnh nhng vn ca van TM

Richard Allen

Mnh ghp (AV graft) chn la cui cng

Mnh ghp dng quai bng cht liu tng hp, cnh tay hay i
t ($US 2,500)
>50% dng USA <10% dng Japan khc bit ln v s dng gia cc trung tm

Richard Allen

Cac ng lay mau

ng lay mau
ng do ong tnh mach

Ty le hoat ong
60-65% (1 nam) 50-65% (2-4 nam)

Li ch
It b/c huyet khoi It b/c nhiem trung ton tai lau

Bat li
Can thi gian lau e trng thanh ( 6-8 tuan) 24-27% khong trng thanh

Manh ghep PTFE

62-83% (1 nam) 50-77% ( 2 nam)

Can 3-4 tuan e trng Ty le huyet khoi va nhien trung cao thanh hn ng do -TM
Dung ngay sau at Giam lu lng mau chay dan en Huyet khoi de s ly giam hieu qua cua ieu tr t tai bien khi at hoac lay ra Khong can am kim khi chay TNT

Catheter 2 nong co 47-54% (1 nam) vong chan 41-43% ( 2 nam)

Bin chng ca ng ly mu
Huyt khi ( thng gp nht) do dng sm, tng sinh ni mc, do h HA lc TNT, tng Hct Nhim trng catheter Ti phnh Hp TM trung tm Hi chng n cp mu Suy tim xung huyt

Hi chng ly cp mu ( Stealing syndrome)

t l mi mc 1 3% thng gp bn T t l mc ca M quay = = M cnh tay iu tr: tht hoc ct k thut DRIL

Chun b m v chm sc AVFistula

Sau m AVF Kim tra cm gic r lin tc ti AVF Hng dn bn kim tra bng tay v tai Khng chch thuc, ly mu, o huyt p, p vo tay m AVF AVF Trng thnh (mature) 1-6 thng, l qu trnh dn, dy thnh TM c th an tan khi chch kim nhiu ln Khng dng AVF khi cha trung thnh Cn thi gian t 6-12 thng trc chy TNT chun b AVF, m khng phi chy TNT qua catheter

Quy trnh vn hnh HD

Mng lc v my TNT

Dialyzer ( Mng lc)

My thn nhn to (thng loai th tch)

Dch lc (Dialysate)
Ten chat oc tnh Aluminium Calcium/ Magnesium Chloramine Fluoride Nitrate Sodium Benh nao, benh xng Hoi chng nc cng gay buon non, non, yeu c, o bng mat, tang hoac giam huyet ap Tan huyet, thieu mau, methemoglobine Nhuyen xng, loang xng, va cac benh xng khac Methemoglobine kem xanh tm, ha huyet ap, va buon non Tang huyet ap, phu phoi cap,lu lan, non, nhc au, tim nhanh, kho th, ong kinh, hon me va chet Nong o toi thieu gay oc (mg/l) 0,06 88 ( Ca+)

0,25 1 21 300

Sulfate Kem Vi khuan

Buon non, non, toan chuyen hoa Thieu mau, buon non, non, sot Sot do phan ng sinh nhiet, lanh run, buon non, ha huyet ap, xanh tm

200 0,2

Mt s tiu chun ca dch lc TNT

(theo AAMI)
Ten chat Aluminium Chloramine Fluoride Nitrate Sulfate Kem Arsenic Barium Cadmium Ch Vi khuan Nong o toi a (mg/L) 0,01 0.1 0,2 2 100 0,1 0,005 0,1 0a001 0,005 <200 khum/ml

Mt s thng s k thut
Toc o mau rut (blood flow) t 250ml/phut - 450mL/phut Thi gian chay TNT: thung t nhat la 3-4 gi x 3 lan /tuan. Lng nc lay ra trong qua trnh chay TNT: tuy tng bn, theo trong lng kho cua bn ( dry weight) Nguy c nhiem benh trong qua trnh chay than nhan tao Can chu y benh lay lan qua ng mau:viem gan sieu vi B va C, HIV Tam soat HBV moi 3 thang va HCV, HIV moi 6-12 thang

Khng ng trong TNT

Dung heparine toan than (systemic anticoagulation): 50-100ui/Kg, sau o 100ui/h Dung na lieu hoac lieu nho Heparine (fractional antigoagulation- Half-dose or minidose heparine): 10-50ui/Kg, sau o truyen 500-1000ui/h Dung heparine tai cho (Regional heparinization): 500-750ui/h, song song vi hoa giai bang protamine Neu bn co chong ch nh dung khang ong th co the chay TNT vi che o khong dung heparine .

Bin chng thng gp

Ha huyet ap trong khi chay TNT: thng gap nhat (20-30%), tang nguy c t vong Vot be,chuot rut (5-20%) lien quan en ha huyet ap, do bn b rut nc nhieu, dung dch loc t Na Buon non, non ( 5-15%): khi rut dch qua nhanh,ha huyett ap Nhc au (5%) au ngc ( 2-5%) au lng (5-5%) Sot va lanh run (<1%)

Bin chng him nhng nguy him

Hoi chng mat quan bnh (disequilibrium syndrome): Phan ng vi mang loc :hoi chng dung lan au ( first use syndrome ) Loan nhp tim : Do roi loan ien giai, nhat la bn dung digitalis hoac chay than vi K+ thap ( 1mEq/L) Tran mau mang ngoai tim, chen ep tim Xuat huyet nao : tren bn co benh ly mach mau nao san, kem cao huyet ap va dung heparine

nh gi lc thn y
1- o giam cua ure mau ( Ure reduction ratio: URR)

URR= BUN trc HD - BUN sau HD

BUN trc HD

Muc tieu can at la URR= 65%.

2- Ty so Kt/V:

Kt/V= -Ln ( R-0,008* t) + ( 4-3,5*R) * UF / W

K la clearance cua dialyzer ( ml/phut) t la thi gian mot lan HD V la the tch phan phoi cua urea se bang the tch nc cua ca c the R :BUN sau TNT / BUN trc TNT T: Thi gian chay TNT UF: The tch sieu loc trong 1 lt W : Can nang bn sau chay TNT Muc tieu can at toi thieu la Kt/V= 1,2 cho bn khong tieu ng va cao hn tren bn tieu ng.

Cc kiu chy TNT

In- Center HD ( chy TNT ti trung tm TNT) Chim phn ln bn TNT Bn n trung tm TNT 3 ln mi tun, mi ln 4h Khi bt u TNT, bn c cn, ly sinh hiu, sau , bn c ghim 2 kim (15-17G) vo AVF ly mu ra v tr mu v bn. Cui k TNT, D rt kim v bng p ti ch Home HD: ( chy TNT ti nh) Tng t In center HD 3 ln/ tun hoc mi ngy 6 ngy/tun v mi ngy 2-3h Bn t o HA, khi ng mu v m kim Bn c hun luyn t 3-6 tun trc v u tin chn ngi tr, khe mnh, tch cc, t bin chng New HD therapies: Phi hp daily in- center HD, nocturnal home HD, 6 ln/tun

Thay i ca ur gia cc chu k TNT

S tch t cc cht trn bn TNT

Ur v hi chng ur huyt cao

Ur l cht b tch t li khi suy thn m c th o t c. Ur ch chim phn nh trong cc triu chng ca hi chng ur mu cao Ur khng l cht duy nht b tch t li trn bn STM giai an ci Ly b ur khng ng ngha vi ht hi chng ur huyt cao Ur l mt ch s o lng c nh gi mt phn hiu qu ca HD v PD

Cc cht ha tan ca HC ur huyt cao

Kh nng ci thin triu chng ca TNT

Factors
Neuromuscular disturbances

Improved
Fatigue. Impaired mentation, lethargy, muscular irritability Peripheral neuropathy Restless leg Syndrome Paralysis Seizures Hypertension Cardiomyopathy

Persistent
Slepp disorders

Developped

Peripheral neuropathy Restless leg Syndrome Musvle cramps Myopathy Hypertension Cardiomyopathy Accelerated atherosclerosis Vascular calcification

Musvle cramps Myopathy

Cardiovascular disease

Accelerated atherosclerosis Vascular calcification Hypotension and arrhythmias

Harrisons texbook of Medicine 16th edi

Kh nng ci thin triu chng ca TNT

Abnormalities
Endocinemetanoluc disturbances

Improved
2nd HPTH Hyperuricemia Hyperglycemia Hypertriglyceridemia Proteinu-energy malnutrition Osteomalacia 9 VitD deficiency) Anorexia Nausea and vomiting GI bleeding Anemia Bleeding diathesis Increased susceptibilityto infection

Persistent
2nd HPTH Hyperuricemia Hyperglycemia Hypertriglyceride mia Sexual dysfunction B2 microglobulin deposition

Developped
Adynamic osteomalacia

B2 microglobulin deposition Hepatitis. Ascites GI bleeding

GI disturbances

GI bleeding

Hematology

Increased susceptibilityto infection

Bleeding diathesis Leukopenia Hypocomplemente mia

Lc thn kt hp vi iu tr ni khoa

iu tr ni khoa trong TNT

iu chnh ty theo ngy c hoc khng chy TNT iu tr tng ng huyt: - ngng hoc gim liu insulin ngy chy TNT - trnh h ng huyt trong TNT iu tr tng huyt p: - Ngng thuc HA trc chy TNT, trnh b/c h huyt p - Thng chn HA trc chy TNT 140- 160/95mmHg THA kh kim sot nu chy TNT khng y Thuc dng: CMC, UCTT, carvedilol bo v tim Khng n hoc n nh trong chy TNT trnh h HA do mu tp trung vng ni tng tiu ha thc n

iu tr ni khoa trong TNT

iu tr thiu mu: - Dng erythropoiein trc khi chm dt chy TNT - Dng ng TM: 120-180ui/Kg/tun, gim s mi chch - B sung St : Hb mc tiu 11-12g/dL - Khng truyn mu: nu bn ang ch ghp thn iu tr tng phosphor mu, cng tuyn ph gip th pht -

iu tr ni khoa trong TNT

Kim sot nc nhp, nht l trn bn khng cn nc tiu: tit ch nc, gio dc v dry weight ( tng < 1Kg/ngy) Dinh dng: tit ch mui NaCl < 6g, protein 0,8-1g/Kg/ngy serum albumin >3g/dL iu tr RL lipid mu: ch n, gim transfat, Statin Phng nga ly cho Vim gan virus B: Chch nga Vim gan virus B trong thi gian chun b truc khi bt u iu tr thay th thn bng TNT Liu chch gp i. Phc 0,1,2 hoc 0,1,6 Theo di v kim tra thng xuyn AVF Bin chng nhim trng: NT catheter, NT AVF, vim ni tm mc,

Nguyn nhn v thi im t vong ca bn chy TNT

USRDS 2011

T vong trong 2 nm chy TNT

(End Stage Renal Disease Clinical Performance Measures Project)

N= 32.065 Chy TNT 3 ln/tun Thi gian theo di 2,2 nm Tin hnh: 2004-2007

Foley R et al, N Engl J Med, 365, 1099-107, 2011

T vong khc nhau gia cc ngy TNT trong tun

(End Stage Renal Disease Clinical Performance Measures Project)

Ngy chy TNT trong tun : HD 1, HD 2, HD 3 Foley R et al, N Engl J Med, 365, 1099-107, 2011

T vong do tim mch bn STMG cui chy TNT so vi cng ng

T l t vong do tim mch ngi tr chy TNT: cao gp 500 ln cng ng ngi>85t chay TNT: cao gp 5 ln cng ng Levey A et al, NKF Task Force, Am J Kid D, 1998, 32 (5),853-

Lin quan gia t vong vi URR v serum albumin bn HD

Owen W et al, N Engl J Med, 329, 1001-6,1993

Lin quan gia t vong vi URR v serum albumin bn HD

Owen W et al, N Engl J Med, 329, 1001-6,1993

Tn sut ri lan lipid bn STMG cui ang iu tr thay th thn

Giai an bnh T l Lipid mu bnh thng Cn iu tr bng thuc T l LDL >100mg/dL tng cn can thip

Chy thn nhn to nh k Thm phn phc mc nh k Ghp thn

20.2% 15.1%

61.1% 78.6%

55.7% 73.2%

5-10%

90-97%

90-97%

NFK DOKI guidelines 2003

iu tr gim LDL-C bn T2, chy TNT

Nghin cu 4D (Die Deutsche Diabetes Dialyze) Randomized, multicenter, double blind, prospective N=1255, T2,18-80t, ang chy TNT Atorvastatin 20mg (n=636) vs Placebo (n=619), Thi gian theo di 4 nm Primary end point: T vong do tim mch, t vong do TBMMN, NMCT v TBMMN khng t vong Secondary end point: t vong do mi nguyn nhn, mc bnh l tim mch, v mch mu no.

Wanner C, et al, N Engl J Med, 2005;353,238-

Nghin cu 4D
Atorvastatin khng gim t vong do tim mch v TBMMN khng gim NMCT, v TBMMN bn T type 2, ang chy TNT

Atorvastatin LDL 72mg/dL Placebo LDL 120mg/dL ( 42%)

Wanner C, et al, N Engl J Med, 2005;353,238-

iu tr gim LDL-C bn chy TNT nh k

Nghin cu AURORA
( A study to Evaluate the Use of ROsuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events)

Randomized, multicenter, double blind, prospective, placebo controlled N=2773, 50-80t, ang chy TNT t nht 3 thng Rosuvastatin 10mg (n=1389) vs Placebo (n=1384) Theo di 3,8 nm Primary end point: T vong do tim mch v do TBMMN, mc NMCT v TBMMN khng t vong Secondary end point: t vong do mi nguyn nhn, mc bnh l tim mch, v mch mu no.

Fellstrom BC et al, N Engl J Med, 2009;360:1395-

Nghin cu AURORA
Rosuvastatin khng gim t vong do tim mch v TBMMN khng gim NMCT, v TBMMN bn ang chy TNT

Fellstrom BC et al, N Engl J Med, 2009;360:1395-

Bnh l tim bn CKD

Dy thnh tim

X ha c tim

Heart Structural heart disease Ultrastructural heart disease Changes to left ventricular function Valvular diseases Conduction defects

Taal M and Brenner BM, The kidney 201

Bnh l mch mu bn CKD

Nhum Von Kaussa: vi ha thnh M

CT Scan vi ha thnh M vnh, MC

Arteries Increased wall thickness Arterial stiffness Endothelial dysfunction Arterial calcification

Taal M and Brenner BM, The kidney 201

Peritoneal dialysis (PD) Thm phn phc mc

Nguyn tc c bn ca Thm phn phc mc

Mng bng l mng lc (dialyzer) Mng bng l mng bn thm, din tch lc 2m2, dy vi mm Nguyn tc Cc cht ha tan khuch tn qua mng bng theo khuynh nng cc cht gia mch mu v dch thm phn Nc c rt theo p lc thm thu ca dch lc u trng. Dch ngm cng lu, p lc thm thu cng gim do hin tng khuch tn ngc ng t dch TP vo mch mu

Nguyn tc vn hnh

Mt ti

Hai ti, Y set, flush out

Quy trnh vn hnh PD

3 lai l vn chuyn trong PD

ng cong Twardowski : nh gi tnh trng vn chuyn cc cht Peritoneal Equilibration Test (PET)

Hng dn chn la iu tri da vo PET

Thnh phn dch lc (dialysate)

TP dch lc kinh in: dch lc dextrose Na 132 mEq/L, Cl 102,96,95 mEq/L Lactate 35 hoac 40 mEq/L Calcium 2,5 hoac 3,5 mEq/L Magnesium 0,5 hoac 1,5 mEq/L Dextrose 1,5- 2,5-4,25 g/dL Dch loc ang trng hoac u trng tuy theo thanh phan dextrose trong dch loc Dch loc vo khuan Dch lc khc: Icodextrin, amino acid

Catheter Tenckhoff PD: 2 cuffs

Catheter Tenckhoff PD: 2 cuffs

Catheter c 2 cuffs gip phng nga bin chng nhim trng

Chm sc Catheter khi chm dt thay dch

Cycler vn hnh PD

Phng thc PD

Continuous ambulatory PD CAPD

Continuous cycling PD CCPD

Cc phng thc PD
TYPE OF DIALYSIS[]
NUMBER OF DAYTIME EXCHANGES NUMBER OF NIGHTTIME EXCHANGES VOLUME OF EXCHANGES (L)

continuous ambulatory PD continuous cycling PD

CAPD CCPD

2-3 1

1-2 3-4

1.0-3.0 1.0-3.0

nocturnal intermittent PD

NIPD

0
1-2

3-5
3-5

2.0-3.0
2.0-3.0

nocturnal intermittent PD NIPD with wet day With wet day tidal peritoneal dialysis TPD intermittent PD IPD

0
5-10

20
5-10

1.0-1.5
1.0-2.0

Bin chng ca PD
Viem phuc mac : (van e mau chot cua TPPM): Tan suat 1 t nhiem trung /bn/12-18 thang (My, Canada) Chan oan: 1- Trieu chng cua viem phuc mac ( au bung , phan ng thanh bung, hoac met moi, buon non , non, tieu chay) 2- Dch loc b uc vi bach cau >100/uL ma >50% la neutrophils 3-Phat hien co vi trung bang nhuom gram hoac cay dch loc ieu tr: Khang sinh vao o bung, neu van cha kiem soat c se dung khang sinh toan than. Tuy mc o nhiem trung, so lan tai phat, hieu qua cua TPPM ma quyet nh tiep tuc TPPM sau o hoac chuyen sang TNT

Dch lc trong v b nhim trng

Dch c trong VPM

Dch lc bnh thng

Bin chng ca PD
X hoa phuc mac viem do tac ong cua acetate trong dch loc, viem phuc mac nhieu lan. Nhiem trung da hoac nhiem trung ng catheter luon di da (tunnel) Catheter b tac Tang ng huyet. Nguyen nhan la do tang hap thu dextrose cua dch loc. ieu tr bao gom dung insuline e kiem soat ng huyet, thay dung dch tham phan dextrose bang icodextrin.

Nhim trng chn ng catheter

Tunnel infection

nh gi hiu qu PD
Tieu chuan anh gia TPPM co hieu qua va u lieu: Ve kha nang thai chat hoa tan: Clearance ure hang tuan (Kt/V > 1,7) bao gom ca chc nang than con lai va clearance creatinine >60L/1,73 m2 da Ve kha nang thai nc: bn khong phu, khong ha huyet ap t the Ve kha nang thai chat ien giai: K mau <6 mEq/L Ve kha nang ieu hoa thang bang acid base: HCO3 > 24 mMol/L Ve kha nang duy tr dinh dng: Lng protein nhap: 1,2-1,5g/Kg, BMI 20-30 kh/m2 da, albumine mau >3,5 g%, Cholesterol mau > 150 mg%.

Cc vn ni khoa ca PD
Kim sat huyt p: PD kim sat HA tt hn, bn dng t thuc huyt p hn Kim sot ng huyt: nguy c tng ng huyt trn bn T, bn c mng lc lai vn chuyn cao, tng nhu cu dng insuline (tan thn, pha vo dch lc) Kim sot in gii: bn d b h Kali mu, khng cn tit ch nghim ngt vi Kali

Cc vn ni khoa ca PD
Thiu mu: Do khng mt mu, nn nhu cu dng erythropoietin t hn HD Bin chng tim mch: Do khng c ri lan huyt ng hc v trao i lin tc, nn PD t c bin chng ri lan nhp tim, h huyt p nh HD Chc nng thn tn lu (Residual Renal Function: RRF) l GFR cn li o bng thanh lc creatinine >1ml/ph/1,73/ngy , gi tr tin quyt trong thnh cng PD