Blood Purification Methods
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1 Blood Purification Methods Kidney function: Excretory (removal of small and middle size molecules) Metabolic (acid- base balance, removal of molecules of higher molecular weight) Endocrine (erythropoetin, vitamine D)
2 Etiol. of CKD Diabetic nephropathy Atherosclerotic renovascular disease Primary and secondary glomerulopathies Chronic tubulointerstitial nefrities Polycystic kidney disease Monoclonal gammapathies.
3 Diagnosis of renal disease A Albuminuria B Blood pressure C Cholesterol D Diabetes E Estimated GFR
4 SEMI-PERMEABLE MEMBRANE
5 Goals of dialysis techniques Transport or clearance of solutes: by diffusion and convection (adequacy of dialysis- Kt/V) Fluid removal or Ultrafiltration
6 Diffusion The transfer of solutes (substances) across the membrane, down a concentration gradient 1 Blood Membrane Dialysate Red blood cell 2 - Bacteria Sodium Potassium Chloride Bicarbonate Urea Creatinine -2-MG Uric acid
7 Hemodialysis monitor Blood circuit- inflow blood line- arterial - dialyzer (semipermable membrane) - outflow blood line- venous - blood pump- roller pump - pressure monitors (prepump, postpump)
8 Vessel acces for hemodialysis Blood flow of 20-50ml/min in peripheral vein Blood flow of more than 500ml/min in AV shunt 16-23% of all hospitalisations of HD patients because of vessel acces problems
9 Vessel access for hemodialysis 1. Native primary- arteriovenous shunt a) radiocephalic b) brachiocephalic c) brachiobasilic -deep localisation usually- not suitable for punction, higher risk of hyperfunction, steal syndrom 2. Vessel prothesis - due to anatomical possibilities- brachio- brachial, axilloaxillar, brachio- jugular, sapheno-femoral synthetic (gore, rapidax ) or autologous (v.saphena)
10 Arteriovenous fistula shunt survival rate 1 year % 2 years % Brachio-brachial AV shunt with synthetic PTFE interposition, right arm
11 Vessel access for hemodialysis - complications -thrombosis -stenosis -steal syndrom -development of aneurysm -n.medianus leasion -infection -heart failure-hypercirculation -punction damagement of vessel graft -risk of stenosis of subclavian vein after CVC
12 Central venous catheter -low blood supply- 200ml/min -vessel access for period of several weeksmonths -recommended use in less than 10% HD patients - increased morbidity Tunneled, cuffed permanent catheter in subclavian vein l.dx.
13 Vessel access for hemodialysis % shunts unsuitable for HD use - poor outcome in old and diabetic patient - shunt survival rate - 1 year % - 2 years % - US - 30% native shunt - Europe % native shunt
14 Duration of the hemodialysis procedure 3-5 hours 2-3 times / week Transportation time Preparation time
15 Bioincompatibility of HD Bioincompatibility of the procedure -noncontinuous puriffication -sudden changes in homeostasis Bioincompatibility of the materials - synthetic materials used- extracorporal tubing, membrane - anticoagulants
16 Complication of hemodialysis Infectious (vessel access, sepsis, endocartitis) Non- infectious Acute: arrhytmias Hypotension bleeding Chronic: cardiovascular- acceleration of atherosclerosis- coronary heart disease, stroke, lower extremity ischemic disease overhydratation (anuric patients) metabolic and endocrine (mineral bone disease) MIA syndrome- (malnutrition, chronic inflammation, atherosclerosis) immunosuppression
17 Continuous Ambulatory Peritoneal Dialysis 1. Infuse fresh dialysate 2. Dwell 3. Drain saturated dialysate
18 Typy chronických peritoneálních katetrů Založení PD katetru Implatovaný PD katetr Napojení v rámci výměny CAPD
19 Types of PD CAPD Continuous Ambulatory Peritoneal APD Automated Peritoneal Dialysis Dialysis
20 CAPD
21 CAPD Manual therapy Prescription volumes are standardized 1500ml, 2000ml, 2500ml, 3000ml solution bags 6-12 hour dwell period each night (depends on type of membrane) 4-5 day exchanges 7 days a week 3-5 hr dwell per day exchange Day exchanges Night dwell
22 Varianty peritoneální dialýzy: 1. CAPD 2. APD - CCPD - NIPD - TPD
23 CAPD : Continous Procedure Drain Fill Dwell +/- 20 +/ hours Old dialysate New solution Disposables thrown away Dialysis
24 APD Treatment Cycler performs exchanges/cycles automatically while patient is sleeping Patient connects when going to bed and disconnects in the morning Long dwell during the day
25 COMPLICATIONS OF PD Infection Abnormal Membrane Permeability Nutrition Related Protein loss Abdominal Structure hernias, omentum Procedure Related
26 COMPLICATIONS OF PD Infection Sources Set/Catheter Junction Catheter/Skin Junction Bag Port Injection Site Internal
27 Acute complication of PD INFECTIOUS - Tunnel infection Treatment- antibiotics -Acute peritonitis (turbid dialysate, subfebrile, abdominal pain, typical laboratory picture) Treatment: -cefalosporine 1.a 3.generation once daily intraperitoneally -cefalosporine 1.generation and aminoglykoside more than 20 days intraperitoneally
28 COMPLICATIONS OF PD Abnormal Membrane Transport Low Transport High Transport Increased Ultrafiltration Dehydration Inadequate Clearances Decreased Ultrafiltration Fluid Overload Increased Protein Loss
29 COMPLICATIONS OF PD Structural - Membrane Leak - Hernia ( pleural,scrotal/labial edema) - Catheter dislocation - Catheter obstruction - Catheter leak
30 Kontraindikace PD Absolutní Ztráta funkce peritonea Anatomické abnormality bez možnosti chirurgického řešení Neschopnost pacienta provádět výměnypsychický stav, porucha drobné motility, poruchy zruku Neoperabilní kýly, brániční kýla Relativní Patologická obezita Stav po intrabdomin. operacích Záněty střevní Divertikuloza Stomie Infekce stěny břišní Plicní restrikce Polycystoza ledvin Imunosuprese
31 Dialysis modalities in Europe % % patients HD(%) PD(%) Czech Belgium Germany Austria Greece Sweden UK
32 Clinical importance of residual renal function - regulation of fluid and electrolyte - balance - nutritional status and survival - preservation of middle size molecules removal
33 years Patient survival WL dialysis transplant Age group Wolfe RA et all: N Engl J Med 1999
34 Léčba CHSL v ČR Funkční štěp Hemodialýza Peritoneální dialýza Celkem léčených
35 Chronic renal insuficiency (terminal CKD) Living- donor transplantation Preemptive listing to kidney tranplatation Hemodialysis Peritoneal dialysis Cadaverous kidney transplantation
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