Yuav Ua Li Cas Sau Daim Ntawv Tshuaj Kho Mob Hemofiltration Dialysis? Cov ntsiab lus ntawm Kev Paub nyob ntawm no!

Kev kwv yees ntev ntev ntawm cov neeg mob hemodialysis yeej ib txwm yog qhov teeb meem tseem ceeb rau cov kws kho mob thiab cov neeg mob. Txawm hais tias qhov muaj sia nyob ntawm cov neeg mob hemodialysis tau nce ntxiv, 5-xyoo kev ciaj sia nyob tsuas yog 41.8 feem pua, thiab tseem muaj ntau chav rau kev txhim kho. Ntawm lawv, kab mob plawv yog qhov ua rau tuag hauv cov neeg mob ntshav lim ntshav, suav txog ntau dua 50 feem pua, thiab tom qab ntawd kis tau ntawm 11 feem pua.

Nyem rau cistanche cov txiaj ntsig thiab cov kev mob tshwm sim rau cov kab mob raum

Ntawm cov kev sim ntau yam los txhim kho qhov kev cia siab ntev ntawm cov neeg mob hemodialysis, lub siab ntim hemodiafiltration thiab high-flux dialysis tau maj mam dhau los ua cov kev xaiv zoo, tab sis cov kev xaiv no yeej ib txwm yog lub hli dawb nyob rau hauv lub siab ntawm ntau tus neeg mob dialysis - kev khib ntawm lawv Cov kev txhim kho tau coj los ntawm cov txiaj ntsig, tab sis kuj txhawj xeeb txog kev ua siab ntev tsis zoo los ntawm nws cov teeb meem. Nyob rau hauv qhov chaw ntawm cov tshuaj tsim nyog, hemodiafiltration (HDF) tseem tuaj yeem ua lub luag haujlwm zoo.

Hemodiafiltration yog dab tsi?

Feem ntau, qhov zoo ntawm HDF tshaj qhov yooj yim hemodialysis (HD) yog nyob rau hauv kev tshem tawm ntawm nruab nrab thiab loj molecular co toxins. Nyob rau hauv cov ntaub ntawv ntawm nruab nrab molecular co toxins, muaj ntau yam muaj peev xwm ua kom cov kev loj hlob ntawm atherosclerotic plawv kab mob.

Tshwj xeeb tshaj yog, HD feem ntau ua tiav cov txheej txheem lim ntshav los ntawm hom diffusion, thaum HDF muaj cov nyhuv convective ntawm lub hauv paus no, uas yog lub hauv paus rau nws zoo dua tshem tawm ntawm nruab nrab thiab loj molecular co toxins.

Ua tsaug rau qhov txiaj ntsig no, tus naj npawb ntawm cov neeg mob HDF online hauv ntiaj teb lossis hauv thaj av Asia-Pacific tau loj hlob sai, nrog rau kev loj hlob mus txog 19 feem pua ​​​​thiab 26 feem pua ​​​​ntawm 2009 txog 2017, thiab feem pua ​​​​ntawm cov neeg mob HDF hauv kuv lub tebchaws. rau lub teb chaws cov neeg mob hemodialysis kuj tau nce mus txog 10 feem pua ​​[1]. Siv cov ntaub ntawv los ntawm daim ntawv ntsuam xyuas ntawm cov neeg mob hemodialysis hauv Shanghai los ntawm 2007 txog 2014 ua piv txwv, qhov feem pua ​​​​ntawm cov neeg mob HDF tau nce los ntawm 7 feem pua ​​​​rau 52 feem pua, thiab feem ntau ntawm lawv tau kho ib zaug ib lub lim tiam.

Puas yog HDF, uas tau dhau los ua ntau thiab ntau qhov kev lees paub, tiag tiag zoo?

Dab tsi yog qhov zoo ntawm high-volume hemofiltration dialysis?

Raws li thaum ntxov xyoo 2007, European Cov Txheej Txheem Kev Ua Zoo Tshaj Plaws rau Ntshav Purification (EBPG) tau pom zoo tias online HDF tuaj yeem siv tag nrho cov permeability ntawm high-flux dialysis membranes, thiab cov convection txaus yuav tsum tau nce ntau npaum li sai tau nyob rau hauv lub premise ntawm kom ntseeg tau. kev ruaj ntseg [3]. Txawm li cas los xij, nyob rau xyoo tas los no, cov lus xaus ntawm ntau qhov kev sim tshuaj ntsuam xyuas (RCTs) ntawm HD thiab HDF ib txwm thuam ib leeg.

Qhov no tsis tau txhais hais tias HDF tsis muaj qhov zoo dua piv nrog HD: qhov kev sib tw sib tw tsis tsuas yog pom tias 2 microglobulin theem ntawm pawg HDF online tau qis dua li ntawm pawg HDF uas tsis tshua muaj, tab sis kuj txo qis kev pheej hmoo ntawm kev tuag thaum. tus nqi txaus siab tshaj 21.95L, thiab cov neeg tuag tuaj yeem txhim kho. 38 feem pua ​​[4]; Turkish kev sim pom tias txhua qhov ua rau thiab cov hlab plawv tuag tuaj yeem raug txo qis thaum lub convective ntws dhau 17.4L [5]; qhov kev sim ESHOL pom tias qhov ciaj sia taus ntawm cov neeg mob hauv pawg HDF yog siab dua li hauv pawg HD, thiab txhua qhov kev tuag tau txo qis thaum cov dej ntws tawm yog 21.7L. , cov kab mob plawv thiab kab mob ntsig txog kev tuag raug txo los ntawm 30 feem pua ​​, 35 feem pua ​​​​, thiab 55 feem pua ​​​​, raws li, thiab qhov xwm txheej ntawm kev lim ntshav ntsig txog ntshav qab zib tuaj yeem txo los ntawm 28 feem pua ​​[6].

Yog li ntawd, HDF nrog lub siab convective ntws yog qhov zoo tshaj hauv kev ua tau zoo. Tom qab kev soj ntsuam tag nrho ntawm cov ntaub ntawv ntawm peb lub RCTs loj, nws tau pom tias thaum lub convective ntws tshaj 23L, tag nrho cov ua rau kev tuag thiab cov kab mob plawv-mob tuag yuav txo tau zoo heev [7]]. Txawm hais tias qhov zoo ntawm HDF yog qhov pom tseeb heev, tseem muaj ntau tus neeg mob uas tsis pom zoo los ntawm ntau yam teeb meem lossis kev tsis txaus siab thaum lawv nkag mus rau HDF kev kho mob thaum pib. Yuav ua li cas ua tiav txhua qhov kev kho HDF?

Dab tsi yog qhov cuam tshuam feem cuam tshuam ntawm HDF?

Muaj ntau yam cuam tshuam rau kev kho mob HDF, uas tuaj yeem faib ua plaub yam raws li kev kho mob hauv kuv lub tebchaws:

Cov neeg mob sab: vascular tej yam kev mob (ruaj khov thiab yooj yim-rau-siv vascular nkag), hemodynamics, hemorheological yam (hemoglobin, hematocrit, thiab lwm yam. tsis ua kom ntshav viscosity), cardiovascular ultrafiltration rate, thiab lwm yam.;

Kev kho mob sab: kev teeb tsa ntshav ntws, hemodialysis lim kev ua tau zoo, cov txheej txheem tiv thaiv coagulation, lub sijhawm kho, thiab lwm yam.;

Cov khoom siv sab: kev sib cuam tshuam ntawm cov ntshav thiab lim, dialysate txaus tus nqi, ultrafiltration transmembrane siab thiab kev teeb tsa hom (phau ntawv / tsis siv neeg), hloov cov kua dej zoo, dialyzer, tshuab lim ntshav, thiab lwm yam.;

Social sab: kev tuav pov hwm kho mob rov qab txoj cai, thiab lwm yam.

In practice, it is often necessary for doctors and nurses to select suitable patients for HDF: in addition to vascular conditions, hemodynamics, and hemorheology supporting high blood flow velocity, ideally, the expected flow rate of the arteriovenous fistula is >600ml / min, thiab tus neeg mob Tsis muaj teeb meem uas yuav ua rau cov ntshav viscosity nce, xws li hematocrit siab, cryoglobulinemia, thiab hemophilia.

Ua ntej no, hemodialysis khoom thiab consumables kuj yuav tsum tau raws li tej yam kev mob (Daim duab 4), ntawm cov uas: zoo heev zoo ntawm hloov kua yuav pab txo tau cov inflammatory txheej txheem thiab ua rau kom cov kev kho mob ntawm high-muaj peev xwm HDF; high-flux dialysis membrane tau pab kom zam siab dua transmembrane siab los txhim kho qhov pom feem; automated system tswj yuav muaj txiaj ntsig kom ua tiav kev kho mob HDF ruaj khov.

Hauv kev xyaum, hom kev kho mob ntawm HDF tuaj yeem muab faib ua kev hloov ua ntej dilution, hloov tom qab dilution, sib xyaw dilution, thiab nruab nrab dilution raws li txoj kev hloov. Tam sim no, tsis muaj cov ntaub ntawv muaj nyob rau kev sib piv ntawm qhov kev ua tau zoo ntawm cov kev hloov pauv sib txawv ntawm cov txiaj ntsig kev kho mob, thiab qhov cuam tshuam ntawm kev siv anterior thiab posterior hloov pauv ntawm qhov kev tshwm sim tseem yuav tau kawm ntxiv.

Raws li rau lub hom phiaj ntws ntawm HDF kev kho mob, cov kev tshawb fawb txawv teb chaws tau pom tias kev txhim kho ntawm cov txheeb ze ciaj sia nyob hauv online HDF cov neeg mob yog txaus-dependant: tom qab lub lim piam ntws mus txog 56.8L, tus txheeb ze ciaj sia taus ntawm cov neeg mob nce linearly nrog rau. tus nqi ntws, thaum thaum tus nqi ntws mus txog 56.8L, tus txheeb ze ciaj sia taus nce linearly nrog tus nqi ntws. Tom qab ncav cuag 75L, cov txiaj ntsig kev ciaj sia tsawg tsawg, qhia tias tsis muaj txiaj ntsig ntxiv rau HDF nrog tus nqi ntws siab heev. Yog li ntawd, cov kev kho mob pom zoo lub hom phiaj ntws ntawm txoj kev tshawb no yog 56.8-75.0L/lub lim tiam[8].

Qee cov kev tshawb fawb tau tshawb nrhiav qhov sib txuas ntxiv HDF (I-HDF), uas yog, cov dialysate ultrapure tau hloov pauv mus rau hauv cov ntshav thaum lub sij hawm HDF txheej txheem, feem ntau 200ml ntawm dialysate ib infusion, infusion ncua sij hawm yog 30min, thiab infusion ceev yog 150ml. / min. Cov txheej txheem no tsis koom nrog kev hloov pauv ua ntej lossis tom qab hloov chaw, thiab cov dej ntws tawm qis dua li HDF online. Txhua lub sijhawm kho yog 4 ~ 5h, thiab tag nrho cov dej ntws ntawm I-HDF tsuas yog 1.4-1.8L. Txoj kev tshawb no tau pom tias I-HDF tuaj yeem txhim kho hemodynamics ntawm cov neeg mob mus rau qee qhov, nce kev tshem tawm ntawm nruab nrab thiab loj molecular solutes, txhim kho ntshav refill, thiab txuag cov kua dej hloov [9]. Txawm li cas los xij, hom kev tshawb nrhiav no tau tawm tsam rau qhov tam sim no qhov tseem ceeb ntawm kev ua kom muaj kev sib txuam siab, thiab nws cov txiaj ntsig tseem yuav tsum tau lees paub ntxiv.

Tsis tas li ntawd, qhov kev tshawb fawb tshiab tshaj plaws hauv kuv lub teb chaws tau pib nrog kev kho mob ntau zaus thiab pom tias cov tshuaj muaj zog HD (HFHD) ua ke nrog HDF ib zaug ib lub lim tiam tuaj yeem txhim kho lub neej luv luv ntawm cov neeg mob hemodialysis, txhim kho kev noj zaub mov zoo, txo qis. lub sij hawm pw hauv tsev kho mob, thiab ntau lub tsev kho mob, thiab txo erythropoiesis. Txo cov neeg tuag [10].

Cov ntsiab lus

Feem ntau, cov ntsiab lus tseem ceeb ntawm HDF qhov chaw muab tshuaj yog tsis muaj dab tsi ntau tshaj li qhov txaus, cov ntshav txaus, hloov hom, hemofilter, thiab hloov cov kua dej ntws. Ntawm lawv, qhov zoo tshaj plaws convective ntws los txhim kho cov kev mob tshwm sim ntawm cov neeg mob tsuas yog ua tiav thaum cov dej ntws mus txog tsawg kawg 20 feem pua ​​​​ntawm tag nrho cov ntshav ntim tau kho hauv txhua qhov kev kho mob, thiab qhov txwv siab tshaj ntawm ultrafiltration tus nqi hauv cov ntshav ntws yog 25. feem pua ​​-30 feem pua ​​ntawm cov ntshav ntws [11 -12].

Txawm li cas los xij, txawm hais tias ntau qhov kev tshawb fawb tau lees paub tias txhua qhov kev tuag ntawm HDF hauv online yog qis dua li HDF, tshwj xeeb tshaj yog vim tias qhov txiaj ntsig ntawm kev hloov pauv hauv online HDF yog qhov pom tseeb dua, cov pov thawj tshawb fawb ntawm kev hloov sab hauv tseem tsis tshua muaj. Yog li ntawd, kev xaiv hom kev kho HDF zoo tshaj plaws tseem yuav tsum tau tshawb nrhiav tas li nyob rau hauv cov lus qhia ntawm kev hloov pauv, hloov cov dej ntim, lub sijhawm kho, thiab kev tshuaj xyuas cov nyhuv.

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