Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,自动化腹膜透析,处方调整,自动化腹膜透析处方调整,1,日本,2,500,欧洲,4,500,其它,4,400,北美,14,000,总计25,400,1996,年全球,APD,病人分布情况,95,到96年的年增长率为40,日本欧洲其它北美总计25,4001996年全球APD 病人分,2,全球,APD,与,CAPD,占有情况,Source:1996 Baxter Patient Report,全球APD与CAPD占有情况Source:1996 Bax,3,US,Europe,美国与欧洲,APD,与,CAPD,占有情况,USEurope美国与欧洲APD与CAPD占有情况,4,全球,APD,病人的增长情况,5,500,9,000,27,600,21,000,35,800,全球APD病人的增长情况5,5009,00027,60021,5,HomeChoice Patients Around the World,9,223,762,2,990,1,945,274,198,226,97,Q1,Total 15618,HomeChoice Patients Around the,6,APD的不同类型,夜间 ,白天 ,潮式 ,非潮式 ,每周进行24,小时，分3次,或以上间歇,进行,APD的不同类型夜间 ,7,制定处方的基本要素,体表面积,(BSA),残余肾功能,(RRF),收集24小时尿标本,每3个月测定一次,腹膜转运特性,标准,PET,开始腹透治疗,2-4,周后进行,制定处方的基本要素体表面积(BSA),8,充分性评估与调整,充分性评估与处方调整,临床评估,营养评估,清除率评估,达到目标?,是,否,继续治疗，无需调整处方,处方调整,常规随访，每4个月进行一次充分性评估,根据,PET,结果调整处方,调整24周后重新进行充分性评估,Source:Peritoneal Dialysis Prescription Management Decision Tree,1997,充分性评估与调整充分性评估与处方调整临床评估营养评估清除率评,9,充分性目标,DOQI guidelines suggest:,For CAPD-KT/V urea of 2.0 per week,Creat.Clr.60L/1.73m body,surface area/wk,For NIPD -KT/V urea of 2.2 per week,Creat.Clr.66L/1.73m body,surface area/wk,For CCPD-KT/V urea of 2.1 per week,Creat.Clr.63L/1.73m body,surface area/wk,2,2,2,充分性目标DOQI guidelines suggest:2,10,清除率目标,Source:Blake et.al.,PDI,1996,CrCl,L/wk/1.73 m,2,70,Kt/V,Weekly,2.10,Guidelines,Use caution,Borderline,Acceptable,Desirable,清除率目标Source:Blake et.al.,PD,11,腹膜转运特性,%患者 膜类型,4,小时 特性,肌酐,D/P,10%,高.81-1.03-腹膜效能非常高,-,溶质转运迅速,-,葡萄糖吸收多,-,可能较难满足超滤要求,53%高,.65-.81-,腹膜效能高,平均-溶质转运较迅速,-,超滤可,31%,低 .50-.65-腹膜效能较低,平均-溶质转运速度较慢,-,超滤较好,6%Low.34-.50-,腹膜效能低,-,溶质转运速度慢,-,无残余肾功能时难以达到清除率目 标,-,超滤很好,腹膜转运特性%患者 膜类型,12,亚洲腹透病人,PET,分布,Sources:,Transport classifications:Baxter Clinical database,US PD patients,n=827,1995.,Patient BSA derived from Cross-sectional Study of Nutrition,T.Chiku,1993.,Body Surface Area m,2,1,2,2,3,3,4,4,1.75,Low,Low Average,High Average,High,6%31%53%10%,1,2,3,4,4,No Wet Day needed if Pt has RRF,Require Wet Day;maximize the overnight fill vol,Do best w/an addl daytime exchange,Most difficult to dialyze on any PD therapy,1,2,3,4,亚洲腹透病人PET分布Sources:Body Surfac,13,APD,总入液量对肌酐清除率的影响,12.5,L(4x2.5L+2.5L),12.5L(3x2.5L+2.5L+2.5L),15L (4x2.5+2.5L+2.5L),20,L APD(7x2.5L+2.5L),20L APD Dry(8x2.5L),APD总入液量对肌酐清除率的影响12.5L(4x2.5L,14,白天“湿腹”的重要性,90%的,APD,患者-除仍有残余肾功能的高转运患者,-,需要白天湿腹以达到透析充分性目标,90%,Wet Day Dry Day,0%,5%,10%,15%,20%,25%,30%,35%,Low,Low,Average,High,Average,High,40%,45%,50%,6%,31%,53%,10%,白天“湿腹”的重要性 90%的APD患者-,15,白天“湿腹”的重要性,总入液量同样为12,L,的,APD,治疗，如使用白天湿腹，则可使清除率每周增加30！,Liters/Week,Creatinine Clearance,42.5,54.0,Source:PD Adequest 1.4,Patient 160 cm,57 kg,.72 4 hr D/P,10 hr therapy,daily UF=1100,白天“湿腹”的重要性总入液量同样为12L的APD治疗，如使用,16,APD,处方调整,Patient,BSA1.86m,2,4,o,D/P0.71,RRF0,UF1.5L,10 hours cycler,CrCl L/wk/1.73m,2,Total Volume20L10L12.5L12.5L,Cycler Night8X2.5L4X2.0L4x2.5L3x2.5L,DayDry2.0L2.5L2.5L+2.5L,Night Dwell(min)41112.5112.5160,Source:PD Adequest,TM,Database,1996,Least,Efficient,43.0,46.0,55.0,Most Efficient,67,8%,20%,21%,57%,APD 处方调整PatientCrCl L/wk/1.73m,17,APD,弹性处方调整，提高透析清除率,Source:PD Adequest 1.4,Patient 160 cm 57 kg.72 4 hr D/P,9 hr therapy,daily UF=1100,Liters/Week,Creatinine Clearance,2,L x 5,+2L,2.5,L x 4,+2L,2.5,L x 3,+2L+2L,2,L x 4,+2L,+1 hour,增加“湿腹”,增加入液量,增加白天换液次数,延长夜间上机时间,51.1,57.3,67.1,61.6,Average Size Patient,High Average PET,APD弹性处方调整，提高透析清除率Source:PD Ad,18,当残余肾功能下降时,通过调整,APD,方案和增加剂量，可提高肌酐清除率,50,-,25,-,-,60,-,30,NIPD,Larger fill CCPD,CCPD,High Dose,CCPD,Dialysis Clearance,Residual Clearance,RRF,Cr Cl/,week,Dialysis,Cr Cl/,week,Time On Dialysis,Brunkhorst,et al,Kidney International,Vol 46,1994.,当残余肾功能下降时通过调整APD方案和增加剂量，可提高肌酐清,19,