Dialysis ´ëÀå°æ Á¤¸®
1. Åõ¼®¾× Á¶¼º
1) HD : Na 135, K 0-4, Ca 2.5-3.5, Acetate 34-38, Bicarbonate 0
(BicarbonateÅõ¼®¾×ÀÇ °æ¿ì 25-30 mEq/L)
2) PD : Na 132, K 0, Ca 3.5 Acetate 35-40, bicarbonate 0
2. HD¿¡¼ Åõ¼®ÀÇ ¾çÀ» °áÁ¤ÇÏ´Â ÀÎÀÚ
body size, residual renal function, dietary intake, complicating illness,
anabolism & catabolismÁ¤µµ
3. Uremic sxÁß Áö¼ÓÀûÀÎ Åõ¼®À¸·Îµµ ÁÁ¾ÆÁöÁö ¾Ê´Â °ÍÀº?
impaired growth, infertility & sexual dysfunction, amenorrhea
hypertriglyceridemia, accelerated atherosclerosis, pruritus
sleep disorder, myopathy, lymphocytopenia, splenomegaly & hypersplenism
4. Åõ¼®½ÃÀÛ ½ÃÁ¡À» °áÁ¤ÇÏ´Â two guidelines(NKF-DOQI guidelines)
i) Ccr < 9-14 mL/min(=weekly Kt/V < 2.0)
ii) protein intake < 0.8 g/kg/d(nPNA<0.8 g/kg/d)
iii) uremic sx(+)
cf. normalized protein equivalent of nitrogen appearance(nPNA)
=1.217*(1-e-0.769Kt/V)
5. CRF¿¡¼ Åõ¼®ÀÇ ÀûÁ¤µµ¸¦ Æò°¡ÇÒ¼ö ÀÖ´Â ÁöÇ¥
i) Kt/V
ii) URR(urea reduction ratio) = Åõ¼®ÀüÈÄ urea/Åõ¼®Àü urea ¡¿ 100
Kt/V¿Í well correlation
acceptable URR = 65%
iii) PCR(protein catabolic rate) acceptable PCR =1.2 g/kg/d
6. HD½Ã Kt/V¸¦ Çâ»ó½Ã۱â À§ÇÑ ¹æ¹ý
: 1ȸ Åõ¼®½Ã°£ ¿¬Àå, Ç÷·ù·® Áõ°¡
7. delivered Kt/V°¡ ¿¹»óÄ¡º¸´Ù ÀûÀ» ¶§ »ý°¢ÇÒ¼ö ÀÖ´Â °Í?
i) blood flow°¡ À¯ÁöµÇÁö ¸øÇÏ´Â °æ¿ì
ii) ȯÀÚÀÇ VolumeÀÌ Ã³À½ °è»êÇѰͺ¸´Ù Ŭ¶§(Kt/V¿¡¼ V°¡ Ä¿Áö¸é Kt/V°¡ ÀÛ¾ÆÁü)
iii) dialyzer KoA°¡ ¿¹»óÄ¡º¸´Ù ÀÛÀ» ¶§(Á¦Á¶À߸ø ȤÀº reuseµîÀ¸·Î KoA °¨¼Ò)
iv) access recirculation: needleÀÌ ³Ê¹« °¡±õ°Å³ª ÇÏ¿© °°Àº Çǰ¡ °è¼Ó µ¼
v) rebound: Åõ¼®Á÷ÈÄ¿¡´Â BUNÀÌ °¨¼ÒÇϳª ½Ã°£ÀÌ Áö³ª¸é rebound·Î BUNÀÌ ¿Ã¶ó°¡´Âµ¥
sampleÀ» ´Ê°Ô ÇÒ °æ¿ì BUNÀÌ ³ôÀº sampleÀ» ÇÏ¿© Kt/V°¡ ³·¾ÆÁü
8. Vascular access infection: S. aureus
9. HD½Ã ¹ß»ýÇÏ´Â ÀúÇ÷¾ÐÀÇ ¿øÀÎ
¨ç blood volume°¨¼Ò
i) ultrafiltration¡è
ii) plasma osmolality¡é
¨è vasoconstrictionÀå¾Ö
i) acetate-containing dialysate
ii) dialysate¿Âµµ°¡ ³Ê¹« µû¶æÇÒ ¶§
iii) autonomic neuropathy
iv) antihypertensive medication
¨é cardiac factor
heart disease, sepsis...
10. Hyponatremic dialysate ÇÕº´Áõ 3°¡Áö
i) hypotension: dialyzed bloodÀÇ ¹°ÀÌ °£Áú·Î À̵¿ÇÏ¸é¼ plasma volumeÀÇ osmotic
contraction »ý±è
ii) muscle cramp
iii) dialysis disequilibrium syndrome: hyponatremic bloodÀÇ ¹°ÀÌ ¼¼Æ÷³»·Î µé¾î°¡¸é¼
cerebral edema¸¦ À¯¹ßÇÏ¿© DDS¸¦ ¾ÇȽÃÅ´
11. HD½Ã ³ªÅ¸³¯ ¼ö ÀÖ´Â ½Å°æÇÐÀû ÀÌ»ó 2°¡Áö
i) dialysis disequibrium syndrome : ºü¸¥ BUNÀÇ Á¦°Å·Î ÀÎÇÑ osmolalityº¯È¶§¹®
ii) dialysis dementia: aluminum accumulation
12. Àå±â Ç÷¾×Åõ¼®½Ã ¹ß»ýÇÏ´Â ½Å°æ°è ÇÕº´Áõ
¨ç CNS : dialysis dementia, brain cortical atrophy, DDS(acute)
¨è PNS : sensory or motor neuropathy, restless legs syndrome
¨é ANS
13. Àå±â Ç÷¾×Åõ¼®½Ã ÃÖ±Ù ÀÓ»óÀûÀ¸·Î ¹®Á¦°¡ µÇ´Â ÇÕº´Áõ 4°¡Áö
dialysis dementia, acquired cystic disease, dialysis-related amyloidosis, MI & CVA
14. Dialysis-related dementia(DRA) : ¥â2-microglobulin, amyloidosis
15. º¹¸·Åõ¼®¿¡¼ º¹¸·Åõ°ú¼º°ú »ýÁ¸·üÀº ¹Ýºñ·ÊÇÑ´Ù.
high transport => longterm outcome¡é
¡ñ i) less effective ultrafiltration
ii) larger protein loss = poor nutritional status & low serum albumin
16. º¹¸·Åõ¼® ÇÕº´Áõ
peritonitis, abdominal hernia, peritoneal ultrafiltration¡é, hyperglycemia, protein
malnutrition
17. º¹¸·Åõ¼®È¯ÀÚ¿¡¼ ÀÜ·ù½Å±â´ÉÀÇ º¸Á¸ÀÌ Áß¿äÇÑ ÀÌÀ¯
º¹¸·Åõ¼® ½ÃÀÛ Ãʱâ ÀÜ·ù ½Å±â´ÉÀº ÃÑ Kt/VÀÇ ¾à 30%, CcrÀÇ 40%¸¦ Â÷ÁöÇϴµ¥ Åõ¼®±â°£ÀÌ
Áõ°¡ÇÔ¿¡ µû¶ó ÇöÀúÈ÷ °¨¼ÒÇÑ´Ù. ½ÅÀåÀº »ç±¸Ã¼ ¿©°ú À̿ܿ¡ »ê¿°±âÁ¶Àý, erythropoietin
»ý¼º ¹× ºÐºñ, RASÁ¶Àý, Vit DȰ¼ºÈ µîÀÇ ³»ºÐºñ ±â´É, amino acid metabolismµî ´Ù¾çÇÑ
±â´ÉÀ» ÇϹǷΠÀÜ·ù½Å±â´ÉÀÇ º¸Á¸Àº ȯÀÚÀÇ ¿¹ÈÄ¿¡ Áß¿äÇÑ ¿µÇâÀ» ³¢Ä£´Ù.
18. º¹¸·Åõ¼®ÀÇ Àý´ëÀû ±Ý±âÁõ
i) peritoneal fibrosis or resection
ii) pleuroperitoneal leak: hydrothorax
iii) active inflammatory bowel disease
19. º¹¸·Åõ¼®È¯ÀÚÀÇ ¿¹ÈİáÁ¤ÀÎÀÚ
age, IDDM, cardiovascular diseaseµ¿¹ÝÀ¯¹«, Kt/V, Ccr, serum albumin,
nutritional status(subjective global assessment, SGA & percentage lean body mass)
20. CAPD¿¡¼ Åõ¼®ÀÇ ÀûÀýµµ¸¦ Æò°¡Çϱâ À§ÇØ »ç¿ëÇÏ´Â ÁöÇ¥ 2°¡Áö
weekly Kt/V, Ccr
21. Automatic PD¸¦ ½ÃÇàÇϱâÀü ÀûÀýÇÑ Åõ¼®·®À» ó¹æÇϱâ À§ÇØ ½ÃÇàÇØ¾ß ÇÒ °Ë»ç 2°¡Áö
PET, residual renal function
22. PET
high transport (D/P)cr 0.82-
high average 0.66-0.81
average 0.65
low average 0.50-0.64
low 0.34-0.49
23. PDÁ¾·ù
1) continuous
CAPD: ³·¿¡ 3-4ȸ, ¹ã¿¡ long bedtime exchange
CCPD(continous cyclic PD): ³·¿¡ long dwell, ¹ã¿¡ 3-4ȸ short-time exchange
2) intermittent
NIPD(nightly intermittent PD): ³·¿¡´Â ¾ÈÇϰí, ¹ã¿¡¸¸ multiple short-time exchanges
DAPD(daytime ambulatory PD): ³·¿¡¸¸ 4¹ø dwell, ¹ã¿¡´Â dwell(-)
IPD: ÇÑÁÖ¿¡ 3-4ȸ, rapid cycling
CAPD°¡ CCPD³ª NIPD¿¡ ºñÇØ º¹¸·¿° ºóµµ°¡ ³ô´Ù.
CCPDÀÇ Kt/V ÃÖ¼Ò ±ÇÀåÄ¡´Â 1.7/weekÀÌ´Ù.
NIPD´Â CAPD³ª CCPD¿¡ ºñÇØ vit B12ÀÇ clearance°¡ Àû´Ù.
NIPD´Â CAPD³ª CCPD¿¡ ºñÇØ recommended minimal urea clearance°¡ ³ô´Ù.
24. °¢ transportÀÇ Æ¯Â¡
1) high transport: peritonititis or hyperpermeable membraneÀ¸·Î ÀÎÇÏ¿© good clearance,
poor ultrafiltration
¡Å long dwellingÇÏ¸é ¼öºÐ°ú´Ù »óŰ¡ µÇ¹Ç·Î Åõ¼®¾×À» ÀÚÁÖ ±³È¯ÇÏ´Â ¹æ¹ýÀ» ¼±ÅÃÇØ¾ß
ÇÑ´Ù.
CAPDÀÇ °æ¿ì CCPD·Î, CCPDÀÇ °æ¿ì NIPD·Î ¹Ù²Û´Ù.
2) average & high average: CAPD, CCPD, NPD µî »ç¿ëÇÒ¼ö ÀÖ´Ù.
3) low average
residual renal function >4 ml/min => CAPD, CCPD
residual renal functionÀÌ ¾ø´Ù¸é => high dose CAPD
4) low transport: poor clearance, poor ultrafiltration
adhesion or peritoneal sclerosis·Î ÀÎÇÏ¿© peritoneal surface area°¡ °¨¼ÒÇϱ⠶§¹®
-> very high dose PD¸¦ ÇϵçÁö, HD·Î ÀüÈ¯ÇØ¾ß ÇÑ´Ù.
25. High transportÀÇ ÇÕº´Áõ
ultrafiltration failure, glucose absorption(-> weight gain)
malnutrition(¡ñhigher protein loss)
26. high transport¿¡¼ »ç¸Á·üÀÌ Áõ°¡ÇÏ´Â ÀÌÀ¯
i) ¼öºÐ ¹× ¼ÒºÐÀÚ ¹°Áú Á¦°Å °¨¼Ò¿Í ÀÌ¿¡µû¸¥ ü³»¼öºÐÀú·ù
ii) Æ÷µµ´ç Èí¼ö Áõ°¡
iii) malnutrition
iv) º¹¸·À» ÅëÇÑ albumin¼Ò½ÇÁõ°¡
v) ÁöÁú´ë»ç ÀÌ»ó
27. º¹¸·Åõ¼® ȯÀÚ¿¡¼ ¿ëÁúÀÇ Á¦°Å°¡ ºÎÀûÀýÇÏ°Ô º¸Àϼö ÀÖ´Â °æ¿ì 5°¡Áö
scleroderma, malignant hypertension, peritoneal fibrosis, vasculitis,
residual renal functionÀÌ ¾ø´Â heavy patient(>70kg)
28. Peritonitis Dx criteria
i) Gram stain or culture»ó ¾ç¼º
ii) WBC 100°³ ÀÌ»ó & poly 50%ÀÌ»ó
iii) abdominal pain & tenderness
¼¼°¡Áö Áß 2°¡Áö ÀÌ»óÀÏ ¶§ Áø´Ü
29. CAPD¿¡¼ catheter outflow failure½Ã °í·Á»çÇ×
i) catheter malposition
ii) omental wrapping
iii) bowel adherence(constipationµî)