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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¿Çϸ鼭 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¸¦ ¾ÇÈ­½ÃÅ´

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)