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腹膜透析的充分性

Authors
John M Burkart, MD
William L Henrich, MD, MACP
Section Editor
Thomas A Golper, MD
Deputy Editor
Alice M Sheridan, MD
Translators
韩庆烽, 主任医师，副教授

引言

和血液透析治疗一样，评价腹膜透析(peritoneal dialysis, PD)治疗[包括持续不卧床腹膜透析(continuous ambulatory peritoneal dialysis, CAPD)和自动腹膜透析(automated peritoneal dialysis, APD)]充分性的最佳方法尚存争议[1]。充分透析较为宽松的临床标准包括患者感觉良好、无尿毒症症状及生化参数控制在合理范围内。然而，上述标准中很多都是主观性的，患者通常会将问题最小化。另一方面，存在尿毒症症状(如恶心、呕吐或心包炎导致的胸痛)或血浆尿素氮(blood urea nitrogen, BUN)及血浆肌酐浓度升高是尿毒症或尿毒症毒素清除不完全的明确证据。其他对渗透充分性进行定量的方法包括使用尿素或肌酐动力学法在实验室测定溶质清除率。

历史观察性研究表明，较高的溶质清除率可改善患者的健康状况及降低死亡的相对危险度(relative risk, RR)。因此，诸如来自美国国家肾脏基金会透析结果质量倡议(National Kidney Foundation Dialysis Outcomes Quality Initiative, NKF-DOQI)的指南推荐，就尿素清除指数(urea clearance index, Kt/Vurea或Kt/V)而言，CAPD患者的总溶质清除需大于2.1/周[2]。部分由于人们逐渐意识到预后不良与透析不充分的相关性及国家指南(如上述KDOQI)的发布，流行病学研究数据表明，在21世纪00年代初期，给予美国患者的平均PD剂量已增加至一个稳定水平[3-6]。2007年，美国行CAPD的患者中93%以上的Kt/V平均值大于1.7/周[6]。由于强调要达到更高的透析剂量，所以有些患者因无法达到Kt/V大于等于2.1/周的目标值而改为行血液透析治疗[7,8]，但可惜的是，基于临床情况患者有时可能不需要进行血液透析。

上述较高的溶质清除率(Kt/V>2.1/周)目标值可能并不需要达到。已有证据表明，每周溶质清除率较低的患者具有相似的生存率。此外，为获得更高的Kt/V目标值而增加透析剂量时，总可能引起与试图增加剂量相关的不良反应。可能包括以下不良反应：输注较大容量的透析液导致腹腔内压力增加，从而引起疝气；换液所需时间延长、体重增加及葡萄糖暴露和吸收更多导致的其他代谢性后果使患者不满意；可能被吸收的PD溶液中的任何一种成分(葡萄糖降解产物)可能导致全身毒性；以及需要额外的透析溶液导致社会成本更高。本专题讨论的每周溶质清除的新目标值可能将上述不良反应降至最低。

评估PD充分性的决定因素和方法将总结在此。这些方法大都局限于对溶质清除率的估计，部分原因是溶质清除率与患者结局相关。然而，大家公认的是，尿毒症的症状和体征与所有潴留溶质及肾功能丢失导致的代谢失控有关。超滤不充分也可能对患者的不良结局具有促进作用[9-12]。

溶质清除率

过去认为，BUN水平小于100mg/dL(36mmol/L)及血浆肌酐浓度小于18mg/dL(1584μmol/L)表明PD的生化治疗充分[13]。随后提出，每周Kt/Vurea和每周肌酐清除率(creatinine clearance, Ccr)的计算值是更加客观的评估充分性的标准。

                       

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Literature review current through: 2017-06 . | This topic last updated: 2015-03-11.
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