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维持性腹膜透析中的快速转运者

Author
John M Burkart, MD
Section Editor
Thomas A Golper, MD
Deputy Editor
Alice M Sheridan, MD
Translators
杜玉君, 主任医师，教授

引言

目前，人们清楚地知道腹膜透析患者具有不同的腹膜转运特点。这些差异通过腹膜平衡试验(peritoneal equilibration test, PET)的应用而得到最好的分类和确定[1]。(参见“腹膜平衡试验”)如果进行标准的PET并获得所有推荐的测量值，这个试验就可以帮助描绘留腹时间、溶质转运、葡萄糖吸收、引流液量和溶质净清除之间的关系的特征。那些扩散转运速度最快的患者被归类为快速转运者。根据不同人群的PET试验，大约15%的患者在腹膜透析开始时是快速转运者。

作为扩散转运速度快的结果，快速转运者转运小分子溶质(如，尿素、肌酐和葡萄糖)很快，这使得在一次腹膜透析液留腹时，透析液与血液之间的小分子溶质浓度相对较早达到平衡(图 1)。这些患者也会迅速吸收透析液中的葡萄糖，从而使得透析液和血液之间维持超滤所需的晶体渗透梯度较早消失。一旦渗透梯度消失，超滤的刺激消失了，超滤停止。然而，通过腹膜淋巴管进行的液体吸收缓慢而持续存在，可能导致净超滤减少、引流量较低和潜在的体循环容量扩张。较低的引流量可能潜在地导致较低的溶质清除率。

如果忽略患者的便利性或生活方式的限制，而仅基于转运特点设计一个腹膜透析处方，以尝试最优化超滤、引流量和肌酐清除率，则快速转运者采用短时间留腹(1.5-3h/次)的效果会最好。理论上讲，当只使用含葡萄糖的溶液时，这样的患者采用自动化疗法[自动腹膜透析(automated peritoneal dialysis, APD)]的效果会最好，如夜间间歇性腹膜透析(nightly intermittent peritoneal dialysis, NIPD)或采用夜间循环治疗[夜间灌入最后一袋(清晨灌入第一袋)]加一次中午交换。相比之下，低平均或低转运者采用长时间留腹的效果会最好，如持续不卧床腹膜透析(continuous ambulatory peritoneal dialysis, CAPD)或夜间交换较少的持续循环性腹膜透析(continuous cycling peritoneal dialysis, CCPD)(图 1)。低平均或低转运者可能需要较大的灌注量，较大灌注量通过最大化接触表面积来提高清除率。对于此类患者，因为对小分子溶质和葡萄糖的转运速度均较低，所以溶质清除率和超滤往往在整个留腹时间中保持稳定。高平均转运患者采用自动化疗法或长时间留腹法的效果通常都良好。

尽管有这些理论概念，但如果医生非常了解腹膜透析动力学和腹膜透析液，并愿意对患者的处方进行个体化处理，则大多数患者都可能使用CAPD或APD。这在有残余肾功能的患者中尤其如此，有残留肾功能更易于维持血容量正常和溶质清除。一项广泛性观察性队列回顾性研究纳入了美国42,942例接受CAPD的患者和23,439例接受APD的患者，这些患者在1996-2004年开始进行腹膜透析，并接受随访至2006年9月；研究显示，透析模式对生存风险没有经证实的影响[2]。此回顾性研究没有对转运类型进行调整。然而，之前的一项纳入澳大利亚和新西兰的腹膜透析患者的回顾性研究对转运类型进行了校正，该研究也显示CAPD或APD导致的死亡风险没有显而易见的差异[3]。相比之下，一项对纳入澳大利亚和新西兰腹膜透析患者的更现代的队列进行的分析发现，与采用CAPD相比，高转运者采用APD治疗的死亡风险更低[4]。在我们的中心，在所有进行腹膜透析的患者中，大约85%采用的是APD。

此外，即使在快速转运者中，较大分子溶质，如B2-微球蛋白的清除也呈留腹时间依赖性。因此，尽管这些患者可能经常会通过NIPD和日间干腹达到最小的Kt/V(尿素清除指数)目标，但大多数患者仍然进行一日24小时留腹的腹膜透析。如果这些患者不这样做，则会因为日间干腹而使中等大小的分子的清除无法达到最佳化。

       

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Literature review current through: 2017-06 . | This topic last updated: 2016-04-08.
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References
Top
  1. Twardowski ZJ. Clinical value of standardized equilibration tests in CAPD patients. Blood Purif 1989; 7:95.
  2. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Vonesh E. The outcomes of continuous ambulatory and automated peritoneal dialysis are similar. Kidney Int 2009; 76:97.
  3. Badve SV, Hawley CM, McDonald SP, et al. Automated and continuous ambulatory peritoneal dialysis have similar outcomes. Kidney Int 2008; 73:480.
  4. Johnson DW, Hawley CM, McDonald SP, et al. Superior survival of high transporters treated with automated versus continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 2010; 25:1973.
  5. Davies SJ, Phillips L, Russell GI. Peritoneal solute transport predicts survival on CAPD independently of residual renal function. Nephrol Dial Transplant 1998; 13:962.
  6. Churchill DN, Thorpe KE, Nolph KD, et al. Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol 1998; 9:1285.
  7. Cueto-Manzano AM, Correa-Rotter R. Is high peritoneal transport rate an independent risk factor for CAPD mortality? Kidney Int 2000; 57:314.
  8. Brimble KS, Walker M, Margetts PJ, et al. Meta-analysis: peritoneal membrane transport, mortality, and technique failure in peritoneal dialysis. J Am Soc Nephrol 2006; 17:2591.
  9. Blake PG. What is the problem with high transporters? Perit Dial Int 1997; 17:317.
  10. Wang T, Heimbürger O, Cheng HH, et al. Does a high peritoneal transport rate reflect a state of chronic inflammation? Perit Dial Int 1999; 19:17.
  11. Tonbul Z, Altintepe L, Sözlü C, et al. The association of peritoneal transport properties with 24-hour blood pressure levels in CAPD patients. Perit Dial Int 2003; 23:46.
  12. Bieber SD, Burkart J, Golper TA, et al. Comparative outcomes between continuous ambulatory and automated peritoneal dialysis: a narrative review. Am J Kidney Dis 2014; 63:1027.
  13. Davies SJ. Mitigating peritoneal membrane characteristics in modern peritoneal dialysis therapy. Kidney Int Suppl 2006; :S76.
  14. Brown EA, Davies SJ, Rutherford P, et al. Survival of functionally anuric patients on automated peritoneal dialysis: the European APD Outcome Study. J Am Soc Nephrol 2003; 14:2948.
  15. Chung SH, Heimbürger O, Stenvinkel P, et al. Influence of peritoneal transport rate, inflammation, and fluid removal on nutritional status and clinical outcome in prevalent peritoneal dialysis patients. Perit Dial Int 2003; 23:174.
  16. Yang X, Fang W, Bargman JM, Oreopoulos DG. High peritoneal permeability is not associated with higher mortality or technique failure in patients on automated peritoneal dialysis. Perit Dial Int 2008; 28:82.
  17. Rumpsfeld M, McDonald SP, Johnson DW. Higher peritoneal transport status is associated with higher mortality and technique failure in the Australian and New Zealand peritoneal dialysis patient populations. J Am Soc Nephrol 2006; 17:271.
  18. Wiggins KJ, McDonald SP, Brown FG, et al. High membrane transport status on peritoneal dialysis is not associated with reduced survival following transfer to haemodialysis. Nephrol Dial Transplant 2007; 22:3005.
  19. Blake PG, Abraham G, Sombolos K, et al. Changes in peritoneal membrane transport rates in patients on long term CAPD. Adv Perit Dial 1989; 5:3.
  20. Dobbie JW, Lloyd JK, Gall CA. Categorization of ultrastructural changes in peritoneal mesothelium, stroma and blood vessels in uremia and CAPD patients. Adv Perit Dial 1990; 6:3.
  21. Chung SH, Chu WS, Lee HA, et al. Peritoneal transport characteristics, comorbid diseases and survival in CAPD patients. Perit Dial Int 2000; 20:541.
  22. Rodrigues A, Martins M, Santos MJ, et al. Evaluation of effluent markers cancer antigen 125, vascular endothelial growth factor, and interleukin-6: relationship with peritoneal transport. Adv Perit Dial 2004; 20:8.
  23. Honda K, Nitta K, Horita S, et al. Morphological changes in the peritoneal vasculature of patients on CAPD with ultrafiltration failure. Nephron 1996; 72:171.
  24. Heimbürger O, Waniewski J, Werynski A, et al. Peritoneal transport in CAPD patients with permanent loss of ultrafiltration capacity. Kidney Int 1990; 38:495.
  25. Davies SJ, Phillips L, Naish PF, Russell GI. Peritoneal glucose exposure and changes in membrane solute transport with time on peritoneal dialysis. J Am Soc Nephrol 2001; 12:1046.
  26. Davies SJ. Longitudinal relationship between solute transport and ultrafiltration capacity in peritoneal dialysis patients. Kidney Int 2004; 66:2437.
  27. Nakayama M, Kawaguchi Y, Yamada K, et al. Immunohistochemical detection of advanced glycosylation end-products in the peritoneum and its possible pathophysiological role in CAPD. Kidney Int 1997; 51:182.
  28. De Vriese AS, Flyvbjerg A, Mortier S, et al. Inhibition of the interaction of AGE-RAGE prevents hyperglycemia-induced fibrosis of the peritoneal membrane. J Am Soc Nephrol 2003; 14:2109.
  29. Linden T, Forsbäck G, Deppisch R, et al. 3-Deoxyglucosone, a promoter of advanced glycation end products in fluids for peritoneal dialysis. Perit Dial Int 1998; 18:290.
  30. Zimmeck T, Tauer A, Fuenfrocken M, Pischetsrieder M. How to reduce 3-deoxyglucosone and acetaldehyde in peritoneal dialysis fluids. Perit Dial Int 2002; 22:350.
  31. Ishikawa N, Miyata T, Ueda Y, et al. Affinity adsorption of glucose degradation products improves the biocompatibility of conventional peritoneal dialysis fluid. Kidney Int 2003; 63:331.
  32. Zeier M, Schwenger V, Deppisch R, et al. Glucose degradation products in PD fluids: do they disappear from the peritoneal cavity and enter the systemic circulation? Kidney Int 2003; 63:298.
  33. Witowski J, Jörres A. Preventing peritoneal fibrosis--an ace up our sleeve? Perit Dial Int 2005; 25:25.
  34. Noh H, Ha H, Yu MR, et al. Angiotensin II mediates high glucose-induced TGF-beta1 and fibronectin upregulation in HPMC through reactive oxygen species. Perit Dial Int 2005; 25:38.
  35. Kolesnyk I, Noordzij M, Dekker FW, et al. A positive effect of AII inhibitors on peritoneal membrane function in long-term PD patients. Nephrol Dial Transplant 2009; 24:272.
  36. Posthuma N, ter Wee PM, Donker AJ, et al. Icodextrin (I) used in CCPD patients during peritonitis: Serum disaccharide (maltose) levels and ultrafiltration (abstract). J Am Soc Nephrol 1997; 8:270A.
  37. Tzamaloukas AH, Murata GH, Fox L. Peritoneal catheter loss and death in continuous ambulatory peritoneal dialysis peritonitis: correlation with clinical and biochemical parameters. Perit Dial Int 1993; 13 Suppl 2:S338.
  38. Dwatwa M, Vladutiu D, Keller J. Nutritional support with Nutrineal for CAPD peritonitis (abstract). Perit Dial Int 1995; 15:39.
  39. Burkart JM, Jordan J, Rocco MV. Cross sectional analysis of D/P creatinine ratios versus serum albumin levels in NIPD. Perit Dial Int 1994; 14:S18.
  40. Nolph KD, Moore HL, Prowant B, et al. Continuous ambulatory peritoneal dialysis with a high flux membrane. A preliminary report. ASAIO J 1993; 39:M566.
  41. Mamoun H, Anderstam B, Lindholm B, et al. Peritoneal dialysis solutions with glucose and amino acids suppress appetite in rats (abstract). J Am Soc Nephrol 1994; 5:498.
  42. Jones CH, Wells L, Stoves J, et al. Can a reduction in extracellular fluid volume result in increased serum albumin in peritoneal dialysis patients? Am J Kidney Dis 2002; 39:872.
  43. Burkart JM. Effect of peritoneal dialysis prescription and peritoneal membrane transport characteristics on nutritional status. Perit Dial Int 1995; 15:S20.
  44. Kathuria P, Moore HL, Khanna R, et al. Effect of dialysis modality and membrane transport characteristics on dialysate protein losses of patients on peritoneal dialysis. Perit Dial Int 1997; 17:449.
  45. Twardowski ZJ, Nolph KD, Khanna R, et al. Daily clearances with continuous ambulatory peritoneal dialysis and nightly peritoneal dialysis. ASAIO Trans 1986; 32:575.