自动化腹膜透析临床应用.pptx

北京大学第一医院肾内科 北京大学肾脏病研究所,卫,生部暨,教,育部肾,脏,病重点,实,验室,董,捷,内容,APD,治疗的现状和趋势,APD,和,CAPD,的比较及评价,APD,常见治疗模式,应用人群,展望,APD,：泛指所有以自动化机器代替手,工进行腹透操作的治疗方式,A,P,D%,50%,Denmark,Ireland,Belgium,US,Portugal,Finland,Canada,Australia,Israel,Nor,w,ay,Netherlands,France,New Zealand,UK,Slovenia,Germany,Spain,20%,HK,Korea,A,P,D%,发达国家,(,依次）发展中国家,(,依次）,50%,Oman,UAE,Tunisia,Brazil,20,50%,Poland,Saudi Arabia,Slovakia,Uruguay,Jordan,Turkey,Croatia,”:,好于,2003,1,1999200,1,USRDS,美国,30,000,1,年生存率和技,术生存率,APDCAPD,2006,2,2000200,3,Baxter,美国,40/869,技术生存率,APDCAPD,2008,4,1999200,4,ANZDATA,澳大利,亚,/,新西,兰,2393/173,5,5,生存率和技术 生存率,APD=CAPD,2009,3,1996200,4,USRDS,美国,42,942/23,439,210,生存率和技术,生存率,APD=CAPD,2009,5,1997200,6,NECOSAD,荷兰,562/87,5,生存率和技术 生存率,APD=CAPD,2011,6,20032008,单中心,英国,178/194,5,生存率和技术 生存率,APD=CAPD,1.Kidney Int,Suppl2003,;(88):S3-12 2.Kidney Int,Suppl2006,;(103):S133-7 3.Kideny Int,2009;76(1):97,107,-,观察性研究,4.Kidney Int,2008;73(4):480-8,Clin,J Am Soc Nephrol,2009;4(5):943-9,Nephrol,Dial Transplant,2011;26:17021708,Perit Dial,Int.,2011;31:301-307,Taiwan,19972008,FU,6.4yrs(mean),161APD,121CAPD,APD,组年龄更轻（）,其他（,BMI,DM%,腹膜转运类 型，生化参数及透析充分性）均无差异,死亡率,技术失败率,Nephrol Dial,Trans-plant.,2010;25:1973-1979,ANZDATA,19992004,FU,6.4yrs(mean),高转运者（,142APD,486CAPD,）,APD,组年龄更轻，白种人更多,糖尿病更少，在大中心治疗的 比例更少；腹膜转运类型和,CAPD,组无差异,CAPD,APD,CAPD,APD,生存率,技术生存率,technique,survival,Group,Patient,survival,Technique,survival,Univariate H,R(,95%CI),Mu,l,t,i,va,r,i,ate HR(95%CI),Univariate H,R(,95%CI),Mu,l,t,i,va,r,i,ate HR(95%CI),High,0.57(0.35-0.94),0.56(0.35-0.87),0.93(0.671.28),0.88(0.641.21),High-A,0.98(0.72-1.34),1.08(0.81-1.45),1.16(0.951.40),1.17(0.951.44),Low-A,0.70(0.46-1.07),0.98(0.66-1.45),0.99(0.751.33),1.02(0.771.35),Low,2.21(1.24-3.93),2.19(1.02-4.70),1.35(0.792.28),1.24(0.672.29),Nephrol Dial,Trans-plant.,2010;25:1973-1979,进一步的病例对照分析显示：在年龄，糖尿病和种族匹配后，,高,R,转,es,运,ults,患,o,者,f,in,接,ten,受,tion-to-t,治,rea,疗,t,C,仍,ox,然,pr,降,op,低,ort,了,ion,总,al,体,ha,死,zar,亡,ds,风,m,险,odel,analyses,of the,relative,ha,A,za,P,r,D,d,of,APD,versus CAPD for patient,surv,(H,iva,R,l,a,0,n,.,d,60,95%,CI,0.360.96),合并症少者死亡率：,APD”,好,2005,1,1994199,7,USRDS,US,9190/2785,6mo-2yr,0.74,VS,0.70,次,/,病,人年,AC,2009,2,2002200,3,多中心,UK,538/325,2yr,0.81 VS,0.66,次,/,病,人年,AC,2009,3,1996200,5,多中心,Canad,a,3180,1.03(0.91-1.16),No,dif,2011,4,2003200,8,单中心,UK,178/194,5y,0.41 VS,0.32,次,/,病人年,AC,2011,5,1993200,7,单中心,Nether,lands,112/93,14yr,0.65,VS,0.62,次,/,病,人年,No,dif,2011,6,Am,Peri,1997200,J,8,Kidney,Dis.,2005;,t,单,Dia,中,l,In,心,t.,2009;29:2,Taiwa,45,n,:372-380,97-302,121/161,4.,5.,6.4yr,Ne,(M,ph,),rol,Dia,Perit Dial,In,Perit Dial,In,0.39,VS,0.24,次,/,病,l,T,人,ra,年,nsplant.,2011;26:1702-170,t.,2011;31:39-47,t,2010;,31(3):301-307,AC,8,3.C,l,in,2014,7,J Am Soc,Nephrol.,2003201,1,2009;4:1195,Aus/N,Z,2761/419,7,8,.,Cl,in,J Am,S,oc,G,N,+,ep,:0,hr,.,o,9,l,2,0,0,(,1,0,4,.,;9,8,:,0,10,-,9,1,1,.0,10,),97,C-:0.81(0.69-0.94),AC AC,腹膜炎,CAPD,VS,APD-RCT,Netherlands,19881991,FU,to,1992 Aug,41 VS 41,patients,Ann Intern Med.,1994;120:264-271,评价,结果,CAPD VS,APD,生存率,No,difference,2 VS 4,死亡,技术生存率,No,difference,平均技术失败时间,26 VS 30,月,腹膜炎,APD,好于,CAPD,0.94,VS,0.51,次,/,病人年,透析充分性,No,difference,Kt/V,Ccr,贫血，高血磷，高血,压控制方面,并发症,No,difference,外口感染，疝气，渗漏等,残余肾功能,No,difference,4.0 to 2.8 mL/min/1.73 m2,VS,5.4 to 2.1 mL/min/1.73,m2,AP,D,对预防腹膜炎方面的作,用,？,益处,减少换液次数,腹透液存腹时间长短对,腹膜免疫功能的影响,白天体力活动增加利于,机体免疫功能,待解决,接头的保护装置,暂时管路分离的安全措施,研发生物相容性更好的透 析液,APD,和,CAPD,同样需要规范培训，减少操作污染；,其他非操作污染导致的腹膜炎风险仍然存在,发表,来源,国家,样本量,(CAPD/APD),随访,结果,“”:,好于,2001,1,19932001,NECOSAD,Netherl,ands,59/37,APDCAPD,Metal,health,less,depression/anxiety,2010,2,Cross-,section,a,l,Turkey,48/20,APD=CAPD,2011,3,20032008,Single-center,UK,178/194,5,yrs,APD=CAPD,2011,4,19972006,NECOSAD,Netherl,ands,486/64,3mo3yr,s,APD=CAPD,APD,对生活质量的影响,-,观察性研究,1.,Perit Dial,Int.2001;21:,306-312,2.,Hemodial,Int.,2010;14:515-522,Nephrol,Dial Transplant.,2011;26:1702-1708,Clin,J Am Soc Nephrol.,2011;6:,537-542,Full,time,Full,time,HK,retrospective cohort,FU,mo,CAPD VS APD:180:,90,CAPD:,6L/d,APD:,Nephrology 2013;18:,356364,APD,全职工作者更多,-,观察性研究,生活质量,CAPD,VS,APD,-RCT,Denmark,CAPD VS,APD:,17:17,25,人完成研究,APD,(n=12),CAPD,(n=13),P,value,More time,for,work,family,and social,activities,3.2,1.2,1.2,0.5,0.00005,Discomfort,(physical),1.9,1.0,2.2,1.3,NS,倾向,+,Discomfort (emotional),1.8,1.0,2.2,1.4,NS,倾向,+,Appetite,(reduced),2.8,1.3,2.9,0.6,NS,Sleep,problems,2.3,0.9,1.8,1.3,NS,Perit Dial,Int.,1999;19:526-533,APD,的水钠清除和残肾丢失,Spain,，前瞻队列研究，,19982002,FU,to,2003,53 CAPD,51,APD,基线年龄、性别、原发病、糖尿病、合并症、腹膜转,运类型和残余肾功能无差别,调整方案,Kt/V,，,Ccr,达标,容量控制,保护残肾,Am J,Kidney Dis,2004;44(1):132-145,水分清除,钠清除,GFR,Am J,Kidney Dis,2004;44(1):132-145,，,发表,来源,国家,样本量,CAPD/APD,随访,水钠清除,“”:,差于,容量状态,2004,1,19982,002,Spain,53/51,1224,APDCAPD,APD,血压控制更差,2007,2,Cross-,sectional,Turkey,32/30,APDCAPD,APD:BNP,和,LVM,更高，但血压无差 别,2009,3,Cross-,sectional,Canad,a,90/68,APD=CAPD,血压、水肿和降压,药无差别,2012,4,Cross-,sectional,Netherl,ands,24/20,2130,mo,APDCAPD,APD,血压控制更差,BNP,更高,1.,Am J Kidney,Dis.,2004;44:,132-145,2.,Perit,Dial,Int.,2007;27:663-668,3.Clin,J Am Soc Nephrol.,2009;4:,1044-1050 4.,ASAIO J.,2012;58:132-13。