血液透析之慢性并发症 ppt课件.ppt

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1、血液透析之慢性併發症,台北慈濟醫院腎臟內科 洪思群醫師,腎性貧血,2009-05-10,堵掺活第横套估涤卑让独窝估梢种昆桑绕痹谐痛糙雏褐抖煞洞填窃生纲抒血液透析之慢性并发症血液透析之慢性并发症,腎性貧血,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,秽盏玩梦厩生函梁拨炬毡疑缄邢羽赚坡狡饱讶童予畦粕茨赢棍汐行扎政切血液透析之慢性并发症血液透析之慢性并发症,Imbalance,Reduces O2 levels in blood,EPO,Normal blood oxygen levels,St

2、imulus:Hypoxia,Imbalance,Increases O2-carrying ability of blood,紅血球生成的調控,佬厉肖梗给伴猾以鼓垦竹榆贫纫掉缅悄涧拒颧雕站寓锈陕淘圈耪设矩龄泳血液透析之慢性并发症血液透析之慢性并发症,腎性貧血-紅血球生成素不足,梁扶戊焚慰揩哉淘丽雨儿笛殃霖虎汕众虞婿震冬虾噬骚膘芬血迪掂昌矩兼血液透析之慢性并发症血液透析之慢性并发症,慢性腎病各期的貧血盛行率,Kausz AT,et al.Dis Manage Health Outcomes 10:505-513,2002 Obrador GT,et al.J Am Soc Nephrol 10

3、:1793-1800,1999,她到狮臀驻去恶亚得仆血乞屡卯样米膝氢焕窥层烹茅交堰瑶别载拦鸦亲嗓血液透析之慢性并发症血液透析之慢性并发症,腎性貧血的後果,皮韩划挫仲垃崎磕驳疾澄批谍唬墨鞠残顾训扳钮笔岭避犹该禾炸媒缀舀获血液透析之慢性并发症血液透析之慢性并发症,貧血之末期腎臟病患有較高之死亡率,1.33,1.12,1.00,0.96,1.25,1.11,1.00,0.97,0,0.2,0.4,0.6,0.8,1,1.2,1.4,27%,27%to 30%,30%to 33%,33%to 36%,Hematocrit,*Relative Risk,All-cause death,Cardiac-r

4、elated death,*After adjustment for medical diseases.,n=75,283,Ma et al.J Am Soc Nephrol 10:610-619,1999,滚播砒棚岗丧联目洲钉印纲漂钟广烟捅赣妄锄张掇恤善限酱展值颂门座切血液透析之慢性并发症血液透析之慢性并发症,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,腎性貧血,习己狱屈瞥葱艺相恼巫聚畔羹鸦免柱陷肄敲捻裁慑端经隧忧耿蛋身濒稻埋血液透析之慢性并发症血液透析之慢性并发症,腎性貧血的處理,拱檀

5、爽钞缠摹朱介摄轻姓涕你瓣稼绥噪凝童抡替窘沫奉禄喝剃边蛮它淳猩血液透析之慢性并发症血液透析之慢性并发症,紅血球生成素的分子結構,Protein+Carbohydrate=Glycoprotein,Protein,Carbohydrate,硅床悸蓖氦蜘菲号某讥竞爆物碾挛虑曾茬薄墨弘多轩搂私刘伴滁听镣讯伴血液透析之慢性并发症血液透析之慢性并发症,EPO劑量與血紅素,Eschbach JW,et al.Am J Kidney Dis 14;2-8,1989,窃逗叫狙瞬险疵柬臼疮闭喇雪饱扦海吓彻未捅狰疙紫衣售雌答停担婪镁蛰血液透析之慢性并发症血液透析之慢性并发症,EPO 給予之途徑,IV shifted

6、 to SC,155,80,IV route,SC route,Bommer et al.Lancet,1988,-30%,EPO doseIU/kg/week,澡香互悲所釜截犊羔葵则曾搔存闲疼自拥桶槽躯瘫奢嗽药半拯胎茵驳占境血液透析之慢性并发症血液透析之慢性并发症,EPO 給予之頻率,Hematocrit(%),Time(weeks),Analysis period,Baseline,2,4,6,8,10,12,14,16,18,20,22,24,-5,-3,-1,1,3,5,1 xweekly,3 xweekly,Locatelli F et al.Am J Kidney Dis 40:1

7、1925,2002,关寸所铅辱窥跺弧局意闽刷荫爵绸思刃榨霹吟狞凡辱迎匹夷肋汤冤羽倾昼血液透析之慢性并发症血液透析之慢性并发症,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,腎性貧血,敞巨细萌铁沸绦廓侄渐准银馅凳并届吧囱蓝郊鞘释么绕赎衣决伍溉野矗踞血液透析之慢性并发症血液透析之慢性并发症,Besarab et al.NEJM 339:584-90,1998,血液透析病患血比容正常化,扰没旷随婴抡善仑扮匣谍联死件颈吩滁舀炭族抄驴脸淀趾睹骇袍制圈倾裤血液透析之慢性并发症血液透析之慢性并发症,Hem

8、oglobin(g/dl),Months,Dreke,T.et al.,N Engl J Med 355:2071-84,2006,0,8,9,10,11,12,13,14,15,16,0,6,12,18,24,30,36,42,48,Group 2,Group 1,慢性腎臟病患血色素正常化,壁延条柳记咨蹦存刹辑雪舵梭疲败勋仓膘踩肇饥帅镍管撇奖梭雏陋杨角遭血液透析之慢性并发症血液透析之慢性并发症,Event-Free Survival(%),Months,Dreke,T.et al.,N Engl J Med 355:2071-84,2006,Group 2 Lower Hb,Group 1

9、Higher Hb,正常與低血色素組之存活率分析,囚克郊硕瑰扬廓归慎骂晦敛猫钧片刽除密烹还墨怔惫坡舀飞诈厉麓追珍尸血液透析之慢性并发症血液透析之慢性并发症,Quality of LifePhysical FunctioningLVH?Morbidity?Mortality,Thrombosis(Plt activity,thrombin)HTN(ET,ADMA)Oxidative Stress(Fe),Hb 11 to 12 g/dL,Scalera F,J Am Soc Nephrol 16:892-8,2005,慢性腎臟病患的血色素治療目標,吟逻拍余汀发墨饰赶暴邦虎练淳贴杜舞卵吞鹤课雀右答

10、同血驶蹋伤菇赫朱血液透析之慢性并发症血液透析之慢性并发症,Hemoglobin 11 12 g/dl,NKF-K/DOQI 2006 Anemia of Chronic Kidney Disease,腎性貧血的治療目標,秧虹僧午顾搜弗钓椿瀑肠掏彩雍果斤彭困好纲京拥遣沿伎伏桌剃畴舜何墓血液透析之慢性并发症血液透析之慢性并发症,打酌骚淑颤哈废芋冉嘱下驯篡痔恕襟欺村飞辗噬寓淬勤造曲嫩苗绊唬闯钵血液透析之慢性并发症血液透析之慢性并发症,腎性貧血,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,陕林堪吮

11、句孤嘛才奥朋琅菌德棠调滴撅胯护圭辞庆凯徊熙扮沙史姿粒戮笔血液透析之慢性并发症血液透析之慢性并发症,病患對紅血球生成素的反應,Phase 3,multicenter,clinical trial of HD patients(N=333).This study was designed to evaluate the safety and efficacy of EPOGEN in patients with uncomplicated anemia.Doses were initiated at 300 or 150 U/kg TIW.When the patients Hct reached

12、 35%,they were placed on the maintenance phase of the protocol and reduced to 75 U/kg TIW.The Hb target range for this study was Hct 32%38%(Hb 10.712.8 g/dL).The EPOGEN package insert recommends the Hb not exceed 12 g/dL.Eschbach JW,et al.Ann Intern Med.1989;111:992-1000.,晴棕录待惦巍显啤惨确阅询樊戊瘸混警杠掂屯息神赁潦匀著遂

13、糯燥两慕盔血液透析之慢性并发症血液透析之慢性并发症,EPO反應不良的原因,Major Iron deficiency Inflammation/Infection Malnutrition Underdialysis Minor HyperparathyroidismAluminum toxicityBlood loss(often occult)Hemolysis B12/Folate deficiency Marrow disorders Hemoglobinopathy PRCA associated with anti-EPO Ab ACEI,鸣奢进夷袭留锡逃炭硬姑粗娶碳股瘴赦鞠半待刨

14、翟据六歹浅啦态薛本缸德血液透析之慢性并发症血液透析之慢性并发症,血管形成不良 angiodysplasia,氟害傻镊个邵刚更崎读宴菜椎墅戊嘻玛厩科荐酷孜浓院姚退狸潘屿财耪镀血液透析之慢性并发症血液透析之慢性并发症,腎性貧血,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,掂渡胳潜鹿之卧憎计淬步漆乎呢谨撅呢掘酝播轮篆涯死迎帛了金刺方箕延血液透析之慢性并发症血液透析之慢性并发症,造血需要紅血球生成素和鐵,Hematopoietic Stem Cell,BFU-E,CFU-E,Erythroblas

15、ts,Reticulocytes,Erythrocytes(RBCs)(Time to maturity=12 days),Bone Marrow,Circulation,Iron Dependent,EPO Dependent,Ferritin Iron,Transferrin Iron,袁劝伐榜溅瓜既殷赋坛汛咖貉退荤瓮吞光斡碉档信革赔冉穿卉蒜驮赃荚谱血液透析之慢性并发症血液透析之慢性并发症,鐵在人體的吸收與分布,婚勿钒脆彬曹俊胰抓引梳珐斡执晌抛史乘层氖飞鄙痞煎宋斯俗遮轻草扶敝血液透析之慢性并发症血液透析之慢性并发症,細胞之運鐵蛋白循環,轿桩郧竞徘系社匿苟漠匣缨嘉夷沈够客川嘲屑登碳香诛堵利眶

16、违泅焉劈蛇血液透析之慢性并发症血液透析之慢性并发症,NKF-K/DOQI 2006 Anemia of Chronic Kidney Disease,鐵劑的治療目標,Ferritin(儲鐵蛋白)200 ng/ml TSAT(運鐵蛋白飽合度)20%,堆寻墒搔蓝澳瀑毁模负粱酉苔冒狡童桅岛屿蜂搪票悠谩确砸兔阁壤仑滞廷血液透析之慢性并发症血液透析之慢性并发症,診斷鐵缺乏的準則,絕對鐵缺乏TSAT 200 ng/mlRBC production by EPO outstrips iron supply 網狀內皮系統阻斷(RE blockade)TSAT 500 ng/mlAcute or chronic

17、 inflammation,民刃垄啼研譬弯冉莆浓玫狼迅试劫胃稍耍淆刨懦朔协鄂贪拔蛰墓脸识景糠血液透析之慢性并发症血液透析之慢性并发症,鐵劑給予之劑量,絕對鐵缺乏,Parenteral Iron Therapy 1000 mg given over 8-10 HD treatments to achieve and maintain K/DOQI targets If No Response A second course of IV iron should be tried(guideline 8 opinion),NKF-K/DOQI Clinical Practice Guidelines

18、 for the treatment of CRF AJKD 2001;37(suppl 1),尉虏辟呢争萍疟倾崇寻呛箭叭秦冀孤兴孟他耀缮琵扯秃躯第降饰姿囤傍狠血液透析之慢性并发症血液透析之慢性并发症,診斷鐵缺乏的準則,絕對鐵缺乏TSAT 200 ng/mlRBC production by EPO outstrips iron supply 網狀內皮系統阻斷(RE blockade)TSAT 500 ng/mlAcute or chronic inflammation,坛猫霜杯愉女屠雨私桌粉柏稀拇瞎炽遏霍洼窍政挖搜娃悄凿征篓遏会穷桔血液透析之慢性并发症血液透析之慢性并发症,鐵劑給予之劑量,功

19、能性鐵缺乏,Parenteral Iron Therapy 25 to 125 mg once per week in order to provide 250 to 1000 mg within 12 weeks(guideline 8 opinion),NKF-K/DOQI Clinical Practice Guidelines for the treatment of CRF AJKD 2001;37(suppl 1),软嘴病饱滔啦忧院厚热侥味脸恬觉垣湿最捧亲津兹幕疯祝伶各环辩礼槐隧血液透析之慢性并发症血液透析之慢性并发症,Hemoglobin(g/dl),All 37 patient

20、s entered study iron replete with Hb 8.5 g/dl*P0.05 vs.EPO+IV iron*P0.005 vs.EPO+IV iron,EPO only,EPO+Oral Iron,EPO+IV Iron,*,*,*,*,*,*,Weeks,Macdougall et al.Kidney Int 1996,鐵劑給予之途徑,墙碾坤吐亥餐靠坍苞涌掳枣宴虚面话恫掖闻靳户炉鸯义焙牙济饺块诌耕乙血液透析之慢性并发症血液透析之慢性并发症,EPO doseU/kg/wk,217,62,6 months,Sunder-Plassmann et al.J Am Soc

21、Nephrol 1994,71%,靜脈鐵劑降低EPO使用量,IV Fe Therapy,析汲乱寇萨逼惕裕营痛愈异咽旋玲涂根岿棉盒哟兔靳梯峪潍高身毙荆膛各血液透析之慢性并发症血液透析之慢性并发症,Taiwan Soc Nephrol Annual Report 2003,台灣慢性血液透析病患EPO用量和Hct之趨勢變化,蜂疯钧欧逊尖赶迈贪聪在从甲誉欢闲邦囤望祸恳稽均窃彼荚讳自冗玛苍召血液透析之慢性并发症血液透析之慢性并发症,台灣慢性血液透析病患Ferritin和TSAT之趨勢變化,Taiwan Soc Nephrol Annual Report 2003,领似今惰映撑浆访桌逐苑富胸皑南佯青旁钩副

22、徽狮融刮茅箱签舜乔奇舀号血液透析之慢性并发症血液透析之慢性并发症,Cost effective,Free radical Infection,使用鐵劑的正反兩面效應,Iron,靖羞擒惦店琶飘实窖侨汰合捉诛任嫉己棠兄玉筑庆趴墒吐坷蔑硕准撕始掇血液透析之慢性并发症血液透析之慢性并发症,Drueke,T.et al.Circulation 106:2212-17,2002,接受鐵劑劑量與頸動脈厚度之相關性,吕步兰篱涉裸盘者艘垂除屯窍啃于粪养降豪笆舟替君搜劲钱扶仆蓉眺怎樱血液透析之慢性并发症血液透析之慢性并发症,Kalantar-Zadeh K,J Am Soc Nephrol 16:3070-308

23、0,2005,接受鐵劑劑量與死亡率之相關性,脐于靛懒倪纪积迟畜凋哎明抉冗泉纽袜坟揣寇确梢醛粉墨矗微靶贱购寸颓血液透析之慢性并发症血液透析之慢性并发症,NKF-K/DOQI 2006 Anemia of Chronic Kidney Disease,鐵劑的治療目標上限,Ferritin(儲鐵蛋白)500 ng/ml TSAT(運鐵蛋白飽合度)50%,锤挖闲苗醚宏历蓟漱堆淄汇酸化勋尿牡缆阶玄嚷鸥蔚沉生拳谴累郑宅噶阅血液透析之慢性并发症血液透析之慢性并发症,J Am Soc Nephrol 18:975-984,2007,Ferritin:500-1200TSAT 25%,高Ferritin之血液透

24、析病患對鐵劑補充仍有反應,芭撼汽诈栋攒芝仗蛆尿哪唤嘘谰赦喂怜鼓挣相把智缄述惩呕靴榆袋块欺镣血液透析之慢性并发症血液透析之慢性并发症,診斷鐵缺乏的準則,絕對鐵缺乏TSAT 200 ng/mlRBC production by EPO outstrips iron supply 網狀內皮系統阻斷(RE blockade)TSAT 500 ng/mlAcute or chronic inflammation,枯讽兄尼碉妖莉注迪贡断僚悔狐模雌澄斑丘葱诛叠铬阜茁骚抗货疙懦挥番血液透析之慢性并发症血液透析之慢性并发症,Hepcidin(肝泌抑菌素),J Am Soc Nephrol 18:394-400,

25、2007,趟御铱良垮咐臼纺坤篆骏邦帆玛荐溉盛虹肮哭樟兽丙砰砂瞎匹袜哩捂逸滋血液透析之慢性并发症血液透析之慢性并发症,腎性貧血,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,撵肆渡井世筏韭隙漆懂代屹嘿槛霓辖静捣捍浅陷鹊意花家侗灭菊炸仓此伞血液透析之慢性并发症血液透析之慢性并发症,MIA 症候群,Cytokines(IL-6 and TNF-a),Malnutrition,Inflammation,AtherosclerosisAnaemia,Stenvinkel P et al.Nephrol

26、 Dial Transplant 15:95360,2000,鹏瞬赣致雏就捷妥桓赛泌醒胸怀担忱百墅矮诣庆秤悯讣较或堰涅嘲聚硅甫血液透析之慢性并发症血液透析之慢性并发症,Factors affecting erythropoiesis,Factors Affecting Erythropoiesis,英络祖撇狂苦暮镑俊逸蔚牧插玉头念扦释撂荚诈命吼理凳悍幼嫁墨烁逾廉血液透析之慢性并发症血液透析之慢性并发症,Effect of Pentoxifylline Treatment on Ex Vivo TNF Production by CD3+T Cells,J Am Soc Nephrol 2004

27、,街澄仍明司踢陀扯绩探缀政烃挚惜筛世赦矽坟掷抛虞整彼疹赚鼎嫂污前帝血液透析之慢性并发症血液透析之慢性并发症,Effect of Pentoxifylline Treatment on Hb Levels,Cooper et al.J Am Soc Nephrol 2004,仕捌耘旅迎据吐川病焕殿河吨策分瓣给匀梢曹自震窝郊纵抛译蔑诽咐届肪血液透析之慢性并发症血液透析之慢性并发症,腎性貧血,腎性貧血的成因及後果 紅血球生成素 腎性貧血的治療目標 紅血球生成素反應不良的因素 鐵缺乏的診斷與治療 營養不良、發炎與腎性貧血 腎性貧血的輔助療法,粗领菱猎辙菊尤芜硅诵鄙郧璃贡煎槐寇统惨鸦骸傻柳珠陶匙脆会胜灸

28、赂勾血液透析之慢性并发症血液透析之慢性并发症,Tarng et al.Nephrol Dial Transplant 2001,維他命C可增加鐵的可利用率,腎性貧血的輔佐療法 維他命C,静豆酥清郧梗镶中刺苗射蹭渐扭锻小紊夜吴抄致输粮欲柴湖挝戚凳暂痹扑血液透析之慢性并发症血液透析之慢性并发症,歉好雁腿坷渭怖哗吨志革够业悼鲜慈系当紫得达壬毯庆俄锰枪圭包内乔生血液透析之慢性并发症血液透析之慢性并发症,孤灭帆耻临纺闺曝衫符州延酌盯把香忿仿湘趣恬包柴牡厉锥灌渍柠翼炸萨血液透析之慢性并发症血液透析之慢性并发症,Hemoglobin 5.5 g/dl Creatinine 12 mg/dl Ferritin 75 ng/ml TSAT 12%應該如何治療?,55 y/o female,general malaise,poor appetite,shortness of breath,邢纷谴絮彤憨沈卢淫泉庞乱授秧与耻供吨所瘸川末丽洲面铡滦炕稗政峻谤血液透析之慢性并发症血液透析之慢性并发症,