principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron)...
TRANSCRIPT
![Page 1: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/1.jpg)
Principes van hemodialyse en peritoneaal dialyse
![Page 2: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/2.jpg)
• Inleiding
• Principes van hemodialyse
• Principes van peritoneaal dialyse
Overzicht
![Page 3: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/3.jpg)
Inleiding
![Page 4: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/4.jpg)
Chronisch nierlijden (CKD), definitie
![Page 5: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/5.jpg)
KDOQI 2002
KDIGO 2004
Chronisch nierlijden (CKD), stadia
![Page 6: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/6.jpg)
Coresh, J. et al. JAMA 2007;298:2038-2047.
NHANES 1988-1994 and 1999-2004
Hypertension: 33,3%
Diabetes: 10,6%
Clinical CVD: 36,3%
Chronisch nierlijden (CKD), preventie
![Page 7: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/7.jpg)
www.kidney.org/professionals/doqi/kdoqi/toc.htm
Chronisch nierlijden (CKD), een stappenplan
![Page 8: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/8.jpg)
Renal
Transplantation
CKD G1-5
CKD G5D
Chronisch nierlijden (CKD), een continuüm
![Page 9: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/9.jpg)
10 Faculteit, departement, dienst …
![Page 10: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/10.jpg)
Wat is de prevalentie van terminale nierinsufficiëntie (in Vlaanderen)?:
A: <0,1%
B: 0,1-1%
C: >1%
Vraag
![Page 11: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/11.jpg)
= 7633/6200000 = 0,12%
NBVN
Prevalentie ESRD, Vlaanderen
![Page 12: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/12.jpg)
Welke dialyse modaliteit wordt het meest toegepast (in Vlaanderen)?
A: Hemodialyse
B: Peritoneaal dialyse
Vraag
![Page 13: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/13.jpg)
NBVN
Dialysemodaliteiten, Vlaanderen
![Page 14: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/14.jpg)
• “uremie” = urine (oeron) in bloed (haima)
• “uremia is a toxic syndrome caused by severe
glomerular insufficiency, associated with disturbances
in tubular and endocrine functions of the kidney. It is
charactarised by retention of toxic metabolites,
associated with changes in volume and electrolyte
composition of the body fluids and excess or
deficiency of various hormones”
Uremie
![Page 15: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/15.jpg)
Uremisch syndroom
![Page 16: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/16.jpg)
Uremische toxines
![Page 17: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/17.jpg)
• Inleiding
• Principes van hemodialyse
• Principes van peritoneaal dialyse
Overzicht
![Page 18: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/18.jpg)
Principes van hemodialyse
![Page 19: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/19.jpg)
Hemodialyse is een proces waarbij de
samenstelling van bloed verandert door
contact met dialysaat via een synthetisch
semi-permeabel membraan
• Diffusie
• Ultrafiltratie (+ convectie)
Principes van hemodialyse
![Page 20: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/20.jpg)
Determinanten
• Concentratie gradient
• Membraankarakteristieken
(oppervlakte, dikte, aantal & grootte
& lading van de poriën)
• Molecuuleigenschappen: MW,
lading, eiwitbinding…
Principe
• Spontaan proces waarbij
molecules in vloeistoffen
een uniforme concentratie
in de oplossing bekomen
door random bewegingen
![Page 21: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/21.jpg)
Determinanten
• membraankarakteristieken
• P : hydrostatische drukgradiënt
• : osmotische drukgradiënt
Principe
verplaatsing van water (samen met permeabele opgeloste stoffen, i.e. solvent drag) doorheen een semipermeablemembraan
![Page 22: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/22.jpg)
• Diffusie
• Qb 200-500 ml/min
• Qd 500 ml/min
• Membraan: KoA
• MW (urea-creat-VitB12)
• UF 500-1000 ml/h
• TMP
• Membraan: KUF
Integratie in de praktijk
![Page 23: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/23.jpg)
• Diffusie
• Qb 200-500 ml/min
• Qd 500 ml/min
• Membraan: KoA
• MW (urea-creat-VitB12)
• UF 500-1000 ml/h
• TMP
• Membraan: KUF
Integratie in de praktijk
![Page 24: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/24.jpg)
Integratie in de praktijk, diffusie
![Page 25: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/25.jpg)
Integratie in de praktijk, ultrafiltratie
![Page 26: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/26.jpg)
1960: Brigham type Kolff artificial kidney 2000: holle vezel (capillaire) membranen
Integratie in de praktijk, dialyse membraan
![Page 27: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/27.jpg)
Integratie in de praktijk, dialyse membraan
![Page 28: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/28.jpg)
• Materiaal
• Cellulose
• Gesubstitueerd cellulose
• Synthetisch (biocompatibel)
• Eigenschappen
• Poriën: grootte, distributie…
• Oppervlakte
Karakteristieken dialyse membraan
![Page 29: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/29.jpg)
• Samenstelling
• Ultrapure water
• Distributie: centraal (ringleiding) - individueel
Dialysaat
![Page 30: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/30.jpg)
37
37P
Evenepoel-
K.U.L.
Ultrapuur water, water treatment unit
50 (pt) x 120 (L/dialyse) x 2 (shifts)= 12.000 Liter/d
![Page 31: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/31.jpg)
Dialyse toestel
![Page 32: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/32.jpg)
Bloedcircuit
• Bloedpomp
• Monitoring
• Pa en Pv
• Luchtdetector
Dialysaatcircuit
• Dialysaatpomp
• (Ontgassen)
• Verwarming
• Monitoring
• Conductiviteit
• Temp
• Bloedlek
Opties
• Anticoagulatie
• Na-profiling
• UF-profiling
• Efficiëntie
• On-line Kt/V
• Bloedvolume
• Recirculatie monitoring
• …
Dialysetoestel, functionaliteiten
![Page 33: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/33.jpg)
» traag bloeddebiet (Qb)
» hoog hematocriet (> 45 %)
» hoge ultrafiltratie snelheid
» intradialytische bloedtransfusie
» intradialytische lipiden toediening
» frequente onderbrekingen pomp
» gedeshydrateerde patiënt (hypotensie)
» lange tijdsduur v/ dialyse
Risicofactoren stolling extracorporieel circuit
![Page 34: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/34.jpg)
arteriële drukmeter
veneuze drukmeter
bloedpompveneus
expansievat
200 ml/min
luchtdetector
(LMW)Heparin
Systemische anticoagulatie
![Page 35: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/35.jpg)
arteriële drukmeter
veneuze drukmeter
bloedpomp
citraat
veneus
expansievat
calcium
chloride
Ca2+-0 (of Ca2+-arm dialysaat)
200 ml/min
luchtdetector
Anticoagulatie, regionaal
![Page 36: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/36.jpg)
• Systemisch vs regionaal
• Heparine vs LMWH vs fondaparinux (factor Xa inhibitor)
• Heparin coated membrane
Anticoagulatie
![Page 37: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/37.jpg)
Bloedcircuit
• Bloedpomp
• Monitoring
• Pa en Pv
• Luchtdetector
Dialysaatcircuit
• Dialysaatpomp
• (Ontgassen)
• Verwarming
• Monitoring
• Conductiviteit
• Temp
• Bloedlek
Opties
• Anticoagulatie
• Na-profiling
• UF-profiling
• Efficiëntie
• On-line Kt/V
• Bloedvolume
• Recirculatie monitoring
• …
Dialysetoestel, functionaliteiten
vaatacces
![Page 38: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/38.jpg)
• Tijdelijk vasculair acces = catheter
• Type: enkellumen-dubbellumen
• Localisatie:
• Definitief vasculair acces:
AV-fistel > AV-synthetische greffe> permanente catheter
vaatacces
![Page 39: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/39.jpg)
• Localisatie
• Niet-dominante arm-
• Distaal (v.cephalica)-
• Maturatie
• Min. 6 wkn.
• Early referral !!
Vaatacces: arterioveneuze fistel
![Page 40: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/40.jpg)
• Bij falen natieve AV-fistel
• Localisatie
• Configuratie
• “straight” vs. “loop”
• “Rijping”
• Min. 2 wkn.
Vaatacces: arterioveneuze greffe
![Page 41: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/41.jpg)
• Hickman – Tesio - Dialock
• Localisatie
• Vena Jugularis Interna
• Rechts
• Maturatie: Onmiddellijk gebruik
• Catheterslot
Vaatacces: permanente catheter
![Page 42: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/42.jpg)
• AV-fistel/greffe
• fibrose, stenose, ...
• thrombose: heelkunde, interventionele radiologie, ...
• ischemie van de hand: ‘steal effect’
• oedeem van de hand
• pseudo-aneurysma
• infectie
• congestief hartfalen: 200 - 500 ml/min: ‘banding’
• Permanente catheter
• infectie
• thrombose
Vaatacces: complicaties
![Page 43: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/43.jpg)
Stenose efferente vene
![Page 44: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/44.jpg)
Arteriële occlusie
![Page 45: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/45.jpg)
Thrombose goretex AV greffe
![Page 46: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/46.jpg)
Thrombose/stenose centrale vene
![Page 48: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/48.jpg)
• Type transport
• Hemodialyse
• (droge) Hemofiltratie
• Hemodiafiltratie • on-line vs substitutie
• pre vs post
• Assistentie• High care HD
• Low care HD
• Home HD
• Duur-frequentie-patroon
• Intermittent
• Slow extended Hemodialysis: bvb. Nachtelijke haemodialyse, Genius…
• Continue technieken
• Continue venoveneuze hemofiltratie
• Continue venoveneuze hemodiafiltratie
• …
Dialyse modaliteiten: heden
![Page 49: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/49.jpg)
62
Dialyse modaliteiten: evolutie
• Self care
• Eenvoudig (single pump)
• Regeneratie dialysaat
• Draagbaar
• Dialyse- efficiëntie: focus op eiwit-gebonden toxines
• Adsorbers
• Artificial kidney
![Page 50: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/50.jpg)
• Inleiding
• Principes van hemodialyse
• Principes van peritoneaal dialyse
Overzicht
![Page 51: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/51.jpg)
Principes van peritoneale dialyse
![Page 52: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/52.jpg)
Peritoneaal dialyse is een proces waarbij
de samenstelling van bloed (in de
peritoneale capillairen) verandert door
contact met dialysaat via het peritoneaal
membraan
Principes van peritoneaal dialyse
![Page 53: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/53.jpg)
• Peritoneum (opp. = lichaamsopp.)
• Visceraal (80%)
• Parietaal (20%)
• Mesotheelcel
Peritoneale caviteit
![Page 54: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/54.jpg)
• Semi-permeabel, heterogeen, heteroporeus
• Transportweerstand: capillaire wand >>interstitium & mesotheel
Peritoneaal membraan
![Page 55: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/55.jpg)
• 3-poriën model
• ultra-small : < 5 Å
transport van water (aquaporines)
niet-gefenestreerd endotheel / proximale tubuli
• small : 40 - 50 Å
transport van laag moleculair gewicht opgeloste stoffen
• large : > 150 Å; < 0,1 %
transport van macromolecules (eiwitten)
• “Effectieve peritoneale membraamopp.”
Peritoneaal membraan
![Page 56: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/56.jpg)
Determinanten
• Concentratiegradient
• Effectieve peritoneaal membraan oppervlakte
• Intrinsieke peritoneale membraan weerstand
• MW, lading…
• Dialysaat flow
Principe
• Spontaan proces waarbij
molecules in vloeistoffen
een uniforme concentratie
in de oplossing bekomen
door random bewegingen
![Page 57: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/57.jpg)
Determinanten• Effectieve peritoneaal membraan oppervlakte
• intrinsieke hydraulische permeabiliteit
• P : hydrostatische drukgradiënt
• : colloid osmotische drukgradiënt
• O : crystalloid osmotische drukgradiënt ~ osmolaliteit : reflectiecoëfficiënt
0 : geen passage; 1 : geen hinder; glucose : 0,03
Principe
verplaatsing van water (samen met permeabele opgeloste stoffen, i.e. solvent drag) doorheen een semipermeablemembraan
![Page 58: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/58.jpg)
• Debiet: 0,5 - 1,5 ml/min
• Factoren:
• PIntraperitoneaal
• Recrutering lymfevaten
• (peritonitis)
B. Maes - K.U.L.
Peritoneale caviteit
![Page 59: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/59.jpg)
• Peritoneal Equilibration Test (PET)
• Procedure: 2 L, 3,86% Glucose; D: 0, 2, 4; P: 2 h
• UF volume
Evaluatie karakteristieken peritoneaal
membraan
![Page 60: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/60.jpg)
• Peritoneale toegangsweg
Peritoneaal dialyse in de praktijk
![Page 61: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/61.jpg)
• Peritoneale toegangsweg
Peritoneaal dialyse in de praktijk
![Page 62: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/62.jpg)
• Dialysevloeistof
• glucose 1,36 % = 1360 mg/dl
• glucose 2,27 % = 2270 mg/dl
• glucose 3.86 % = 3860 mg/dl
• icodextrine 7,5 % (icodial ®)
• aminozuren 1,1 % (nutrineal ®)
• HCO3- (physioneal ®)
Peritoneaal dialyse in de praktijk
![Page 63: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/63.jpg)
• Wisseling : manueel
Peritoneaal dialyse in de praktijk
Y-transfer set
“Drain before fill” (double-bag
system)
•Connect transfer set
•Drain
•Flush
•Fill
•Disconnect
•Dwell time 4-12h
![Page 64: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/64.jpg)
• Wisseling : automatisch
Peritoneaal dialyse in de praktijk
![Page 65: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/65.jpg)
• CAPD versus CCPD
Peritoneaal dialyse in de praktijk
![Page 66: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/66.jpg)
• Indicaties - Contraindicaties
• pro : vaataccess problemen
refractair hartfalen / kleplijden / artimieën / angor
perifeer vaatlijden
anemie / HIV / bloedingsstoornissen
behoud restfunctie nier
diabetes (?)
actieve levenstijl / onafhankelijkheid
• contra : malnutritie
meerdere abdominale ingrepen / adhesies
chronische / recurrente abdominale aandoenigen (pancreatitis, diverticulitis, IBD, …)
hernia inguinalis / umbilicalis / diafragmatica - hiatus hernia
ernstige COPD
ernstige hypertriglyceridemie
Peritoneaal dialyse in de praktijk
![Page 67: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/67.jpg)
• Peritoneaal dialyse voorschrift
• Factoren
• Peritoneaal transportkarakteristieken
• Persoonlijke voorkeur
• Beoordeling-evaluatie
• Droog gewicht
• Dialyse-efficiëntie
• Kliniek
• Biochemie: metabole correctie
• Berekende parameters van dialyse-efficiëntie:
• Kt/V
• Creatinine klaring
Peritoneaal dialyse in de praktijk
![Page 68: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/68.jpg)
Schatting droog gewicht
ondervulling overvulling
CVD laag CVD hoog
staande huidplooien pitting oedeem
posturale duizeligheid hypertensie
posturale BD val > 15 mm Hg cardiomegalie
tachycardie derde harttoon
spierkrampen reutels / dyspnoe / orthopnoe
nachtelijk hoesten
Peritoneaal dialyse in de praktijk
![Page 69: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/69.jpg)
• Complicaties
• UF falen
• Infecties
• Mechanische complicaties
• Metabole complicaties
Peritoneaal dialyse in de praktijk
![Page 70: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/70.jpg)
‘exit-site’ of catheterpoort infectie
tunnelinfectie
peritonitis :
• uni - microbieel
• route kiem
- contaminatie bij connecties S. epidermidis, S. aureus, Acinetobacter
- pericatheter (exit site / tunnel) S. epidermidis, S. aureus, Pseudomonas,
Proteus, schimmel
- translocatie / transmuraal mulibacterieel + anaeroben & fungi
- hematogeen Streptokokken, Mycobacteriën
- ascenderend (vagina) Pseudomonas, gist
• diagnose : abdominale pijn - rebound tenderness
troebele uitloop + > 100 cellen /µl (polynucleairen)
positieve cultuur
• R/ AB intraperitoneaal
Infecties
![Page 71: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/71.jpg)
onvermogen om vochtbalans (droog gewicht) te behouden ondanks het gebruik
van > 3 hypertone (glucose 3,86 %) wisselingen in combinatie met
vochtrestrictie
etiologie : niet-enzymatische glycosylatie van transportkanalen, ...
peritoneale membraanfunctie : groter effect op ‘fluid -’ dan ‘solute removal’
> 4 j klaring kleine molecules = of
netto UF
klinisch : meer nood aan hypertone wisselingen
1 j 2,6 %
3 j 9,5 %
6 j 30 %
4 - 12 % conversie van PD naar hemodialyse
Ultrafiltratie-falen
![Page 72: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/72.jpg)
• Liesbreuk, navelbreuk, buikwandbreuk…
• Buikwandlek/pericatheterlek
• Hydrothorax
• Rugpijn
Mechanische complicaties
![Page 73: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/73.jpg)
• Dyslipidemie
• Malnutritie:
• Anorexie
• Peritoneaal ewitverlies: 0.5 g/L, tot 20 g/d
• Ionenstoornissen
Metabole complicaties
![Page 74: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/74.jpg)
91 Faculteit, departement, dienst …
![Page 75: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/75.jpg)
• Inleiding
• Principes van hemodialyse
• Principes van peritoneaal dialyse
• Dialyse en overleving
Overzicht
![Page 76: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/76.jpg)
SEER, US National Cancer Institute, 1995-2001
ADR, US Renal Data System, 2001
ESRD 29.8%
5 year survival rate (%) by disease
ESRD: a life threatening disease
![Page 77: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/77.jpg)
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
40-44
35-39
30-34
25-29
20-24
15-19
0-14
Age
1.71.62.11.9
2.12.02.52.5
2.42.43.02.9
2.82.83.63.5
3.23.24.44.1
3.83.75.05.1
4.34.45.76.1
5.05.26.77.0
5.96.17.88.1
6.86.99.09.5
7.58.010.510.8
8.79.411.612.2
10.411.413.014.1
12.914.014.416.4
15.216.216.618.6
15.416.916.218.0
FMFM
WhiteBlack
Dialysis Population, 97†‡
6.35.26.25.1
8.97.28.46.8
12.09.711.18.8
15.412.513.911.0
19.112.517.113.6
23.015.720.616.4
27.319.324.419.6
31.727.328.423.0
36.631.732.626.7
41.036.136.930.5
45.840.741.434.5
50.645.246.038.6
55.549.950.642.9
60.454.555.447.2
65.259.260.251.7
74.868.769.761.1
FMFM
WhiteBlack
US Population, 95*
50.6 13.025-29
45-4945-49 36.6 5.9
55-59 19.3 4.4
65-69 13.6 4.1
Reprinted from the United States Renal Data System, 1999.
Expected Remaining Lifetimes for US Population (1995) and Stage 5 CKD Patients on Dialysis (1997) by Age, Race, Sex
ESRD, a life threatening disease
![Page 78: Principes van hemodialyse en peritoneaal dialyse · 2018. 3. 13. · •“uremie”= urine (oeron) in bloed (haima) •“uremia is a toxic syndrome caused by severe glomerular insufficiency,](https://reader036.vdocuments.us/reader036/viewer/2022071416/6113a4c06739a247dd496b5a/html5/thumbnails/78.jpg)
Relative risk of death
CVD = cardiovascular disease; GP = general population.
Foley FN, et al. Am J Kidney Dis. 1998;32(suppl 3):S112-S119.