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自动化腹膜透析处方调整日本2,500欧洲4,500其它4,400北美14,000总计25,4001996年全球APD病人分布情况‘95到‘96年的年增长率为40％全球APD与CAPD占有情况Source:1996BaxterPatientReport10%24%020,00040,00060,00080,000100,000120,00019921993199419951996APDCAPD13%18%24%41%48%0%20%40%60%80%100%909294962000APDCAPDUSEurope10%12%15%21%40%0%20%40%60%80%100%909294962000美国与欧洲APD与CAPD占有情况全球APD病人的增长情况6,14218,00010,3007517,50016,50014,0003,9222,0341,2004,5006,6004,5002,50037502,0004,0006,0008,00010,00012,00014,00016,00018,00020,000199219931994199519961997199819992000NorthAmericaEuropeJapan5,5009,00027,60021,00035,800HomeChoicePatientsAroundtheWorld9,2237622,9901,94527419822697Q1Total15618APD的不同类型NIPD（夜间间歇性腹透）NTPD（夜间潮式腹透）CCPD（连续循环式腹透）CTPD（连续潮式腹透）IPD（间歇性腹透）APD（自动化腹膜透析）夜间＋＋＋＋白天＋＋潮式＋＋非潮式＋＋每周进行24小时，分3次或以上间歇进行制定处方的基本要素•体表面积(BSA)•残余肾功能(RRF)–收集24小时尿标本–每3个月测定一次•腹膜转运特性–标准PET–开始腹透治疗2-4周后进行充分性评估与调整充分性评估与处方调整临床评估营养评估清除率评估达到目标?是否继续治疗，无需调整处方处方调整•常规随访，每4个月进行一次充分性评估•根据PET结果调整处方•调整2－4周后重新进行充分性评估Source:PeritonealDialysisPrescriptionManagementDecisionTree,1997充分性目标DOQIguidelinessuggest:ForCAPD-KT/Vureaof2.0perweekCreat.Clr.60L/1.73mbodysurfacearea/wkForNIPD-KT/Vureaof2.2perweekCreat.Clr.66L/1.73mbodysurfacearea/wkForCCPD-KT/Vureaof2.1perweekCreat.Clr.63L/1.73mbodysurfacearea/wk222清除率目标Source:Blakeet.al.,PDI,1996CrClL/wk/1.73m24950-5960-6970Kt/VWeekly1.701.70-1.891.90-2.092.10GuidelinesUsecautionBorderlineAcceptableDesirable腹膜转运特性%患者膜类型4小时特性肌酐D/P10%高.81-1.03-腹膜效能非常高-溶质转运迅速-葡萄糖吸收多-可能较难满足超滤要求53%高.65-.81-腹膜效能高平均-溶质转运较迅速-超滤可31%低.50-.65-腹膜效能较低平均-溶质转运速度较慢-超滤较好6%Low.34-.50-腹膜效能低-溶质转运速度慢-无残余肾功能时难以达到清除率目标-超滤很好亚洲腹透病人PET分布Sources:Transportclassifications:BaxterClinicaldatabase,USPDpatients,n=827,1995.PatientBSAderivedfromCross-sectionalStudyofNutrition,T.Chiku,1993.BodySurfaceAream212233441.401.40-1.751.75LowLowAverageHighAverageHigh6%31%53%10%12344NoWetDayneededifPthasRRFRequireWetDay;maximizetheovernightfillvolDobestw/anadd’ldaytimeexchangeMostdifficulttodialyzeonanyPDtherapy1234APD总入液量对肌酐清除率的影响67637362738634434055515847497558493960250102030405060708090100LowLowAvgHighAvgHighLitersofCrCl/week/1.73m212.5L(4x2.5L+2.5L)12.5L(3x2.5L+2.5L+2.5L)15L(4x2.5+2.5L+2.5L)20LAPD(7x2.5L+2.5L)20LAPDDry(8x2.5L)白天“湿腹”的重要性90%的APD患者-除仍有残余肾功能的高转运患者-需要白天湿腹以达到透析充分性目标90%WetDayDryDay0%5%10%15%20%25%30%35%LowLowAverageHighAverageHigh40%45%50%6%31%53%10%白天“湿腹”的重要性•总入液量同样为12L的APD治疗，如使用白天湿腹，则可使清除率每周增加30％！01020304050602Lx62Lx5+2LLiters/WeekCreatinineClearance42.554.0Source:PDAdequest1.4Patient160cm,57kg,.724hrD/P10hrtherapy,dailyUF=1100APD处方调整01020304050607080PatientBSA1.86m24oD/P0.71RRF0UF1.5L10hourscyclerCrClL/wk/1.73m2TotalVolume20L10L12.5L12.5LCyclerNight8X2.5L4X2.0L4x2.5L3x2.5LDayDry2.0L2.5L2.5L+2.5LNightDwell(min)41112.5112.5160Source:PDAdequestTMDatabase,1996LeastEfficient43.046.055.0MostEfficient678%20%21%57%APD弹性处方调整，提高透析清除率Source:PDAdequest1.4Patient160cm57kg.724hrD/P9hrtherapy,dailyUF=110001020304050607080Liters/WeekCreatinineClearance2Lx5+2L2.5Lx4+2L2.5Lx3+2L+2L2Lx4+2L+1hour•增加“湿腹”•增加入液量•增加白天换液次数•延长夜间上机时间51.157.367.161.6AverageSizePatient,HighAveragePET当残余肾功能下降时通过调整APD方案和增加剂量，可提高肌酐清除率50-25--60-30NIPDLargerfillCCPDCCPDHighDoseCCPDDialysisClearanceResidualClearanceRRFCrCl/weekDialysisCrCl/weekTimeOnDialysis•Brunkhorst,etal,KidneyInternational,Vol46,1994.