Renal replacement therapy Indications for prompt initiation of

신대체요법 Renal replacement therapy

즉각 투석 시작의 적응증 Indications for prompt initiation of dialysis • Uremic pericarditis • Uremic encephalopathy • Intractable muscle cramping • Clinically significant bleeding diathesis • Persistent nausea and vomiting • Evidence of malnutrition • Refractory ECF volume overload • Refractory hyperkalemia

혈액투석 Hemodialysis

AV fistula Nondominat arm 에 시술 : 평소 혈관 아껴 야 Radiocephalic 이 기본 Maturation : 6~8 주 걸림

Arteriovenous (AV) Fistula

AV graft AV fistula보다 Thrombosis와 Infection 이 더 많다

투석기 (dialyzer) • 모세섬유관 투석기 (hollow fiber dialyzer) : 가장 많이 사용됨 • 평행판 투석기 (parallel plate dialyzer)

혈액투석의 기본원리 반투막을 경계로 Solute removal • 확산 (diffusion) • 대류 (convection) Fluid removal • 한외여과 (ultrafiltration) * Convection에 의한 용질의 제거는 일반 투석 시 에는 영향이 적으나 High flux dialysis 나 CVVH에서는 (contineous venous hemofiltration) 의미있는 역할을 한다.

확산 (diffusion)

대류 (convection)

투석액의 조성과 합병증 • Na – Intradialytic symptom, interdialytic weight gain, hypertension • K – Sudden cardiac death, arrhythmia, hypertension, hypotension • Ca – CKD-MBD, vascular calcification • HCO 3 – CKD-MBD, nutrition • Mg – Cardiovascular event rates, arrhythmia • Glucose – Hypoglycemia during HD • Water – Aluminum, chloramine, bacteria, endotoxin

Concentrations of dialysate components Dialysate conc. Target predialysis level Sodium (meq/L) 135 to 155 - Potassium (meq/L) 1. 5 -2. 5 5. 0 -5. 5 Calcium (mmol/L) 1. 25 to 1. 75 (2. 5 to 3. 5 m. Eq/L) 8. 5 -9. 5 Magnesium (mmol/L) 0 to 0. 75 (0 to 1. 5 m. Eq/L) - Chloride (meq/L) 87 to 120 - Bicarbonate (meq/L) 27 -35 20 -22. 5 Glucose (mg/d. L) 0 to 200 -

복막투석 Peritoneal dialysis

3 pore model 1) Aquaporin • 40% of water 2) Small pore • • Major solute 60% of water 3) Large pore • Larger MW solutes

한외여과 장애 (Uf failure) • Small pore 증가 - 복막에서 혈액으로 glucuse 흡수 증가 : osmotic gradient 소실 • Lymphatic absorption • Aquaporin channel 소실 • 복강내 hydrostatic pressure 증가

신장이식 Kidney Transplantation

Polyomavirus type BK (BKV) nephropathy • Allograft failure in renal-transplant recipients • 1~5% of renal-transplant recipients • seroprevalence rates of polyomavirus infection; 90% • Immunosuppression w/ Tacrolimus, Mycophenolate mofetil • Reducing the level of maintenance immunosuppression • Decoy cells viral inclusions in the urine, Non-specific • BKV DNA quantifiable surrogate marker for course of disease

Polyomavirus type BK (BKV) nephropathy