中国血液透析临床实践指南2015

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血液透析充分性临床实践指南[1]

Standard Kt/V Normalized Kt/V
进一步研究的建议
一些正在进行的前瞻性、随机研究使用的是双室可变容积模型，这些数据可用于评价双室模型的优缺点，并明确与病人预后的关系。
需要通过观察性研究评价平衡后Kt/V的可行性和长期有效性。
对儿科血液透析病人，单室可变容积模型、双室可变容积模型作为判断预后的预测因素的合理性，还需要进一步的验证。
指南1 开始血液透析
1.1 肾衰竭时的准备 1.2 评估肾功能 1.3 治疗时机
肾衰竭时的准备（B级证据）
对于CKD-4期患者及家属及时给予教育，使其了解肾衰竭、可供选择的肾脏替代治疗方法（包括肾移植、 PD、HD）以及保守治疗
指南1 开始血液透析
1.1 肾衰竭时的准备 1.2 评估肾功能 1.3 治疗时机
举例
一患者体重70kg，期望Kt/V=1.2，K=0.18L/min 计算该患者应透析多长时间？
70 ×0.58 ×1.2
t=
0.18
= 270min ≈4.5h
一患者体重70kg，K=0.18L/min，治疗时间240min，计算Kt/V
0.18 ×240 Kt/V = 70×0.58 =1.06
足够的超滤量，维持水、电解质平衡纠正代谢性酸中毒良好的血压控制
充分透析的临床标准
无明显钙磷代谢障碍全身情况和营养状态良好,贫血改善心血管、尿毒症、周围神经病变和中枢神
经系统紊乱等慢性并发症减轻或减少，患者体力恢复，生活质量较高，经济适宜
透析不充分的临床评价
神经系统不安腿综合征、头痛、失眠、抽搐、痛性痉挛、意识障碍等。胃肠系统呃逆、口炎、胃肠炎、溃疡、厌食、恶心、呕吐等。血液系统贫血、出血等。免疫系统易感染、肿瘤、对疫苗的反应降低、皮试无反应性等。心血管系统高血压、低血压、动脉粥样硬化、心肌病变、心包炎等。皮肤皮疹、色素沉着、伤口愈合延迟等。内分泌系统糖耐量降低、甲旁亢、高脂血症、阳痿、闭经等。

KDOQI临床实践指南血液透析充分性(更新版)2015

KDOQI CLINICAL PRACTICE GUIDELINE FORHEMODIALYSIS ADEQUACY:2015UPDATEAbstractThe National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative(KDOQI)has provided evidence-based guidelines for all stages of chronic kidney disease(CKD)and related complications since1997. The2015update of the KDOQI Clinical Practice Guideline for Hemodialysis Adequacy is intended to assist practitioners caring for patients in preparation for and during hemodialysis.The literature reviewed for this update includes clinical trials and observational studies published between2000and March2014.New topics include high-frequency hemodialysis and risks;prescriptionﬂexibility in initiation timing,frequency,duration, and ultraﬁltration rate;and more emphasis on volume and blood pressure control.Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendation Assessment,Devel-opment,and Evaluation(GRADE)approach.Limitations of the evidence are discussed and speciﬁc suggestions are provided for future research.Keywords:Hemodialysis;Clinical Practice Guideline;hemodialysis prescription;hemodialysis frequency;initiation;adequacy;treatment time;hemoﬁltration;urea modeling;evidence-based recommendation;KDOQI.884Am J Kidney Dis.2015;66(5):884-930Work Group Membership Work Group ChairsJohn T.Daugirdas,MD University of Illinois College of MedicineChicago,ILThomas A.Depner,MD University of California,Davis Sacramento,CAWork Group MembersJula Inrig,MD,MHSDuke University Medical CenterYorba Linda,CARajnish Mehrotra,MDUniversity of WashingtonDivision of Nephrology,Harborview Medical CenterSeattle,WAMichael V.Rocco,MD,MSCEWake Forest School of MedicineWinston Salem,NCRita S.Suri,MD,MSc,FRCPCUniversity of MontrealMontreal,QuebecDaniel E.Weiner,MD,MSTufts Medical CenterBoston,MAEvidence Review TeamUniversity of Minnesota Department of MedicineMinneapolis VA Center for Chronic Disease Outcomes Research,Minneapolis,MN,USANancy Greer,PhD,Health Science SpecialistAreef Ishani,MD,MS,Chief,Section of Nephrology,Associate Professor of MedicineRoderick MacDonald,MS,Senior Research AssistantCarin Olson,MD,MS,Medical Editor and WriterIndulis Rutks,BS,Trials Search Coordinator and Research AssistantYelena Slinin,MD,MS,Assistant Professor of MedicineTimothy J.Wilt,MD,MPH,Professor of Medicine and Project DirectorAm J Kidney Dis.2015;66(5):884-930885KDOQI LeadershipMichael Rocco,MD,MSCEKDOQI ChairHolly Kramer,MDVice Chair,ResearchMichael J.Choi,MDVice Chair,EducationMilagros Samaniego-Picota,MDVice Chair,PolicyPaul J.Scheel,MD,MBAVice Chair,PolicyKDOQI Guideline Development StaffKerry Willis,PhD,Chief Scientiﬁc OfﬁcerJessica Joseph,MBA,Vice President,Scientiﬁc ActivitiesLaura Brereton,MSc,KDOQI Project Director886Am J Kidney Dis.2015;66(5):884-930NOTICESECTION I:USE OF THE CLINICAL PRACTICE GUIDELINEThis Clinical Practice Guideline document is based upon the best information available as of June2015.It is designed to provide information and assist decision making.It is not intended to deﬁne a standard of care,and should not be construed as one,nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients,available resources,and limitations unique to an institution or type of practice.Every health care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.The recommendations for research contained within this document are general and do not imply a speciﬁc protocol.SECTION II:DISCLOSUREKidney Disease Outcomes Quality Initiative(KDOQI)makes every effort to avoid any actual or reasonably perceived conﬂicts of interest that may arise as a result of an outside relationship or a personal,professional,or business interest of a member of the Work Group.All members of the Work Group are required to complete, sign,and submit a disclosure and attestation form showing all such relationships that might be perceived or actual conﬂicts of interest.This document is updated annually and information is adjusted accordingly.All reported information is onﬁle at the National Kidney Foundation(NKF).Am J Kidney Dis.2015;66(5):884-930887Table of ContentsContents Figures (889)Abbreviations and Acronyms (890)Current CKD Nomenclature Used by KDOQI (891)Executive Summary (892)Gathering the Evidence (892)Initiating HD (892)Frequency and Duration of Dialysis (892)Membranes and Hemodiaﬁltration Versus HD (893)Small-Solute Clearance (893)Adverse Effects of Dialysis (893)Limitations of“Adequacy” (893)Structure of the Work Group (893)Methods (893)ERT Study Selection and Outcomes of Interest (894)Guideline Statements (895)Guideline1:Timing of Hemodialysis Initiation (896)Rationale for Guideline1.1 (896)Research Recommendations (897)Rationale for Guideline1.2 (897)Guideline2:Frequent and Long Duration Hemodialysis (902)Background and Deﬁnitions (902)Evidence Overview (902)Rationale for Guidelines2.1and2.2 (903)Research Recommendations (905)Rationale for Guidelines2.3and2.4 (905)Research Recommendations (907)Rationale for Recommendation2.5 (907)Research Recommendations (907)Guideline3:Measurement of Dialysis—Urea Kinetics (908)Rationale (908)Target Dose(Guideline3.1) (908)Adjustments for Kru(Guideline3.2) (909)HD Schedules Other Than Thrice Weekly(Guideline3.3) (910)Limitations of the Guidelines (910)Research Recommendations (911)Appendix to Guideline3 (911)Guideline4:Volume and Blood Pressure Control—Treatment Time And Ultraﬁltration Rate (913)Rationale for Guideline4.1 (913)Rationale for Guideline4.2 (914)Research Recommendations (916)Guideline5:Hemodialysis Membranes (917)Rationale (917)Hemodiaﬁltration (918)Research Recommendations (918)Acknowledgements (919)Biographic and Disclosure Information (920)References (924)888Am J Kidney Dis.2015;66(5):884-930TablesTable1.Grade for Strength of Recommendation (895)Table2.Summary Data From Observational Studies That Assessed the Association Between Serum Creatinine–Based Estimates of Kidney Function at the Time of Initiation of Dialysis andRisk for Death (899)Table3.Summary Data From Observational Studies That Assessed the Association Between Measured Kidney Function at the Time of Initiation of Dialysis and Risk for Death (900)monly Used Validated GFR Estimating Equations in Adults (900)Table5.Clinical Settings Affecting Creatinine Generation (901)Table6.Descriptive Nomenclature for Various HD Prescriptions (903)Table7.Summary:Randomized Trials of More Frequent HD (904)Table8.Published Clinical Studies on the Effect of Lowering Dialysate Sodium onSubsequent BP (915)FiguresFigure1.Systematic errors from2commonly used linear formulas based on percent reduction in urea concentration (909)Figure2.Data from the Netherlands Cooperative Study showing a marked increase in risk of death in patients with no residual native kidney function (910)Figure3.Delivered dialysis doses in the HEMO Study (912)Am J Kidney Dis.2015;66(5):884-930889Abbreviations and AcronymsACTIVE Advanced Cognitive Training for Independent and Vital ElderlyAV ArteriovenousavCpre Average predialysis blood urea nitrogenBP Blood pressureBSA Body surface areaBUN Blood urea nitrogenCANUSA Canadian-USA Study on Adequacy of Peritoneal DialysisCI Conﬁdence intervalCi Dialysate inlet conductivitiesCKD Chronic kidney diseaseCKD-EPI Chronic Kidney Disease Epidemiology CollaborationCL cr Creatinine clearanceCo Dialysate outlet conductivitiesCV CardiovascularD DialysanceDRIP Dry Weight Reduction InterventionECV Extracellular volumeeGFR Estimated glomerularﬁltration rateeKt/V Equilibrated Kt/VERT Evidence Review TeamESA Erythropoiesis-stimulating agentESHOL Estudio de Supervivencia de Hemodiaﬁltración On-LineESRD End-stage renal diseaseFHN Frequent Hemodialysis NetworkG Urea generationGFAC G-factorGFR Glomerularﬁltration rateGRADE Grading of Recommendations Assessment,Development,and Evaluation HD HemodialysisHEMO NIH study of HD dose and membraneﬂuxHR Hazard ratioIDEAL Initiating Dialysis Early and LateKDIGO Kidney Disease:Improving Global OutcomesKDOQI Kidney Disease Outcomes Quality InitiativeKru Residual kidney functionKRT Kidney replacement therapyLVH Left ventricular hypertrophyMDRD Modiﬁcation of Diet in Renal DiseasemGFR Measured glomerularﬁltration rateMPO Membrane Permeability OutcomeNa SodiumNCDS National Cooperative Dialysis StudyNECOSAD Netherlands Cooperative Study on the Adequacy of DialysisNIH National Institutes of HealthNKF National Kidney FoundationNS Not speciﬁedPCR Protein catabolic ratePD Peritoneal dialysisPIDI Preceding interdialysis intervalPru Percent reduction in urea concentrationQb Bloodﬂow rateQd Dialysateﬂow rateQf UltraﬁltrationﬂowR Ratio of postdialysis to predialysis BUNRAAS Renin-angiotensin-aldosterone systemRCT Randomized controlled trialRR Relative riskSA-sdtKt/V Surface area–adjusted standard Kt/VScr Serum creatinineScys Serum cystatin Csp Single-pool(Kt/V)std Standard(Kt/V)T Treatment time in hoursTiME Time to Reduce Mortality in End-Stage Renal Disease trialUf Ultraﬁltration rateURR Urea reduction ratioUSRDS US Renal Data SystemV Urea volume890Am J Kidney Dis.2015;66(5):884-930Current CKD Nomenclature Used by KDOQICKD Categories DeﬁnitionCKD CKD of any stage(1-5),with or without a kidney transplant,including bothnon–dialysis-dependent CKD(CKD1-5ND)and dialysis-dependent CKD(CKD5D)CKD ND Non–dialysis-dependent CKD of any stage(1-5),with or without a kidneytransplant(ie,CKD excluding CKD5D)CKD T Non–dialysis-dependent CKD of any stage(1-5)with a kidney transplantSpeciﬁc CKD StagesCKD1,2,3,4Speciﬁc stages of CKD,CKD ND,or CKD TCKD3-4,etc Range of speciﬁc stages(eg,both CKD3and CKD4)CKD5D Dialysis-dependent CKD5CKD5HD Hemodialysis-dependent CKD5CKD5PD Peritoneal dialysis–dependent CKD5Am J Kidney Dis.2015;66(5):884-930891Executive SummaryWhen hemodialysis(HD)was introduced as an effective workable treatment in1943,1the outlook for patients with advancing kidney failure suddenly changed from anticipation of impending death to in-deﬁnite survival.Since then,implementation of dia-lysis has advanced from an intensive bedside therapy to a more streamlined treatment,sometimes self-administered in the patient’s home,using modern technology that has simpliﬁed dialysis treatment by reducing the time and effort required by the patient and caregivers.Standards have been established to efﬁciently care for large numbers of patients with a balance of resources and patient time.However, simpliﬁed standards can lead to inadequate treatment, so guidelines have been developed to assure patients, caregivers,andﬁnancial providers that reversal of the uremic state is the best that can be offered and com-plications are minimized.The National Kidney Foundation(NKF)continues to sponsor this forum for collaborative decision making regarding the aspects of HD that are considered vital to achieve these goals. Over400,000patients are currently treated with HD in the United States,with Medicare spending approaching$90,000per patient per year of care in 2012.2Unfortunately,although mortality rates are improving(30%decline since1999),they remain several-fold higher than those of age-matched in-dividuals in the general population,and patients experience an average of nearly2hospital admissions per year.3Interventions that can improve outcomes in dialysis are urgently needed.Attempts to improve outcomes have included initiating dialysis at higher glomerularﬁltration rates(GFRs),increasing dialysis frequency and/or duration,using newer membranes, and employing supplemental or alternative hemoﬁl-tration.Efforts to increase the dose of dialysis admin-istered3times weekly have not improved survival, indicating that something else needs to be addressed.GATHERING THE EVIDENCEThe literature reviewed for this adequacy update includes observational studies and clinical trials published from2000to2014.In some cases,high-quality data have been presented to support conclu-sions,but in most cases,clinicians are left with incomplete or inadequate data.In these situations,as in many aspects of general medical care,decisions about treatments must be based on logic and obser-vation.A major goal of the Work Group and Evi-dence Review Team(ERT)was to compile and evaluate as much information as possible to arrive at a reasonable answer to the questions posed in Box1,not all of which can be answered deﬁnitively with support from controlled clinical trials.Initiating HDDespite lack of evidence from randomized controlled trials(RCTs)about the optimal time to start kidney replacement therapy(KRT),there has been a trend,which has leveled off since2010,in the United States toward earlier initiation of dialysis at higher levels of kidney function.2,3If earlier dialysis is inef-fective,this trend would lead to greater resource utili-zation without clinical beneﬁt.Published in2010, results of the IDEAL(Initiating Dialysis Early and Late)trial explored this issue,and data from this trial constitute the best evidence regarding timing of dialysis initiation,motivating the update of this guideline.4 Frequency and Duration of Dialysis Observational and controlled nonrandomized studies had suggested that more frequent and/or longer dialysis improves the patient’s quality of life,controls hyperphosphatemia,reduces hypertension,and results in regression of left ventricular hypertrophy(LVH).5,6 Abbreviation:CKD,chronic kidney disease.KDOQI HD Adequacy Guideline:2015Update892Am J Kidney Dis.2015;66(5):884-930Based on theseﬁndings,more frequent and longerdialysis sessions have become more common.Since theprevious KDOQI(Kidney Disease Outcomes QualityInitiative)update,7several RCTs that compared morefrequent or extended dialysis to conventional dialysis have been completed.8-11This update reviews thisevidence.Membranes and Hemodiaﬁltration Versus HD Cardiovascular(CV)disease is the leading cause ofdeath in patients with CKD stage5,2with uremic toxinsand the kidney failure milieu including volume expan-sion likely important contributing pared tolow-ﬂux dialysis,high-ﬂux dialysis and convectivetherapies such as hemoﬁltration and hemodiaﬁltrationprovide higher clearance of larger solutes,removal ofwhich might improve CV outcomes.This update re-views the evidence for use of high-ﬂux compared tolow-ﬂux dialyzer membranes,as well as convectivemodes of KRT compared to conventional HD.Small-Solute ClearanceThis update addresses only the dialysis treatmentwhile acknowledging that there are limits to what dial-ysis can accomplish.Assessment of dialysis requiresmeasurement of the dialysis dose.Included herein arethe current recommended methods for measuring whatdialysis does best,the purging of small dialyzable sol-utes,with the assumption that this function is the essence of the life-prolonging effect of dialysis.How-ever,while optimization of small-solute removal shouldbe considered theﬁrst priority,assessment of dialysisadequacy should not stop there as the absence of nativekidneys entails loss of many vital functions,only one ofwhich is small-solute removal.Adverse Effects of DialysisEarly investigators postulated that exposure of theblood to a large foreign surface for several hours wouldcause an inﬂammatory response in the patient anddeplete vital constituents of the blood,such as platelets and clotting factors.Removal of low-molecular-weighthormones,vitamins,and other vital molecules wasalso a concern.Membranes were developed to be “biocompatible,”causing less interaction with blood constituents.While the postulated depletion syndromesapparently never materialized,in recent years,concernhas been raised about transient intra-and postdialysisalkalosis and dialysis-associated reductions in blood pressure(BP),serum potassium,and serum phosphorus and changes in other electrolytes and proteins that may amount to a“perfect storm”of stress potentially responsible for acute cardiac events,as well as long-term effects on the brain and CV system.12-14More frequent and more prolonged dialysis,while improving solute clearance and volume removal,could enhance blood-membrane interaction,add to the burden on pa-tients and caregivers,15and even accelerate loss of native kidney function and vascular access dam-age.16,17The current guideline update includes a listing and recommendations regarding potential beneﬁts and adverse effects associated with more frequent dialysis. Limitations of“Adequacy”The ultimate goal of treatment for patients with CKD stage5is improvement in quality of life,with prolon-gation of life often an additional goal.This requires more than the dialysis treatment itself.In recent liter-ature,adequacy of dialysis is sometimes confused with adequacy of other aspects of patient management,with the erroneous assumption that having achieved dialysis adequacy,the goal of dialysis has been accomplished. In the opinion of the Work Group,this is incorrect:it is important to distinguish adequacy of the dialysis from adequacy of patient care.Dialysis-dependent patients require a number of treatments independent of or only partially dependent on the dialysis itself,many of which were implemented long before the patient’s dialysis started.Guidelines for some of these are addressed in other publications by KDOQI,including management of anemia,nutrition,metabolic bone disease,diabetes,and CV disease.18-22STRUCTURE OF THE WORK GROUPThe volunteer members of the Work Group were selected for their clinical experience,as well as experience with clinical trials and familiarity with the literature,especially regarding the issues surrounding dialysis adequacy.All are practicing nephrologists who have many years of experience with care of pa-tients dependent on KRT.METHODSIn consultation with the KDOQI Hemodialysis Ad-equacy Clinical Practice Guidelines Update Work Group,the Minnesota ERT developed and followed a standard protocol for all steps of the review process. The guideline update effort was a multidisciplinary undertaking that included input from NKF scientiﬁc staff,the ERT from the Center for Chronic Disease Outcomes Research at the Minneapolis Veterans Af-fairs Medical Center,and the Work Group.The comprehensiveﬁndings from the systematic literature review prepared for this update are presented in detail in the accompanying article from Slinin et al.23Brieﬂy, MEDLINE(Ovid)was searched from2000to March 2014for English-language studies in populations of all ages.Additional searches included reference lists of recent systematic reviews and studies eligible for in-clusion to identify relevant studies not identiﬁed inKDOQI HD Adequacy Guideline:2015UpdateAm J Kidney Dis.2015;66(5):884-930893MEDLINE and to identify any recently completed studies.ERT Study Selection and Outcomes of Interest Studies were included if they were randomized or controlled clinical trials in people treated with, initiating,or planning to initiate maintenance HD for CKD.To be included,studies needed to report the effects of an intervention on all-cause mortality,CV mortality,myocardial infarction,stroke,all-cause hospitalization,quality of life,depression or cognitive performance,BP or BP treatment,left ventricular mass, interdialytic weight gain,dry weight,or harms or complications related to vascular access or the process of dialysis.Observational studies considered by the Work Group that were not selected by the evidenceKDOQI HD Adequacy Guideline:2015Updateteam and are not included in the Evidence Report by the ERT include those evaluating mortality,hard out-comes,and pregnancy-related outcomes with frequent dialysis.For frequency and duration of HD sessions,trials that assigned individuals to more frequent HD (.3times a week)or longer (.4.5hours)dialysis versus conventional HD were included.For studies that compared high-ﬂux to low-ﬂux dialysis membranes or hemo ﬁltration or hemodia ﬁltration to conventional HD,the ERT included trials that enrolled at least 50participants with a minimum of 12months ’follow-up in each treatment arm.GUIDELINE STATEMENTSThe Work Group distilled these answers in the form of 5guidelines,some of which are similar to the pre-vious guidelines published in 20067but have been re-emphasized or reinterpreted in light of new data (Box 2).For each of the guidelines,the quality of the evidence and the strength of the recommendations were graded separately using the Grading of Recommenda-tions Assessment,Development,and Evaluation (GRADE)approach criteria 24:scales of A to D for quality of the evidence and 1or 2for strength of the recommendation,including its potential clinical impact (Table 1;Box 3).The guideline statements were based on a consensus within the Work Group that the strengthof the evidence was suf ﬁcient to make de ﬁnitive statements about appropriate clinical practice.When the strength of the evidence was not suf ﬁcient to make such statements,the Work Group offered recommen-dations based on the best available evidence and expert opinion.In cases in which controversy exists but data are sparse,the guideline is ungraded,based on consensus opinion of the Work Group.For a few of the guidelines,not all of the Work Group members agreed,and in such cases,the reasons for disagreement are spelled out in the rationale that follows the guideline statement.For all guidelines,clinicians should be aware that circumstances may appear that would require straying from the recommendations of the WorkGroup.Table 1.Grade for Strength of RecommendationImplicationsBased on Uhlig et al.24aThe additional category “Not Graded”was used,typically to provide guidance based on common sense or where the topic does not allow adequate application of evidence.The most common examples include recommendations regarding monitoring intervals,counseling,and referral to other clinical specialists.The ungraded recommendations are generally written as simple declarative statements,but are not meant to be interpreted as being stronger recommendations than Level 1or 2recommendations.KDOQI HD Adequacy Guideline:2015UpdateGuideline1:Timing of Hemodialysis Initiation1.1Patients who reach CKD stage4(GFR,30mL/min/1.73m2),includingthose who have imminent need for mainte-nance dialysis at the time of initial assess-ment,should receive education about kidneyfailure and options for its treatment,including kidney transplantation,PD,HD inthe home or in-center,and conservativetreatment.Patients’family members andcaregivers also should be educated abouttreatment choices for kidney failure.(NotGraded)1.2The decision to initiate maintenance dialysisin patients who choose to do so should bebased primarily upon an assessment of signsand/or symptoms associated with uremia,evidence of protein-energy wasting,and theability to safely manage metabolic abnor-malities and/or volume overload with med-ical therapy rather than on a speciﬁc level ofkidney function in the absence of such signsand symptoms.(Not Graded)RATIONALE FOR GUIDELINE1.1 Recent KDIGO(Kidney Disease:Improving Global Outcomes)and prior KDOQI guidelines recommend referral of all individuals with GFR,30mL/min/1.73m2to a nephrologist,stress-ing that timely nephrology referral maximizes the likelihood of adequate planning for KRT to optimize decision making and outcomes.7,25,26While deter-mining the rate of progression and precise timing of referral is beyond the scope of this guideline,the implication is clear—that patients,their families,and caregivers should have ample time to make informed decisions regarding KRT and to implement these decisions successfully.27Multiple dialysis modalities are available for KRT, including modalities performed in the home and mo-dalities in dialysis facilities,none of which is conclu-sively demonstrated to be superior to the others.28,29 Additionally,conservative nondialysis care may be the appropriate decision for many older or more inﬁrm individuals,30while pre-emptive or early trans-plantation may be the best for many other patients.In patients considering maintenance dialysis,it is impor-tant to acknowledge that each KRT modality adds a unique burden of treatment to the already high burden of disease.In this context,patients,their families,and their caregivers are best positioned to determine which tradeoffs they are willing to make,particularly given the lack of deﬁnitive evidence for the superiority of one dialysis modality over the other and the possibility that conservative care may be the option that bestﬁts some individual patients’goals.Morton and colleagues31 recently provided a thematic synthesis of18qualita-tive studies that reported the experience of375patients and87caregivers.They identiﬁed4major themes central to treatment choices:confronting mortality (choosing life or death,being a burden,living in limbo), lack of choice(medical decision,lack of information, constraints on resources),gaining knowledge about options(peer inﬂuence,timing of information),and weighing alternatives(maintaining lifestyle,family inﬂuence,maintaining status quo).However,none of the essential decisions can be made in an informed manner without adequate time for education and contemplation.As illustrated by Morton and colleagues’systematic review,electing conservative therapy rather than dia-lysis or kidney transplantation is an important option for many people with kidney failure.In one study of 584patients with CKD stages4and5,a total of61%of the patients who had started HD regretted this deci-sion,30and when asked why they chose dialysis,52% attributed this decision to their physician.While this study is limited by a homogeneous population,it is apparent that education prior to dialysis regarding treatment options was insufﬁcient in many,and that this led to dissatisfaction with KRT decisions.The limited ability of care providers to predict patient choice was illustrated by a recent study reporting on focus groups and interviews with11nephrologists and29patients older than65years with advanced CKD.32Both pa-tients and nephrologists acknowledged that discussions about prognosis are rare and patients cope most often with their diagnosis through avoidance,while ne-phrologists expressed concern over evoking negative reactions if they challenge this coping strategy.The Work Group recognizes that the experiences reported in this study are not unique to these patients and phy-sicians;accordingly,we stress the need for patient-centered education to begin early;to involve patients, their families,and their caregivers,if possible;and to be continually reinforced in a positive and patient-sensitive manner.27,31Further,given the high preva-lence of cognitive impairment33and delirium34among patients with kidney failure,as well as acknowledged difﬁculties predicting the rate of progression to kidney failure among patients with advanced CKD,35-38it is imperative that patients’informants and proxy decision makers be involved in this decision-making process. Few clinical trials have evaluated the potential beneﬁts of referral and education prior to the need for dialysis39,40;accordingly,statements made on this KDOQI HD Adequacy Guideline:2015Update。

血液透析充分性临床实践指南

● 透析时间(t)：低血压、依从性、抗凝不充分
死亡率与透析剂量（Kt/V）的关系
（日本42341例HD患者统计资料）
Hemo研究
• RCT, 1711患者 • 常规剂量血透
– spkt/V1.32±0.09
• 大剂量血透 – spkt/V1.71±0.11
• 两组生存率无显著差异
HEMO研究结果
美国推荐的 Kt/V 和 URR 值
时间 Kt/v >1.0 1.2 处方1.3, 实际1.2 ， DM 1.4 处方1.3, 实际1.2 ， DM1.4 处方1.3, 实际1.2 ， DM1.4 处方70%, 实际65％处方70%, 实际65％ URR 1985(NCDS) 1993(RPA） 1997(DOQI) 2001(DOQI)
7％的误差将导致Kt/V误差为２０％
五、在线电导测定法
尿素 Na+ 跨膜转运的特征及清除率基本一致
透析液电导度改变
根据透析液电导度（钠）改变测定，与尿素的跨膜转运与清除基本一致；优点：与实际值相关性好、可多次在线监测、不需采血；缺点：存在个体差异。
六、β2–微球蛋白下降率测定
价开始肾脏替代治疗的利弊及风险；对未至CKD-5期的患者，如有肾衰竭的特征性并发症应立即开始肾脏替代治疗。
评估肾功能
根据验方程或测定肌酐和尿素清除率评估GFR，不能单纯以血肌酐和尿素氮评判肾功能
血液透析充分性临床实践指南
1.开始血液透析 3.血BUN标本的采集 5.容量和血压的控制 7.质量改善计划
血液透析充分性临床实践指南
1990-2010全球维持性透析患者人数
2,500,000
1,490,000

血液透析充分性评估

Kt/V
K是透析器的尿素清除率，单位是L/min 它是单位面积的清除率（K0A）和血流速
与透析液流速的函数 T是透析时间，单位min V是尿素分布容积（体重x0.58），单位L Kt/V是无单位的比值，反映每次透析的尿素清除分数，也叫尿素清除指数
Kt/V与死亡相对危险性
R R
RR=0.89/5,%(P)
腹膜透析、血滤、灌流可提高中分子物质清除目前未明确中分子毒素的确切组份维生素B12和β2-GM清除率可以间接反映中分子毒素
清除
如何更多的清除尿毒症患者中、大分子毒素？
高通量透析？？血液滤过？？血液灌流吸附？？
HD患者血循环中积累2-MG的原因
影响Kt/V和URR因素
病人的体重、营养状态透析器复用残余肾功能治疗频次、时间超滤量
血管通路再循环透析后尿素再分布透析后血标本采集时机透析相关因素
体重对Kt/V和URR因素
相同的透析剂量（Kt）,不同体重者Kt/V值不同体型小、体重低，其V值小，Kt/V值高体重大，其V值大，Kt/V值低
血液透析充分性评估
血液透析充分性定义
在良好的营养摄入情况下：通过透析有效的清除体内毒素和水分消除尿毒症症状和体征维持血压正常水平避免心脑血管和神经系统并发症保持水电解质和酸碱平衡
血液透析充分性目标
血液透析充分性认识过程
80年代初期，美国透析协作组（NCDS）首先提出采用平均尿素浓度评价血液透析充分性
1.art Kt/Vequil=art Kt/Vsp-(0.6×art Kt/Vsp/T)+0.03(适用于动静脉内瘘) 2.ven Kt/Vequil=ven Kt/Vsp-(0.47 × venKt/Vsp/T)+0.02(适用于静脉插管) 目前，临床上尚不清楚Kt/V和eKt/V那个更有价值

中国血液透析用血管通路专家共识(第2版)解读(医学知识)

量4倍、无法达到充分性透析。 • 原因：纤维蛋白鞘和/或血栓形成
医药医学
30
导管功能不良的预防
定期采用尿激酶封管可以降低导管的血栓发生率
尿激酶浓度差别较大(10000～50000IU/ml)，目前尚无统一认识
经常发生导管血栓或流量不佳的高凝患者，可考虑服用血小板抑制剂或抗凝剂，但需定期监测凝血功能。
医药医学
3
一、血管通路的临床目标
首选AVF(autogenous arteriovenous fistula) 次选AVG(arteriovenous graft) 最后TCC(tunnel-cuffed catheter)
医药医学
4
一、血管通路的临床目标
血管通路的比例：AVF＞80%、TCC＜10%
初始建立AVG的失败率：前臂直型 AVG＜15%、前臂袢型 AVG＜10%、上臂AVG＜5%
AVF并发症和通畅性：①血栓形成＜0.25次/患者年、②感染＜1%、③使用寿命≥3年
AVG 并发症及通畅性：①血栓＜0.5 次/患者年、②感染 ≤10%、③使用寿命≥2 年、④PTA术后使用寿命：≥4个月
首次透析的血管通路类型选择：内瘘第一
股静脉临时导管原则上不超过1周，长期卧床者可以视情况酌情延长至2～4周
医药医学
26
导管长度的选择
导管长度
临时、NCC (导管体内长
度)
半永久、TCC (导管全长)
右颈内静脉（CM）
12～15
36～40
左颈内静脉（CM）
股静脉（CM）
15～19
>19
40～45
>45
医药医学
27
儿童患者
• 不能配合置管操作的儿童患者施行颈内静脉或锁骨下静脉置管时建议采用基础麻醉

血液透析护理操作规程2015.9

血液透析操作规程（一）用物准备。

透析机、血液透析器、血液透析管路、穿刺针、无菌治疗巾、生理盐水、消毒物品、止血带、一次性手套、透析液等。

（二）评估和观察要点。

1、评估患者的临床症状、血压、体重等，合理设置脱水量和其他治疗参数。

2、评估血管通路的状态，如动静脉内瘘局部的触诊和听诊、中心静脉置管的评估等，及时发现相关的并发症，并确保通路的通畅。

3、透析过程中，认真巡视，检查机器的运转情况，血管通路的情况，体外循环的情况，定时测量生命体征，及时发现血液透析相关并发症并及时处理，如出血，溶血、肌肉痉挛、心律失常、低血压等。

（三）操作要点1.透析前准备（1）备齐用物，核对患者姓名、透析器、透析管路的型号及有效期、透析机及透析方式。

（2）准备机器、开机、机器自检。

2.检查血液透析器及透析管路有无破损，外包装是否完好，查看有效期、型号，遵循无菌原则按照体外循环的血流方向依次安装管路和透析器。

3.预充。

（1）启动透析机血泵80-100ml/min,用生理盐水先排净透析管路和透析血室（膜内）气体，生理盐水流向为动脉端→透析器→静脉端，不得逆流向预冲。

（2）将泵速调至200-300 ml/min，连接透析液接头与透析器旁路，排净透析液室（膜外）气体。

（3）生理盐水预冲量，应严格按照透析器说明书中的要求进行；进行密闭室循环或肝素生理盐水预冲，应在生理盐水预冲量达到500ml后再进行。

（4）预冲生理盐水直接流入废液收集袋中，并将废液收集袋放于机器液架上，不得低于操作者腰部以下。

（5）冲洗完毕后再次核对，根据医嘱设置治疗参数。

4.动静脉内瘘穿刺。

（1）检查患者自身血管通路：有无红肿，渗血，硬结；并摸清血管走向和搏动。

（2）选择好穿刺点，消毒穿刺部位。

（3）根据血管的粗细和血流量要求等选择穿刺针。

（4）采用阶梯式、纽扣式等方法，以合适的角度穿刺血管；先穿刺静脉，再穿刺动脉，以动脉端穿刺点与动静脉内瘘口3cm以上，动静脉穿刺点之间的距离在10cm以上为宜，固定穿刺针。

(整理)临床护理实践指南第十六章.

临床护理实践指南（2011版）第十六章血液净化专科护理操作一、血液透析二、血液灌流三、血浆置换四、血液滤过五、持续不卧床腹膜透析换液（CAPD）六、自动化腹膜透析（APD）七、更换腹膜透析短管八、腹膜透析导管外出口处换药及护理九、腹膜平衡试验（PET）十、腹膜透析新患者培训第十六章血液净化专科护理操作自20世纪60年代血液透析操作技术问世以来，血液净化操作技术迅猛发展。

治疗的指征也从单纯的肾脏替代治疗扩展到血液病、风湿病、自身免疫性疾病、药物或毒物中毒、重症肝炎以及危重患者抢救等多个领域。

护士在血液净化治疗中发挥着重要作用。

护士不仅需要掌握规范的操作流程，严格遵循无菌原则，准确、安全、熟练地进行技术操作；同时也需要严密监测患者的生命体征及各项指标的变化，预防和处理并发症；更要为长期透析的患者提供健康指导，促进他们自我管理和康复。

一、血液透析（一）评估和观察要点。

1.评估患者的临床症状、血压、体重等，合理设置脱水量和其他治疗参数。

2.评估血管通路的状态，如动静脉内瘘局部的触诊和听诊，中心静脉置管的评估等，及时发现相关并发症，并确保通路的通畅。

3.透析过程中，认真巡视，检查机器的运转情况，血管通路的情况，体外循坏情况，定时测量生命体征，及时发现血液透析相关并发症并及时处理，如出血、溶血、肌肉痉挛、心律失常、低血压等。

（二）操作要点。

1.透析前准备。

（1）备齐用物，核对患者姓名、透析器、透析管路的型号及有效期、透析机及透析方式。

（2）准备机器，开机，机器自检。

2.检查血液透析器及透析管路有无破损，外包装是否完好，查看有效日期、型号，遵循无菌原则按照体外循环的血流方向依次安装管路和透析器。

3.预冲。

（1）启动透析机血泵80～100ml/min，用生理盐水先排净透析管路和透析器血室（膜内）气体，生理盐水流向为动脉端→透析器→静脉端，不得逆向预冲。

（2）将泵速调至200～300ml/min，连接透析液接头与透析器旁路，排净透析器透析液室（膜外）气体。

维持性血液透析患者容量管理的最佳证据总结

・84・JournalofNursingScience Jan2021Vol.36No.2•循证护理•维持性血液透析患者容量管理的最佳证据总结王爽】，黄海燕2,吕芳芳3,张玉曼4,祝筠1摘要：目的检索、评价并整合维持性血液透析患者容量管理的最佳证据，为完善维持性血液透析患者容量管理提供参考％方法系统检索循证资源及文献数据库、专业协会网站中有关维持性血液透析患者容量管理的证据，包括临床决策、指南、证据总结、最佳临床实践信息册、推荐实践、专家共识及系统评价%结果共纳入文献12篇，包括临床决策2篇、指南6篇、专家共识1篇、证据总结2篇、系统评价1篇，从评估与监测、钠水限制、容量超负荷处理、提高患者依从性4个方面汇总14条证据%结论医护人员可结合所在机构环境与患者意愿，选择性应用证据，为患者制定个性化容量管理方案，从而提高护理质量％关键词：终末期肾脏病；维持性血液透析；容量管理；证据总结中图分类号.R473.5文献标识码：A DOI：10.3870/j.issn.1001-4152.202102.084Evidence summary on fluid management in maintenance hemodialysis patients Wang Shuang$Huang Haiyan$L d Fangfang$ Zhang Yu.an$Zhu Yun.Department of Nursing$Shandong Provincial Hospital Affiliated to Shandong First Medical University$Jinan250021$ChinaAbstract:Objective To retrieve,assess and summarize the existing evidence on fluid management in maintenance hemodialysis patients. Methods Systematic searches for evidence were performed across multiple sources as electronic databases and websites,to retrieve clinical decision,guideline,evidence summary,best practice information sheet,recommended practice,expert consensus and systematic review on fluid management in maintenance hemodialysis patients.Results Two best practice reports,6guidelines,1expert consensus statement,2evidence summaries and1systematic review were included.Four aspects with14pieces of evidence were summarized,including assessment and monitoring,sodium and fluid restriction,management of volume overload and enhancing patient compliance.Conclusion Medical staff could imple-menttheevidenceintoclinicalpracticebyconsideringsituationoftheinstitutionandpatient'spreference thustodeveloppatient-centeredfluid managementprotocolandimprovenursingqualityKey words:end stage renal disease；maintenance hemodialysis；维持性血液透析(Maintenance Hemodialysis, MHD)是终末期肾脏病患者最主要的肾脏替代治疗方式。

中国血液透析充分性临床实践指南

透析充分性ＨＪ，本指南在充分考虑各地实际条件、医疗资源、卫生经济学的前提下，提出如下标准，以期最大限度满足血液透析患者基本治疗要求：推荐单次透析ｓｐＫｔ／Ｖ≥１．２，条件允许时ｓｐＫｔ／Ｖ≥１．４
ｍｌ／ｍｉｎ）可增加透析
器膜内外溶质浓度梯度，促进血循环中毒素转运，提
高透析充分性。
附：ｐ：－ＭＧ清除率
例信息登记数据，截至２０１４年底我国在透血液透析患者近３４万。但根据全国性流行病学调查数据，我国慢性。肾脏病（ＣＫＤ）患者１．２亿，其中３期以上
ＣＫＤ患者１９００余万…，糖尿病患者１．１亿忙Ｊ，高血
及标准的参数，希望更好地推动血液透析长期医疗
质量的提升。
压患者２．５亿。３Ｊ。因此，随着国家医疗保障制度的不断完善，维持性血液透析患者数量将出现持续高
析５～５．５ｈ）。本指南提出的血液透析充分性标准适用于接受上述血液透析方案的患者。
过小（对于体型较大者而言），透析中凝血导致有效膜面积下降（患者高凝、抗凝剂剂量不足等），复用透析器、特别是在过度复用状态时将发生血液透析充分性不足，应按照不同的原因进行技术改进。
４．血液／透析液流速：常规透析血流量一般为
１．７３ｍｌ・ｍｉｎ～・
的标准。可以考虑每日短时透析疗法，或转为腹膜透析治疗。３．技术因素：血流量低（如内瘘功能不良、临时
或半永久导管功能不良、严重心律失常导致血流量低下等），无效再循环（如血管通路近心端出现狭窄
或阻塞、动静脉穿刺针间距太小等），透析器膜面积
ｍ。２时，如采用每周２次血液透析，建议每次透
２００～３００
２．血液透析充分性标准的依据：血液透析治疗只是部分替代了肾脏功能，治疗总体目标是有效清除毒素、调控体液容量、最大限度保持患者体内微环境稳定。虽然尿毒症毒素的有效清除有助于改善患者生活质量及预后，但是也有证据表明，过高的Ｋｔ／Ｖ值对患者生存率并无益处。日本透析登记数据表明，ｓｐＫｔ／Ｖ值＞１．８增加血液透析患者死亡率＂ｏ。

NKF—K／DOQI血液透析充分性的临床实践指南

用平均ＴＶ是不可取的。Ｃ
原理
指南１总血室容积基础值的测量（１证据）
器使患者死亡危险增加了１％０。值得注意的是这项报告并没有就透析并发症的发病率和透析充分性的不同进行控制。而且，它所报告的死亡危险性的
所采纳。这些推荐是由专家小组做出的，是目前
容积基础值的测量除外。见指南１，总血室容积基（１础值的测量）。
原理
因为经济原因，在美国通常复用血液透析
有关透析器复用程序的最佳指南。
器。１９年，美国有７％的透析单位复用透析器。９５３在复用透析器的单位，复用次数的中位数在１８年９６是９次，１９９４年是１次。在此期间所报道的最大４使用次数的中位数分别是２和３次。但还没有儿３０
但实际２组的ＫＶ分别为１０和１１。工作组特．５．０
维普资讯
差别。因此，血液透析充分工作组认为依赖生产
商提供的ＴＶ是不合适的。ＡＭ推荐的将大约１ＣＡＩ０个透析器复用前测定的血室容积平均值作为ＴＶ的Ｃ方法也是不可取的。例如，如果一个透析器有相对大的血室容积，由于成批ＴＶ的平均值较其低，Ｃ
定）及实际透析剂量会下降。随着复用次数的增
加，尿素的清除下降。一个极端的例子是一项研究发现高流量聚砜膜的透析器用福尔马琳和漂白粉再

KDOQI血液透析充分性临床实践指南2015更新版-开始血液透析的时机解读

！扛匿血速渔丝垒Ｑ！鱼笙璺旦笠！墨鲞筮璺趟￡ｂｉ旦。Ｉ璺！ＱＱ鱼￡坠！ｉｆ：△坚ｇ婪苎！，星Ｑ！鱼。ｙＱ！！！墨，丛Ｑ！璺
・３８５・
・指南解读・
ＫＤＯＱＩ血液透析充分性临床实践指南２０１５更新版一开始
血液透析的时机解读
赵新菊’ 左力
中图分类号：Ｒ３１８．１６
文献标识码：Ａ
ｄｏ］：ｌＯ．３９６９／ｊ．ｉｓｓｎ．１６７卜４０９１．２０１６．０８．Ｏｌ
１
早在１９９７年，美国肾脏病基金会（ｎａｔｉｏｎａｌ
ｋｉｄｎｅｙａｌｙｓｉｓ
ｆｏｕｎｄａｔｉｏｎ，ＮＫＦ）透析质量预后委员会（ｄｉ—
ｏｕｔｃｏｍｅｓ
ｑｕａｌｉｔｙ
ｉｎｉｔｉａｔｉｖｅ，ＤＯＱＩ）第一
２０１５更新指南关于开始血液透析的时机的阐述
背景２０１５更新指南回顾了２０００年到２０１４年３月间
Ｄｉａｌｙｓｉ
受肾衰竭及治疗选择的教育，治疗选择包括。肾移植、
腹膜透析（ＰｅｒｉｔｏｎｅａｌＳ，ＰＤ）、家庭或透析
对于达到ＣＫＤ４期［ｅＧＦＲ＜３０ｍｌ／（ｍｉｎ・１．７３舻）］
塔金来源：卫牛公益性｛ｊ：业科研专项：项目名称：优化尿毒症患者管理模式的研究；批号：２０１５０２０１０作者单ｆ讧：１０００４４北京，’北京大学人民医院肾内科
病因，在决定开始透析前一定要纠正这些可逆的因素。一般认为，尿毒症性心包炎或浆膜炎、尿毒症脑病危及患者生命，是ＥＳＲＤ患者开始透析治疗的绝对指征，甚至需要紧急透析。患者营养状况恶化、持续或难治性水负荷过重、严重的疲乏无力、轻度的认知
者更健康。大多数的ＩＤＥＡＬ受试者接受过全面的前
期肾脏病管理，只有６％的受试者有过充血性心力衰竭的病史，而相比之下，美国有三分之一的新进入透析的患者有充血性心力衰竭的病史。工作组根据ＩＤＥＡＬ研究和观察性研究的结果得出了几项关键的结论。首先，没有有力的证据能表明单独基于测定的肾功能开始透析可以改善临床预

维持性血液透析的抗凝剂_选择普通肝素还是低分子肝素_黄琪

临床研究结果证实 LMWH 可减少或趋于减少血液透荐选择低分子肝素作为血液透析的抗凝药物”[1]。
析患者的出血并发症。 [16，17] 并且，由于血液透析时该观点被 2010 年出版的《血液净化标准操作规程》
LWMH 为单剂量静脉注射，而血液透析过程中的凝血采用[22]。
活化发生在体外循环；血液透析过程中患者体内的
LMWH 是由 UFH 经化学或酶法解聚而成，平均分子质量约为 4200～6000。因其不具备凝血酶的结合位点，因此主要通过增强抗凝血酶Ⅲ灭活Ⅹa 因子活性发挥抗凝作用，对凝血酶及其他凝血因子影响较小。其分子质量越低，抗血栓作用越强，抗凝血作用越弱(见图 1)[4]。这样就使抗血栓作用与出血并发症分离，保持了 LMWH 的抗血栓作用而降低了
别；提示 LWMH 作为血液透析抗凝剂同样具有发生出
LMWH 的相对分子质量较小，未与抗凝血酶Ⅲ结血的风险[18]。我们 2007 年进行的中国北方城市 7 个
合的 LMWH 可被透析器清除而降低其抗凝效用。血液净化中心的 842 例维持性血液透析患者抗凝治
有研究结果显示在使用高通量血滤器时经动脉端疗的流行病学调查结果中，171 例(20.3%总结国内外研究文献，提出：“对于临
等不良反应；而 LMWH 上述作用较小，因其对血小板床上没有出血性疾病的发生和风险；没有显著的脂
的影响相对小，故可能会减少出血风险[13]。
代谢和骨代谢的异常；血浆抗凝血酶Ⅲ活性在 50%
肝素诱导的血小板减少症是肝素治疗中的严以上；血小板数量、血浆部分活化凝血酶原时间、凝
合理选择血液透析的抗凝治疗方案，是提高血液透析治疗质量的重要环节。 [1] 普通肝素(UFH)一直是我国维持性血液透析患者最常应用的抗凝剂；近年来低分子肝素(LMWH)的应用比例有所升高[2]。目前美国血液透析抗凝剂应用仍以 UFH 为主，而西欧国家则更倾向于选择 LMWH[3]。作为血液透析的抗凝剂，UFH 与 LMWH 在抗凝效果、不良反应以及卫生经济学上，谁更具有优势？本文对此进行综述，目的在于为血液透析抗凝剂的临床应用提供参考和建议。 1 肝素类药物的药理特点与差异

血透患者干体重达标标准及控制方法

血透患者干体重达标标准及控制方法判断干体重达标标准干体重不是固定不变的，它和正常人的体重一样，是一个变数，随着季节、年龄、饮食、排泄、天气等因素的变化而变化。

判断干体重是否达标，在《中国血液透析充分性临床实践指南》中给出的干体重标准为：（1）透析过程中无明显的低血压；（2）透析前血压得到有效控制；（3）临床无浮肿表现；（4）胸部X线无肺淤血征象；（5）心胸比值：男性＜50％，女性＜53％；（6）有条件者也可以应用生物电阻抗法进行评估。

干体重不达标的解决方法影响干体重不达标的因素有很多，如透析次数过少、透析时间不足、高盐饮食、水分摄入过多等。

因此想要干体重达标，则需要从透析、护理及饮食等多方面管理。

1、控制体重增长血液透析人群干体重达标，推荐透析间期体重增长率＜5%干体重。

即两次透析间隙体重增加幅度不超过干体重（基础体重）的5%。

2、加强透析选择合适的超滤率及血透时间。

二者决定了透析治疗中水的清除量，直接与透析间期体重增长相关。

而保持较低的超滤率对于避免血液透析过程中并发症的发生是有益的。

因此，《中国血液透析充分性临床实践指南》中的建议是：（1）强化超滤脱水，缓慢达到干体重值；（2）延长透析时间或增加透析次数，保持较低的超滤率；（3）采用低温透析（透析液温度＜35℃）；3、限盐限水水钠摄入过多，会导致两次透析间隙体重增加过多，饮食上来应限盐限水。

采用低盐饮食，每日食盐摄入量＜5g，并以3g以下为宜，避免咸菜、腌肉、酱料等各种高盐食物。

每日饮水量为500ml加前一天的尿量。

尽量避免含水量多的食物，如稀饭、汤汁、牛奶等；将一日可喝的水，用带有刻度的容器装好，并分配饮用，小口慢喝。

血液透析专项检查工作指南

血液透析专项检查工作指南血液透析是一种常见的治疗慢性肾脏疾病的方法。

在进行血液透析治疗前，医生会为患者进行一系列的检查，以确保患者适合接受透析治疗，并且指导透析治疗的方案。

本文将介绍血液透析专项检查的工作指南。

一、患者个人资料收集二、临床评估在进行血液透析专项检查时，医生会进行全面的临床评估，包括患者的体格检查、病史询问、疼痛评估、心理评估等。

通过临床评估，可以评估患者是否适合进行透析治疗，以及制定透析治疗方案。

三、血液检查血液检查是进行血液透析专项检查的重要环节。

常规的血液检查项目包括血常规、生化指标、肝肾功能、电解质测定等。

通过血液检查，可以了解患者的肾功能状况、身体代谢情况等，为透析治疗方案的制定提供参考依据。

四、尿液检查尿液检查也是进行血液透析专项检查的重要环节之一、通过尿液检查，可以了解患者的尿液量、蛋白质排泄量、尿液中的电解质含量等情况，为透析治疗方案的制定提供参考。

五、影像学检查影像学检查在进行血液透析专项检查中也是必不可少的环节。

常见的影像学检查项目包括胸部X光片、腹部B超、心脏超声等。

通过影像学检查，可以评估患者的心脏、肾脏、肺部等器官的情况，为透析治疗方案的制定提供参考。

六、心理评估在进行血液透析专项检查时，医生还会对患者进行心理评估。

透析治疗是一个长期的过程，患者需要做好心理准备并保持积极的心态。

通过心理评估，可以评估患者的心理状态、心理需求，并为透析治疗提供心理支持。

七、专家会诊在进行血液透析专项检查时，有需要的情况下，医生会组织专家会诊。

专家会诊可以为患者的透析治疗方案提供更多的专业意见和建议，确保治疗方案的科学性和合理性。

八、讨论治疗方案在完成上述检查和评估后，医生会根据患者的具体情况综合评估，讨论制定最合适的治疗方案。

治疗方案包括透析频率、透析时长、透析处方、透析设备选择等方面。

确保治疗方案的合理性和有效性。

总之，在进行血液透析专项检查时，严谨认真的态度是非常重要的。

更新版血液透析血管通路临床实践指南解读

更新版血液透析血管通路临床实践指南解读血液透析血管通路并发症不仅是血液透析患者的一个主要发病原因，而且是终末期肾病(ESRD)患者系统治疗的一项主要开支。

美国肾脏数据系统(USRDS)估计每个有风险的患者每年因透析管路发病导致的费用接近8000 美元。

保守的估计，这个数字相当每个血液透析患者总耗费的17%。

因透析管路相关的疾病住院占ESRD 患者住院总天数的25%，住院费用则达总住院费用的50%。

医疗机构在计划患者人均费用时，估计约有1/3 的ESRD 总费用被用于血液透析血管通路的建立和维护。

因此，对ESRD项目而言，血管通路的维护不仅是保持大量瘘管的血流量，而且是一个患者发病的主要原因，应倍受关注。

1997年，美国肾脏病基金会制定了透析质量控制的临床实践指南(DOQI)，其中血管通路的指南共六大部分38 条，内容包括：①血管通路建立前患者的评估；②监测和维护；③感染并发症的预防；④并发症的处理：干预的时机；⑤并发症处理：治疗并发症的最佳方法；⑥医护标准的质量。

2000年补充和更改为肾脏疾病质量控制的临床实践指南(NKF-KDOQI)，对其中的部分内容作了修改和补充，此后，血管通路指南的实践敦促了美国提出“Fistula First BreakthroughInitiative(FFBI)”计划，并提出到2009 年底，自体内瘘制作使用达到65%以上。

第一次修改的血管通路指南总体框架和条目无变化，在以后的许多临床实践研究和对瘘管失功的监测的实用性存在一定难度，2006年对指南重新进行较大的第二次修订，以便更加适用于临床。

2006 年更新的血管通路实践指南分为三大部分，即临床实践指南(CPG)、临床实践的建议(CPR)和通路研究建议。

第一部分是具有明确临床循证医学证据的实践指南，该部分包括8 项CPG 如下，①制作永久血液透析通路的患者准备，②血管通路的选择与制作，③自体内瘘和移植血管通路的穿刺以及导管和带皮下埋置盒(Port)导管的使用；④血管通路失功的检查、监测和诊断性试验；⑤自体内瘘并发症的处理；⑥移植内瘘并发症的处理；⑦留置导管和皮下埋置盒并发症的防治；⑧临床结果的目标。