Download - Curs Hemodializa Optional Studenti[1]
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Ce este hemodializa?
Clinica de Nefrologie Iasi
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Ce este dializa?
Insuficienta renala cronica in stadiul uremic
• Care sunt posibilitatile de tratament?– Tratament conservator: exitus in zile-
saptamini-luni !
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Care sunt posibilitatile de tratament?
• Hemodializa cronica
• Dializa peritoneala continua ambulatorie
• - tratamentul modern permite o supravietuire indelungata: ani - zeci de ani, pacientul fiind adeseori recuperat in cea mai mare parte fizic, psihic si social
• - totusi, rata rel. mare a complicatiilor acute si cronice
• - totusi, pacientii, mentin o stare de uremie cronica
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Care sunt posibilitatile de tratament?
• Transplantul renal - singurul tratament radical al insuficientei renale cronice avansate
- perfecta recuperare fizica, psihica si sociala
- morbiditate/mortalitate net inferioare dializei
Totusi:
- riscurile imunosupresiei
- nici o grefa renala nu este “pentru totdeauna”
- intoarcere la hemodializa
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Ce este dializa?
• Dializa = procesul de transfer a unor substante printr-o membrana semipermeabila
• membrana semipermeabila:– membrana sintetica/semisintetica (dializor) -
hemodializa– membrana peritoneala - dializa peritoneala
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Principiile dializei - DIFUZIUNEA si OSMOZA
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Principiile hemodializei - difuziunea
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Principiile hemodializei - ultrafiltrarea
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Dializorul
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Schema circuitului de hemodializa
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Cateterul de dializa
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Fistula artero-venoasa
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Proteza vasculara
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Imagine idilica? Da si Nu...
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Indepartarea deseurilor metabolice
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INDICATIILE INITIERII DIALIZEI
• BCR std. 5 (STD. UREMIC)
• INSUFICIENTA RENALA CRONICA
ACUTIZATA (temporar)
• INSUFICIENTA RENALA ACUTA SEVERA
(temporar)
• unele intoxicatii
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INDICATIILE INITIERII DIALIZEI
• Retenţie azotată majoră (uree > (180-200 mg/dl, creatinină > 8 mg/dl) sau clearance de creatinină < 10 (15) ml/min/1,73 m2
(Indicaţie clasa I)
• Hiperhidratare majoră, cu tendinţă la IVS şi eventual HTA severă – indicaţie de urgenţă
(Indicaţie clasa I)
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INDICATIILE INITIERII DIALIZEI
• Acidoză metabolică severă (pH sangvin < 7,3, RA < 15 mEq/l) - indicaţie de urgenţă
(Indicaţie clasa I)
• Hiperkaliemie cu risc vital (K+ 6,5 mEq/l) - indicaţie de urgenţă
• Alte tulburări hidro-electrolitice şi acido-bazice necorectabile conservator (de ex. datorită riscului de supraîncărcare volemică)
Na+ > 160 mEq/l Na+ < 120 mEq/l RA > 40 mEq/l
• Hipocalcemie, hiperfosfatemie
(Indicaţie clasa I)
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INDICATIILE INITIERII DIALIZEI
• Pericardită uremică – indicaţie de urgenţă
(Indicaţie clasa I)
• Intoleranţă digestivă majoră datorată uremiei
(Indicaţie clasa IIa)
• Encefalopatie uremică edem cerebral – indicaţie de urgenţă hiperexcitabilitate neuromusculară, convulsii ataxie, somnolenţă comă uremică
(Indicaţie clasa I)
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INDICATIILE INITIERII DIALIZEI
• Tulburări de coagulare secundare uremiei (fără răspuns terapeutic la tratamentul conservator)
• (Indicaţie clasa IIa)
• Toxine dializabile (ex: paracetamol, bilirubină)
• (Indicaţie clasa IIa)
• Epurarea mediatorilor inflamaţiei (IL6, IL8, TNF-)
• (Indicaţie clasa IIa)
• hipotermia
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INDICATIILE INITIERII DIALIZEI
• Indicaţii rare:
unele intoxicaţii medicamentoase (alternativă la hemoperfuzie)
hipercalcemia severahiperuricemia severa
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Alegerea modalitatii de substitutie renala
• Hemodializa cronica sau dializa
peritoneala continua ambulatorie ?• preferintele pacientului
• preferintele medicului
• indicatii si contraindicatii strict medicale
• indicatii si contraindicatii psiho-sociale
• posibilitati tehnico-economice
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HD - PENTRU
• metoda mult mai eficienta /unitatea de timp• dializa buna chiar si la pacientii anurici• efectuarea tratamentului nu depinde atit de
mult de complianta pacientului• poate fi aplicata fara probleme la pacienti cu
contraindicatii la dializa peritoneala (mari obezi, anurici, operatii abdominale multiple, boli intestinale multiple, incapacitati)
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HD -CONTRA
• face pacientul “dependent” de centrul de dializa
• problematica la pacientul instabil hemodinamic, cu aritmii, cu tendinta la singerare
• necesita un access vascular bun
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DPCA sau HD?
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Complicatii evitabile sau nu...
Frecventa si severitatea complicatiilor functie de:
• patologia asociata preexistenta
• initierea tirzie a dializei
• complianta pacientului
• posibilitati tehnice si medicale
– calitatea dializei/disponibilitatea medicatiei
• competenta personalului medical
• factorul TIMP
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Complicatii acute
• hiperhidratarea - hipertensiunea - insuficienta cardiaca
diureza (CAPD>HD); complianta la restrictia hidro-salina
• hipotensiunea arteriala intradialiticasporul interdialitic in greutate, neuropatia vegetativa autonoma
• tulburari hidroelectrolitice - hiperkaliemia nr. 1 tulburari acute de ritm si conducere
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Complicatii acute intradialitice
• crampe musculare
• greata, voma
• cefalee
• sindromul “picioarelor nelinistite”
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Complicatii acute intradialitice
• reactii alergice
• sindromul de dezechilibru (1. dializa)
• hemoliza acuta
• embolism gazos
• trombozarea sistemului arterial
• fisurarea sistemului extracorporeal
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Alte complicatii
• pericardita asociata dializei risc de
tamponada cardiaca
• septicemia asociata cateterului
• predispozitia crescuta la infectii
• tromboza/stenoza/infectia fistulei
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CALITATEA DIALIZEI
Complicatia cronica nr. 1 in dializa:
DIALIZA INADECVATA
“DOZA DE DIALIZA”
Kt/V
URR
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“Doza” de dializa
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Factori de risc cardiovascular la pacientul renal
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Complicatii cronice
• “cardiomiopatia uremica”hipertrofie/dilatatie ventriculara stinga
disfunctie sistolica/diastolica
– hipertensiune/hipervolemie– “mediul uremic”– anemia renala– hiperparatiroidismul secundar
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Factori de risc cardiovasculari: ischemică coronariană vs cardiomiopatie uremică
Tradiţionali
HTAhiperlipidemiediabet zaharathipertrofia VSfumatsedentarism
Specifici uremieidislipidemie? lipoproteina (a)factori trombogenihiperhomocisteinemia? stres-ului oxidativhipoalbuminemiestare inflamatorieanomaliile ionilordivalenţi
Boală ischemică coronariană
Factori de risc
Suprasolicitare de volum
retenţie hidrosalinăfistulă arterio-venoasăanemie renală
Suprasolicitarede presiune
HTAStenoză aorticăArterioscleroza
Altele
hipoalbuminemieboală coronarianăHPT
Cardiomiopatie uremică
Factori de risc
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Complicatii cronice ale dializei
• Hiperparatiroidism secundar - tertiar
----osteodistrofie renala
----calcificari in tesuturile moi
----calcificari vasculare
• Stare microinflamatorie cronica
amiloidoza asociata dializei
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Complicatii cronice ale dializei
Neuropatia uremica
• - senzoriala
• - motorie
• - vegetativa
– hipotensiune arteriala ortostatica si
intradialitica, tulburari de mers, parestezii,
sindromul picioarelor nelinistite, impotenta
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Complicatii cronice ale dializei
• Infertilitate
• Probleme psihiatrice
• Patologia fistulei a-v
– stenoze, tromboze, infectii, anevrisme
Infectii cu virusurile hepatitice B si C
(transfuzii!)
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Copyright © 2007 by the American Roentgen Ray Society
Zhang, J. et al. Am. J. Roentgenol. 2006;186:1436-1442
Stenoza FAV
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Today, we’re making a scrumptious,sodium free, low potassium, low
phosphorus,low carbohydrate, low protein and lipid-
freechicken casserole
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Complications
• Dezvoltare anevrismala
• Stenoza
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Complications
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Pneumothorax
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IRC- magnitudinea problemei
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Valorile creatininei serice pot fi inselatoare...
Creatinina serica! 1,2 mg/dl
Clearance-ul creatinic! 35 ml/min versus 100 ml/min