血液净化疗法进展与钙磷代谢(2015年-12博士研究生课) (1).pptVIP

* * 短时高效血液净化技术具有对小分子、中分子物质较高的清除率，血液动力学比较稳定，患者容易耐受，纠正电解质和酸碱失衡满意等优点。如果每周治疗时间不少于9小时，长期效果不逊于CHD。 短时血液净化也存在一些缺点，由于短时间内排除大量溶质和水分，对部分患者，特别有心脏疾病者可导致血容量急剧减少，心搏出量下降，使心脏灌流和冠状动脉血流量减少，出现心绞痛、血压下降或心律不齐等。其次由于使用高通量血滤器，可以千万反超（backfiltration）或反弥散(backdifusion)，发生致热反应。 近年来许多作者报道，短时高效血液净化尽管治疗效率提高，但透析生存率与透析时间成正相关，甚至有作者指出，短时血液透析使死亡率增加要在5年后才能显示出来。在有些作者对短时血液净化已失去兴趣。笔者认为，HDF和用血滤器（如F6）作CHD（每周12小时）是比较可靠和实用的。 * * * * * It is important to keep in mind that serum calcium level represents only a tiny fraction of total body calcium and is tightly regulated within a relatively narrow range. Of the total body calcium store of approximately 1000 g, approximately 99% is stored in the skeleton. The remaining 1%, or 10 g, can move rapidly between the intracellular, interstitial, and plasma compartments as needed to maintain a steady calcium concentration in the plasma. Typically, of the 10 g of extraskeletal calcium, 90% exists in the intracellular compartment, 7.5% in the interstitial fluid, and just 2.5% in the plasma. Therefore, serum calcium is a poor indicator of total body calcium load. * 继发性甲旁亢①CRF时低血钙高血磷，刺激PT H分泌增高；②CRF时la羟化酶不足，使1，25（OH）D3生成减少。③骨对PTH的对抗，促使PTH过度分泌，PTH增高④PTH分解下降，同时CRF对PTH的排泄减少。⑤分泌调节的异常在中度和重度肾哀时1，25（OH）D3产生的大大减少，对PTH调节抑制作用大大减弱，故PTH分泌亢进。 血浆PTH持久异常增高，可引起周围神经和中枢神经系统的损害 纤维囊性骨炎：骨皮质减少，长度缩短 骨痛、骨折、骨畸形 2、加重钙、磷代谢异常： 转移性钙化：软组织、血管、脏器异位钙化、皮肤肢体坏死 3、严重皮肤搔痒 4、严重贫血 5、神经系统损害：周围神经炎、尿毒症脑病 6、心血管损害：心肌肥厚、非粥样硬化性心肌缺血、心肌梗塞 * In renal failure, calcitriol deficiency causes decreased intestinal calcium absorption and hypocalcemia. Hypocalcemia is a potent stimulus for parathyroid gland hyperplasia and consequently increases in circulating PTH. Chronically high serum PTH levels increases bone turnover rate (by osteoclast activation) and causes renal osteodystrophy ( a term used to describe the many different patterns of skeletal abnormalities that occur in the course of CKD). Theses include bone loss or osteopenia, bone pain and fracture. The hyperactivity of bone turnover causes release of calcium a