中国血液透析临床实践指南2015
血液透析充分性临床实践指南[1]
![血液透析充分性临床实践指南[1]](https://img.taocdn.com/s3/m/d2d0cc43a5e9856a57126051.png)
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)
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。
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万方数据
主堡医堂苤盍！！！！生！旦！旦筮堕鲞筮丝翅盟！！！丛型』堡！ｉ塑，！！Ｐ！！里！！！！，！！！ｉ：！！！：堕：盟！：丝
的重要性。推荐血液采样方法：透析前血样从血管
通路的动脉端采集，透析后血样采集首先停止超滤， 降低血流为５０ ｍｌ／ｍｉｎ，等待１５ ｓ后从动脉端采血 作为透析后血样Ｍ。５ Ｊ。采样时避免样本受到盐水、抗 凝剂等的稀释。
透析充分性Ｈ Ｊ，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
（４—３．５Ｒ）×ＡＢＷ／ＢＷ，Ｒ为透后尿素氮／透前尿素
氮，ｔ为治疗时间，ＡＢＷ为超滤量，ＢＷ为透后体重。
然每次血液透析充分性的好坏能够影响患者生活质 量及长期生存率，部分客观数据或指标可以反映长
期透析质量水平，并预测患者未来不良预后；但既往
为了更加精确地评估尿素清除率，考虑到血液 透析治疗后中心池尿素水平的反跳，也可以采用平
析５～５．５ ｈ）。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
度＜３５℃）；（７）合理用药，减少大量药物应用导致
的患者水摄人量增加。 （二）透析间期体重的控制标准
１３２－ＭＧ清除率：１３２－ＭＧ下降率Ｉ＞３０％，理想值Ｉ＞５０％ 或膜清除率＞２０
ｍｌ／ｍｉｎ。
目前增加中分子毒素清除的手段通常是采用高 通量透析或血液透析滤过，相比普通透析，高通量透 析要求更好的膜材料及更优质的透析用水。为了实 现更强的对流清除，高通量透析模式要求使用超纯
对于血液透析充分性不达标的患者，积极分析
并寻找原因至关重要，常见原因与解决方法如下： １．血清肌酐和尿素氮水平：当血液透析患者透
析前血清肌酐和尿素氮均明显增高，但每次透析后 两者下降幅度＞７０％，结合其他指标提示患者营养 良好；如果单次透析后尿素与肌酐指标下降幅度＜ ５０％时，则提示患者透析不充分；如果透析前血肌酐 和尿素氮指标均较低，则提示患者可能存在营养不 良，多与透析不充分相关，此时患者多表现为体重明
透析医疗质量控制工作，结果显示我国血液透析的 整体治疗水平有待提高，特别是血液透析充分性的
检测及其达标率亟待提升。因此，以循证医学结果
除率（ｓｐＫｔ／Ｖ）≥１．２；尿素下降率（ＵＲＲ）ｔ＞６５％；尿素 清除率监测频率：推荐每３个月１次，建议每月１次。 （一）血液透析充分性的指标及其计算与血液
样本采集
衡后Ｋｔ／Ｖ（ｅＫｔ／Ｖ）方法进行评估，但最常用仍为
ｓｐＫｔ／Ｖ。
血液透析充分性评价更多关注单次６０／ｃｍａ．ｊ．ｉｓｓｎ．０３７６。２４９１．２ｕ１５．３４．００４
３．ＵＲＲ的计算方法：较Ｋｔ／Ｖ计算简单易行，通
过测量透前、透后尿素氮浓度即可得出：ＵＲＲ＝ （Ｃ。一Ｃ）／Ｃ。，Ｃ。为透前尿素氮，Ｃ为透后尿素氮。 ４．血液样本的采集：血液采样部位及采样时间 可影响Ｋｔ／Ｖ和ＵＲＲ的测定结果，导致血液透析充 分性评估出现误差。因此，强调规范采集血液样本
血监测，但实际上部分地区半年左右才监测１次。
因此，本指南推荐每３个月１次，建议有条件的血液 透析中心每月１次。 （二）血液透析充分性标准的说明 １．适用的血液透析方案：美国肾脏病患者生存 质量指南（Ｋ／ＤＯＱＩ）指出，每周２次血液透析不适
用于残肾肾小球滤过率（ＧＦＲ）＜２
１．７３ ｍｌ・ｍｉｎ～・
白质限制过严，有可能诱发蛋白营养不良，应进一步 计算患者的蛋白摄人量；如果透析前患者血清肌酐 水平较低，而尿素氮水平明显升高，则有可能为血液 透析不充分，此时患者多可能是消瘦者，肌肉含量不
主堡医堂苤查！Ｑ！！生！旦！旦筮！ｉ鲞筮翌塑盟！！！丛塑』ｇ丛塑，！！Ｐ！！坐！笪！：！Ｑ！！，Ｙ！！：堕，盟！：丝
．标准与规范．
中国血液透析充分性临床实践指南
中国医师协会肾脏病医师分会血液透析充分性协作组
我国尿毒症防治形势严峻，据全国血液净化病 血清肌酐、尿素氮水平及超滤脱水，而对影响患者生 活质量与长期生存率的主要并发症控制关注不足。 为此，本指南加入了血液透析患者的医疗质量指标
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。
况。随着血液透析技术的发展和我国医疗保障制度 的完善，本指南也将不断进行完善与更新，以更好地 为血液透析医护人员提供指导，更好地服务血液透 析患者。
净化标准操作规程（２０１０版）》以来，国家肾病学专
业医疗质量管理与控制中心开展了全国范围的血液
一、单次血液透析充分性评价指标与标准
推荐单次血液透析的尿素清除率：单室尿素清
１．７３ ｍｌ・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
近年，维持性血液透析患者中分子毒素对长期
生存的影响越来越受到关注，高通量透析和血液透 析滤过在欧洲已是非常普遍的治疗模式。虽然，大 规模的长期预后临床研究的证据显示，高通量透析 仅能改善部分特定患者的临床预后旧Ｊ，但其对中分
子毒素的清除作用仍有助于提高患者治疗效果与生
更佳；单次透析ＵＲＲ≥６５％，条件允许时ＵＲＲ≥
量＜５ ｇ，并以３ ｇ以下为宜；（３）对于透析前血钠＜
１３５
患者体内中分子毒素水平以及评价透析模式的中分
子溶质清除能力的标志物，大量文献提示血Ｂ：．ＭＧ
水平与患者淀粉样变、腕管综合征等并发症密切相 关¨０Ｉ。据全国血液净化病例信息登记系统的数据， 我国高通量透析逐年增加，２０１４年底２７．９％的患者 采用了高通量透析。因此，考虑到我国现有技术与
透析液，以降低细菌和内毒素引起的慢性炎症状态 风险；膜材料方面除要求较高通量以外，也要求采用
血液透析的重要功能除了毒素清除就是体液调 节，通过超滤去除透析问期增长的水分。超滤可导 致血管内容量下降以及血压波动，如果透析间期患 者体内容量增加过多，血管内容量增加必将导致血
压升高以及心脏负荷增加，增加心血管疾病以及死 亡的风险。因此，透析间期患者能够把体重增长控 制在一个合理的范围内，可最大限度减少患者体内
基金项目：国家十二五科技支撑计划项目（２０１１ＢＡＩＩＯＢ００）；国 家卫生和计划生育委员会公益性行业科研专项（２０１５ＳＱ００１２４）：北 京市科学技术委员会科技计划重大项目（Ｄ１３ｌ １００００４７１３００１） 通信作者：陈香美，１００８５３北京，解放军总医院慢性肾病国家Ｉ临 床医学研究中心暨肾脏疾病国家重点实验室，Ｅｍａｉｌ：ｘｍｃｈｅｎ３０１＠
７０％更佳。
（三）单次血液透析充分性不达标的建议与
策略
万方数据
史堡医堂盘查！！！！生！旦！旦箍堕鲞筮翌翅塑！！！丛塑』鱼也！：！！Ｐ！！里！竺！：！Ｑ！！：！！！：箜，盟！：翌
活质量‘９ ｏ。目前临床上普遍应用１３２－ＭＧ作为反映
３．干体重不达标的治疗策略：（１）强化超滤脱 水，缓慢达到干体重值；（２）低盐饮食，每Ｅｔ钠摄入
足所致。
ｍ。２的患者。４ Ｊ。增加透析次数有助于改善睡
２．患者因素：由于心功能等因素（如严重心肌 病变、心律失常、严重低血压等）患者不能耐受透析
治疗，不能有效达到上述每周３次、每次４～４．５
ｈ
眠、睡眠中缺氧以及营养状态等Ｈ Ｊ。国内回顾性研
究证明，每周２次血液透析需要在延长单次透析时
间，并且控制周总超滤量的前提下，方可收到较好的 治疗效果∞Ｊ。故本指南推荐血液透析方案：每周３ 次，每次４～４．５ ｈ（残肾ＧＦＲ＞２
显低下，肌肉含量较少；如果患者透析前血清肌酐水 平明显升高，而尿素氮水平较低，此时常提示患者蛋
５．尿素清除率的监测频率：不同国家和地区对 于监测尿素清除率的周期要求不同，如美国、欧洲均 要求每月进行１次采血监测血液透析充分性，加拿 大则采用６—８周的监测间隔。我国现行《血液净 化标准操作规程（２０１０版）》要求为每３个月１次采
合成膜；在关键参数上满足治疗要求［超纯透析液： 内毒素＜３０ ＥＵ／Ｌ，细菌＜１００ ＣＦＵ／Ｌ；高通量透析 膜：超滤系数Ｋｕｆ＞２０ ｍｌ・ｈ一・ｍｍＨｇ‘１（１
０．１３３ ｍｍＨｇ＝
容量波动以及相应的心血管系统的冲击。Ｋ／ＤＯＱＩ 中建议患者工作Ｅｔ体重增长不要超过１ ｋｇ，周末不
要超过１．５～２
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１ ９００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。３ Ｊ。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
速增长的局面，必将带来巨大经济负担。在此背景 下，如何提高血液透析患者的生活质量与生存率、获 得卫生经济学最佳化，已经成为政府与广大血液净 化学者共同关心的重要内容。自２０１０年颁布《血液