千呼萬喚始出來,KDOQI針對血液透析的建議,過了好幾年終於有更新版了,趕緊來瞧瞧有什麼內容吧!
KDOQI 足量血液透析治療指引 2015 (KDOQI HD adequacy guideline: 2015 update):
一、開始透析的時機:
1.1 當慢性腎臟病患者的腎功能剩下 30分以下時 (GFR <30 ml/min/1.73m2),應該要提供患者充分的資訊,以因應將來腎臟衰竭時,所要面對的種種問題,如:腎臟替代療法的種類(腎臟移植、血液透析、腹膜透析、或安寧支持療法)、各類治療的優點與缺點。此外,照顧者與家人也應該參予學習這些資訊,以利於患者與家屬在做各種選擇時,能充分按照自己之偏好或狀況,來做決定。
1.2 何時開始洗腎(透析),最主要的三個決定因素,在於是否出現了尿毒症狀、是否有營養不良、以及是否有能力維持各項生理機能(如電解質的平衡、或體液過多)這三個因素。抽血數值中的毒素高低,並不是開始洗腎於否的決定性因素。
二、針對更頻繁或更長時間的透析之建議:
在機構院所之頻繁血液透析 (註A)
2.1 在機構院所執行傳統一週三次之血液透析之外,更頻繁次數但時間較短的血液透析(註B),可作為另一種血液透析模式。
2.2 考慮這種透析模式時,應該和患者解釋告知,這樣的方式與傳統方式相比,血管出問題的比例較高,且透析中低血壓的情況也較多。
家中之長時間血液透析
2.3 若患者較喜歡在家透析的模式,可被建議的方式是考慮長時間(利用夜間)透析,每週3-6次、每次6-8小時。
2.4 考慮這種透析模式時,應該和患者解釋告知,這樣的方式與傳統方式相比,血管出問題的比例較高,照顧者的壓力與負擔增加,且會加速殘餘腎功能的下降。
三、透析清除率的測量
3.1 一週三次透析的患者單次透析清除率,Kt/V (single pool,spKt/V) 建議達到 1.4 以上,而最少應該要 1.2以上。
3.2 若患者仍有殘餘腎功能(Kru),透析的量也許可以減少,但是 Kru要定期測量,以免發生透析不足。
3.3 若患者的透析模式並不是一週三次,則建議目標為每週 standard Kt/V 2.3 以上,至少要 2.1,計算時要記得算入殘餘腎功能。
四、體液量與血壓的控制:透析時間與脫水速度
4.1 若患者的殘餘腎功能非常低 (< 2 cc/min),接受一週三次血液透析時,每次最少最少要3小時以上。
4.1.1 若患者的每次體重增加很多、脫水速度很快、血壓控制很差、很難脫水到達目標體重、或電解質異常的話,應該要增加透析時間或者每週透析次數來改善。
4.2 建議患者要減少鹽分(鈉鹽)的攝取、以及利用透析將鈉與水適當去除,以控制血壓、避免體液過多、改善心臟肥大問題。
4.2.1 保持透析過程穩定、且盡量減少透析不適的大前提下,控制脫水速度,以達到體液正常、血壓正常、以及足夠的清除效率這些目標。
五、新人工腎臟種類選擇
5.1 高通透性(high-flux)與低通透性(low-flux)之生物相容性(biocompatible)人工腎臟,都是建議可以使用的。
註A:就台灣建保規範下實際狀況,一週最多是三次的給付,要增加次數,只能以自費處理。
註B:這裡指的短時間,定義是 <3小時,這裡指的頻繁,指的是一週5-7次。
先把大綱翻譯出來,接下來,會再詳細的翻譯裡頭的討論內容。
其實,只看大綱看不大懂是正常的,看討論內容才能真正看到透析的進展趨勢。
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National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am. J. Kidney Dis. 66, 884–930 (2015).