RU2001638C1 - Method for administering peritoneal dialysis - Google Patents

Description

the process and with it does not significantly impair the dialysis properties of the peritoneum.

Also take into account the time from the beginning of dialysis, the rate of ultrafiltration of water, the set dialysis time.

The osmolarity of the dialysis fluid is calculated using the following formula:

ODR A + (Smoch - Kt) + R y.

The formula was obtained as follows: the osmolarity of the solution (Odr) was selected, which would ensure a satisfactory diffusion rate and its direction of blood - peritoneum - dialysis solution. Moreover, it is taken into account that the osmolarity of the nominal plasma (0Pl) consists mainly of the salt component (sodium, chlorine, bicarbonate ions, etc.), the value of which reaches 290 mine / liter. However, dialysis is intended to purify uremic plasma, where urea at a rate of 8.3 mmol / L reaches 30-60 mmol / L, increasing Opl from 290 to 340 mosm / L. Considering that a significant increase in the concentration of the salt component will lead to the back diffusion of salts from the solution into the plasma and dyselectrolytemia, the requirements for the diffusion flow are realized mainly by an increase in the concentration of glucose in the solution. Moreover, it is known from clinical practice that the Odm osmolarity gradient - mosm / l satisfactorily provides the dialysis process and at the same time does not significantly impair the dialysis properties of the peritoneum.

When purifying a non-uremic plasma, for example, in order to remove exogenous da mosm / l + 50 mosm / l 340 mosm / l A. To clean the uremic plasma, it is necessary to add the osmolarity provided by the actual concentration of urea in the plasma, i.e. Odr A + Smok. But such a law will satisfy only the beginning of dialysis. Since the dialial process (according to its main purpose) leads to a gradual decrease in plasma urea, and hence 0Pl, after a time t the osmolarity gradient will be 50 mosm / l, which will provoke osmogenic peritoneal injury factor. Thus, in order to ensure the ODR -Qr ™ const, it is necessary to reduce Odr after a certain period of time t

by the value of Kt. Coefficient K (-: -) ha-

L BSEC

it determines the rate of decrease in osmolarity of urea in plasma, which depends on the rate of flow of the solution, the area of the peritoneum involved in dialysis (large subjects, children, adhesions in the abdominal cavity

etc.), the degree of damage to the dialysis properties of the peritoneum (peritonitis), etc. In standard situations (from practice) at mmol / l and a flow rate of 7 l / hour

, 2 mosm. Then the final expression

L BSEC

law (Smoch-Kt.) (mosm / l).

The most mobile component of Odr is glucose. Odr correction over time t reduces the glucose concentration by Kt. In our example, 2.2 mmol / L for every 1 hour of the dialysis process.

Taking into account that the cost of glucose significantly exceeds the cost of salts, and its greater diffusion into the blood carries diabetic and atherogenic negative effects, it is advantageous to strengthen the initial Odr to certain limits due to the salt component, especially since an increase in sodium concentration by 1 mmol / l, leads to an increase in Odr by 2 mosm / l due to its anions (chlorine and acetate). For example, at mmol / L, an initial increase in the concentration of salts by 10 mmol / L in sodium with a gradual decrease to the norm by Kt will lead to a glucose saving of 560 mmol / session, or about 100 g of dry matter.

The expression of R y in the presented formula characterizes the additional osmolarity of the solution, which must be applied in order to settle any excess water from the uremic patient's body. If there is no overhydration (),

as r.

A method for performing peritoneal dialysis is exemplified by several typical clinical situations. The dialysis time is selected so that the blood urea does not decrease by more than 20 mmol / l, since its sharp decrease is life-threatening.

PRI me R 1. Patient N. entered dialysis for the first time (peritoneum without osmogenic lesions). Blood urea upon admission was 38 mmol / L (its osmolarity was 38 mosm / L), blood sugar was 3.9 mmol / L (there are no signs of diabetes: any glucose concentrations may be used), sodium 148 mmol / L (hypernatremia: increased sodium dangerous in solution). No evidence of hyperhydration

(therefore R y 0) Implanted

abdominal catheter. Its clearance does not allow an average flow rate to exceed 6.5

l / hour (K 3

my

-). Duration

L dialysis hour is scheduled for 6 hours.

Taking into account hypernatremia and normal blood sugar, it is advisable to manipulate only the glucose component of the solution, i.e. A value will consist of 290 mmol / L salt component and 50 mosm / L glucose.

Initial (t-O) Odr

50 glitch

(38-3 glitch for

OH

378 mine / l

The initial Odr consisted of 310 mosm / l salt component and 70 mosm / l glucose.

Thus, during the course of the process, the salinity of the salt component decreases from 6 to 290 mosm / l within 6 hours. which, in terms of concentration, is equivalent to a decrease in sodium from 145 to 135 mmol / L. The glucose concentration throughout the entire session remains 70 mmol / L or 12.6 g / L of solution.

Example 3. Patient K. was admitted to dialysis with blood urea 32 mmol / L, sodium 143 mmol / L. Hyperhydration l.

It was decided to dialyze at a speed

Finite () Odr 50 + (38-3-6) 360mOSM / „

glitch

glucose

Thus, during the process, the glucose concentration in the solution gradually decreased over the course of 6 hours from 50 + 38 88 (mmol / L) 15.8 g / l to 50 + 20 70 (mmol / L) 12.6 g / l.

PRI me R 2. Patient P. entered dialysis for the first time. Blood urea 40 mmol / L, blood glucose 7.2 mmol / L, diabetes mellitus, sodium 135. A catheter was implanted to achieve maximum

lut / 4f ful

flow rates 7 l / h (, 2. c)

L MES

No evidence of overhydration (R 0)

The duration of dialysis is scheduled for 6 hours.

In order not to aggravate diabetes mellitus, it is advisable to partially conduct the initial strength of the resin in the solution at the expense of salts, based on the fact that an increase of 1 mmol / L leads to an increase in osmolarity by 2 mmol / L due to the cation (chlorine, acetate, lactate etc.) sodium salt. In this case, the expected decrease in plasma urea by 19.2 mmol / L completely and without negative consequences can be provided by the initial addition of salts up to 10 mmol / L in sodium. A urea residue of 20 mmol / L is blocked by glucose.

Initial () Audr50 + (40-3.2 -0) 380 glucose glucose

+

+

Ultimate () ODR 50 + (40-3.2 glucose glucose

6X

6l / h (K

twenty

25

thirty

35

40

45

fifty

55

my

-) for 8 hours

l hour

It is known from experience that ultrafiltration through the peritoneum of 1 liter of water per hour provides an osmolarity of 220 mosm / l; Rmos hour h, 2 ° c changes are carried out

l

glucose because sodium is already high. Then the starting t-Odr is 290 + 50 (32-2.5 0) +220 3 Ј 454.5 (mosm / l)

Of course t-8 0 290 + 50 (32-2.5. 8) + 220x 3 xg 434.5 (mine /).

The initial glucose concentration cc is 164.5 mmol / L or 29.6 g / L. Within 8 hours, glucose is reduced to 144.5 mmol / L or 26 g / L.

3095 sessions were carried out in a semi-permanent peritoneal mode in 121 patients. At the same time, the duration of preservation of the dialysis properties of the peritoneum was achieved - 1.5 years. With this method, dialysis was absolutely painless, no fibrin separation was observed. Loss of protein amounted to 0.149 g / l of the solution (from 3.5 to 13.2 g / session), which is about 20 times lower than in known technologies.

A decrease in glucose concentration in a solution can serve as an effect on reducing ODR. According to the Law Odr A- (Smoch-Kt), in our example the difference between the initial (15.8 g / l) and final (12.6 g / l) glucose concentrations will be 3.17 g / l.

In order to save expensive glucose, the initial ODR can be enhanced by the salt component to a level of not more than 145 mmol / L sodium (to avoid excessive back diffusion of sodium into the blood). Conventional solutions contain a sodium concentration of 135 mmol / L. Taking into account that along with the increment of sodium by 10 mmol / L, the concentration of chlorine anions and

atom (their ratio of masses in solution is 2: 1), then the total increase in Odr due to the salt component will be 20 mosm / l.

Claims (1)

The claims METHOD FOR PERITONAL DIALYSIS, characterized in that, in order to reduce osmogenous damage to the peritoneum and reduce protein loss of the body, the patient determines the initial concentration of urea in the blood, the amount of hyperhydration of the body, take into account the maximum osmolarity of the dialysis solution, which does not damage the peritoneum, time t from the beginning of dialysis, the ultrafiltration rate of water, the given dialysis time, then the osmolarity of the Analyzing solution is calculated by the formula / One p A + Smoch - K (t) + RY. 0 5 0 (56) I.I. Derbin et al. Peritoneal dialysis. M .: Medicine, 1977. 168. 172. where O dr - osmolarity of the dialysate, mosm / l; A - maximum osmolarity of the dialysis solution, which does not damage the peritoneum, mosm / l; Smoch - osmolarity of pre-dialysis blood urea, mosm / l; K is the coefficient of decrease in osmolarity of urea in the blood per unit time at a given solution flow rate. mosm / (l / h); t is the time from the beginning of dialysis, h; R - coefficient of ultrafiltration rate of water, my h / l; V is the volume of hyperhydration, l; T is the estimated dialysis time, h, and the dialysis is carried out with a variable calculated osmolarity.