HemodialysisReview Article: Medical ProgressNEJM, Nov.4, 2010 H23.1 80 20 1 Dialyser NEJM 1 6.6 15.6 21.7 1 21.7 AV fistula 3 1 4 1 1980 Kt/V urea Vml t 1.4 8 12 DFC: Dialysis Facility Compare
DFC http://www.cms.gov/dialysisfacilitycompare/ Dialysis Facility Compare 3 10.0 12.0g/dl UPR65% UPR BUN BUN/ BUN 11 12 NEJM, March10,2005 Anemia of Chronic Disease TFC:080703010 10 Hb 8 10 11 odds Ht 33 36 Hb Hb 11 12 erythropoietin 25 Brookline Dialysis Massachusetts General Hospital 10 3 Massachusetts General Hospital 17 Brookline Dialysis 3 12 16 Massachusetts General Hospital 0 % Brookline Dialysis 4 UPR65
96 Massachusetts General Hospital 100% Brookline Dialysis 99 2006 2009 441 3995 562 Massachusetts General Hospital Brookline Dialysis NEJM 1972 75 2008 MIPPA: Medicare improvements for Patients and Providers Act bundled payment 2011 erythropoietin cherry-picking : NEJM 16
NEJM 1. 2. 4 3 3. 200ml 400ml/ 4. 2 5. 10ml/kg/h 6. Kt/V urea 1.4 7. 5 8. Hb 10 12 9. 10. Kt/V urea 11. 12. 13. 3 14. http://www.cms.gov/dialysisfacilitycompare/. 15. 1 6.6 15.6 21.7 16. Hemodialysis Review Article: Medical Progress NEJM, Nov.4, 2010 H23.1 Jonathan Himmelfarb, M.D. T.Alp Ikizler, M.D. Vanderbilt 50 Belding Scribner blood-access Scribner AV fistula 100
dialysatebicarbonate compartmentalized 2microglobulin p-cresol ultrafiltration 10ml/kg/h sorbent Dialyzer: hollow-fiber dialyzer High-flux membrane low-flux membrane 4 3 QOL 200ml 400ml/ blood-access dialysate 2
Ultrafiltration 10ml/kg/h Nasodium 130 145mmol/L Na Kpotassium 2 3mmol/L K K K 30 Ca 1.25 1.75mmol/L Ca Ca Mg 0.5mmol/LMg Mg flux Alkaline buffers 30 40mmol/L. Chloride alkaline buffer Glucose 100 200mg/dl D
single-pool Kt/Vurea>1.4 5 ultrapure 10 12g/dl AV fistula() Ca 8.4 9.5mg/dlP 3.5 5.5mg/dl Intact PTH 2 D phosphate binder PTH 4.0g /dl PKNa LDL 100mg/dl Quantifying the dose and adequacy of dialysis Kt/V urea K 1 mlt V urea Kt/Vurea Vml t 500 30000 high-flux
2microglobulin high-flux 1980 1 8 12 40 3 3 CaP QOL 1972 ESRD: End-Stage Renal Disease 1972
75 2008 MIPPA: Medicare improvements for Patients and Providers Act (ESRD) bundled payment 2011 cherry-picking : 2003 CMSCenters for Medicare and Medicaid Services arteriovenous fistulas Fistula First fistula CMS DFC (Dialysis Facility Compare) http://www.cms.gov/dialysisfacilitycompare/. Dialysis Facility Compare 20 2 20 13 2 / 1 / 1996 2002 1 6.6 15.6 21.7
AV fistule() tunneled catheter 1970 NCDSthe National Cooperative Dialysis Study single-pool Kt/V urea V ml t 1.2 1990 higher permeability characteristics Kt/V urea 1.4 Homocysteine erythropoietin p-cresol sulfateindoxyl sulfate phosphate
NEJM 1. 2. 4 3 3. 200ml 400ml/ 4. 2 5. 10ml/kg/h 6. Kt/V urea 1.4 7. 5 8. Hb 10 12 9. 10. Kt/V urea 11. 12. 13. 3 14. http://www.cms.gov/dialysisfacilitycompare/. 15. 1 6.6 15.6 21.7 16.