337.2 🩺 國考版

337.2.1 高頻考點

337.2.1.1 Indications for Dialysis

  • Uremic symptoms (encephalopathy, pericarditis, bleeding)
  • Refractory hyperkalemia, acidosis, volume
  • eGFR < 10 or symptomatic
  • IDEAL 2010: defer until symptomatic

337.2.1.2 HD Vascular Access (KDOQI 2019)

  • AV fistula (gold standard): radiocephalic > brachiocephalic > brachiobasilic
  • AV graft (synthetic) if fistula not feasible
  • Tunneled CVC last resort
  • Vein preservation (avoid subclavian, PICC)

337.2.1.3 HD Frequency Options

  • In-center: 3x/week × 4h (standard)
  • Daily HD: 5-6x/week × 2-3h (FHN trial)
  • Nocturnal home HD: 5-6 nights × 6-8h
  • Home HD: independence

337.2.1.4 Intradialytic Complications

  • Hypotension (most common)
  • Cramps
  • Disequilibrium (first sessions)
  • Nausea, headache
  • Pruritus
  • Cardiac (arrhythmia, MI)

337.2.1.5 PD Modalities

  • CAPD: manual exchanges, 4-5/day
  • APD: cycler at night (most common)
  • Solutions: glucose-based, icodextrin (long dwells), bicarbonate-based, amino acid-based

337.2.1.6 PD Peritonitis (Cardinal Complication)

  • Cloudy effluent + abdominal pain

  • 100 WBC/ÎŒL with > 50% neutrophils

  • Pathogens: S. epidermidis (most), S. aureus, GNR, fungi
  • Treatment: intraperitoneal antibiotics (gentamicin + cefazolin or vancomycin)
  • Catheter removal if fungal, refractory, severe

337.2.1.7 PD vs HD Outcomes

  • Similar survival
  • PD better first 1-2 years
  • PD: less hemodynamic stress, preserved residual function
  • HD: long-term sometimes better
  • Choice individualized

337.2.1.8 Adequacy Markers

  • HD: Kt/V ≥ 1.2 per session
  • HD: URR > 65%
  • PD: weekly Kt/V ≥ 1.7

337.2.1.9 Mortality

  • 20-25%/year in US dialysis
  • CV leading cause
  • Infection 2nd
  • Renal transplant > dialysis for survival

337.2.1.10 Key Trials

  • IDEAL (2010): defer dialysis until symptomatic
  • FHN (2010): daily HD improved outcomes
  • KARNI Catheter-Free Dialysis Trial: emerging

337.2.1.11 Difelikefalin

  • Kappa-opioid receptor agonist
  • For HD-associated pruritus
  • FDA approved 2021
  • KALM-1, KALM-2 trials

337.2.2 易混淆比范

Feature HD PD
Modality Blood through dialyzer Peritoneum as membrane
Frequency 3x/wk standard Continuous (CAPD) or nocturnal (APD)
Setting In-center or home Home
Vascular access Fistula, graft, CVC Tenckhoff catheter
Solutes Diffusion-dominant Diffusion + osmotic UF
Main complication Hypotension; vascular access Peritonitis
Residual function Variable Better preserved early

337.2.3 Special Topics

337.2.3.1 Hemodiafiltration (HDF)

  • Combines diffusion + convection
  • Better middle molecule removal
  • More common in Europe + Asia
  • CONVINCE trial 2023 — improvement vs HD

337.2.3.2 Frequent / Daily HD Benefits

  • Better BP control
  • Reduced LVH
  • Better phosphate clearance
  • Improved survival (some studies)

337.2.3.3 Renal Transplant vs Dialysis

  • Better survival + QoL
  • Increasing preemptive transplants
  • Wait list often years