337.4 📋 章末速蚘 Summary

337.4.1 🔑 䞀句話瞜結

Dialysis is RRT for ESKD (eGFR < 15 + symptoms) — alongside renal transplantindicationsuremic symptoms (encephalopathy, pericarditis, bleeding) + refractory hyperkalemia / acidosis / volumeIDEAL 2010 says defer until symptomaticHD modality3x/week × 4h in-center standard, daily/nocturnal home options (FHN — improved CV)vascular access KDOQI 2019: AV fistula gold standard > AV graft > tunneled CVC last resort; vein preservation; PD modalitiesCAPD (manual 4-5 exchanges/day) + APD (nocturnal cycler, most common); solutions glucose-based, icodextrin for long dwells, bicarbonate-based, amino acid-based; HD complications: intradialytic hypotension (most common) + cramps + disequilibrium + headache + vascular access (thrombosis, infection, stenosis); PD complications: peritonitis (cardinal — cloudy effluent + abd pain, > 100 WBC + > 50% neutrophils) — intraperitoneal antibiotics (gentamicin + cefazolin or vancomycin); exit site/tunnel infection; mechanical (catheter dysfunction, hernia, leak, hydrothorax); metabolic (hyperglycemia, lipid); membrane failure (long-term); PD vs HD outcomes similar; PD better first 1-2 years + residual function + cardiac stability; adequacy: HD Kt/V ≥ 1.2 / URR > 65%; PD weekly Kt/V ≥ 1.7; mortality 20-25%/year in US dialysis; CV leading cause; emerging 2024: CONVINCE 2023 HDF > HD mortality, difelikefalin (FDA 2021) for HD pruritus, wearable + bioartificial kidney research。

337.4.2 💊 治療粟芁

  • HD setupblood pump 200-500 mL/min, dialysate 500-800 mL/min, 4-hr session, 3x/week standard
  • HD accessAV fistula preferred (radiocephalic > brachiocephalic > brachiobasilic; mature 6-12 weeks) > AV graft (synthetic, 2-4 weeks) > tunneled CVC (last resort, highest infection)
  • PD CAPDmanual 4-5 exchanges per day, 1.5-4.25% glucose dialysate
  • PD APDnocturnal cycler, 8-10 hours
  • PD peritonitis treatmentintraperitoneal gentamicin + cefazolin (empiric) → tailored per culture; catheter removal if fungal/refractory/severe
  • intradialytic hypotensioncool dialysate (35°C) + reduce UF rate + midodrine prophylactic + sodium modeling
  • HD pruritusdifelikefalin (kappa-opioid receptor agonist, FDA 2021) + antihistamines + gabapentin
  • vaccinationsflu, pneumococcal (PCV20 + PPSV23), COVID, hepatitis B (high-dose), RSV ≥ 60; avoid live vaccines

337.4.3 🎯 盧醫垫的考前提醒

  1. IDEAL trial (2010)early (eGFR 10-14) vs late (5-7) RRT initiation → no mortality benefit, defer until symptomatic — practice-changing
  2. KDOQI 2019 vascular access“fistula first” + “catheter last” + vein preservation (avoid subclavian, PICC, repeated needle sticks in non-dominant arm)
  3. AV fistula 順序radiocephalic (wrist) > brachiocephalic > brachiobasilicmaturation 6-12 weeksplan ≥ 3-6 months pre-HD
  4. intradialytic hypotension 是 HD 最垞芋䜵癌症 (~ 20%)management = reduce UF rate, cool dialysate (35-35.5°C), sodium modeling, midodrine prophylactic
  5. PD peritonitis cardinal complicationcloudy effluent + abdominal pain + > 100 WBC/ÎŒL with > 50% neutrophilsmost common S. epidermidis (contamination)treatment intraperitoneal gentamicin + cefazolin empiric → tailored
  6. PD catheter (Tenckhoff): surgically placed, tunneled subcutaneous; exit site care critical; mupirocin prophylaxis at nostrils + exit site reduces S. aureus
  7. CONVINCE (2023) hemodiafiltration (HDF) > high-flux HD23% ↓ mortality in Europe — likely practice-changing
  8. PD vs HD modality choicesimilar long-term survival; PD better first 1-2 years + residual function + cardiac stability + travel flexibility; HD for severe abdominal disease, non-compliant, vascular issues
  9. difelikefalin (Korsuva) FDA 2021 for HD-associated pruritus (KALM-1, KALM-2 trials)peripheral kappa-opioid receptor agonist
  10. dialysis mortality 20-25%/year in US — high; CV leading cause of death; renal transplant offers better survival + QoL than long-term dialysis — refer early