Locatelli Francesco, Covic Adrian, Chazot Charles, Leunissen Karel, Luño José, Yaqoob Mohammed
Department of Nephrology and Dialysis, Ospedale A. Manzoni, Via Dell'Eremo 11, 23900 Lecco, Italy.
Nephrol Dial Transplant. 2004 Apr;19(4):785-96. doi: 10.1093/ndt/gfh102.
Introduction. From the beginning of the dialysis era, the most appropriate composition of the dialysate has been one of the central topics in the delivery of dialysis treatment.
A discussion is employed to achieve a consensus on key points relating to the composition of the dialysate, focusing on the relationships with blood pressure behaviour.
Sodium balance is the cornerstone of intra-dialysis cardiovascular stability and good inter-dialysis blood pressure control. Hypernatric dialysis carries the risk of positive sodium balance, with the consequent possibility of the worsening sense of thirst and hypertension. Conversely, hyponatric dialysis may lead to negative sodium balance, with the possibility of intra-dialysis cardiovascular instability and 'disequilibrium' symptoms including fatigue, muscle cramps and headache. The goal is to remove with dialysis the exact amount of sodium that has accumulated in the inter-dialysis interval. The conductivity kinetic model is applicable on-line at each dialysis session and has been proved to be able to improve intra-dialytic cardiovascular stability in hypotension-prone patients. Therefore, it should be regarded as a promising tool to be implemented in everyday clinical practice. Serum potassium concentration and variations during dialysis treatment certainly play a role in the genesis of cardiac arrhythmia. Potassium profiling, with a constant gradient between plasma and dialysate, should be implemented in clinical practice to minimize the arrhythmogenic potential of dialysis. Calcium plays a role both in myocardial contractility and in peripheral vascular resistance. Therefore, an increase in dialysate calcium concentration may be useful in cardiac compromised hypotension-prone patients. Acid-buffering by means of base supplementation is one of the major roles of dialysis. Bicarbonate concentration in the dialysate should be personalized in order to reach a midweek pre-dialysis serum bicarbonate concentration of 22 mmol/l. The role of convective dialysis techniques in cardiovascular stability is still under debate. It has been demonstrated that dialysate temperature and sodium balance play a role and this should be taken into account. Whether removal of vasoactive, middle-sized compounds by convection plays an independent role in improving cardiovascular stability is still uncertain.
The prescription of dialysis fluid is moving from a pre-fixed, standard dialysate solution to individualization of electrolyte and buffer composition, not only during the dialysis session, but also within the same session (profiling) in order to provide patients with an optimal blood purification coupled with a high degree of tolerability.
引言。从透析时代开始，透析液的最合适成分一直是透析治疗实施过程中的核心话题之一。
通过讨论就与透析液成分相关的关键点达成共识，重点关注其与血压变化的关系。
钠平衡是透析期间心血管稳定性及透析间期良好血压控制的基石。高钠透析存在钠正平衡风险，进而可能导致口渴感加重和高血压。相反，低钠透析可能导致钠负平衡，引发透析期间心血管不稳定以及包括疲劳、肌肉痉挛和头痛在内的“失衡”症状。目标是通过透析清除透析间期累积的精确钠量。传导动力学模型可在每次透析过程中在线应用，且已被证明能够改善易发生低血压患者的透析期间心血管稳定性。因此，应将其视为日常临床实践中一种有前景的工具。透析治疗期间血清钾浓度及其变化肯定在心律失常的发生中起作用。临床实践中应采用血浆与透析液之间保持恒定梯度的钾浓度分布模式，以将透析致心律失常的可能性降至最低。钙在心肌收缩力和外周血管阻力方面均起作用。因此，提高透析液钙浓度可能对心脏功能受损且易发生低血压的患者有益。通过补充碱进行酸缓冲是透析的主要作用之一。透析液中的碳酸氢盐浓度应个体化，以使周中透析前血清碳酸氢盐浓度达到22 mmol/L。对流透析技术在心血管稳定性方面的作用仍存在争议。已证明透析液温度和钠平衡起作用，对此应予以考虑。通过对流清除血管活性中分子化合物在改善心血管稳定性方面是否起独立作用仍不确定。
透析液的处方正从预先设定的标准透析液溶液转向电解质和缓冲成分的个体化，不仅在透析期间，而且在同一次透析过程中（浓度分布模式），以便为患者提供最佳的血液净化并具有高度耐受性。
