Practical Dialysis in the Year 2009

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Practical Dialysis in the Year 2009 §”π” ¥â«¬§«“¡°â“«Àπâ“∑“ß«‘∑¬“»“ µ√å·≈–‡∑§‚π‚≈¬’¡’°“√‡ª≈’ˬπ·ª≈ßÕ¬Ÿàµ≈Õ¥‡«≈“ ∑”„Àâ §«“¡√âŸ√«¡∑—È߇§√◊ËÕß¡◊ÕÕÿª°√≥å∑’ˇ°’ˬ«¢âÕß°—∫°“√√—°…“¥â«¬«‘∏’ Dialysis ‰¥âæ—≤π“„Àâ¡’ª√– ‘∑∏‘¿“æ∑’Ë¥’ ¢÷ÈπÕ¬à“ßµàÕ‡π◊ËÕß ∫ÿ§≈“°√∑—Èß·æ∑¬å·≈–欓∫“≈∑’ˇ°’ˬ«¢âÕß®÷ß¡’§«“¡®”‡ªìπ∑’˵âÕßµ‘¥µ“¡§«“¡ °â“«Àπ⓵à“ßÊ ‡À≈à“π’È ‡æ◊ËÕ∑’Ë®–‰¥âπ”¡“ª√—∫„™â„À⇢⓰—∫ß“π∑’ˉ¥âªØ‘∫—µ‘Õ¬Ÿà Àπ—ß ◊Õ çPractical Dialysis in the Year 2009é ´÷Ëߪ√–°Õ∫¥â«¬∫∑π‘æπ∏宓°«‘∑¬“°√ºâŸ∑√ß §≥ÿ «≤ÿ ∑‘ „’Ë ™ªâ √–°Õ∫°“√∫√√¬“¬®¥— ∑”‡ªπì Àπß—  Õ◊ ¡Õ∫„À·â °ºà ‡Ÿâ ¢“â √«à ¡ª√–™¡ÿ «™‘ “°“√çDialysisWeekendé ´÷Ëß®—¥‚¥¬ ¡“§¡‚√§‰µ·Ààߪ√–‡∑»‰∑¬ ™¡√¡‚√§‰µ‡¥Á°·Ààߪ√–‡∑»‰∑¬ ·≈–™¡√¡æ¬“∫“≈‚√§‰µ ·Ààߪ√–‡∑»‰∑¬ ‡æ◊ËÕ„ÀâºâŸ‡¢â“√à«¡ª√–™ÿ¡‰¥âµ‘¥µ“¡§«“¡°â“«Àπâ“¥â“π°“√√—°…“¥â«¬«‘∏’ Dialysis „π«—π∑’Ë 31 ¡°√“§¡ ·≈– 1 °ÿ¡¿“æ—π∏å æ.». 2552 ‡π◊ÈÕÀ“¢Õß∫∑π‘æπ∏å„πÀπ—ß ◊Õ‡≈à¡π’ȉ¥â∑∫∑«π§«“¡√Ÿâ·≈– ¢âÕ¡Ÿ≈§«“¡‡ª≈’ˬπ·ª≈ß∑“ß«‘™“°“√¢Õß°“√√—°…“∫”∫—¥∑¥·∑π‰µ¥â«¬«‘∏’ Dialysis „π√Õ∫ªï∑’˺à“π¡“ ‰«âÕ¬à“ߧ√∫∂â«π ®÷߇À¡“–°—∫·æ∑¬å·≈–欓∫“≈‰¥â𔉪»÷°…“µàÕ‡π◊ËÕߥ⫬µπ‡ÕßµàÕ‰ª „πªïπ’Ȭ—߉¥â®—¥„Àâ¡’°“√Ωñ°Õ∫√¡‡™‘ߪؑ∫—µ‘°“√ (Workshop) ‡æ◊ËÕ„À⇰‘¥∑—°…–¥—߇™àπ°“√ ªØ‘∫—µ‘ß“π®√‘ß ‚¥¬¡’«‘∑¬“°√§Õ¬„À⧔·π–π”Õ¬à“ß„°≈♑¥ ·≈–¡’‡§√◊ËÕß¡◊ÕÕÿª°√≥å “∏‘µ„Àâ≈ß¡◊Õ ªØ‘∫—µ‘‰¥â¥â«¬µπ‡Õß ∫∑§«“¡∑’Ë„™âª√–°Õ∫°“√Ωñ°Õ∫√¡‡™‘ߪؑ∫—µ‘°“√ (Work Instruction) ´÷Ë߉¥âÕ∏‘∫“¬ ¢—ÈπµÕπ°“√ªØ‘∫—µ‘∑’≈–¢—ÈπµÕπÕ¬à“ß≈–‡Õ’¬¥ ‰¥â√«∫√«¡‰«â„Àâ„πÀπ—ß ◊Õ‡≈à¡π’ȇ™àπ‡¥’¬«°—π ‡æ◊ËÕ‰«â„™â ∑∫∑«π§«“¡√⟷≈–Õâ“ßÕ‘ß„π¢≥–ªØ‘∫—µ‘ß“π §≥–ºŸâ®—¥∑”Àπ—ß ◊Õ çPractical Dialysis in the Year 2009é ¢Õ¢Õ∫æ√–§ÿ≥«‘∑¬“°√ºâŸ∑√ß §ÿ≥«ÿ≤‘∑ÿ°∑à“π∑’ˉ¥â¡Õ∫∫∑π‘æπ∏å‡æ◊ËÕ≈ßµ’æ‘¡æå ∑“ߧ≥–ºâŸ®—¥∑”¡ÿàßÀ«—ß«à“Àπ—ß ◊Õ çPractical Dialysis in the Year 2009é π’È ®–‡ªìπª√–‚¬™πå„π«ß°«â“ß·°à∫ÿ§≈“°√∑“ß°“√·æ∑¬å·≈–欓∫“≈∑’ˉ¥â∑ÿࡇ∑ªØ‘∫—µ‘ ß“π¥·Ÿ ≈ºŸâªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß∑’Ë®”‡ªìπµâÕ߉¥â√—∫°“√√—°…“∫”∫—¥∑¥·∑π‰µ¥â«¬«‘∏’ Dialysis ·≈–𔧫“¡√Ÿâ ‡æ‘Ë¡‡µ‘¡≈à“ ÿ¥∑’ˉ¥â√—∫®“°°“√ª√–™ÿ¡·≈–°“√Ωñ°Õ∫√¡‡™‘ߪؑ∫—µ‘°“√ ‰ªæ—≤π“ß“π„πÀπ૬‰µ‡∑’¬¡ ·≈–°“√¥·Ÿ ≈ºŸâªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß„À⥒¬‘Ëߢ÷Èπ‰ª ∫√√≥“∏‘°“√ ∏π‘µ ®‘√π—π∑å∏«—™  ‘√‘¿“ ™â“ß»‘√‘°ÿ≈™—¬ ∏π—𥓠µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°ÿ≈ i

Practical Dialysis in the Year 2009 §≥–Õπÿ°√√¡°“√«™‘ “°“√  ¡“§¡‚√§‰µ·Ààߪ√–∑»‰∑¬ 1. ». πæ. « —πµå  ÿ‡¡∏°ÿ≈ 2. æ≠. ∏π—𥓠µ√–°“√«π‘™ 3. º». πæ. ∑«’ ™“≠™—¬√ÿ®‘√“ 4. πæ. °”∏√ ≈’≈“¡–≈‘ 5. π.Õ. πæ. ∑«’æß…å ª“®√’¬å 6. πæ. «ÿ≤‘‡¥™ ‚Õ¿“»‡®√‘≠ ÿ¢ 7. √». πæ. ¬‘Ë߬» Õ«‘À‘ß “ππ∑å 8. æ.Õ. πæ. Õÿª∂—¡¿å »ÿ¿ ‘π∏ÿå 9. √». πæ. ™“§√’¬å °‘µ‘¬“°√ 10. √». æ≠.  ‘√‘¿“ ™â“ß»‘√‘°ÿ≈™—¬ 11. √». πæ. ®—°√™—¬ ®÷ß∏’√æ“π‘™ 12. º». πæ. æ√™—¬ °‘Ëß«—≤π°ÿ≈ 13. æ.µ.∑. πæ. ∏π‘µ ®‘√π—π∑å∏«—™ 14. º». πæ. Õπ‘√ÿ∑∏‘Ï ¿—∑√“°“≠®πå ∑Ë’ª√÷°…“: ».πæ. ¥ÿ ‘µ ≈È”‡≈‘»°ÿ≈ 𓬰 ¡“§¡‚√§‰µ·Ààߪ√–‡∑»‰∑¬ ii

Practical Dialysis in the Year 2009 §≥–°√√¡°“√ ™¡√¡‚√§‰µ‡¥°Á ·Àßà ª√–‡∑»‰∑¬ ª√–∏“π: √». æ.Õ.À≠‘ß ª√–‰ææ‘¡æå ∏’√§ÿªµå «™‘ “°“√: ». æ≠. Õ—®©√“  —¡∫ÿ≥≥“ππ∑å ª√–™“ ¡— æπ— ∏:å º». πæ. æ√™—¬ °‘Ëß«—≤π°ÿ≈  “√ π‡∑»: º». πæ. Õπ‘√ÿ∏ ¿—∑√“°“≠®πå ‡À√≠— ≠°‘ : º». æ≠. °“≠®π“ µ—Èßπ√“√—™™°‘® ‡≈¢“π°ÿ “√: æ.∑. Õ¥‘ √≥å ≈”‡æ“æß»å °√√¡°“√: √». πæ. ®—°√™—¬ ®÷ß∏’√æ“π‘™ º». πæ.  ÿ‚√®πå »ÿ¿‡«§‘π √». æ≠. ‡ “«≈—°…≥å ‚Õ¿“ ∂‘√°ÿ≈ º». πæ. æ√»—°¥‘Ï ¥‘ π’‡«∑¬å ∑ªË’ √°÷ …“: ». æ≈.µ.À≠‘ß «≥‘™ «√√≥惰…å ». πæ. ª√– ‘∑∏‘Ï øµŸ √–°≈Ÿ º». æ≠. Õ√ÿ≥ «ß…宑√“…Æ√å √». æ≈.µ.À≠‘ß ¬ÿæ“æ‘π ®ÿ≈‚¡°¢å iii

Practical Dialysis in the Year 2009 §≥–Õπÿ°√√¡°“√«‘™“°“√ ™¡√¡æ¬“∫“≈‚√§‰µ·Àßà ª√–‡∑»‰∑¬ 1. æ.µ.∑.À≠‘ß ©—µ√ ÿ¥“ ‡Õ◊ÈÕ¡“π–æß…å 2. ªîòπ·°â« °≈⓬ª√–¬ß§å 3.  ÿ«‘¡≈ π‘≈ ‘π 4. π.∑.À≠‘ß  ‘√‘°√ ¢ÿπæ√À¡ 5. π—π∑π“ ¬—ߪ√“ß»å 6. æ√æ√√≥ ™§—∂∏“¥“ 7. æ.µ.∑.À≠‘ß ®—π∑π“ ™◊Ëπ«‘ ‘∑∏‘Ï 8. · ß∑‘æ¬å  §Ÿ ’√’ 9. ª«’≥“  ‘ßÀå∑‘» 10.  ÿ∏‘¥“ ‚µæ—π∏“ππ∑å 11. π—π∑“ ¡À—∏π—π∑å 12. ®“√ÿ≥’ ™“§√“ππ∑å 13. Õ¿— √“ Õ√—≠«—≤πå ∑ª’Ë √°÷ …“: ‡∫≠®æ√ ≈’≈–«—≤πå ª√–∏“π™¡√¡æ¬“∫“≈‚√§‰µ·Ààߪ√–‡∑»‰∑¬ Õ‘…≥’ æÿ∑∏‘¡πµ√’ √Õߪ√–∏“πΩÉ“¬«‘™“°“√ iv

Practical Dialysis in the Year 2009  ¡“§¡‚√§‰µ·Ààߪ√–‡∑»‰∑¬ ™¡√¡‚√§‰µ‡¥Á°·Ààߪ√–‡∑»‰∑¬ ·≈–™¡√¡æ¬“∫“≈‚√§‰µ ·Ààߪ√–‡∑»‰∑¬ ¢Õ¢Õ∫§ÿ≥∫√‘…—∑‡§√◊ËÕß¡◊Õ·æ∑¬åµàÕ‰ªπ’È ´÷Ëß¡’ à«π™à«¬ π—∫ πÿπ‡§√◊ËÕß¡◊Õ·æ∑¬å  ”À√—∫°“√Ωñ°Õ∫√¡‡™‘ߪؑ∫—µ‘°“√·≈–°“√®—¥æ‘¡æåÀπ—ß ◊Õ çPractical Dialysis in the Year 2009é π’È 1. ∫√…‘ ∑— ·∫°Á ‡µÕ√凌≈∏å·§√å (ª√–‡∑»‰∑¬) ®”°—¥ ºâŸ·∑π®”Àπà“¬‡§√◊ËÕß≈â“߉µ∑“ß™àÕß∑âÕßÕ—µ‚π¡—µ‘ çBaxter Home Choiceé 2. ∫√…‘ —∑ ‡ø√´‡’ π¬’   ‡¡¥‘§Õ≈ ·§√å (ª√–‡∑»‰∑¬) ®”°—¥ ºâŸ·∑π®”Àπà“¬‡§√◊ËÕß≈â“߉µ∑“ß™àÕß∑âÕßÕ—µ‚π¡—µ‘ çFresenius PD Nighté ·≈–‡§√◊ËÕßøÕ°‡≈◊Õ¥ çFresenius √ÿàπ 4008H Online HDFé 3. ∫√…‘ ∑— ‡ÕÁ¥«“√å¥ å ‰≈øቴ‡ÕπÁ ´å (ª√–‡∑»‰∑¬) ®”°—¥ ºŸâ·∑π®”Àπà“¬‡§√◊ËÕßøÕ°‡≈◊Õ¥ çAquarius CRRT Machineé 4. ∫√‘…—∑ ·Õ ‚∑√‡¡¥ ®”°—¥ ºŸâ·∑π®”Àπà“¬‡§√◊ËÕßøÕ°‡≈◊Õ¥ çGambro Prismaflex CRRT machineé 5. ∫√‘…∑— 𑧧‘‚´ ‡¡¥§‘ —≈ (ª√–‡∑»‰∑¬) ®”°—¥ ºŸâ·∑π®”Àπà“¬‡§√◊ËÕßøÕ°‡≈◊Õ¥ çNIKKISO √ÿàπ DBB 05 online HDFé 6. ∫√…‘ ∑— ∑√“π ‡å ¡¥‘§ (ª√–‡∑»‰∑¬) ®”°¥— ºŸâ·∑π®”Àπà“¬‡§√◊ËÕßøÕ°‡≈◊Õ¥ çInfomed HF440 Blood purification machineé 7. ∫√‘…∑— ‰≈øá Õπ‘ ‡µÕ√å·§√å ®”°¥— ºŸâ·∑π®”Àπà“¬‡§√◊ËÕß«—¥§«“¡‡√Á«‡≈◊Õ¥ çTransonicé v

Practical Dialysis in the Year 2009 ºπŸâ æ‘ π∏å °≈»√ ¿§— ‚™µ“ππ∑,å æ.∫. Àπ૬‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿¡Ÿ ‘æ≈Õ¥ÿ≈¬‡¥™ °“≠®π“ µ—ßÈ π√“√™— ™°®‘ , æ.∫. Àπ૬‚√§‰µ ¿“§«‘™“°ÿ¡“√‡«™»“ µ√å §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °”∏√ ≈≈’ “¡–≈,‘ æ.∫. ß“π‚√§‰µ °≈ÿà¡ß“πÕ“¬ÿ√»“ µ√å ‚√ß欓∫“≈√“™«‘∂’ ‡°ÈÕ◊ ‡°¬’ √µ‘ ª√–¥…‘ ∞æå √»≈‘ ª,á æ.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ ™≈∏‘ª æß» å °≈ÿ , æ.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ ™àÕº°“  °≈ÿ »√®’ ‘π¥“, æ¬.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ ∑«’ ™“≠™—¬√®ÿ √‘ “, æ.∫.  “¢“«‘™“«—°°–«‘∑¬“ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ∑«’ »√‘ «‘ ß»å, æ.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ ∑«æ’ ß…å ª“®√¬’ å, æ.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿¡Ÿ ‘æ≈Õ¥ÿ≈¬‡¥™ ∏π—𥓠µ√–°“√«π™‘ , æ.∫. Àπ૬‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å «‘∑¬“≈—¬·æ∑¬»“ µ√å°√ÿ߇∑æ¡À“π§√·≈–«™‘√欓∫“≈ ∏𵑠®‘√ππ— ∑å∏«—™, æ.∫. Àπ૬‰µ °≈ÿà¡ß“πÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈µ”√«® ∏µ‘ ‘¬“ æ«— «‰‘ ≈, æ.∫. °≈ÿà¡ß“πÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈æ√–π§√»√’Õ¬ÿ∏¬“ ∏’√–π™ÿ ‡æ™√√ÿàß, æ¬.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿¡Ÿ ‘æ≈Õ¥ÿ≈¬‡¥™ πæ¡“» ¢” ¡∫—µ,‘ æ¬.∫. Àπ૬‰µ °≈ÿà¡ß“π欓∫“≈ ‚√ß欓∫“≈µ”√«® vi

Practical Dialysis in the Year 2009 ππ— ∑«π— ªî¬–¿“≥,’ æ.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“°ÿ¡“√‡«™»“ µ√å §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ π¿‘ “ Õ—¬ “ππ∑å, æ¬.∫.††† ß“π°“√欓∫“≈Õ“¬ÿ√»“ µ√å·≈–®‘µ‡«™»“ µ√å ΩÉ“¬°“√欓∫“≈ §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ª√“√∂π“ µπ—  ∏ÿ ≠— ≈—°…≥å, æ¬.∫. Àπ૬‰µ‡∑’¬¡ ¡Ÿ≈π‘∏‘‚√§‰µ·Ààߪ√–‡∑»‰∑¬ µ÷°°—≈¬“≥‘«—≤π“ ‚√ß欓∫“≈ ß¶å ª«’≥“  ‘ßÀå∑»‘ , æ¬.∫. Àπ૬‰µ‡∑’¬¡ ¡≈Ÿ π‘∏‘‚√§‰µ·Ààߪ√–‡∑»‰∑¬ µ÷°°—≈¬“≥‘«—≤π“ ‚√ß欓∫“≈ ß¶å ª“π∑æ‘ ¬å ‡®µπ«π‘™¬,å æ¬.∫.††† ß“π°“√欓∫“≈Õ“¬ÿ√»“ µ√å·≈–®‘µ‡«™»“ µ√å ΩÉ“¬°“√欓∫“≈ §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ æß»∏√ §™‡ π,’ æ.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™ æ𑥓 °«π‘ ‚Õ¿“°≈Ÿ , æ¬.∫. 欓∫“≈‰µ‡∑’¬¡ ß“π‚√§‰µ °≈ÿà¡ß“πÕ“¬ÿ√»“ µ√å √æ.√“™«‘∂’ æ𑥓 ™Ë◊π¡’»√’, æ¬.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™ æ√æ√√≥ ™§∂— ∏“¥“, æ¬.∫. 欓∫“≈‰µ‡∑’¬¡ ß“π‚√§‰µ °≈ÿà¡ß“πÕ“¬ÿ√»“ µ√å √æ.√“™«‘∂’ æ√‡æ≠Á · ß∂«≈— ¬,å æ.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å æ‘®‘µ√“ ∑Ÿ≈¡“≈“, æ¬.∫. 欓∫“≈‰µ‡∑’¬¡ ß“π‚√§‰µ °≈ÿà¡ß“πÕ“¬ÿ√»“ µ√å √æ.√“™«‘∂’ ¿“«‘≥¬’ å ∞µ‘ ‘¡‚πæ≤— π,å æ¬.∫. Àπ૬‰µ‡∑’¬¡ ¡Ÿ≈π‘∏‘‚√§‰µ·Ààߪ√–‡∑»‰∑¬ µ÷°°—≈¬“≥‘«—≤π“ ‚√ß欓∫“≈ ß¶å ¡“¥’ µÿ≈¬«»π‘ æß…,å æ¬.∫. 欓∫“≈‰µ‡∑’¬¡ ß“π‚√§‰µ °≈ÿà¡ß“πÕ“¬ÿ√»“ µ√å √æ.√“™«‘∂’ ¬ÿ«¥’ ∏’√»‘≈ª,á æ¬.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ vii

Practical Dialysis in the Year 2009 «≈—¬ æ≈– «— ¥,Ï‘ æ¬.∫. ß“π°“√欓∫“≈°ÿ¡“√‡«™»“ µ√å ΩÉ“¬°“√欓∫“≈ §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬ ¡À‘¥≈ « —πµå  ÿ‡¡∏°≈ÿ , æ.∫. Àπ૬‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ «—≈¬“ ª≈Õ¥®“°‡¢Á≠, æ¬.∫. 欓∫“≈‰µ‡∑’¬¡ ß“π‚√§‰µ °≈ÿà¡ß“πÕ“¬ÿ√»“ µ√å √æ.√“™«‘∂’ »‘√Ï°‘ “≠®πå ·™¡à ≈”‡®¬’ °, æ¬.∫. Àπ૬‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬»√’π§√‘π∑√«‘‚√≤ »¿ÿ ƒ°…å ®‘µµ‘°“ππ∑,å æ.∫. Àπ૬‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à  “∏‘µ §√Ÿ –∑Õß, æ.∫. Àπ૬‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å «‘∑¬“≈—¬·æ∑¬»“ µ√å°√ÿ߇∑æ¡À“π§√·≈–«™‘√欓∫“≈  “¬Ωπ π‘≈®≈ÿ °–, æ¬.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™  ‘√‘¿“ ™“â ß»‘√°‘ ÿ≈™¬— , æ.∫. Àπ૬‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬»√’π§√‘π∑√«‘‚√≤  ™ÿ “¬ »√’∑æ‘ ¬«√√≥, æ.∫.  “¢“«‘™“«—°°–«‘∑¬“ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈  ªÿ πí ™ÿ≥À–π—π∑πå, æ¬.∫. Àπ૬‰µ °≈ÿà¡ß“π欓∫“≈ ‚√ß欓∫“≈µ”√«® Õπ—πµå ‡™◊ÈÕ ÿ«√√≥, æ.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™ Õ√«√√≥ ¢π—  ”√,’ æ¬.∫.  “¢“«‘™“‚√§‰µ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ Õ“√¬‘ “ æß»“∫≠ÿ ¡“, æ¬.∫. Àπ૬‚√§‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈¿¡Ÿ ‘æ≈Õ¥ÿ≈¬‡¥™ Õ‘…≥’ æÿ∑∏¡‘ πµ√,’ æ¬.∫. Àπ૬‰µ‡∑’¬¡ ¡≈Ÿ π‘∏‘‚√§‰µ·Ààߪ√–‡∑»‰∑¬ µ÷°°—≈¬“≥‘«—≤π“ ‚√ß欓∫“≈ ß¶å Õªÿ ∂¡— ¿å »ÿ¿ ‘π∏åÿ, æ.∫. Àπ૬‰µ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“ viii

Practical Dialysis in the Year 2009  “√∫≠— 1. Fundamentals of Hemodialysis .......................................................................................................... 1 « —πµå  ÿ‡¡∏°ÿ≈ 2. Water Treatment: What is the Optimal Standard? .......................................................................... 13 °≈»√ ¿—§‚™µ“ππ∑å 3. Technology Insight of Hemodialysis Machine and Apparatus......................................................... 21 ™≈∏‘ª æ߻堰ÿ≈ 4. Know How! Know Why!! in Chronic Hemodialysis Prescription .................................................... 33 ∑«’ ™“≠™—¬√ÿ®‘√“ 5. Practical Points of Continuous Renal Replacement Therapy .......................................................... 65 æß»∏√ §™‡ π’ 6. Practical Recommendations for Central Vein Occlusion ................................................................. 89 °”∏√ ≈’≈“¡–≈‘ 7. Pitfalls in Vascular Access for Dialysis Nurses .............................................................................. 113 ª«’≥“† ‘ßÀå∑‘» 8. Practical Guidelines to Reduce Cardiovascular Risk of Dialysis Patients...................................... 143 »ÿ¿ƒ°…å ®‘µµ‘°“ππ∑å 9. Current Management of Anemia in Dialysis Patients ................................................................... 163 æ√‡æÁ≠ · ß∂«—≈¬å 10. Fundamental Basis of Pediatric Hemodialysis ............................................................................... 197 °“≠®π“ µ—Èßπ√“√—™™°‘® 11. Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis ...................... 211 π—π∑«—π ªî¬–¿“≥’ 12. Pediatric Care in Adult Hemodialysis Units: Nursing role ............................................................. 227 «≈—¬ æ≈– «— ¥‘Ï ix

Practical Dialysis in the Year 2009 13. Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis ................... 239  ‘√‘¿“ ™â“ß»‘√‘°ÿ≈™—¬ 14. Infectious Control Requirements for Hemodialysis Facilities ........................................................ 259  “∏‘µ §Ÿ√–∑Õß, ∏π—𥓠µ√–°“√«π‘™ 15. Anti-EPO Associated Pure Red Cell Aplasia: The Updated Situation in Thailand ......................... 289 ‡°◊ÈÕ‡°’¬√µ‘ ª√–¥‘…∞åæ√»‘≈ªá 16. Past, Present and Future in Peritoneal Dialysis............................................................................. 299 ∑«’ »‘√‘«ß»å 17. Nursing Intervention in Hemodialysis ............................................................................................ 313 Õ√«√√≥ ¢—π ”√’ 18. Hemodialysis Procedures: Step by Step........................................................................................ 329 »‘√‘Ï°“≠®πå ·™à¡≈”‡®’¬° 19. Get to Know çIntradialytic Parenteral Nutritioné ........................................................................... 351 Õÿª∂—¡¿å »ÿ¿ ‘π∏ÿå 20. Work Instruction: Automated Peritoneal Dialysis .......................................................................... 365 ∏π‘µ ®‘√π—π∑å∏«—™,  ÿ™“¬ »√’∑‘欫√√≥, πæ¡“» ¢” ¡∫—µ‘,  ÿªíπ ™ÿ≥À–π—π∑πå, π‘¿“ Õ—¬ “ππ∑å, ª“π∑‘æ¬å ‡®µπ«π‘™¬å 21. Work Instruction: Machine Continuous Renal Replacement Therapy........................................... 407 ∑«’æß…å ª“®√’¬å, æß»∏√ §™‡ π’, Õπ—πµå ‡™◊ÈÕ ÿ«√√≥, æ𑥓 ™◊Ëπ¡’»√’, ∏’√–πÿ™ ‡æ™√√ÿàß,  “¬Ωπ π‘≈®ÿ≈°–, Õ“√‘¬“ æß»“∫ÿ≠¡“ 22. Work Instruction: Online Hemodiafiltration .................................................................................... 435 ™àÕº°“  °ÿ≈»√’®‘π¥“, ¬ÿ«¥’ ∏’√»‘≈ªá 23. Work Instruction: Physical Examination, Pressure and Flow monitoring of Vascular Access...... 459 °”∏√ ≈’≈“¡–≈‘, ∏‘µ‘¬“ æ—««‘‰≈, ¡“¥’ µÿ≈¬«»‘πæß…å, «—≈¬“ ª≈Õ¥®“°‡¢Á≠, æ‘®‘µ√“ ∑Ÿ≈¡“≈“, æ𑥓 °«‘π‚Õ¿“°Ÿ≈, æ√æ√√≥ ™§—∂∏“¥“ 24. Work Instruction: Buttonhole Cannulation: New Insight ............................................................... 485 °”∏√ ≈’≈“¡–≈‘, Õ‘…≥’ æÿ∑∏‘¡πµ√’, ¿“«‘≥’¬å ∞‘µ‘¡‚πæ—≤πå, ª√“√∂π“ µ—π ÿ∏—≠≈—°…≥å, ª«’≥“  ‘ßÀå∑‘» Index ...................................................................................................................................................... 497 x

Fundamentals of Hemodialysis 1 Fundamentals of Hemodialysis « π— μå  ÿ‡¡∏°≈ÿ 1. ∫∑π” 2. °≈‰°°“√°”®—¥¢Õ߇ ’¬¥«â ¬«‘∏’ Hemodialysis 3. °√–∫«π°“√°“√‡μ√¬’ ¡π”È ¬“øÕ°‡≈Õ◊ ¥ 4. °≈‰°°“√π”‡≈◊Õ¥¡“°√Õß 5. °≈‰°°“√°√ÕßπÈ” «à π‡°‘π 6. ¿“§ªØ∫‘ μ— ‘¢Õß°“√√°— …“‚¥¬°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ 7. ∫∑ √ªÿ 1

Practical Dialysis in the Year 2009 1. ∫∑π” ‚√§‰μ‡√Õ◊È √ß— √–¬–∑“â ¬‡ªπì √–¬–∑¡’Ë °’ “√‡ª≈¬’Ë π·ª≈ßÀ≈“¬ª√–°“√„π√“à ß°“¬¢ÕߺªâŸ «É ¬°≈“à « §◊Õ ¡’§«“¡º‘¥ª°μ‘„π°“√§«∫§ÿ¡¥ÿ≈¬å¢Õß “√πÈ”·≈–‡°≈◊Õ·√àÀ≈“¬™π‘¥ ‰¥â·°à Sodium, Potassium, Chloride, Calcium, Phosphorus, Magnesium ‡ªìπμâπ πÕ°®“°π’È „π√à“ß°“¬¬—ß¡’°“√§—ËߢÕß°√¥™π‘¥ Nonvolatile Acid À√◊Õ Fixed acid (‰¥â·°à Titratable acid ·≈– Ammonium) ·≈–¬—ß¡’°“√§—ËߢÕß “√æ‘…∑’Ë ‡°‘¥®“°°√–∫«π°“√ metabolism ¢Õß “√∑’Ë¡’ nitrogen ‡ªìπÕߧåª√–°Õ∫ ‰¥â·°à urea, creatinine, uric acid ·≈– “√Õ◊ËπÊ ¥—ßπ—Èπ°“√√—°…“¥â«¬«‘∏’ dialysis ®÷ß¡’‡ªÑ“À¡“¬„π°“√¢—∫¢Õ߇ ’¬  “√πÈ”·≈–‡°≈◊Õ·√à ∑’Ë¡’ °“√ – ¡„π√“à ß°“¬ ·°‰â ¢§«“¡‡ªπì °√¥„π‡≈Õ◊ ¥ ´ß÷Ë ®–¡º’ ≈∑”„À≈â ¥Õ“°“√§ß—Ë ¢Õß “√æ…‘ „π‡≈Õ◊ ¥ (uremia) ·≈–®–™à«¬§«∫§ÿ¡§«“¡¥—π‚≈À‘μ ≈¥¿“«–·∑√°´âÕπÕ◊ËπÊ ∑’Ë¡—°®–æ∫„πºŸâªÉ«¬‚√§‰μ‡√◊ÈÕ√—ß√–¬–∑⓬ ‡™àπÕ“°“√ÕàÕπ‡æ≈’¬ §≈◊Ëπ‰ âÕ“‡®’¬π Õ“°“√‡Àπ◊ËÕ¬®“°πÈ”∑à«¡ªÕ¥ ·≈–Õ“°“√∑“ß√–∫∫ª√– “∑ Õ¬à“߉√°Áμ“¡°“√√—°…“¥â«¬«‘∏’π’È ®–‰¡à™à«¬∑¥·∑πÀπâ“∑’Ë°“√ √â“ß hormone ®“°‰μ ´÷Ë߉¥â·°à°“√ √â“ß erythropoietin „π∫∑πÈ’ ®–°≈“à «∂ß÷ °√–∫«π°“√√°— …“‚¥¬°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡ (hemodialysis) ‡ªìπÀ≈—° 2. °≈‰°°“√°”®—¥¢Õ߇ ¬’ ¥«â ¬«∏‘ ’ Hemodialysis ¢∫«π°“√ Hemodialysis À¡“¬§«“¡∂ß÷ °“√∑‡Ë’ ≈Õ◊ ¥∂°Ÿ π”ÕÕ°¡“°√Õß·¬°‡Õ“ “√∑‡Ë’ ªπì ¢Õß ‡ ’¬∑’ˇ°‘¥®“° metabolism (metabolic waste product) ÕÕ°πÕ°√à“ß°“¬‚¥¬°“√„™âμ—«°√Õß∑’Ë¡’§ÿ≥ ¡∫—μ‘ ‡ªìπ‡¬◊ËÕ∫ÿ∑’ˬա„Àâ “√≈–≈“¬∫“ß™π‘¥ºà“π‰¥â (semipermeable membrane) ·≈–°”®—¥ÕÕ°πÕ°√à“ß°“¬ ‚¥¬≈–≈“¬‰ª°—∫πÈ”¬“øÕ°‡≈◊Õ¥ (dialysis fluid À√◊Õ dialysate) ‚¥¬∑—Ë«‰ª  “√≈–≈“¬∑’Ë®–∂°Ÿ °”®—¥ÕÕ° ¥â«¬«‘∏’°“√øÕ°‡≈◊Õ¥‰¥â¥’®–¡’πÈ”Àπ—°‚¡‡≈°ÿ≈ª√–¡“≥ 500-2000 °‘‚≈¥“≈μ—π ‚¥¬®–¡’ª√– ‘∑∏‘¿“æ ßŸ ¡“°„π°“√øÕ° “√≈–≈“¬∑’Ë¡’πÈ”Àπ—°‚¡‡≈°ÿ≈πâÕ¬°«à“ 300 °‘‚≈¥“≈μ—π 1 „π·ßà¢Õß°“√°√ÕߢÕ߇ ’¬π—Èπ ®–μâÕß„™âμ—«°√Õ߇≈◊Õ¥´÷Ëß¡’ à«πª√–°Õ∫‡ªìπ‡¬◊ËÕ∫ÿ∑’Ë¡’√Ÿ‡ªî¥ ¢π“¥‡≈Á°Ê ®”π«π¡“° ¥—ßπ—Èπ “√≈–≈“¬∑’Ë¡’¢π“¥‡≈Á°°«à“√‡Ÿ ªî¥°Á®–∂°Ÿ °√Õߺà“π‰ª‰¥â ·≈– “√≈–≈“¬ ∑’Ë¡’¢π“¥„À≠à°«à“√Ÿ‡ªî¥°Á®–ºà“π‰¡à‰¥â ‡√’¬°«à“‡ªìπ semipermeable membrane Õ—μ√“°“√°√ÕߢÕß  “√≈–≈“¬°Á®–º°º—π°—∫¢π“¥¢Õß “√≈–≈“¬  ”À√—∫ “√πÈ”®–‰À≈ºà“π‰ª‰¥â‚¥¬¡’Õ—μ√“°“√ºà“π·ª√ μ“¡¢π“¥¢Õß√‡Ÿ ª¥î „πμ«— °√Õ߇≈Õ◊ ¥‡™πà ‡¥¬’ «°π— 2 ‚¥¬®–‡√¬’ °μ«— °√Õ߇≈Õ◊ ¥∑ Ë’ “¡“√∂„À â “√π”È ‰À≈º“à π ‰¥â¡“°«à“ high flux dialyzer «‘«—≤π“°“√¢Õß°“√ √â“ß membrane ‡√‘Ë¡μâπ®“°°“√º≈‘μ¥â«¬ “√ Cellulose ‚¥¬„π¬ÿ§·√°Ê ¢Õß°“√øÕ°‡≈◊Õ¥ membrane ∑’Ë„™â®–‡ªìπ™π‘¥ Cuprophane μàÕ¡“‡¡◊ËÕ¡’§«“¡√Ÿâ‡√◊ËÕß bioincompatibility ¡“°¢πÈ÷ °¡Á °’ “√æ≤— π“ Cellulose membrane ‡ªπì substituted cellulose ‡™πà Hemophane À√◊Õ modified cellulose ‡™àπ cellulose triacetate ´÷Ëß®–¡’º≈°√–μÿâπ complement πâÕ¬°«à“ membrane ™π¥‘ Cuprophane membrane μÕà ¡“¡«’ «‘ ≤— π“°“√¢Õß°“√º≈μ‘ synthetic membrane ´ßË÷ ‰¥·â °à Polysulfone, Polyacrylonitrile, Polymethylmethacrylate ·≈– Polyamide ´÷Ëß “¡“√∂º≈‘μ„Àâ¡’ ultrafiltration coefficient  ßŸ ®÷ß∑”„Àâ¡’ “√πÈ”‰À≈ºà“π‰¥â¡“°·≈–∑”Àπâ“∑’ˇªìπ high flux dialyzer ‰¥â‡ªìπÕ¬à“ߥ’ 2

Fundamentals of Hemodialysis °“√øÕ°‡≈Õ◊ ¥ (Hemodialysis)  “¡“√∂°”®¥— ¢Õ߇ ¬’ ÕÕ°πÕ°√“à ß°“¬¥«â ¬°≈‰°∑‡Ë’ √¬’ °«“à °“√ ´÷¡ºà“π (diffusion) ·≈–°“√π”æ“ (convection) ‚¥¬¡’À≈—°°“√∑’ˇ°’ˬ«¢âÕߥ—ßπ’È °“√´÷¡ºà“π (diffusion): ‡ªìπ°≈‰°À≈—°„π°“√°”®—¥¢Õ߇ ’¬®“°°“√øÕ°‡≈◊Õ¥ ∑—Èßπ’ÈÕ—μ√“°“√°”®—¥ ¢Õ߇ ’¬¥â«¬«‘∏’°“√´÷¡ºà“π ®–¢÷ÈπÕ¬Ÿà°—∫ √–¥—∫§«“¡·μ°μà“ߢÕߧ«“¡‡¢â¡¢âπ (concentration gradient) ¢Õß “√≈–≈“¬·μà≈–™π‘¥√–À«à“߇≈◊Õ¥ ·≈–πÈ”¬“øÕ°‡≈◊Õ¥ (dialysate), ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥ ·≈– π”È ¬“øÕ°‡≈Õ◊ ¥, §≥ÿ  ¡∫μ— ¢‘ Õß dialysis membrane √«¡∑ßÈ— ¢π“¥·≈–§≥ÿ  ¡∫μ— ∑‘ “ß°“¬¿“æ·≈–∑“߇§¡’ ¢Õß “√≈–≈“¬∑’Ë∂°Ÿ °”®—¥ÕÕ°·μà≈–™π‘¥ °“√´÷¡ºà“π‡ªìπ°√–∫«π°“√‡∫◊ÈÕßμâπ„π°“√¢®—¥¢Õ߇ ’¬ÕÕ° πÕ°√“à ß°“¬¢ÕߺªŸâ «É ¬∑√’Ë ∫— °“√øÕ°‡≈Õ◊ ¥·≈–‡ªπì º≈¢Õß°“√∑‡’Ë ≈Õ◊ ¥¢ÕߺªŸâ «É ¬‰À≈¡“∑μ’Ë «— °√Õ߇≈Õ◊ ¥ ·≈– ¡“∫√√®∫°—∫πÈ”¬“øÕ°‡≈◊Õ¥ (dialysate) ∑’ˉÀ≈ºà“πÕ’°¥â“πÀπ÷ËߢÕßμ—«°√Õ߇≈◊Õ¥ ·≈–¡’°“√´÷¡ºà“π¢Õß  “√≈–≈“¬‚¥¬§«“¡·μ°μ“à ߢÕߧ«“¡‡¢¡â ¢πâ ¢Õß “√≈–≈“¬‡™πà urea (´ßË÷ ¡§’ «“¡‡¢¡â ¢πâ  ßŸ „π‡≈Õ◊ ¥) ´¡÷ ºà“πμ—«°√Õ߇≈◊Õ¥‡¢â“ àŸπÈ”¬“øÕ°‡≈◊Õ¥ (´÷Ëß¡’§«“¡‡¢â¡¢âπ¢Õß urea μË”¡“°§◊Õ‰¡à¡’‡≈¬) °“√´÷¡ºà“π¢Õß  “√≈–≈“¬®–∑”„À⧫“¡‡¢â¡¢âπ¢Õß “√≈–≈“¬®“°‡≈◊Õ¥∑’˺à“π‡¢â“‰ª¬—ß dialysate ·≈–®“° dialysate ‰ª ¬ß— ‡≈Õ◊ ¥≈¥≈߇√Õ◊Ë ¬Ê ®“° concentration gradient∑≈’Ë ¥≈ß®π‡¢“â  ®àŸ ¥ÿ  ¡¥≈ÿ ¬å ∑ß—È π’È§æ— ∑∑å “ß‡∑§π§‘ ∑°’Ë ”Àπ¥ Õ—μ√“°“√¢®—¥¢Õ߇ ’¬ÕÕ°πÕ°√à“ß°“¬ºà“π semipermeable membrane ‡√’¬°«à“ mass transfer °≈à“«§◊Õ mass transfer (À√◊Õ solute flux) ®–·ª√º—πμ“¡√–¥—∫§«“¡‡¢â¡¢âπ¢Õß “√≈–≈“¬„π‡≈◊Õ¥ ¢π“¥¢Õßμ—« °√Õ߇≈◊Õ¥ §«“¡æ√ÿπ¢Õßμ—«°√Õß (permeability) ·≈–Õ—μ√“∑’ˇ≈◊Õ¥·≈–πÈ”¬“øÕ°‡≈◊Õ¥‰À≈ºà“πμ—«°√Õß ‡≈◊Õ¥ „π∑“ߪؑ∫—μ‘ ®–®—¥„Àâ‡≈◊Õ¥·≈–πÈ”¬“øÕ°‡≈◊Õ¥‰À≈ºà“πμ—«°√Õ߇≈◊Õ¥„π∑‘»∑“ß∑’Ë «π°—π ¿“¬„πμ—«°√Õߥ⫬՗μ√“°“√‰À≈ 300-500 ´’´’μàÕπ“∑’ ·≈– 500-800 ´’´’μàÕπ“∑’ μ“¡≈”¥—∫ (√Ÿª∑’Ë 1)  “‡Àμ∑ÿ ‡’Ë ≈Õ◊ ¥·≈–πÈ”¬“øÕ°‡≈Õ◊ ¥ μÕâ ß¡∑’ »‘ ∑“ß°“√‰À≈ «π∑“ß°π— ‡πÕ◊Ë ß®“° °“√´¡÷ º“à π¢Õß “√≈–≈“¬ ®–≈¥§«“¡‡¢¡â ¢πâ ¢Õß “√≈–≈“¬„π‡≈Õ◊ ¥·≈–‰ª‡æ¡‘Ë §«“¡‡¢¡â ¢πâ ¢Õß “√≈–≈“¬„ππÈ”¬“øÕ°‡≈Õ◊ ¥ ∑”„Àâ เลอื ดท่นี าํ มากรอง เลอื ดทก่ี ลบั ผูปว ย ตัวกรองเลอื ด (dialysis membrane) น้ํายาทผ่ี านออก นํ้ายาท่ผี านเขา √Ÿª∑’Ë 1 · ¥ß°“√º“à πÕÕ°¢Õß “√≈–≈“¬®“°‡≈Õ◊ ¥‡¢“â  àŸ dialysate ‚¥¬º“à π dialysis membrane ·≈–®–‡ÀπÁ «“à ∑»‘ ∑“ß °“√‰À≈¢Õ߇≈◊Õ¥ ·≈– dialysate ‡ªìπ‰ª„π∑»‘ ∑“ß∑μË’ √ß°—π¢â“¡°π— 3

Practical Dialysis in the Year 2009 §«“¡·μ°μà“ߢÕߧ«“¡‡¢â¡¢âπ (concentration gradient) ¢Õß “√≈–≈“¬√–À«à“߇≈◊Õ¥·≈– dialysate ≈¥ ≈߇√◊ËÕ¬Ê ®πÕ“®∑”„Àâ‰¡à‡°‘¥°“√´÷¡ºà“π„π∑’Ë ÿ¥  ¿“«°“√≥套߰≈à“« “¡“√∂·°â‰¢‰¥â¥â«¬°“√„Àâ °√–· °“√‰À≈‡ªπì ‰ª„π∑»‘ ∑“ß∑μ’Ë √ߢ“â ¡°π— (countercurrent flow) ®“°°“√®¥— √–∫∫¥ß— ¢“â ßμπâ ∑”„À§â «“¡ ‡¢¡â ¢πâ ¢Õß “√≈–≈“¬„ππÈ”¬“øÕ°‡≈Õ◊ ¥¡√’ –¥∫— μË”∑ ’Ë ¥ÿ ‡¡Õ◊Ë ‰À≈‡¢“â  μàŸ «— °√Õß(dialyzer) „π «à π∑‡’Ë ≈Õ◊ ¥‰À≈ ÕÕ° ·≈–¡’§à“§«“¡‡¢â¡¢âπ ßŸ ∑’Ë ÿ¥∫√‘‡«≥®ÿ¥ÕÕ°®“° dialyzer μ√ßμ”·Àπà߇≈◊Õ¥‰À≈‡¢â“ (‡ªìπ®ÿ¥∑’˧«“¡ ‡¢â¡¢âπ¢Õß “√≈–≈“¬„π‡≈◊Õ¥¡’§à“ ßŸ ∑’Ë ÿ¥) º≈®“°¢â“ßμâπ∑”„À⧫“¡·μ°μà“ߢÕߧ«“¡‡¢â¡¢âπ®–¬—ß§ß Õ¬Ÿàμ≈Õ¥‡ âπ∑“ß°“√‰À≈ºà“π¢ÕߢÕ߇À≈« °“√π”æ“ (Convection): ‡ªìπÕ’°°≈‰°Àπ÷ËߢÕß°“√°”®—¥¢Õ߇ ’¬ÕÕ°πÕ°√à“ß°“¬ ¢∫«π°“√π’ȇªìπº≈ μ“¡¡“®“° ultrafiltration ´ß÷Ë ‡ªπì °“√°”®¥—  “√πÈ”ÕÕ°πÕ°√“à ß°“¬μ“¡§«“¡·μ°μ“à ߢÕß·√ß¥π— ¢∫«π°“√ ultrafiltration ®–¡º’ ≈∑”„À â “√≈–≈“¬∂°Ÿ ¥ß÷ ÕÕ°‰ª®“° “√πÈ”„π¢≥–∑ ’Ë “√πÈ”‰À≈º“à πμ«— °√Õ߇≈Õ◊ ¥ §«“¡  “¡“√∂„π°“√°”®—¥ “√≈–≈“¬¥â«¬«‘∏’ convection ¢÷ÈπÕ¬Ÿà°—∫ —¡ª√– ‘∑∏å¢Õß·√߇ ’¬¥∑“π (sieving coefficient) ´ß÷Ë ¡§’ “à ‡∑“à °∫—  ¥—  «à π√–À«“à ߧ«“¡‡¢¡â ¢πâ ¢Õß “√≈–≈“¬„π “√πÈ”∑∂’Ë °Ÿ °√ÕßÕÕ°πÕ°√“à ß°“¬ °—∫§«“¡‡¢â¡¢âπ¢Õß “√≈–≈“¬π—Èπ„πæ≈“ ¡“ °≈à“«§◊ÕÀ“°§”π«≥§à“ sieving coefficient ‰¥â‡∑à“°—∫ 1 ®–∫ßà ∫Õ°«“à  “√≈–≈“¬ππ—È ∂°Ÿ °√ÕßÕÕ°¡“‰¥Àâ ¡¥‚¥¬‰¡¡à ·’ √߇ ¬’ ¥∑“π„π∑“ßμ√ß°π— ¢“â ¡À“°§“à sieving coefficient ‡∑“à °∫— 0 ∫ßà «“à  “√ππÈ— ‰¡ à “¡“√∂∂°Ÿ °√ÕßÕÕ°¡“‰¥â  “√≈–≈“¬∑¡’Ë ’¢π“¥„À≠à®–¡§’ “à sieving coefficient ‡¢â“„°≈â 0  à«π “√≈–≈“¬∑’Ë¡’¢π“¥‡≈Á°®–¡’§à“ sieving coefficient ‡¢â“„°≈â 1 „π∑“ߧ≈‘π‘° °“√°”®¥— ¢Õ߇ ¬’ ¥«â ¬«∏‘ ’ convection ®–¡∫’ ∑∫“∑¡“°„π°“√°√Õß “√≈–≈“¬∑¡Ë’ ¢’ 𓥄À≠à ‡™πà «μ‘ “¡π‘ ∫’12 ´÷Ëßμ√ß°—π¢â“¡°—∫°“√°”®—¥¢Õ߇ ’¬¥â«¬«‘∏’°“√´÷¡ºà“π (diffusion) ´÷Ëß®–¡’∫∑∫“∑¡“°„π°“√°√Õß  “√≈–≈“¬∑’Ë¡’¢π“¥‡≈Á° °≈‰°¢Õß°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ ª√–°Õ∫¥â«¬°≈‰°¬àÕ¬ “¡ª√–°“√ §◊Õ °≈‰° °“√‡μ√¬’ ¡πÈ”¬“øÕ°‡≈Õ◊ ¥ °≈‰°°“√π”‡≈Õ◊ ¥¡“°√Õß·≈–°≈‰°°“√°√ÕßπÈ” «à π‡°π‘ ¥«â ¬«∏‘ ’ ultrafiltration3 ´÷Ëß®–‰¥â°≈à“«μàÕ‰ª 3. °√–∫«π°“√°“√‡μ√¬’ ¡π”È ¬“øÕ°‡≈Õ◊ ¥ πÈ”¬“øÕ°‡≈◊Õ¥ (dialysate fluid) ¡’Àπâ“∑’Ë√Õß√—∫¢Õ߇ ’¬∑’Ë∂°Ÿ ¢—∫ÕÕ°¡“¥â«¬«‘∏’ diffusion ·≈– convection ·≈–¢—∫ÕÕ°πÕ°√à“ß°“¬ πÕ°®“°π’ÈπÈ”¬“øÕ°‡≈◊Õ¥¬—ß¡’ à«πª√–°Õ∫∑“߇§¡’∑’˙૬ªÑÕß°—π ‰¡à„Àâ√à“ß°“¬ Ÿ≠‡ ’¬‡°≈◊Õ·√à∑’Ë ”§—≠√–À«à“ß°“√øÕ°‡≈◊Õ¥  “√‡§¡’·≈–‡°≈◊Õ·√à∑’ˇªìπ à«πª√–°Õ∫ ¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥¡“μ√∞“π‰¥â·°à NaCl, NaHCO3, CaCl2, KCl, MgCl2 ·≈–πÈ”μ“≈°≈‚Ÿ §  πÈ”¬“øÕ° ‡≈◊Õ¥‰¥â®“°°“√º ¡‡°≈◊Õ·√à‡¢â¡¢âπ¢Õß à«πª√–°Õ∫ Concentrate A, Concentrate B ·≈–πÈ”∫√‘ ÿ∑∏‘Ï ‚¥¬ „™â concentrate A 1  à«π º ¡ concentrate B 1.8  à«π ·≈–πÈ”∫√‘ ÿ∑∏‘Ï 34  à«π concentrate A ·≈– B ¡’ §«“¡‡¢â¡¢âπ¢Õß “√‡§¡’μ“¡ à«πª√–°Õ∫¥—ßπ’È 4

Fundamentals of Hemodialysis Na K Ca Mg Cl HCO3 Acetic (Meq/L) Concentrate A 81 2 3.5 0.7 87.2 0 4 Concentrate B 59 0 0 0 20 39 0 º≈√«¡ 140 2 3.5 0.7 107.2 39 4 À¡“¬‡Àμÿ: §«“¡‡¢â¡¢âπ¢Õß Ca, HCO3 ·≈–πÈ”μ“≈  “¡“√∂ª√—∫‰¥âμ“¡§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬·μà≈– √“¬ ‚¥¬∑—Ë«‰ª‡§√◊ËÕ߉μ‡∑’¬¡®–„™â√–∫∫‰¡‚§√‚ª√‡´ ‡´Õ√å‡æ◊ËÕº ¡ Concentrate A, B ·≈–πÈ” ∫√‘ ÿ∑∏‘Ï πÈ”¬“øÕ°‡≈◊Õ¥®–¡’Õÿ≥À¿¡Ÿ ‘ª√–¡“≥ 36 Õß»“‡´≈‡´’¬  ·≈–®–¡’°≈‰°§«∫§ÿ¡Õÿ≥À¿Ÿ¡‘‰¡à„Àâ  Ÿß‡°‘π‰ª·≈–μË”‡°‘π‰ª ‚¥¬¡’¢âÕæ÷ß√–«—ߧ◊ÕÀ“°Õÿ≥À¿Ÿ¡‘μË”‡°‘π‰ª §π‰¢â®–¡’Õ“°“√Àπ“« —Ëπ ·≈– ≠Ÿ ‡ ’¬æ≈—ßß“π¡“° ·≈–À“°Õÿ≥À¿Ÿ¡‘ Ÿß‡°‘π‰ª §π‰¢â®–¡’§«“¡¥—π‚≈À‘μμË” ·≈–¡’°“√ √â“ßæ≈—ßß“π ¿“¬„π√à“ß°“¬¡“°®π‡ªìπÕ—πμ√“¬‰¥â 4. °≈‰°°“√π”‡≈Õ◊ ¥¡“°√Õß ‡≈◊Õ¥®–∂°Ÿ π”ÕÕ°®“°√à“ß°“¬‡¢â“ Ÿàμ—«°√Õ߇≈◊Õ¥‚¥¬ºà“π‡¢Á¡‡ âπ‡≈◊Õ¥·¥ß (arterial needle) ·≈–‡≈◊Õ¥∑’Ë∂Ÿ°°√ÕߢÕ߇ ’¬ÕÕ°·≈â«®–‰À≈‡«’¬π°≈—∫®“°μ—«°√Õ߇≈◊Õ¥°≈—∫ àŸ√à“ß°“¬‚¥¬ºà“π‡¢Á¡ ‡ âπ‡≈◊Õ¥¥” (venous needle) ‚¥¬∑—Ë«‰ª‡¢Á¡‡ âπ‡≈◊Õ¥·¥ß·≈–‡ âπ‡≈◊Õ¥¥”®–∂°Ÿ «“ß∑‘»∑“ß «π∑“ß°—π ‡æ◊ËÕªÑÕß°—π‰¡à„Àâ¡’°“√À¡ÿπ‡«’¬π¢Õ߇≈◊Õ¥∑’Ë∂°Ÿ π”¡“°√Õß4 ‡≈◊Õ¥®–∂°Ÿ ¥¥Ÿ ®“°‡¢Á¡‡ âπ‡≈◊Õ¥·¥ß‡¢â“ Ÿàμ—« °√Õ߇≈Õ◊ ¥‚¥¬„™ªâ ¡öí ·≈–®–¡√’ –∫∫∑μË’ √«®À“≈¡ (air detector) ‡æÕË◊ ªÕÑ ß°π— ‰¡„à À¡â ≈’ ¡º ¡‡¢“â ¡“°∫— ‡≈Õ◊ ¥ ∑’Ë®–‰À≈°≈—∫√à“ß°“¬ºà“π‡¢Á¡‡ âπ‡≈◊Õ¥¥” (air detector) ´÷Ëß∑”ß“π‚¥¬„™â infrared scan À√◊Õ ultrasound ·≈–¡’√–∫∫∑’Ë· ¥ß„Àâ‡ÀÁπ§à“¢Õߧ«“¡¥—π„π√–∫∫‡ âπ‡≈◊Õ¥¥” (venous pressure) ∑’Ë®–‰À≈°≈—∫√à“ß°“¬ ´÷Ëß¡’ª√–‚¬™πå¡“°À“°‡¢Á¡‡ âπ‡≈◊Õ¥¥”‡≈◊ËÕπÀ≈ÿ¥®“°«ß®√¢Õß°“√°√Õ߇≈◊Õ¥ (¡’Õÿ∫—μ‘°“√≥堟߇¡◊ËÕºŸâ ªÉ«¬À≈—∫·≈–¡’°“√¢¬—∫·¢π√–À«à“ß°“√øÕ°‡≈◊Õ¥) √–À«à“ß°“√√—°…“‚¥¬°“√øÕ°‡≈◊Õ¥ À“°‡æ‘Ë¡ª√‘¡“≥‡≈◊Õ¥∑’Ë∂Ÿ°π”¡“°√Õß ‡™àπ‡æ‘Ë¡¢÷Èπ®“° 250 ‡ªìπ 300 ´’´’μàÕπ“∑’ ®–¡’º≈∑”„Àâ‡æ‘Ë¡Õ—μ√“°“√°”®—¥¢Õ߇ ’¬ (clearance) ´÷Ëß¡’Àπ૬‡ªìπ ´’´’μàÕπ“∑’ ‚¥¬¡’μ—«·ª√§◊Õ§ÿ≥ ¡∫—μ‘¢Õßμ—«°√Õ߇≈◊Õ¥∑’Ë„™â«à“¡’§à“ mass transfer area coefficient  ŸßÀ√◊ÕμË” (√Ÿª∑’Ë 2) °≈à“«§◊Õ§à“ clearance ¢Õß “√¢π“¥‡≈Á°‡™àπ urea ®–‡æ‘Ë¡¢÷Èπ‡√◊ËÕ¬Ê ‡¡◊ËÕ‡æ‘Ë¡Õ—μ√“°“√π”‡≈◊Õ¥ ¡“°√Õß®“° 200 ‡ªìπ 400 ´’´’μàÕπ“∑’ ·μà‡¡◊ËÕ‡æ‘Ë¡Õ—μ√“°“√π”‡≈◊Õ¥¡“°√Õ߇°‘π 400 ´’´’μàÕπ“∑’·≈â« Õ—μ√“°“√°”®—¥¢Õ߇ ’¬ (clearance) ®–‡æ‘Ë¡¢÷Èπ‰¡à¡“°¡—° πÕ°®“°π’È √ªŸ ∑’Ë 2 ¬—ß· ¥ß„Àâ‡ÀÁπ«à“ μ—«°√Õß ‡≈◊Õ¥∑’Ë¡’§à“ mass transfer area coefficient  Ÿß°«à“ 800 ´’´’μàÕπ“∑’ (‰¥â·°à high flux dialyzer) ®–¡’§«“¡  “¡“√∂„π°“√°”®—¥¢Õ߇ ’¬¥’°«à“μ—«°√Õ߇≈◊Õ¥∑’Ë¡’§à“ mass transfer area coefficient μË”°«à“ 800 ´’´’μàÕ π“∑’ (‰¥â·°à low flux dialyzer) μàÕ‡¡◊ËÕ∑”°“√øÕ°‡≈◊Õ¥‚¥¬„™âÕ—μ√“°“√π”‡≈◊Õ¥¡“°√Õß Ÿß°«à“ 300 ´’´’ μàÕπ“∑’‡∑à“π—Èπ 5

Practical Dialysis in the Year 2009 √ªŸ ∑Ë’ 2 §«“¡ —¡æπ— ∏√å –À«à“ßÕμ— √“°“√‡æ‘¡Ë ¢Õß blood flow °∫— Õ—μ√“°“√‡æ‘¡Ë ¢Õß clearance ¢Õß urea ®”·π°μ“¡ μ«— °√Õß™π‘¥ low flux ·≈– high flux (‡ πâ ∑∫÷ §Õ◊ °“√øÕ°‡≈Õ◊ ¥‡¡ÕË◊ ‡ª¥î dialysate flow 500 ´´’ μ’ Õà π“∑’ ·≈– ‡ πâ ª√–§Õ◊ °“√øÕ°‡≈Õ◊ ¥‡¡ÕË◊ ‡ª¥î dialysate flow 800 ´’´μ’ Õà π“∑’) (¥¥— ·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘ À¡“¬‡≈¢ 4) ª√–‡¥πÁ  ”§≠— Õ°’ ª√–°“√Àπß÷Ë ∑μ’Ë Õâ ß√–≈°÷ ‰«‡â  ¡Õ§Õ◊ ‡¡Õ◊Ë ‡æ¡‘Ë Õμ— √“°“√π”‡≈Õ◊ ¥¡“°√Õß„π°“√ √—°…“‚¥¬°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ (´÷Ëß„™â°≈‰°°“√¢—∫¢Õ߇ ’¬‚¥¬«‘∏’ diffusion ‡ªìπÀ≈—°) π—Èπ ®–  “¡“√∂‡æ¡‘Ë Õμ— √“°“√°”®¥— ¢Õ߇ ¬’ ∑¡’Ë ¢’ 𓥇≈°Á ‡∑“à ππ—È ·μ®à –‰¡¡à º’ ≈μÕà °“√°”®¥— ¢Õ߇ ¬’ ∑¡’Ë ¢’ 𓥄À≠à ¥ß— ∑‰Ë’ ¥·â  ¥ß„π√ªŸ ∑Ë’ 3 ¥ß— ππÈ— °“√‡æ¡Ë‘ °“√°”®¥— ¢Õ߇ ¬’ ∑¡Ë’ ¢’ 𓥄À≠à ®–∑”‰¥‡â ¡ÕË◊ ‡æ¡Ë‘ √–¬–‡«≈“¢Õß°“√ øÕ°‡≈◊Õ¥‡∑à“π—Èπ 5. °≈‰°°“√°√Õßπ”È  «à π‡°‘π °√–∫«π°“√π’ȇ°‘¥¢÷Èπ‚¥¬°“√°àÕ„À⇰‘¥§«“¡·μ°μà“ߢÕß√–¥—∫·√ߥ—ππÈ” (hydrostatic pressure gradient) √–À«à“ß Õߥâ“π¢Õ߇¬◊ËÕ°√Õß (dialyzer membrane) §«“¡·μ°μà“ßπ’ȇ√’¬°«à“ transmembrane pressure (TMP) ´÷Ëß®–¡’º≈∑”„Àâ “√πÈ”‡§≈◊ËÕπ¬â“¬®“°¥â“π∑’Ë¡’·√ߥ—π Ÿß (§◊Õ¥â“π¢Õß ‡¬◊ËÕ°√Õß∑’Ë —¡º— °—∫‡≈◊Õ¥∑’Ë∂Ÿ°π”¡“°√Õß)  àŸ¥â“π∑’Ë¡’·√ߥ—πμË” (§◊Õ¥â“π¢Õ߇¬◊ËÕ°√Õß∑’Ë —¡º— °—∫πÈ”¬“ dialysate ) ·≈–®–¡’º≈∑”„Àâ “√πÈ”∂Ÿ°°”®—¥ÕÕ°πÕ°√à“ß°“¬ºŸâªÉ«¬  “√πÈ”∑’Ë∂Ÿ°°”®—¥ÕÕ°πÕ°√à“ß°“¬ ¥â«¬°≈‰°π’È ®–‰¡à¡’Õߧåª√–°Õ∫Õ◊Ëπ¢Õ߇≈◊Õ¥ª–ªπ¡“¥â«¬ ‡™àπ ‡´≈≈åμà“ßÊ „π∑“ߪƑ∫—쑇√’¬°°≈‰°°“√ °”®¥—  “√π”È ¥«â ¬«∏‘ π’ «È’ “à ultrafiltration ´ßË÷ ®–·ª√μ“¡§«“¡Àπ“·≈–§«“¡„À≠¢à Õß™Õà ß∑¡Ë’ Õ’ ¬„àŸ π‡¬ÕË◊ °√Õß ·≈–¬—ß·ª√μ“¡ª√–‡¿∑¢Õßμ—«°√Õß∑’Ë∂Ÿ°º≈‘μÕÕ°¡“®”Àπà“¬ 6

Fundamentals of Hemodialysis √ªŸ ∑Ë’ 3 §«“¡·μ°μ“à ß√–À«“à ߺ≈¢Õß°“√‡æË¡‘ blood flow μÕà clearance ¢Õß “√∑¡Ë’ ¢’ 𓥇≈Á° (urea, creatinine) ‡∑¬’ ∫°—∫ clearance ¢Õß “√∑’Ë¡¢’ 𓥄À≠à (B12) (¥¥— ·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘ À¡“¬‡≈¢ 4) °“√°”Àπ¥Õ—μ√“°“√°√ÕßπÈ” (Ultrafiltration rate)  “¡“√∂§”π«≥‰¥â‚¥¬ ¡°“√ Ultrafiltration rate (UFR) = ultrafiltration coefficient × transmembrane pressure ‚¥¬∑’Ë UFR ¡’Àπ૬‡ªìπ ´’´’μàÕ™—Ë«‚¡ß Ultrafiltration coefficient ¡’Àπ૬‡ªìπ ´’´’μàÕ¡‘≈≈‘‡¡μ√ª√Õ∑ Transmembrane pressure ¡’Àπ૬‡ªìπ ¡‘≈≈‘‡¡μ√ª√Õ∑ ««‘ ≤— π“°“√¢Õß°“√º≈μ‘ μ«— °√Õ߇≈Õ◊ ¥¡¡’ “°¢πÈ÷ ‡√ÕË◊ ¬Ê·μ¬à ß— §ßÀ≈°— °“√∑ Ë’ ”§≠— ¥ßÈ— ‡¥¡‘ §Õ◊ „Àâ ¡’‡≈◊Õ¥‰À≈ºà“πμ—«°√Õß∑’Ë¡’æ◊Èπº‘«°«â“ߥ⫬՗μ√“°“√‰À≈‡«’¬π∑’ˉ¡à‡√Á«‡°‘π‰ª ‡æ◊ËÕ„À⇰‘¥°√–∫«π°“√ ´÷¡ºà“π (diffusion) Õ¬à“߇μÁ¡∑’Ë „π¬ÿ§‡√‘Ë¡μâπ¢Õß°“√øÕ°‡≈◊Õ¥ ª√–‡¿∑¢Õßμ—«°√Õ߇≈◊Õ¥∑’Ë„™â‰¥â·°à μ—« °√Õß√Ÿª·∫∫¢¥ (coil dialyzer) μàÕ¡“‰¥â¡’°“√‡ª≈’ˬπ·ª≈߇ªìπ√Ÿª·∫∫·ºàπ·∫π (flat plate dialyzer) ®π °√–∑ß—Ë ª√–¡“≥™«à ß 1980 ®ß÷ ‰¥¡â °’ “√‡ª≈¬’Ë π·ª≈߇ªπì ™π¥‘ ∑ª’Ë √–°Õ∫‰ª¥«â ¬‡¬Õ◊Ë ∫∑ÿ ¡’Ë √’ °Ÿ ≈«ß (hollow fiber dialyzer) ´÷Ë߇Õ◊ÈÕÕ”π«¬μàÕ°“√§«∫§ÿ¡°√–∫«π°“√°√ÕßπÈ” (ultrafiltration) ¥â«¬«‘∏’°“√§«∫§ÿ¡ª√‘¡“μ√„Àâ ·¡πà ¬”¢πÈ÷ ·≈–‰¥√â ∫— °“√„™‡â ªπì √ªŸ ·∫∫μ«— °√Õß¡“μ√∞“π®π∂ß÷ ª®í ®∫ÿ π— ««‘ ≤— π“°“√¢Õß°“√ª√–¥…‘ ∞μå «— °√Õß¡’¡“°¢÷Èπ‡√◊ËÕ¬Ê ·≈–„πªí®®ÿ∫—π ‰¥â¡’°“√„™âμ—«°√Õß hollow fiber ª√– ‘∑∏‘¿“æ ŸßÕ¬à“ß·æ√àÀ≈“¬ 5 ¢Õâ ¥¢’ Õßμ«— °√Õߪ√– ∑‘ ∏¿‘ “æ ßŸ §Õ◊ ¡§’ “à ª√– ∑‘ ∏¿‘ “æ¢Õß°“√°√Õßπ”È ultrafiltration coefficient (Kuf) ¢Õß 7

Practical Dialysis in the Year 2009  “√πÈ” Ÿß¡“° ·≈– “¡“√∂‡æ‘Ë¡°“√°”®—¥¢Õ߇ ’¬¥â«¬°≈‰°°“√π”æ“ (´÷Ë߇ªìπº≈æ≈Õ¬‰¥â¢Õß°“√¡’ Kuf  ßŸ ) √à«¡°—∫°≈‰°°“√´÷¡ºà“π (´÷Ë߇ªìπ°≈‰°ª°μ‘¢Õß°“√°”®—¥¢Õ߇ ’¬¢Õßμ—«°√Õߪ°μ‘) 6 À“°ºâŸ√—°…“μâÕß°“√‡æ‘Ë¡Õ—μ√“°“√°√ÕßπÈ” (UFR)  “¡“√∂∑”‰¥â‚¥¬‡≈◊Õ°„™âμ—«°√Õß∑’Ë¡’§à“ Ultrafiltration coefficient  Ÿß (‡™àπ high flux dialyzer) À√◊Õ‡æ‘Ë¡ transmembrane pressure „π°√≥’∑’ˇ≈◊Õ°„™â μ—«°√Õß∑’Ë¡’§à“ Ultrafiltration coefficient μË” (low flux dialyzer) „π∑“ߪؑ∫—μ‘ °“√‡æ‘Ë¡ Transmembrane pressure  “¡“√∂∑”‰¥‚â ¥¬‡æ¡Ë‘ ·√ߥπ— π”È ¥“â π∑‡Ë’ ≈Õ◊ ¥ ¡— º — °∫— ‡¬ÕË◊ °√Õß (ª°μ®‘ –¡§’ “à ‡ªπì ∫«°) À√Õ◊ ª√∫— ·√ߥ—π¥â“π∑’ˇ¬◊ËÕ°√Õß —¡º— °—∫πÈ”¬“ dialysate „À⇪ìπ≈∫¡“°¢÷Èπ ´÷Ëß “¡“√∂∑”‰¥â‚¥¬°“√„™â‡§√◊ËÕߥ¥Ÿ Õ“°“» (suction) ∑ßÈ— π°È’ “√‡æ¡Ë‘ TMP  “¡“√∂∑”‰¥‚â ¥¬°“√ª√∫— ·√ߥπ— π”È ¢Õß∑ßÈ—  Õߥ“â π¢Õ߇¬ÕË◊ ∫‰ÿ ¥â ‚¥¬ °“√ª√∫— ∑‡Ë’ §√ÕË◊ ßøÕ°‡≈Õ◊ ¥∑≈’ –§√ßÈ— À√Õ◊ ®–°”Àπ¥„À‡â §√ÕË◊ ߉μ‡∑¬’ ¡‡æ¡Ë‘ TMP ¥«â ¬°≈‰°Õμ— ‚π¡μ— √‘ –À«“à ß °“√øÕ°‡≈Õ◊ ¥·μ≈à –§√ß—È ‡æÕ◊Ë „À‰â ¥ªâ √¡‘ “≥ “√πÈ”∑μ’Ë Õâ ß°“√°”®¥— ÕÕ°πÕ°√“à ß°“¬μ“¡Õμ— √“∑μ’Ë Õâ ß°“√ „π ª®í ®∫ÿ π— ‡§√Õ◊Ë ß‰μ‡∑¬’ ¡®–¡°’ ≈‰°°“√§«∫§¡ÿ ultrafiltration rate ∑¥’Ë ¢’ π÷È °«“à „πÕ¥μ’ ‚¥¬°“√„™√â –∫∫ balancing chamber À√◊Õ microprocessor controlled-flow sensor ´÷Ëß®–™à«¬„ÀâÕ—μ√“°“√°√ÕßπÈ”ÕÕ°πÕ°√à“ß°“¬ ‡ªπì ‰ªÕ¬“à ß·¡πà ¬”μ“¡∑º’Ë √⟠°— …“μÕâ ß°“√‰¡«à “à ®–„™μâ «— °√Õß™π¥‘ „¥À√Õ◊ ¡°’ “√‡ª≈¬’Ë π·ª≈ߢÕßTMP ¡“° πâÕ¬‡∑à“„¥ √–À«à“ß°“√√—°…“‚¥¬°“√øÕ°‡≈◊Õ¥°Áμ“¡ 6. ¿“§ªØ∫‘ μ— ¢‘ Õß°“√√°— …“‚¥¬°“√øÕ°‡≈◊Õ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑’¬¡ „πª®í ®∫ÿ π— ¡°’ “√æ≤— π“·π«ªØ∫‘ μ— ¢‘ Õß°“√√°— …“‚¥¬°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡¢π÷È ¡“° ‡™πà ·π«ªØ∫‘ μ— ∑‘ ‡’Ë √¬’ °«“à K/DOQI guidelines ‡æÕ◊Ë °”À𥇪“Ñ À¡“¬¢Õß°“√√°— …“‚¥¬°“√øÕ°‡≈Õ◊ ¥7 Õ¬“à ߉√ °Áμ“¡‡¡◊ËÕμ‘¥μ“¡º≈√–¬–¬“« æ∫«à“ºâŸªÉ«¬∑’Ë√—∫ chronic hemodialysis ¡’Õ—μ√“°“√‡ ’¬™’«‘μ ßŸ ¡“°∂÷ß 235 √“¬μÕà ºªâŸ «É ¬ 1000 √“¬-ªï (¢Õâ ¡≈Ÿ USRDS 2005) ·≈–‡¡ÕË◊ «‡‘ §√“–À å “‡Àμ¢ÿ Õß°“√‡ ¬’ ™«’ μ‘ ®–æ∫«“à  “‡Àμÿ ¢Õß∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥§◊Õ °“√‡ ’¬™’«‘μ “‡Àμÿ®“°‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥ (æ∫ª√–¡“≥§√÷ËßÀπ÷ËߢÕß°“√ ‡ ’¬™’«‘μ∑—ÈßÀ¡¥) ¥—ßπ—Èπ®÷ß¡’°“√»÷°…“‡æ‘Ë¡‡μ‘¡‡æ◊ËÕª√–‡¡‘π«à“À“°ª√—∫°“√√—°…“‚¥¬°“√øÕ°‡≈◊Õ¥‚¥¬ ¡’‡ªÑ“À¡“¬‡æ◊Ëՙ૬¢—∫¢Õ߇ ’¬‡æ‘Ë¡¢÷Èπ ®–¡’º≈≈¥Õ—μ√“°“√‡ ’¬™’«‘μ¢Õߺ⟪ɫ¬À√◊Õ‰¡à 8 °“√»°÷ …“∑‡’Ë √¬’ °«“à HEMO study ‡ªπì °“√»°÷ …“·∫∫‰ª¢“â ßÀπ“â (prospective study) ´ß÷Ë √“¬ß“π „πªï 2002 ‚¥¬¡’ ¡¡ÿμ‘∞“π«à“ºŸâªÉ«¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥¡“° (¡’ dialysis index ™π‘¥ eKT/V = 1.45 μàÕ °“√øÕ°‡≈Õ◊ ¥ÀπßË÷ §√ßÈ— ·≈– ª— ¥“À≈å – 3 §√ßÈ— ) ®–¡Õ’ μ— √“°“√Õ¬√àŸ Õ¥√–¬–¬“« ßŸ °«“à ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√øÕ° ‡≈◊Õ¥¡“μ√∞“π (¡’ dialysis index ™π‘¥ eKT/V = 1.05 μàÕ°“√øÕ°‡≈◊Õ¥Àπ÷Ëߧ√—Èß·≈– —ª¥“Àå≈– 3 §√—Èß) ·μà °≈—∫æ∫«à“‡¡◊ËÕμ‘¥μ“¡∂÷ß 5 ªï ºŸâªÉ«¬∑—Èß Õß°≈ÿà¡ ¡’Õ—μ√“°“√Õ¬àŸ√Õ¥∑’ËÀ⓪ï‡∑à“°—π§◊Õ 40% ´÷Ë߇ªìπº≈∑’ˉ¡à §“¥§‘¥¡“°àÕπ (√Ÿª∑’Ë 4) ∑ßÈ— π§È’ ≥–º»Ÿâ °÷ …“‰¥∑â ”°“√«‡‘ §√“–À‡å æ¡Ë‘ ‡μ¡‘ ‡æÕË◊ À“§”Õ∏∫‘ “¬«“à ‡Àμ„ÿ ¥®ß÷ ‡ªπì ‡™πà πÈ’ ·≈–æ∫ «à“ À“°π”§à“ e KT/V ¢Õߺ⟪ɫ¬∑—Èß Õß°≈ÿà¡¡“§”π«π equivalent renal clearance μàÕ —ª¥“Àå (´÷Ë߇ªìπ KT/ V ¡“μ√∞“π ·≈– “¡“√∂„™‡â ª√¬’ ∫‡∑¬’ ∫√–À«“à ß°≈¡ÿà ºªâŸ «É ¬∑√’Ë °— …“‚¥¬°“√øÕ°‡≈Õ◊ ¥ ·≈–∑√’Ë °— …“‚¥¬°“√ ≈â“ß™àÕß∑âÕß) æ∫«à“ °≈ÿà¡∑’ËøÕ°‡≈◊Õ¥¡“°®–¡’§à“ Equivalent renal clearance ‡∑à“°—∫ 15 ´’´’μàÕπ“∑’ ‡¡◊ËÕ ‡∑’¬∫°—∫°≈ÿà¡∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥¡“μ√∞“π®–¡’§à“ equivalent renal clearance ‡∑à“°—∫ 11 ´’´’μàÕπ“∑’ 9 8

Fundamentals of Hemodialysis √ªŸ ∑Ë’ 4 · ¥ßÕμ— √“°“√Õ¬Ÿà√Õ¥¢Õߺ⟪ɫ¬∑Ë’Õ¬Ÿà„π°“√»°÷ …“ HEMO ‚¥¬‡ª√¬’ ∫‡∑’¬∫°≈à¡ÿ ∑’ˉ¥√â ∫— hemodialysis ¢π“¥  Ÿß (high dose) ‡∑’¬∫°—∫°≈¡àÿ ∑’ˉ¥√â —∫ hemodialysis ¢π“¥¡“μ√∞“π (standard dose) æ∫«à“‰¡·à μ°μà“ß°π— Õ¬à“ß¡π’ ¬—  ”§—≠ ´÷Ëߧ‘¥‡ªì𧫓¡·μ°μà“ß‡æ’¬ß 4 ´’´’μàÕπ“∑’ ·≈–‰¡àμà“ß°—π¡“° (√Ÿª∑’Ë 5) ‡π◊ËÕß®“°°“√øÕ°‡≈◊Õ¥¥â«¬ ‡§√◊ËÕ߉μ‡∑’¬¡‡ªìπ°“√√—°…“‰¡àμàÕ‡π◊ËÕß ‚¥¬∑’Ë√–¥—∫¢Õ߇ ’¬®–∂Ÿ°¢—∫ÕÕ°¡“°√–À«à“ßøÕ°‡≈◊Õ¥ ·μà®– ‰¡∂à °Ÿ ¢∫— ÕÕ°‡≈¬„π™«à ß∑‰’Ë ¡‰à ¥øâ Õ° ´ß÷Ë ·μ°μ“à ß®“°°“√√°— …“‚¥¬«∏‘ ’ CAPD ´ß÷Ë ¡°’ “√¢∫— ¢Õ߇ ¬’ ÕÕ°μ≈Õ¥ ‡«≈“ ¥ß— ππÈ— ·π«∑“ß°“√ª√∫— °“√√°— …“‚¥¬°“√øÕ°‡≈Õ◊ ¥∑‡Ë’ À¡“– ¡ ”À√∫— ºªâŸ «É ¬∑¡Ë’ ‚’ √§À«— „® §Õ◊ °“√‡æ‘Ë¡®”π«π§√—ÈߢÕß°“√øÕ°‡≈◊Õ¥μàÕ —ª¥“Àå ‡™àπ‡æ‘Ë¡‡ªìπ 4 §√—Èß ´÷Ëß®–¡’º≈‡æ‘Ë¡ standard KT/V ‰¥â¥’ °«“à °“√‡æ¡Ë‘ ¢π“¥¢Õß KT/V „π°“√øÕ°·μ≈à –§√ßÈ— ·≈–®–¡º’ ≈¥„’ π·ß¢à Õß°“√¢∫—  “√π”È ÕÕ°πÕ°√“à ß°“¬ (ultrafiltration) ´ßË÷ ¡º’ ≈≈¥Õ∫ÿ μ— °‘ “√≥¢å Õß°“√‡°¥‘ ‚√§π”È ∑«à ¡ªÕ¥‰¥¥â  ’ ”À√∫— ºªâŸ «É ¬‰μ«“¬∑¡Ë’ ‚’ √§À«— „®√«à ¡ ¥â«¬ ·≈–§«√‡®“–‡≈◊Õ¥μ√«®√–¥—∫‡°≈◊Õ·√à‚ªμ— ‡´’ˬ¡ À“°æ∫«à“μË”°«à“ 4.0 meq/L °Á§«√®–ª√—∫√–¥—∫ ‚ªμ— ‡´’ˬ¡„ππÈ”¬“ dialysate ‡ªìπ 3.0 meq/L ·∑π∑’Ë 2.0 meq/L ∑—Èßπ’È¡’¢âÕ¡Ÿ≈«à“Õ—μ√“°“√‡ ’¬™’«‘μ¢Õߺ⟠ªÉ«¬øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡®– ßŸ ¢÷Èπ À“°√–¥—∫‚ªμ— ‡´’ˬ¡„π‡≈◊Õ¥¡’§à“μË”°«à“ 4.0 À√◊Õ Ÿß°«à“ 5.9 meq/l 10 ª√–‚¬™πåÕ◊Ëπ¢Õß°“√‡æ‘Ë¡®”π«π§√—ÈߢÕß°“√øÕ°‡≈◊Õ¥®“° 3 ‡ªìπ 4 §√—ÈßμàÕ —ª¥“Àå§◊Õ °“√ §«∫§ÿ¡ phosphorus ®–¥’¢÷Èπ 11 ·≈–¡’¢âÕ¡Ÿ≈«à“ “¡“√∂™–≈Õ°“√°”‡√‘∫¢Õß vascular calcification 12 ·≈– °“√¢—∫ Beta 2 microglobulin ®–¡“°¢÷Èπ13 ´÷ËßÕ“®¡’º≈™à«¬≈¥Õÿ∫—μ‘°“√≥å¢Õß‚√§·∑√°∑“ß°√–¥°Ÿ ‚¥¬ ‡©æ“– Beta-2 microglobulin amyloidosis „ÀâπâÕ¬≈ß Õ¬à“߉√°Áμ“¡ §«√§”π÷ß∂÷ßªí®®—¬¥â“π‡»√…∞“π– ·≈–§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬√à«¡¥â«¬‡ ¡Õ °“√ª√—∫°“√√—°…“‚¥¬‡æ‘Ë¡®”π«π§√—ÈߢÕß°“√øÕ°‡≈◊Õ¥π—Èπ ®–¡’ª√–‚¬™πå„π√“¬∑’Ë¡’‚√§À—«„®√à«¡¥â«¬ ·≈–‰¡à§«√ªØ‘∫—쑇°‘𧫓¡®”‡ªìπ 9

Practical Dialysis in the Year 2009 √Ÿª∑’Ë 5 · ¥ß§«“¡ ¡— æπ— ∏√å –À«“à ß equilibrated hemodialysis KT/V (·°π X) ‡∑¬’ ∫°∫— Equivalent renal clearance (·°π Y) μ“¡„π√Ÿª®–æ∫«“à ºâŸª«É ¬∑’ËøÕ°‡≈◊Õ¥‰¥â equilibrated KT/V = 1.0 ·≈–øÕ° —ª¥“À≈å – 3 §√ß—È ®–‰¥â§à“ equivalent renal clearance ‡∑à“°—∫ 11 ´’´’μÕà π“∑’ ·≈–°“√øÕ°‡≈◊Õ¥∑Ë’‰¥â equilibrated KT/V ‡∑à“°—∫ 1.4 ‡ªìπ‡«≈“ 3 §√È—ßμàÕ —ª¥“Àå ®–‰¥â§à“ equivalent renal clearance ‡∑à“°—∫ 15 ´’´’μàÕπ“∑’ (¥—¥·ª≈ß®“°‡Õ° “√Õâ“ßÕ‘ß∑Ë’ 9) 7. ∫∑ √ÿª °“√√°— …“‚¥¬°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡ (hemodialysis) ‡ªπì °“√√°— …“∑¥·∑π‰μ∑¡Ë’ „’ ™â „π‡«™ªØ‘∫—μ‘¡“π“π °√–∫«π°“√π’È¡’À≈—°°“√∑’Ë™—¥‡®π „πªí®®ÿ∫—π ∫ÿ§§≈“°√∑“ß°“√·æ∑¬å∑ÿ°§π §«√§”π÷߉«â‡ ¡Õ«à“ªí≠À“∑’Ë ”§—≠·≈–∑â“∑“¬¡“°§◊Õ ∑”Õ¬à“߉√„ÀâºâŸªÉ«¬∑’Ë√—∫°“√øÕ°‡≈◊Õ¥¡’™’«‘μ∑’Ë ¬◊𬓫 ·≈–¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’§«∫§Ÿà°—π‰ª §”∂“¡π’Ȭ—߉¡à¡’§”μÕ∫∑’Ë¥’∑’Ë ÿ¥ ·μà∫ÿ§§≈“°√∑“ß°“√ ·æ∑¬∑å °ÿ §π §«√®–¡·’ 𫧥‘ „π°“√»°÷ …“§πâ §«“â ‡æ¡Ë‘ ‡μ¡‘ ·≈–μÕà ‡πÕË◊ ß Õπ— ®– ßà º≈„À¡â °’ “√‡æ¡Ë‘ æπŸ ∑°— …– ∑—Èß∑“ߥâ“π∑ƒ…Ø’·≈–ªØ‘∫—μ‘ ‡æ◊Ëՙ૬„π°“√¥Ÿ·≈√—°…“ºâŸªÉ«¬‚√§‰μ«“¬‡√◊ÈÕ√—߉¥âÕ¬à“ß¡’À≈—°°“√ ·≈–  “¡“√∂«“ß·ºπ°“√√—°…“‰¥â¥’¢÷Èπ Õ—π®–¡’º≈μàÕ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§‰μ‡√◊ÈÕ√—ß„À⥒¬‘Ëߢ÷ÈπμàÕ‰ª 10

Fundamentals of Hemodialysis ‡Õ° “√Õ“â ßÕß‘ 1. Griffith TF, Reddan D, Owen Jr WF. Hemodialysis adequacy. In: Therapy in Nephrology and Hypertension. Second edition. Brady HR, Wilcox CS (eds). Saunders, Philadelphia, 2003, p 797-9. 2. Yeun JY, Depner TA. Principles of Hemodialysis. In: Chronic kidney disease, dialysis, transplantation. Second edition. Pereira BJG, Sayegh MH, Blake P (eds). Elsevier, Philadelphia, 2005, p 307-40. 3. Levy J, Morgan J, Brown E (eds). Oxford handbook of dialysis. Second edition. Oxford University Press, Oxford, 2001, p 74-6. 4. Daugirdas JT, Van Stone, JC, Boag JT. Hemodialysis: Hemodialysis apparatus. In: Handbook of Dialysis. Third edition. Daugirdas, JT, Blake PG, Ing, TS (eds). Lippincott Williams & Wilkins, Philadelphia, 2001, p 46-66. 5. Schulman G, Levin NW. Membrane for hemodialysis. Semin Dialysis 1994;7: 251-6. 6. Pastan S, Bailey J. Dialysis therapy. N Engl J Med 1998; 338:1428-37. 7. K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations 2006 Updates Hemodialysis Adequacy, Peritoneal Dialysis Adequacy, Vascular Access. Am J Kidney Dis 2006; 48(Suppl 1): S1. 8. Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW, et al. N Eng J Med 2002; 347: 2010-9. 9. Casino FG, Lopez T. Nephrol Dial Transplant. 1996; 11: 1574-81. 10. Kovesdy CP, Regidor DL, Mehrotra R, Jing J, Mcallister CJ, Greenland S, et al. Clin J Am Soc Nephrol 2007; 2: 999- 1007. 11. Mucsi I, Hercz G, Uldall R, Ouwendyk M, Francoeur R, Pierratos A. Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis. Kidney Int 1998; 53: 1399-404. 12. Yuen D, Pierratos A, Richardson RM, Chan CT. The natural history of coronary calcification progression in a cohort of nocturnal hemodialysis patients. Nephrol Dial Transplant. 2006; 21: 1407-12. 13. Raj DS, Ouwendyk M, Francoeur R, Pierratos A. Beta (2) - cryoglobulin kinetics in nocturnal hemodialysis. Nephrol Dial Transplant 2000; 15: 58-64. 11



Water Treatment: What is the Optimal Standard? 2 Water Treatment: What is the Optimal Standard? °≈»√ ¿—§‚™μ“ππ∑å 1. §ÿ≥¿“æπ”È ∫√ ‘ ÿ∑∏Ï‘∑πË’ ”¡“„™·â ≈–°“√μ√«® Õ∫§ÿ≥¿“æπ”È 2. §ÿ≥≈—°…≥–¢ÕßÕÿª°√≥å∑Ë’„™â„π√–∫∫π”È ∫√‘ ∑ÿ ∏Ï‘ 3. °“√∫”√ÿß√°— …“·≈–μ√«® Õ∫√–∫∫π”È ∫√ ‘ ÿ∑∏Ï‘ 13

Practical Dialysis in the Year 2009 „π√–∫∫∫√‘°“√ hemodialysis ‡ªìπ∑’Ë∑√“∫°—π¥’«à“ √–∫∫°“√‡μ√’¬¡πÈ”∫√‘ ÿ∑∏‘Ï¡’§«“¡ ”§—≠ ‡ªìπÕ¬à“ß¡“° ‡æ√“–À“°¡’°“√§«∫§ÿ¡§ÿ≥¿“æ¢Õß√–∫∫πÈ”∫√‘ ÿ∑∏‘ω¡à¥’æÕ ®– àߺ≈‡ ’¬μàպ⟪ɫ¬∑—Èß „π√–¬– —Èπ·≈–√–¬–¬“« ·≈–∫“ߧ√—ÈßÕ“®√ÿπ·√ß®π‡ªì𠓇Àμÿ„À⺟âªÉ«¬‡ ’¬™’«‘μ‰¥â ¥—ßπ—Èπ®÷ßμâÕß¡’°“√ «“ß¡“μ√∞“π¢ÕßπÈ”∫√‘ ÿ∑∏‘Ï∑’Ëπ”¡“„™â·≈–¡’°“√«“ß·π«∑“ߪؑ∫—쑇°’ˬ«°—∫√–∫∫πÈ”∫√‘ ÿ∑∏‘Ï∑’Ë„™â  ”À√∫— °“√∑” hemodialysis ·π«∑“ߪØ∫‘ μ— ∑‘ ¡Ë’ °— 𬑠¡Õ“â ßÕß‘ °π— „πª®í ®∫ÿ π— ‰¥·â °·à π«∑“ߢÕß Association for the Advancement of Medical Instrumentation (AAMI)1, 2 ·≈–¢Õß European Best Practice Guideline3 „π à«π¢Õߪ√–‡∑»‰∑¬‡Õß°Á‰¥â¡’°“√«“ß·π«∑“ߪؑ∫—μ‘„π‡√◊ËÕßπ’ȉ«â‚¥¬ ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬ (©∫—∫ªï 2550)4 ‡æ◊ËÕ„À⻟π¬å‰μ‡∑’¬¡„πª√–‡∑»‰∑¬„™â‡ªìπ·π«∑“ߪؑ∫—μ‘¢—Èπæ◊Èπ∞“π ‚¥¬‰¥âæ‘®“√≥“π” ·π«∑“ߪؑ∫—μ‘¢Õßμà“ߪ√–‡∑»¡“ª√—∫„™â„Àâ‡À¡“– ¡°—∫ ¿“懻√…∞“π–·≈– —ߧ¡¢Õߪ√–‡∑»‰∑¬ ¡“μ√∞“π‡°¬Ë’ «°∫— √–∫∫π”È ∫√ ‘ ∑ÿ ∏∑Ï‘ „Ë’ ™°â ∫— hemodialysis ‚¥¬∑«Ë— ‰ª·∫ßà ÕÕ°‡ªπì 3  «à π„À≠Êà ¥—ßπ’È 1. §ÿ≥¿“æπÈ”∫√‘ ÿ∑∏∑Ï‘ Ë’π”¡“„™â·≈–°“√μ√«® Õ∫§≥ÿ ¿“æπ”È πÈ”∫√‘ ÿ∑∏‘Ï∑’Ëπ”¡“„™â®–μâÕß¡’§ÿ≥¿“槫“¡∫√‘ ÿ∑∏‘Ï∑—Èß„π¥â“𰓬¿“æ ‡§¡’·≈–™’«¿“æ °≈à“«§◊Õ ®–μâÕß„  –Õ“¥ ª√“»®“°μ–°Õπ °≈‘Ëπ ’ ‰¡à¡’ª√‘¡“≥ “√‡§¡’μà“ßÊ ªπ‡ªóôÕπÀ√◊Õ¡’πâÕ¬ ¡“°§◊ÕμâÕß¡’‰¡à¡“°°«à“‡°≥±å∑’Ë°”À𥉫â„π AAMI  “√‡§¡’∑’˧«√√–¡—¥√–«—߇ªìπ摇»…§◊Õ aluminum, chlorine/chloramines, copper, fluoride, lead, nitrate, sulfate, zinc ‡π◊ËÕß®“°‡§¬¡’À≈—°∞“π°“√°àÕ„À⇰‘¥ º≈·∑√°´âÕπ„πºâŸªÉ«¬¡“·≈â« πÕ°®“°π’È “√∫“ß™π‘¥∂÷ß·¡â®–‡ªìπ à«πª√–°Õ∫∑’Ë ”§—≠Õ¬Ÿà„π√à“ß°“¬ μ“¡ª°μ‘ ·μà∂â“¡’®”π«π¡“°‡°‘π‰ª°ÁÕ“®‡°‘¥º≈·∑√°´âÕπ‰¥â §◊Õ calcium, magnesium, potassium ·≈– sodium §ÿ≥¿“æπÈ”∫√‘ ÿ∑∏‘Ï∑’Ë ”§—≠Õ’°ª√–°“√Àπ÷Ëߧ◊Õ ®–μâÕ߉¡à¡’‡™◊ÈÕ‚√§·≈– endotoxin ªπ‡ªóôÕπ ‚¥¬°”Àπ¥„À®â ”π«π‡™ÕÈ◊ ·∫§∑‡’ √¬’ „ππ”È ∫√ ‘ ∑ÿ ∏·Ï‘ ≈–„π dialysate μÕâ ßπÕâ ¬°«“à 200 CFU/mL ·≈–ª√¡‘ “≥ endotoxin μâÕßπâÕ¬°«à“ 2 EU/mL μ“¡≈”¥—∫ (°”Àπ¥„Àâ¡’ action level ¢Õß®”π«π‡™◊ÈÕ·∫§∑’‡√’¬∑’Ë 50 CFU/mL ·≈–ª√‘¡“≥ endotoxin ∑’Ë 1 EU/mL) °“√μ√«® Õ∫§ÿ≥¿“æπÈ”∫√‘ ÿ∑∏‘Ï∂◊Õ«à“‡ªìπÀ—«„®¢Õß°“√°”°—∫¥Ÿ·≈√–∫∫πÈ”∫√‘ ÿ∑∏‘Ï ‡æ√“– ‡ªìπ ‘Ëß∑”„Àâ¡—Ëπ„®‰¥â«à“πÈ”∑’Ëπ”¡“„™â„π°“√∑” hemodialysis ¡’§ÿ≥¿“æÕ¬àŸ„π‡°≥±å¡“μ√∞“πÕ¬Ÿà‡ ¡Õ ·≈–‡ªπì °“√ªÕÑ ß°π— ‰¡„à À‡â °¥‘ º≈‡ ¬’ ·∑√°´Õâ πμ“à ßÊ μÕà ºªâŸ «É ¬ Õπ— ‡°¬Ë’ «‡πÕË◊ ß¡“®“°§≥ÿ ¿“æπ”È ∑πË’ ”¡“„™â °“√μ√«® Õ∫§ÿ≥¿“æπÈ”∫√‘ ÿ∑∏‘Ï·∫àßÕÕ°‡ªìπ °“√μ√«® Õ∫∑“߇§¡’ ·≈–°“√μ√«® Õ∫∑“ß™’«¿“æ °“√μ√«® Õ∫∑“߇§¡’„Àâμ√«® Õ∫‚¥¬°“√ àßμ√«®À“ª√‘¡“≥ “√∑’Ë°”À𥉫â„π‡°≥±å¢Õß AAMI ªï≈– 1 §√—Èß  à«π°“√μ√«® Õ∫∑“ß™’«¿“æ „Àâ àßμ√«®‡æ“–‡™◊ÈÕ·≈–π—∫®”π«π‡™◊ÈÕ·∫§∑’‡√’¬‡ªìπª√–®”∑ÿ° 1 ‡¥◊Õ𠧫∫§Ÿà‰ª°—∫°“√À“ª√‘¡“≥ endotoxin ªí®®ÿ∫—π„πª√–‡∑»‰∑¬¬—ߪ√– ∫ªí≠À“·À≈àß√—∫μ√«® endotoxin ¡’πâÕ¬ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πμà“ß®—ßÀ«—¥∫“ß·ÀàßÕ“®‰¡à “¡“√∂ àßμ√«®‰¥â ·≈–§à“„™â®à“¬ „π°“√μ√«®¬—ß¡’√“§“§àÕπ¢â“ß Ÿß  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬®÷ß·π–π”„À⧫√ àßμ√«®Õ¬à“ßπâÕ¬∑ÿ° 3 ‡¥◊Õπ ·μà ”À√—∫»Ÿπ¬å‰μ‡∑’¬¡∑’Ë¡’°“√∑” hemodiafiltration μâÕß„À⧫“¡ ”§—≠¢Õß°“√μ√«®À“ª√‘¡“≥ endotoxin ‚¥¬‡§√àߧ√—¥ ‡π◊ËÕß®“°πÈ”∑’Ëπ”¡“„™â®–‡¢â“ àŸ°√–· ‡≈◊Õ¥¢ÕߺŸâªÉ«¬‚¥¬μ√ß §ÿ≥¿“æπÈ” 14

Water Treatment: What is the Optimal Standard? ∫√‘ ÿ∑∏‘Ï∑’Ëπ”¡“„™â®÷ßμâÕß¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß¢÷Èπ„π√–¥—∫ ultrapure °≈à“«§◊Õ®”π«π‡™◊ÈÕ·∫§∑’‡√’¬∑—Èß„ππÈ” ∫√‘ ÿ∑∏‘Ï·≈–„π dialysate μâÕßπâÕ¬°«à“ 0.1 CFU/mL ·≈–ª√‘¡“≥ endotoxin μâÕßπâÕ¬°«à“ 0.03 EU/mL μ“¡≈”¥—∫ „πμà“ߪ√–‡∑»‚¥¬‡©æ“–Õ¬à“߬‘Ëߪ√–‡∑»·∂∫∑«’ª¬ÿ‚√ª ·π–π”„Àâ„™â ultrapure water ‡ªìπ¡“μ√∞“π„π»Ÿπ¬å‰μ‡∑’¬¡∑—Ë«‰ª ‚¥¬„™â°—∫°“√∑” hemodialysis ∑—Èß™π‘¥ conventional hemodialysis ·≈– hemodiafiltration/hemofiltration ‡π◊ËÕß®“°¡’À≈—°∞“π°“√‡°‘¥º≈·∑√°´âÕπμà“ßÊ μàÕºŸâªÉ«¬πâÕ¬°«à“ º≈°“√√—°…“„π√–¬–¬“«¥’°«à“ ·≈–‡∑§π‘§°“√∑” ultrapure water ‰¡à‰¥â¬ÿà߬“° ‡æ’¬ß„ àμ—«°√Õß∑’Ë¡’ pore size ¢π“¥‡≈Á°‡æ‘Ë¡∑’Ë®ÿ¥®à“¬πÈ”∫√‘ ÿ∑∏‘Ï°àÕπ®à“¬„Àâ°—∫‡§√◊ËÕ߉μ‡∑’¬¡·μà≈–‡§√◊ËÕß ·≈–‡æ‘Ë¡μ—«°√Õß™π‘¥ ‡¥’¬«°—ππ’È∑’Ë®ÿ¥®à“¬πÈ” dialysate ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡·μà≈–‡§√◊ËÕß °àÕπ à߇¢â“μ—«°√Õ߇≈◊Õ¥·≈–°àÕπ∑’Ë®– „™â‡ªìπ “√≈–≈“¬∑¥·∑π‡¢â“ àŸ°√–· ‡≈◊Õ¥ºâŸªÉ«¬ ·μà°“√∑” ultrapure water ®– ‘Èπ‡ª≈◊Õß§à“„™â®à“¬ Ÿß ¢÷Èπ·≈–μâÕß°“√°“√∫”√ÿß√—°…“∑’ˇ¢â¡ß«¥°«à“ §◊Õ®–μâÕß¡’°“√Õ∫¶à“‡™◊ÈÕ„π√–∫∫∂’Ë¢÷Èπ (·π–π”„Àâ∑”∑ÿ° 1 ‡¥◊Õπ) ·≈–°√–∫«π°“√μ√«®À“®”π«π‡™◊ÈÕ·∫§∑’‡√’¬·≈– endotoxin μâÕß¡’§«“¡‰«‡æ’¬ßæÕ ‡∑§π‘§«‘∏’°“√‡°Á∫μ—«Õ¬à“ßπÈ” àßμ√«®·≈–‡∑§π‘§°“√‡æ“–‡™◊ÈÕ¡’§«“¡ ”§—≠ ·≈–μâÕß ªØ‘∫—μ‘„Àâ∂Ÿ°μâÕß (¥Ÿ√“¬≈–‡Õ’¬¥„π·π«∑“ߪؑ∫—μ‘¢Õß ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬) ‡æ√“–∂â“∑”‰¡à ∂Ÿ°«‘∏’®– àߺ≈∑”„Àâ§à“∑’Ëμ√«®π—∫‰¥â¡’§«“¡º‘¥æ≈“¥∑—Èß„π·ßà¡“°·≈–πâÕ¬°«à“§«“¡‡ªìπ®√‘ß ‡∑§π‘§ °“√‡°Á∫μâÕß –Õ“¥‡æ◊ËÕªÑÕß°—π contamination °“√‡æ“–‡™◊ÈÕ®“°πÈ”∫√‘ ÿ∑∏‘ÏμâÕßÕ“»—¬ media 摇»… (trypticase soy agar À√◊Õ Reasonerûs 2A agar ´÷Ë߇ªìπ low nutrient media) ‡π◊ËÕß®“°‡™◊ÈÕ·∫§∑’‡√’¬∑’Ë  “¡“√∂ª√—∫ ¿“æ„Àâ§ß™’«‘μÕ¬àŸ‰¥â„ππÈ”∫√‘ ÿ∑∏‘Ï ®–쓬‰¥âßà“¬‡¡◊ËÕπ”¡“≈߇擖‡™◊ÈÕ„π media ∏√√¡¥“ ∑’Ë„™â°—π‚¥¬∑—Ë«‰ª„πÀâÕßØ‘∫—μ‘°“√ Õ’°∑—Èß°“√μ√«®π—∫®”π«π‡™◊ÈÕμâÕß¡’§«“¡‰«‡æ’¬ßæÕ ¥—ßπ—Èπª√‘¡“≥ μ—«Õ¬à“ßπÈ”∫√‘ ÿ∑∏‘Ï„π°“√≈߇擖‡™◊ÈÕμâÕß„™âª√‘¡“≥¡“°°«à“°“√‡æ“–‡™◊ÈÕ®“° ‘Ëß àßμ√«®Õ◊ËπÊ ∑’ˉ¥â®“° √à“ß°“¬ºŸâªÉ«¬ °“√∑’Ë»Ÿπ¬å‰μ‡∑’¬¡μ√«®‰¡àæ∫‡™◊ÈÕ·∫§∑’‡√’¬À√◊Õμ√«®æ∫πâÕ¬°«à“‡°≥±å∑’Ë°”Àπ¥μâÕß ·πà„®«à“‡∑§π‘§°“√ àßμ√«®∂Ÿ°μâÕß·≈â« ®¥ÿ ‡°∫Á μ«— Õ¬“à ßπÈ”∑·’Ë π–π”„À â ßà μ√«®‡ªπì ª√–®”‰¥·â °àμ«— Õ¬“à ßπÈ”„π√–∫∫∑Õà ®“à ¬πÈ”∫√ ‘ ∑ÿ ∏‘Ï (loop) ·≈–®ÿ¥∑’Ëπ”πÈ”‰ª„™â ‰¥â·°à ®ÿ¥®à“¬πÈ”„Àâ°—∫‡§√◊ËÕ߉μ‡∑’¬¡ ®ÿ¥∑’Ë„™â≈â“ßμ—«°√Õ߇≈◊Õ¥ ·≈–®ÿ¥∑’Ë„™â º ¡πÈ”¬“‰μ‡∑’¬¡·∫∫√«¡»πŸ ¬å (°√≥’„™â√–∫∫ central delivery dialysate) °“√‡°Á∫μ—«Õ¬à“ßπÈ”„π√–∫∫ ∑àÕ®à“¬πÈ”∫√‘ ÿ∑∏‘Ï „À⇰Á∫®“°®ÿ¥μâπ∑“ß·≈–ª≈“¬∑“ߢÕß loop ‡ªìπª√–®”∑ÿ°§√—Èß∑’Ë àßμ√«®  ”À√—∫ μ—«Õ¬à“ßπÈ”®“°®ÿ¥®à“¬πÈ”„Àâ°—∫‡§√◊ËÕ߉μ‡∑’¬¡·μà≈–‡§√◊ËÕß „π¡“μ√∞“π‡¥‘¡„À⇰Á∫∑—Èß®“°®ÿ¥®à“¬πÈ” ∫√‘ ÿ∑∏‘Ï°àÕπ‡¢â“‡§√◊ËÕ߉μ‡∑’¬¡·μà≈–‡§√◊ËÕß·≈–‡°Á∫μ—«Õ¬à“ß®“° dialysate ∑’˺à“π°“√º ¡°—∫πÈ”¬“‰μ ‡∑’¬¡‡¢â¡¢âπ·≈â«¢Õ߇§√◊ËÕ߉μ‡∑’¬¡·μà≈–‡§√◊ËÕß „π¡“μ√∞“π„À¡à¢Õß AAMI (2004) „Àâ àßμ√«®‡©æ“– dialysate ‡∑à“π—Èπ ‰¡à®”‡ªìπμâÕß àßμ—«Õ¬à“ßπÈ”∫√‘ ÿ∑∏‘Ï°àÕπ‡¢â“‡§√◊ËÕ߉μ‡∑’¬¡μ√«® ‡π◊ËÕß®“°¡’§«“¡‡ÀÁπ «“à °“√‡°∫Á μ«— Õ¬“à ßπÈ” ßà μ√«®®“°„π loop ∑ß—È μπâ ∑“ß·≈–ª≈“¬∑“ߢÕß loop π“à ®–‡æ¬’ ßæÕ·≈«â °“√μ√«® dialysate „À â ¡ÿà  ßà μ√«®®“°‡§√Õ◊Ë ß‰μ‡∑¬’ ¡‡ªπì ª√–®”∑°ÿ ‡¥Õ◊ π Õ¬“à ßπÕâ ¬ 2 ‡§√Õ◊Ë ßμÕà ‡¥Õ◊ π ·μ∑à ß—È π„’È π 1 ªï ∑ÿ°‡§√◊ËÕßμâÕ߉¥â√—∫°“√μ√«®Õ¬à“ßπâÕ¬ 1 §√—Èß ®–‡ÀÁπ‰¥â«à“®“°¢âÕ·π–π”„À¡àπ’È∑”„Àâ®”π«πμ—«Õ¬à“ßπÈ” ∑’ËμâÕß àßμ√«®„π·μà≈–‡¥◊Õπ≈¥≈ß®“°‡¥‘¡¡“° ∑”„Àâ “¡“√∂ª√–À¬—¥§à“„™â®à“¬„π°“√μ√«® ‚¥¬ ‡©æ“–Õ¬à“߬‘Ëß„π»Ÿπ¬å∑’Ë¡’‡§√◊ËÕ߉μ‡∑’¬¡®”π«π¡“° 15

Practical Dialysis in the Year 2009 πÕ°®“°°“√ àßμ√«®§ÿ≥¿“æπÈ”‡ªìπª√–®”∑’Ë°≈à“«¡“·≈â« „π°“√μ‘¥μ—Èß√–∫∫πÈ”∫√‘ ÿ∑∏‘Ï §√—Èß·√°À√◊Õ¡’°“√´àÕ¡·°â‰¢„π√–∫∫ μâÕß¡’°“√μ√«®‡æ◊ËÕ¬◊π¬—𧫓¡∫√‘ ÿ∑∏‘Ï¢ÕßπÈ”∑’˺≈‘μ‰¥â®“°√–∫∫ ∑’Ëμ‘¥μ—Èß ‚¥¬‡°Á∫μ—«Õ¬à“ßπÈ”∫√‘ ÿ∑∏‘Ï àßμ√«®„π®ÿ¥∑’Ë·π–π”„Àâ àßμ√«®‡ªìπª√–®”·≈–μâÕ߇°Á∫μ—«Õ¬à“ß ‡æ‘Ë¡Õ’°∑’ËÀ≈—ß™ÿ¥ RO ·≈–„π∂—߇°Á∫πÈ”∫√‘ ÿ∑∏‘Ï (∂â“¡’) 2. §≥ÿ ≈—°…≥–¢ÕßÕªÿ °√≥å∑’„Ë ™„â π√–∫∫πÈ”∫√‘ ∑ÿ ∏Ï‘ ·∫àßÕÕ°‡ªìπ√–∫∫°“√º≈‘μπÈ”∫√‘ ÿ∑∏‘Ï·≈–√–∫∫®à“¬πÈ”∫√‘ ÿ∑∏‘Ï √–∫∫º≈‘μπÈ”∫√‘ ÿ∑∏‘Ï ·π–π”„Àℙ⇪ìπ√–∫∫ reverse osmosis (RO) ‡π◊ËÕß®“°‰¡àμâÕß∫”√ÿß √—°…“∫àÕ¬·≈–¡’‚Õ°“ ‡°‘¥°“√·æ√à°√–®“¬¢Õ߇™◊ÈÕ‚√§„π√–∫∫®à“¬πÈ”πâÕ¬°«à“√–∫∫ deionization (DI) „π√–∫∫ deionization ·¡â«à“®– “¡“√∂≈¥ª√‘¡“≥ “√‡§¡’ªπ‡ªóôÕπ‰¥â¥’°«à“ RO ·μà°Á¡’‚Õ°“ ‡°‘¥ ªí≠À“ “√‡§¡’∫“ßμ—«ªπ‡ªóôÕπ ßŸ ¡“°‡ªìπ™à«ßÊ ‰¥â∂â“°“√∫”√ÿß√—°…“‰¡à¥’æÕ·≈– “√°√Õ߇√´‘π„π™ÿ¥ DI ‡√‘Ë¡‡ ◊ËÕ¡ ¿“æ „π√–∫∫º≈‘μπÈ”∫√‘ ÿ∑∏‘Ï®–μâÕß¡’Õÿª°√≥å„π°“√μ√«®§ÿ≥¿“槫“¡∫√‘ ÿ∑∏‘Ï¢ÕßπÈ”∑’ˉ¥â ®“°°“√º≈‘μ · ¥ß„Àâ‡ÀÁπ‰¥âμ≈Õ¥‡«≈“ Õ“®„™â‡ªìπ¡“μ√«—¥§à“ conductivity À√◊Õ resistivity À√◊Õ TDI °Á‰¥â „π√–∫∫º≈‘μπÈ”∫√‘ ÿ∑∏‘Ï®”‡ªìπμâÕß¡’™ÿ¥ pretreatment ‡æ◊ËÕ≈¥ª√‘¡“≥μ–°Õπ·¢«π≈Õ¬·≈–  “√‡§¡’ªπ‡ªóôÕπ„ππÈ”¥‘∫≈ß∫â“ß°àÕπ‡¢â“ àŸ√–∫∫ RO ∑—Èßπ’ȇæ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ·≈–≈¥§«“¡‡ ’¬À“¬∑’Ë ®–‡°‘¥¢÷Èπ°—∫™ÿ¥°√Õß RO  “√‡§¡’∑’Ë®”‡ªìπμâÕß≈¥ª√‘¡“≥≈ß„Àâ‡À≈◊ÕπâÕ¬∑’Ë ÿ¥°àÕπ‡¢â“ Ÿà√–∫∫ RO §◊Õ calcium, magnesium ·≈– chlorine/chloramines ‡π◊ËÕß®“° “√ª√–°Õ∫¢Õß calcium ·≈– magnesium Õ“®μ°μ–°Õπ®—∫‡ªìπμ–°√—π„π™ÿ¥ RO ‰¥â chloramines/chloramines ¡’ƒ∑∏‘Ï∑”≈“¬·ºàπ°√Õß RO „Àâ©’° ¢“¥·≈–√—Ë« ‚¥¬∑—Ë«‰ª™ÿ¥ pretreatment ®–ª√–°Õ∫¥â«¬  à«π™ÿ¥°√Õßμ–°Õπ  à«π™ÿ¥≈¥§«“¡°√–¥â“ß (softener) ·≈– à«π™ÿ¥ºß°√Õß carbon ™ÿ¥≈¥§«“¡°√–¥â“ß (softener) „™â≈¥ª√‘¡“≥ “√ calcium ·≈– magnesium ™¥ÿ ºß°√Õß carbon „™≈â ¥ª√¡‘ “≥ chloramines/chloramines ·≈– “√Õπ‘ ∑√¬’ å °“√∫”√ßÿ √°— …“™¥ÿ pretreatment ‡ªìπª√–®”®÷ß¡’§«“¡ ”§—≠™à«¬∑”„Àâª√– ‘∑∏‘¿“æ°“√°√ÕߢÕß™ÿ¥ pretreatment §ß  ¿“楒μ≈Õ¥‡«≈“ ·≈– àߺ≈¥’μàÕÕ“¬ÿ°“√∑”ß“π¢Õß™ÿ¥ RO ∑—Èßπ’ÈμâÕß¡’°“√μ√«® Õ∫§ÿ≥¿“æ¢ÕßπÈ” ∑’˺à“π°“√°√Õß®“°™ÿ¥ pretreatment Õ¬à“ß ¡Ë”‡ ¡Õ „π·π«∑“ߪؑ∫—μ‘©∫—∫ªï 2550 ¢Õß ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬ ‰¥â·π–π”„Àâ„™â™ÿ¥ºß °√Õß carbon ®”π«π 2 ∂—ß«“ßμàÕÕπÿ°√¡°—πμ“¡∑’Ë·π–𔉫â„π AAMI ‡æ◊ËÕ„Àâ°“√°”®—¥ “√ chlorine/ chloramines ¡’ª√– ‘∑∏‘º≈Õ¬à“ß·∑â®√‘ß ‰¡à„À⇰‘¥ªí≠À“ “√ chlorine/chloramines À≈ÿ¥≈Õ¥‰ª∑”≈“¬ ·ºπà °√Õß RO ·≈–À≈¥ÿ ≈Õ¥‡¢“â ‰ª‡°¥‘ º≈°√–∑∫μÕà ºªâŸ «É ¬‰¥â ¡°’ “√∂°‡∂¬’ ß°π— ¡“°∂ß÷ §«“¡®”‡ªπì „π¢Õâ πÈ’ ‡π◊ËÕß®“°„πª√–‡∑»‰∑¬‰¡à§àÕ¬æ∫ªí≠À“∑’ˇ°‘¥®“° “√§≈Õ√’πÀ≈ÿ¥≈Õ¥®π°àÕªí≠À“°—∫ºâŸªÉ«¬∑—ÈßÊ ∑’Ë »Ÿπ¬å‰μ‡∑’¬¡ à«π„À≠à„πÕ¥’μ„™â∂—ߧ“√å∫Õπ‡æ’¬ß∂—߇¥’¬« (Õ“®‰¡à¡’°“√√“¬ß“πÀ√◊Õ°“√ ◊∫§âπμ√«®  Õ∫À“ “‡Àμÿ∑’Ë·∑â®√‘ߢÕ߇Àμÿ°“√≥剡àæ÷ߪ√– ß§åμà“ßÊ) Õ’°∑—Èß°“√‡æ‘Ë¡™ÿ¥ºß carbon ‡ªìπ 2 ∂—ß®– ∑”„Àâ ‘Èπ‡ª≈◊Õß§à“„™â®à“¬¡“°¢÷Èπ ·μஓ°¢âÕ¡Ÿ≈∑’Ëæ∫‚¥¬ à«π„À≠à°≈—∫æ∫«à“ „ππÈ”¥‘∫∑’Ë»Ÿπ¬å‰μ‡∑’¬¡ π”¡“„™â¡—°‰¡à¡’ “√§≈Õ√’πÀ≈߇À≈◊ÕÕ¬àŸ°àÕπ∑’Ë®–®à“¬„Àâ°—∫™ÿ¥ pretreatment ‡π◊ËÕß®“°¡’°“√°”®—¥ “√ 16

Water Treatment: What is the Optimal Standard? §≈Õ√’π„ππÈ”¥‘∫ÕÕ°‰ª∫â“ß·≈â«‚¥¬√–∫∫°√ÕßπÈ”¢Õß‚√ß欓∫“≈ πÕ°®“°π’È¡—°¡’°“√‡°Á∫°—°πÈ”¥‘∫‰«â ∫𥓥øÑ“¢ÕßÕ“§“√°àÕπ∑’Ë®–π”¡“®à“¬„Àâ°—∫ÀâÕ߉μ‡∑’¬¡ ´÷ËßÕ“®‡ªì𠓇Àμÿ„Àâ “√§≈Õ√’π„ππÈ”¥‘∫¡’ ‚Õ°“ √–‡À‘¥ Ÿ≠À“¬‰ª ®÷ß∑”„À≡àæ∫ªí≠À“®“° “√§≈Õ√’πÀ≈ÿ¥≈Õ¥®“°™ÿ¥ºß°√Õß carbon ¥—ß°≈à“« °“√‰¡àæ∫ “√§≈Õ√’π„ππÈ”¥‘∫Õ“® àߺ≈¥â“πμ√ߢⓡ§◊Õ °àÕ„À⇰‘¥ªí≠À“°“√·æ√à°√–®“¬‡™◊ÈÕ ·∫§∑’‡√’¬„π√–∫∫πÈ”∫√‘ ÿ∑∏‘ω¥â ´÷Ëߪí≠À“°“√·æ√à°√–®“¬‡™◊ÈÕ¬—ߧ߇ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬„π»Ÿπ¬å‰μ ‡∑’¬¡„πª√–‡∑»‰∑¬ ¥—ßπ—Èπ„π°√≥’∑’Ëμ√«®‰¡àæ∫§≈Õ√’π„ππÈ”¥‘∫ À√◊Õ°√≥’∑’Ëæ∫ªí≠À“æ∫®”π«π‡™◊ÈÕ ·∫§∑’‡√’¬„π√–∫∫πÈ”∫√‘ ÿ∑∏‘Ï¡“°°«à“‡°≥±å∑’Ë°”Àπ¥∫àÕ¬§√—Èß  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬®÷ß·π–π” „À⧫√μ‘¥μ—Èß™ÿ¥®à“¬ “√§≈Õ√’πº ¡„ππÈ”¥‘∫‡æ◊ËÕ¶à“‡™◊ÈÕ·∫§∑’‡√’¬„ππÈ”¥‘∫°àÕπªÑÕππÈ”‡¢â“ àŸ™ÿ¥ pretreatment¥«â ¬‡Àμºÿ ≈°“√„À§â «“¡ ”§≠— ¢Õß°“√¡ ’ “√§≈Õ√π’ „ππÈ”¥∫‘ ®ß÷ μÕâ ß·π–π”„À„â ™∂â ß— §“√∫å Õπ 2 ∂—ßμ“¡∑’Ë°≈à“«¡“ ‡æ◊ËÕªÑÕß°—π‰¡à„Àâ¡’ “√§≈Õ√’πÀ≈ÿ¥≈Õ¥‡¢â“ àŸ™ÿ¥ RO ‰¥â √–∫∫®à“¬π”È ∫√‘ ÿ∑∏Ï‘ §«“¡ ”§—≠Õ¬àŸ∑’Ë°“√ªÑÕß°—π°“√°àÕΩíßμ—«·≈–·æ√à°√–®“¬¢Õ߇™◊ÈÕ ·∫§∑’‡√’¬„π∑àÕ®à“¬πÈ”·≈–„π™‘Èπ à«πÕÿª°√≥å¢Õß√–∫∫®à“¬πÈ” ‚¥¬°“√°”Àπ¥„ÀâÕÿª°√≥å„π√–∫∫®à“¬ πÈ”∑’ËμâÕß —¡º— °—∫πȔլŸàμ≈Õ¥‡«≈“μâÕß¡’º‘«‡√’¬∫ ‰¡à‡°‘¥ π‘¡ ≈¥¢âÕμàÕÀ√◊ÕÀ—°ßÕ„ÀâπâÕ¬∑’Ë ÿ¥ §«“¡ ¬“«¢Õß√–∫∫∑àÕ®à“¬πÈ”‰¡à¬“«‡°‘𧫓¡®”‡ªìπ μâÕ߉¡à¡’≈—°…≥– à«πª≈“¬ªî¥ À√◊Õ dead end °“√μàÕ ‡™◊ËÕ¡√–∫∫∑àÕ®à“¬πÈ”μâÕß¡’≈—°…≥–‡ªìπ«ß®√‰À≈°≈—∫‰¥â (loop) ·≈–μâÕ߇ªî¥„ÀâπÈ”¡’°“√‰À≈„π√–∫∫ ∑àÕ®à“¬πÈ”μ≈Õ¥‡«≈“‰¡àÀ¬ÿ¥π‘Ëߥ⫬§«“¡‡√Á«Õ¬à“ßπâÕ¬√–¥—∫Àπ÷Ëß ‡æ◊ËÕ≈¥°“√‡°“–Ωíßμ—«¢Õ߇™◊ÈÕ ·∫§∑’‡√’¬∑’˺‘«∑àÕ „π√–∫∫∑’Ë¡’∂—߇°Á∫πÈ”∫√‘ ÿ∑∏‘Ï„π√–∫∫®à“¬πÈ”®–¡’‚Õ°“ ‡°‘¥°“√·æ√à°√–®“¬‡™◊ÈÕ‰¥âßà“¬¢÷Èπ ‡π◊ËÕß®“°πÈ”¡’‚Õ°“ æ—°μ—«π‘ËßÕ¬àŸ„π∂—ß „π√–∫∫π’ÈμâÕ߇æ‘Ë¡¡“μ√°“√Õ◊ËπÊ Õ’°‡™àπ °“√μ‘¥μ—Èß™ÿ¥°”‡π‘¥· ß ultraviolet (UV) Õ¬à“ßπâÕ¬ 1 ·Ààß ∑’Ëμâπ∑“ߢÕß√–∫∫®à“¬πÈ”‡æ◊ËÕ¶à“‡™◊ÈÕ‚√§„ππÈ”°àÕπ∑’ËπÈ”®–∂Ÿ°®à“¬‰ª ¬—߇§√◊ËÕ߉μ‡∑’¬¡ ·≈–μâÕß¡’™ÿ¥¥—°°√Õß·∫§∑’‡√’¬ (submicron filter) ∑’Ëμâπ∑“ß·≈–ª≈“¬∑“ߢÕß√–∫∫ ®à“¬πÈ” 3. °“√∫”√ÿß√°— …“·≈–μ√«® Õ∫√–∫∫π”È ∫√ ‘ ÿ∑∏Ï‘ °“√μ√«® Õ∫ ¿“æπÈ”¥∫‘ §«√∑”‡ªπì ª√–®”Õ¬“à ßπÕâ ¬∑°ÿ 2 ‡¥Õ◊ π À√Õ◊ ‡¡Õ◊Ë ¡°’ “√‡ª≈¬’Ë π·ª≈ß ·À≈àßπÈ”¥‘∫ À√◊Õ‡¡◊ËÕ¡’ªí≠À“‡°’ˬ«°—∫§ÿ≥¿“æ¢ÕßπÈ”∫√‘ ÿ∑∏‘Ï∑’˺≈‘μ‰¥â °“√μ√«®‚¥¬∑—Ë«‰ª„Àâμ√«®¥∑Ÿ “ß °“¬¿“楧Ÿ «“¡¢πàÿ  ’ μ√«®§«“¡°√–¥“â ß·≈–ª√¡‘ “≥§≈Õ√π’ §«√¡§’ «“¡°√–¥“â ßπÕâ ¬°«“à 500 mg/L ¡’ª√‘¡“≥§≈Õ√’πÕ‘ √–Õ¬à“ßπâÕ¬ 0.3 mg/L °“√μ√«® Õ∫™ÿ¥°√Õßμ–°Õπ „Àâμ√«®«à“¡’°“√Õÿ¥μ—π‡°‘¥¢÷ÈπÀ√◊Õ‰¡à ‚¥¬¥§Ÿ «“¡μ“à ߢÕß·√ß ¥—ππÈ”°àÕπ·≈–À≈—ß™ÿ¥°√Õßμ–°Õ𠪰쑉¡à§«√¡’§à“μà“ß°—π‡°‘π 10 psi πÕ°®“°π’È„Àâμ√«®°“√∑”ß“π ¢Õß√–∫∫≈â“ß backwash §«√∑”°“√≈â“ß backwash ∑ÿ°«—𠇪≈’ˬπ “√°√ÕßÀ√◊Õ·ºàπ°√Õ߇ªìπ√–¬– μ“¡Õ“¬ÿ°“√„™âß“πÀ√◊Õ‡¡◊ËÕ‡ ◊ËÕ¡ ¿“æ °“√μ√«® Õ∫™ÿ¥ softener ∑’Ë ”§—≠§◊Õ μ√«® Õ∫ª√– ‘∑∏‘¿“æ¢Õß “√°√Õß‚¥¬°“√μ√«® §«“¡°√–¥â“ß„ππÈ”∑’ˉÀ≈ÕÕ°®“°™ÿ¥ softener ´÷Ëߧ«√¡’§à“πâÕ¬°«à“ 17.1 mg/L À√◊Õ 1 grain/gallon À√◊Õ 17

Practical Dialysis in the Year 2009 ∂“â μ√«®·∫∫semiquantitative§«√‰¥ºâ ≈≈∫§«√μ√«®‡ªπì ª√–®”∑°ÿ «π— À≈ß— °“√„À∫â √°‘ “√ºªŸâ «É ¬‡ √®Á  π‘È ·≈«â ·≈–§«√¡’°“√ regenerate  “√°√Õ߇ªìπ√–¬–Ê ¢÷ÈπÕ¬àŸ°—∫ª√‘¡“≥°“√∑” hemodialysis ·≈– ª√– ‘∑∏‘¿“æ¢Õß™ÿ¥ “√°√Õß ‡¡◊ËÕæ∫«à“ “√°√Õ߇√‘Ë¡‡ ◊ËÕ¡ª√– ‘∑∏‘¿“æ„À⇪≈’ˬπ “√°√Õß„À¡à πÕ°®“°π’È„Àâμ√«® Õ∫¥Ÿ°“√Õÿ¥μ—π‚¥¬¥Ÿ§à“·√ߥ—ππÈ”‡À¡◊Õπ°“√μ√«® Õ∫™ÿ¥°√Õßμ–°Õπ °“√μ√«® Õ∫™ÿ¥ºß°√Õß carbon ∑’Ë ”§—≠§◊Õ μ√«® Õ∫ª√– ‘∑∏‘¿“æ¢Õß “√°√Õß‚¥¬°“√ μ√«®ª√‘¡“≥ “√§≈Õ√’π„ππÈ”∑’ˉÀ≈ºà“πÕÕ°®“°∂—ߺ߰√Õß carbon ∂—ß∑’Ë 1 ‡ªìπª√–®”∑ÿ°«—π ‚¥¬„Àâ μ√«®„πμÕπ‡™â“°àÕπ‡√‘Ë¡„Àâ∫√‘°“√ºâŸªÉ«¬ ∂â“æ∫ª√‘¡“≥§≈Õ√’πÕ‘ √–¡“°°«à“ 0.5 mg/L À√◊Õ chloramines ¡“°°«à“ 0.1 mg/L · ¥ß«à“ “√°√ÕßÀ¡¥ ¿“æ„À⇪≈’ˬπ “√°√Õß„À¡à‚¥¬π”∂—ß carbon ∂—ß∑’Ë 2 ¡“‰«â „πμ”·Àπàß∂—ß∑’Ë 1 ‡¥‘¡·≈–π”∂—ß carbon ∂—ß„À¡à¡“‰«â„πμ”·Àπàß∂—ß∑’Ë 2 ·∑π μâÕß¡’°“√≈â“ß “√ °√Õß‚¥¬«‘∏’ backwash ∑ÿ°«—π πÕ°®“°π’È„Àâμ√«® Õ∫°“√Õÿ¥μ—π‚¥¬¥Ÿ§à“·√ߥ—ππÈ”‡À¡◊Õπ°“√μ√«®  Õ∫™ÿ¥°√Õßμ–°Õπ °“√μ√«® Õ∫ ¿“æ™ÿ¥°√Õß RO ∑’Ë ”§—≠§◊Õ °“√μ√«®¥§Ÿ ÿ≥¿“æπÈ”∫√‘ ÿ∑∏‘Ï∑’˺≈‘μ‰¥â ‚¥¬ ¥Ÿ§à“ conductivity À√◊Õ resistivity À√◊Õ TDI ‚¥¬¥Ÿ‡∑’¬∫°—∫§à“∑’ˇ§¬μ√«®‰¥âμÕπμ‘¥μ—Èß™ÿ¥°√Õß„À¡àÊ ´÷Ëß¡’°“√¬◊π¬—π§ÿ≥¿“槫“¡∫√‘ ÿ∑∏‘Ï¢ÕßπÈ”‚¥¬μ√«®∑“߇§¡’‰¥âμ“¡‡°≥±å¢Õß AAMI ·≈â«  ”À√—∫§à“ conductivity ¢ÕßπÈ”∫√‘ ÿ∑∏‘Ï∑’ˉ¥â®“°°“√º≈‘μ¢Õß™ÿ¥ RO ∑’ˇÀ¡“– ¡ ”À√—∫°“√∑” hemodialysis ¬—ß ‰¡¡à °’ “√°”À𥉫‡â ªπì ¡“μ√∞“𙥗 ‡®π ·μ‚à ¥¬∑«—Ë ‰ª„π∑“ߪØ∫‘ μ— ‰‘ ¡§à «√„À¡â §’ “à ¡“°°«“à 10 microsiemen/ cm („À¥â ºŸ ≈°“√μ√«®∑“߇§¡μ’ “¡ AAMI ‡ªπì  ”§≠— ) ·μ à ”À√∫— ™¥ÿ DI (·π–π”„À„â ™‡â ªπì ™¥ÿ ‡ √¡‘ μÕà ®“°™¥ÿ RO ‡©æ“–°√≥’∑’ËμâÕß°“√„Àâ§ÿ≥¿“æπÈ”∑“߇§¡’¥’¢÷Èπ) μâÕßμ—Èß§à“·®â߇μ◊Õπ‡æ◊ËÕ„À¡’°“√ regenerate  “√ °√Õ߉«∑â ’Ë 1 microsiemen/cm πÕ°®“°π„’È π™¥ÿ RO ∫“ß™π¥‘ Õ“®¡¡’ “μ√«¥— · ¥ß§“à percent solute rejection ‡æ◊ËÕ· ¥ßª√– ‘∑∏‘¿“æ¢Õß°“√°√ÕߢÕß™ÿ¥ RO ·≈–Õ“®„™â·∑π§à“§«“¡∫√‘ ÿ∑∏‘Ï¢ÕßπÈ”∑’˺≈‘μ‰¥â ´÷Ëß §«√¡’§à“¡“°°«à“ 90% ¢÷Èπ‰ª °“√μ√«® Õ∫ª√– ‘∑∏‘¿“æ¢Õß™ÿ¥ RO ∑’ËμâÕߥ‡Ÿ ªìπª√–®”Õ’°Õ¬à“ßÀπ÷Ëß §◊Õ ¥Ÿ°“√‡°‘¥°“√Õÿ¥μ—π¢Õß·ºàπ°√Õß RO ‚¥¬μ√«® Õ∫§à“·√ߥ—π¢ÕßπÈ”·≈–Õ—μ√“°“√‰À≈¢ÕßπÈ” ‚¥¬π”¡“§”π«≥‡ªìπ recovery rate ∂ⓧà“π’È≈¥πâÕ¬≈ß®“°‡¥‘¡ ∫àß∫Õ°∂÷߇√‘Ë¡¡’°“√Õÿ¥μ—π‡°‘¥¢÷Èπ„π™ÿ¥ RO ·≈â« §«√√“¬ß“π™à“ߺŸâ™”π“≠‡æ◊ËÕ°“√·°â‰¢ °“√μ√«® Õ∫¥Ÿ·≈„π√–∫∫®à“¬πÈ”∑’Ë ”§—≠§◊Õ °“√Õ∫¶à“‡™◊ÈÕ (disinfection) „π√–∫∫®à“¬πÈ” ‡ªìπª√–®”Õ¬à“ßπâÕ¬∑ÿ° 6 ‡¥◊Õπ ¥â«¬«‘∏’¡“μ√∞“π∑’ˇ™◊ËÕ∂◊Õ‰¥â ‚¥¬∑—Ë«‰ª·π–π”„ÀâÕ∫¶à“‡™◊ÈÕ‚¥¬„™â “√ ‡§¡’‡™àπ formalin, peracetic acid, chlorine ·≈– ozone ‡ªìπμâπ À√◊Õ∫“ß·ÀàßÕ“®„™â§«“¡√âÕπÕ∫¶à“‡™◊ÈÕ „π√–∫∫‡ªìπ¡“μ√°“√‡ √‘¡ °àÕπ‡≈◊Õ°„™â·μà≈–«‘∏’°“√μâÕß»÷°…“„Àâ·πà„®«à“«‘∏’∑’ˇ≈◊Õ°„™â®–‰¡à∑”≈“¬ «— ¥ÿÕÿª°√≥åμà“ßÊ „π√–∫∫®à“¬πÈ”„À⇠’¬À“¬‰¥â √–¬–‡«≈“∑’Ë„™âÕ∫®–·μ°μà“ß°—π‰ª„π·μà≈–™π‘¥¢Õß  “√‡§¡’ Õ“®μâÕß¡’°“√Õ∫¶à“‡™◊ÈÕ°àÕπ°”Àπ¥„π°√≥’∑’Ëæ∫¡’°“√·æ√à°√–®“¬‡™◊ÈÕ„π√–∫∫πÈ”∫√‘ ÿ∑∏‘Ï ¡“°°«à“‡°≥±å∑’Ë°”À𥉫â·≈–æ‘®“√≥“·≈â««à“‰¡à‰¥â‡°‘¥®“° contamination ¢Õß°“√ àßμ√«®„π»πŸ ¬å‰μ ‡∑’¬¡∑’Ë¡’ªí≠À“æ∫‡™◊ÈÕ·∫§∑’‡√’¬∫àÕ¬Ê ·¡â«à“®–‰¡à∂÷߇°≥±å∑’Ë°”Àπ¥ À√◊Õ¡’ªí≠À“¥â“𧫓¡‡™◊ËÕ∂◊Õ‰¥â ¢Õߺ≈°“√μ√«®À√◊Õ°“√μ√«®¡’§«“¡‰«‰¡à‡æ’¬ßæÕ §«√Õ∫¶à“‡™◊ÈÕ√–∫∫„Àâ∫àÕ¬°«à“∑’Ë·π–π”‰«â ‚¥¬¬÷¥ À≈—° çª≈Õ¥¿—¬‰«â°àÕπé ¥’°«à“ πÕ°®“°°“√Õ∫¶à“‡™◊ÈÕ„π√–∫∫®à“¬πÈ”·≈â«μâÕß¡’°“√‡ª≈’ˬπÕÿª°√≥å∑’Ë  ”§—≠μ“¡«“√–‡™àπ bacteria filter, UV lamp, air filter ‡ªìπμâπ 18

Water Treatment: What is the Optimal Standard? ‡Õ° “√Õâ“ßÕ‘ß 1. Association for the Advancement of Medical Instrumentation. American National Standard, ANSI/AAMI RD52:2004: Dialysate for hemodialysis. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2004. 2. AAMI Standards and Recommended Practices, ANSI/AAMI RD62:2006: Water treatment equipment for hemodialysis applications. Association for the Advancement of Medical Instrumentation, Arlington, Virginia; 2007. 3. European Best Practice Guideline: Dialysis fluid purity. Nephrol Dial Transplant 2002; 17 [suppl 7]: 45-62. 4.  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬: ·π«∑“ߪؑ∫—쑇√◊ËÕß°“√‡μ√’¬¡πÈ”∫√‘ ÿ∑∏‘χæ◊ËÕ°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ ©∫—∫ ªï 2550. °√ÿ߇∑æ¡À“π§√,  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬, 惻®‘°“¬π 2550. 19



Technology Insight of Hemodialysis Machine and Apparatus 3 Technology Insight of Hemodialysis Machine and Apparatus ™≈∏ª‘ æß» å °ÿ≈ Arterial drip chamber Anticoagulant pump Dialyzer venous Pressure monitor Air detector Arterial blood pump Venous drip chamber P art monitor Venous line clamp Arterial needle Venous needle dialyzer Controller Outlet dialysate Dialysate pump UF pump Inlet dialysate 1. «ß®√‡≈Õ◊ ¥ 2. «ß®√ «à ππ”È ¬“ 3. ‡∑§‚π‚≈¬’„À¡Êà „π°“√øÕ°‡≈◊Õ¥ 4.  √ÿª 21

Practical Dialysis in the Year 2009 °“√√—°…“¥â«¬°“√øÕ°‡≈◊Õ¥®”‡ªìπμâÕß„™â‡§√◊ËÕß¡◊Õ∑’Ë´—∫´âÕπ ºâŸªÉ«¬μâÕßÕ¬Ÿàμ‘¥°—∫‡§√◊ËÕß øÕ°‡≈◊Õ¥§√—Èß≈–À≈“¬™—Ë«‚¡ß §«“¡‡ ’ˬߢÕß°“√√—°…“πÕ°®“°‡°‘¥®“°¡πÿ…¬å (human error) ·≈â« ¬—ß Õ“®‡°‘¥®“°§«“¡∫°æ√àÕߢÕ߇§√◊ËÕß¡◊Õ‡Õß ¥—ßπ—ÈπºâŸ¥Ÿ·≈®÷ßμâÕß¡’§«“¡‡¢â“„®À≈—°°“√∑”ß“π¢Õß ‡§√◊ËÕßøÕ°‡≈◊Õ¥Õ¬à“ß∂àÕß·∑â ‡æ◊ËÕ∑’Ë®–‰¥â√–¡—¥√–«—ߪÑÕß°—π‰¡à„À⇰‘¥§«“¡º‘¥æ≈“¥®“°‡§√◊ËÕß¡◊Õ √«¡ ∑—Èß√ŸâÀ≈—°°“√·°â‰¢‡¡◊ËÕ¡’°“√‡μ◊Õ𧫓¡º‘¥æ≈“¥®“°‡§√◊ËÕß¡◊Õ „π∫∑π’È®–‰¥â°≈à“«∂÷ßÀ≈—°°“√∑”ß“π ¢Õ߇§√◊ËÕßøÕ°‡≈◊Õ¥„π√–¥—∫∑’Ë∫ÿ§≈“°√·æ∑¬å§«√√⟠‡§√Õ◊Ë ßøÕ°‡≈Õ◊ ¥‡ªπì ‡§√Õ◊Ë ß¡Õ◊ ´ß÷Ë ∑”Àπ“â ∑ª’Ë ¡íö πÈ”¬“dialysate·≈–‡≈Õ◊ ¥¢ÕߺªâŸ «É ¬º“à πμ«— °√Õß ‚¥¬‡≈◊Õ¥°—∫ dialysate ·¬°®“°°—π¥â«¬ semipermeable membrane ‡§√◊ËÕßøÕ°‡≈◊Õ¥π—Èπ®–μâÕß ª√–°Õ∫¥â«¬ à«π∑’ˇªìπμ—«μ√«®«—¥ (detector),  à«π§«∫§ÿ¡ (controller),  à«πμ√«® Õ∫ (monitor) ·≈–  «à π∑‡Ë’ °¬Ë’ «¢Õâ ß°∫— §«“¡ª≈Õ¥¿¬— (safety device) ∑ßÈ— À¡¥π®È’ –√«à ¡°π— §«∫§¡ÿ °“√‰À≈¢Õ߇≈Õ◊ ¥·≈–π”È ¬“ dialysate μ≈Õ¥®π§«∫§¡ÿ ultrafiltration rate  «à πª√–°Õ∫¢ÕßπÈ”¬“ √«¡∂ß÷ ·√ß¥π— „π «à πμ“à ßÊ ¢Õß√–∫∫ ‡æ◊ËÕ§«“¡ßà“¬„π°“√∑”§«“¡‡¢â“„® ®–¢Õ·∫àß°“√∑”ß“π‡ªìπ Õß à«π§◊Õ  à«π«ß®√‡≈◊Õ¥ (blood circuit) ·≈–«ß®√πÈ”¬“ (dialysate circuit) ‚¥¬®–°≈“à «∂ß÷ ‡©æ“–‡§√Õ◊Ë ßøÕ°‡≈Õ◊ ¥∑«—Ë ‰ª1,2 ‰¡√à «¡∂ß÷ hemodiafiltration ·≈–®–°≈à“«∂÷ßÀ≈—°°“√¢Õß online monitoring ‚¥¬ —߇¢ª„π à«π∑⓬ 1. «ß®√‡≈◊Õ¥ ¡’ à«πª√–°Õ∫§◊Õ pressure monitor,  “¬ à߇≈◊Õ¥, ªíö¡‡≈◊Õ¥, ªíö¡‡Œª“√‘π, μ—«μ√«®®—∫øÕß Õ“°“» ·≈– clamps (√Ÿª∑’Ë 1) 1.1 Arterial pressure monitor (prepump) ‡ªìπ à«π∑’Ëμ√«® Õ∫·√ߥ—π√–À«à“ß vascular access °—∫ªíö¡‡≈◊Õ¥ ‡π◊ËÕß®“°ªíö¡‡≈◊Õ¥¥¥Ÿ ‡≈◊Õ¥ ÕÕ°®“°ºŸâªÉ«¬ ·√ߥ—π à«ππ’È®÷߇ªìπ≈∫ §◊Õ¡’§à“μË”°«à“·√ߥ—π∫√√¬“°“»·≈–·√ߥ—π®–°≈“¬‡ªìπ∫«° ‡¡◊ËÕºà“πªíö¡‡≈◊Õ¥‰ª·≈â« (√Ÿª∑’Ë 2) ‡§√◊ËÕßøÕ°‡≈◊Õ¥∫“ß√ÿàπ®–‰¡à¡’°“√ monitor ·√ߥ—π®ÿ¥π’È ·≈–∂÷ß·¡â«à“ ‡§√Õ◊Ë ß®–¡§’ ≥ÿ  ¡∫μ— ¥‘ ß— °≈“à «·μÀà π«à ¬‰μ «à π„À≠‰à ¡‰à ¥„â ™ â “¬ ßà ‡≈Õ◊ ¥∑¡’Ë ®’ ¥ÿ μÕà ‡æÕ◊Ë «¥— ·√ß¥π— ¢Õßarterial pressure‡πÕ◊Ë ß®“°·√ß¥π—  «à ππ‡’È ªπì ≈∫®ß÷ ‡ªπì ®¥ÿ ∑‡’Ë  ¬’Ë ßμÕà °“√¥¥Ÿ Õ“°“»®“°¿“¬πÕ°‡¢“â  √Ÿà –∫∫·≈–‡°¥‘ air embolism ‰¥â ·√ߥ—π®–‡ªìπ≈∫¡“°¢÷Èπ„π°√≥’∑’˧«“¡¥—π‚≈À‘μ¢Õߺ⟪ɫ¬μË”≈ß, ¡’°“√À—°ßÕ¢Õß ∑àÕ à߇≈◊Õ¥√–À«à“߇¢Á¡·≈–ªíö¡ ¡’°âÕπ‡≈◊Õ¥Õÿ¥μ—π ·≈–¡’°“√¥Ÿ¥μ‘¥¢Õ߇¢Á¡ºπ—ßÀ≈Õ¥‡≈◊Õ¥∑’Ë·∑߇¢Á¡ „π°√≥’∑’Ë·√ߥ—π Ÿß¢÷Èπ (§◊Õ‡ªìπ≈∫πâÕ¬≈ß) ‡°‘¥®“°§«“¡¥—π‚≈À‘μ∑’Ë Ÿß ∑àÕ à߇≈◊Õ¥„π à«π arterial ©’° ¢“¥À√◊ÕÀ≈ÿ¥ À√◊Õ “¬πÈ”‡°≈◊Õ„π infusion line ‰¡à‰¥âªî¥ clamp 1.2 Venous pressure monitor (post dialyzer) μ√«®®—∫·√ߥ—π„π‡≈◊Õ¥∑’Ë venous drip chamber ®π∂÷߇¢Á¡∑’Ë·∑ßÀ≈Õ¥‡≈◊Õ¥´÷Ëß√«¡∂÷ß·√ߥ—π „π vascular access ¥â«¬ ·√ߥ—π„π™à«ßπ’ȇªìπ∫«° „π°√≥’∑’Ë·√ߥ—π ŸßÀ√◊ÕμË”°«à“∑’Ëμ—È߉«â ‡§√◊ËÕß®–μâÕß clamp blood line À¬ÿ¥ªíö¡‡≈◊Õ¥ ·≈– àß —≠≠“≥‡μ◊Õπ„Àâ∑√“∫  “‡Àμÿ¢Õß·√ߥ—π∑’ËμË”°«à“ª°μ‘§◊Õ ∑àÕ  à߇≈◊Õ¥À≈ÿ¥ÕÕ°®“°À≈Õ¥‡≈◊Õ¥·≈– blood flow ∑’ËπâÕ¬  à«π “‡Àμÿ¢Õß·√ߥ—π∑’ˠߟ º‘¥ª°μ‘§◊Õ °“√À—° ¢Õß∑àÕ à߇≈◊Õ¥ ¡’°âÕπ‡≈◊Õ¥„π venous drip chamber À√◊Õ°“√∑’Ë vascular access μ’∫μ—π 22

Technology Insight of Hemodialysis Machine and Apparatus Arterial drip chamber Anticoagulant pump Dialyzer venous Pressure monitor Air detector Arterial blood pump Venous drip chamber P art monitor Venous line clamp Arterial needle Venous needle √Ÿª∑’Ë 1 «ß®√‡≈Õ◊ ¥ Venous Pressure Prepump Post pump pressure pressure Roller pump √Ÿª∑’Ë 2 Venous line clamp Pressure profile in blood circuit 23

Practical Dialysis in the Year 2009 1.3 ªö¡í ‡≈◊Õ¥ ‡ªìπ≈—°…≥– peristaltic pump §◊Õ√’¥‡≈◊Õ¥„π∑àÕ à߇≈◊Õ¥‚¥¬‰¡à¡’ à«π∑’Ë —¡º— °—∫‡≈◊Õ¥ ‚¥¬ ∑«—Ë ‰ª¡≈’ °Ÿ °≈ß‘È 2 μ«— À¡πÿ √Õ∫·°π‚¥¬¡ ’ «à π∑‡’Ë ªπì  ª√ß‘ √Õß√∫— ≈°Ÿ °≈ß‘È ‡æÕ◊Ë ‰¡„à À¡â ·’ √ß°√–∑”μÕà ∑Õà  ßà ‡≈Õ◊ ¥ ¡“°®π‡°¥‘ Õπ— μ√“¬¡Õ‡μÕ√∑å „’Ë ™¡â °— ‡ªπì ¡Õ‡μÕ√°å √–· μ√ß„™·â √ß¥π— ‰øμË”‡æÕ◊Ë ªÕÑ ß°π— Õπ— μ√“¬·°ºà „⟠™ßâ “π Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥¢÷Èπ°—∫®”π«π√Õ∫∑’ËÀ¡ÿπ·≈–¢π“¥¢Õß∑àÕ à߇≈◊Õ¥ ¥—ß Ÿμ√ BFR = rpm x tubing volume (Pi × r2 × l) ‚¥¬∑’Ë r §◊Õ√—»¡’¿“¬„π¢Õß∑àÕ ·≈– l §◊Õ§«“¡¬“«√–À«à“ß≈°Ÿ °≈‘Èß∑—Èß Õßμ—« r π—Èπ ·ª√‡ª≈’ˬπμ“¡·√ߥ—π∑’ˇªìπ≈∫„π à«ππ’È °≈à“«§◊Õ∂â“·√ߥ—π≈∫¡“°¢÷Èπ ¢π“¥¢Õß∑àÕ®–‡≈Á°≈ß ‡§√◊ËÕß ∫“ß√ÿàπ®÷ß· ¥ßÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥∑’Ë correct ®“° negative arterial pressure ·≈â« ∂Ⓣ¡à„Àâ correct °—∫·√ߥ—π≈∫Õ“®∑”„ÀâÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥πâÕ¬°«à“∑’Ë· ¥ß∫πÀπ⓪í¥∂÷ß 10-20% ∑”„À⇰‘¥ªí≠À“ under dialysis ‰¥â 1.4 Heparin pump ‚¥¬∑—Ë«‰ª‡ªìπ≈—°…≥– syringe pump ‚¥¬μàÕÕ¬àŸ°—∫ à«π∑’Ë¡’·√ߥ—π‡ªìπ∫«° §◊ÕÀ≈—ß®“°ªíö¡ ‡≈◊Õ¥°àÕπ‡¢â“μ—«°√Õ߇æ◊ËÕªÑÕß°—π°“√‡°‘¥ air embolism 1.5 Air leak detector ‡ªìπ à«π ”§—≠¡“°„π‡§√◊ËÕßøÕ°‡≈◊Õ¥ ¡—°¡’‡æ◊ËÕ°“√®—∫øÕßÕ“°“»∑’ËÕ“®À≈ÿ¥√Õ¥‡¢â“‰ª„π √–∫∫´÷ËßÕ“®°àÕ„À⇰‘¥ Air embolism ‰¥â ®ÿ¥∑’ËÕ“°“»‡¢â“„π√–∫∫‰¥â ‰¥â·°à ‡¢Á¡·∑ßÀ≈Õ¥‡≈◊Õ¥·¥ß, ∑àÕ  à߇≈◊Õ¥°àÕπ∂÷ߪíö¡‡≈◊Õ¥ À√◊Õ®“°∂ÿßÀ√◊Õ∑’Ë„Àâ “√πÈ”„π√–∫∫«à“ß≈ß·≈–¡’Õ“°“»‰ª·∑π∑’Ë À≈—°°“√μ√«® ®—∫„™â§≈◊Ëπ‡ ’¬ßÕ—≈μ√“´“«¥å ´÷Ëß®–¡’§«“¡∂’ˇª≈’Ë¬π‰ª‡¡◊ËÕ¡’Õ“°“»ªπÕ¬Ÿà„π‡≈◊Õ¥ μ√«®®—∫‰¥â∑—ÈßÕ“°“» ∑’˪πÕ¬Ÿà„π‡≈◊Õ¥ ·≈–øÕßÕ“°“»∑’Ëªπ¡“°—∫πÈ”‡°≈◊Õ ‡¡Ë◊Õμ√«®®—∫‰¥â·≈â«®– à߇ ’¬ß‡μ◊Õπ·≈–ªíö¡‡≈◊Õ¥ ®–À¬ÿ¥∑”ß“π ·≈–μâÕß clamp ‡≈◊Õ¥°àÕπ‡¢â“À≈Õ¥‡≈◊Õ¥¢ÕߺŸâªÉ«¬ 1.6 Blood tubing clamp ®–μâÕßμâ“π·√ߥ—π„π∑àÕ à߇≈◊Õ¥‰¥â¡“°°«à“ 800 ¡¡.ª√Õ∑ ‡π◊ËÕß®“°„π∫“ߧ√—È߇¡◊ËÕÀ¬ÿ¥ªíö¡ ‡≈Õ◊ ¥·≈«â ‡≈Õ◊ ¥ «à π∑§’Ë ß§“â ß„πμ«— °√ÕßÕ“®∂°Ÿ ∫∫’ „À‰â À≈¡“∑“ß∑Õà  ßà ‡≈Õ◊ ¥·≈–‡¢“â  ºàŸ ªâŸ «É ¬‰¥â ·≈–®–μÕâ ß ‰¡à∑”„Àâ “¬ à߇≈◊Õ¥∑’Ë∂Ÿ° clamp π—Èπ™”√ÿ¥ À√◊Õ©’°¢“¥ 2. «ß®√ à«ππÈ”¬“ (Dialysis circuit) „π «à ππ®È’ –∑”Àπ“â ∑‡Ë’ °¬Ë’ «°∫— π”È ¬“dialysate μßÈ— ·μ§à «∫§¡ÿ Õ≥ÿ À¿¡Ÿ ¢‘ Õßπ”È ∫√ ‘ ∑ÿ ∏Ï‘º ¡π”È ¬“ ‡¢â¡¢âπμ“¡ à«π ª√—∫·μàߧ«“¡‡¢â¡¢âπ¢ÕßπÈ”¬“ §«∫§ÿ¡°“√‰À≈·≈–·√ߥ—π¢ÕßπÈ”¬“ ‚¥¬Õߧåª√–°Õ∫ À≈—°§◊Õ  à«π∑”§«“¡√âÕπ,  à«π‰≈àÕ“°“» (deaeration),  à«π§«∫§ÿ¡ (monitor),  à«π∑’ˇ°’ˬ«°—∫Õ—μ√“°“√ °√Õß ·≈– à«π°”®—¥‡™◊ÈÕ„π√–∫∫ (√Ÿª∑’Ë 3) °“√º ¡πÈ”¬“‡¢â¡¢âπ°—∫πÈ”∫√‘ ÿ∑∏‘Ï„πª√–‡∑»‰∑¬π—Èππ‘¬¡„™â °“√º ¡·μà≈–‡§√◊ËÕß¡“°°«à“°“√º ¡·≈â«®à“¬®“°‡§√◊ËÕß à«π°≈“ß 24

Technology Insight of Hemodialysis Machine and Apparatus Deaerator Bicarbonate Filter pH probe mixing Acid/acetate mixing Treated Bicarbonate Acid/acetate Conductivity water Heater concentrate cell drain concentrate Temperature monitor Dialyzer 14.0 Conductivity Pump Flow meter display Blood leak detector Dialysate Bypass pressure √Ÿª∑’Ë 3 «ß®√π”È ¬“ 2.1  «à π∑”§«“¡√âÕπ (Heating of the dialysate) ∑”Àπ“â ∑‡’Ë æ¡‘Ë Õ≥ÿ À¿¡Ÿ ¢‘ ÕßπÈ”∫√ ‘ ∑ÿ ∏∑‘Ï ‡’Ë ¢“â ¡“„π‡§√Õ◊Ë ß„À‡â ∑“à °∫— Õ≥ÿ À¿¡Ÿ √‘ “à ß°“¬  «à ππ∑’È ”¥«â ¬ stainless steel ·≈–§«∫§ÿ¡„Àâ¡’Õÿ≥À¿Ÿ¡‘™à«ß 33-39 Õß»“ 2.2  à«π‰≈àÕ“°“» (Dialysate deaeration) „ππÈ” ‚¥¬‡©æ“–∑¡’Ë Õ’ ≥ÿ À¿¡Ÿ μ‘ Ë”®–¡Õ’ “°“»≈–≈“¬Õ¬Ÿà´ß÷Ë √∫°«π°“√∑”ß“π¢Õ߇§√Õ◊Ë ßøÕ°‡≈Õ◊ ¥‚¥¬ Õ“°“»∑”„À⇰‘¥°“√Õÿ¥μ—π¢ÕßπÈ”¬“„π°√–∫Õ° dialyzer (air locking) À√◊Õ√∫°«π°“√∑”ß“π¢Õß à«π §«∫§ÿ¡ª√‘¡“μ√°“√°√Õß  à«ππ’ÈμàÕ¡“®“° à«π∑’Ë∑”§«“¡√âÕπ ‚¥¬Õ“°“»®–√–‡À¬®“°πÈ”¬“·≈– πÈ”¬“ à«ππ’È®–∂Ÿ°¥Ÿ¥‰ª‡¢â“ à«π∑’ˇªìπ air trap Õ“°“»®–∂Ÿ°¥¥Ÿ ÕÕ°‰ª„π∑“ß air vent (√ªŸ ∑’Ë 4) 2.3 Dialysate proportioning ‡ªìπ à«π∑’Ë∑”Àπâ“∑’˺ ¡πÈ”¬“∫√‘ ÿ∑∏‘Ï∑’Ë∂Ÿ°Õÿàπ·≈â«°—∫πÈ”¬“‡¢â¡¢âπ‚¥¬„™âªíö¡Õ—μ√“ à«π (proportioning pump) ´ß÷Ë  ¥—  «à π¡§’ “à ·μ°μ“à ß°π— ‰ªμ“¡¬À’Ë Õâ ¢Õߺ≈μ‘ ¿≥— ±åª®í ®∫ÿ π— ¡°— „™âbicarbonate ¡“° °«à“ acetate ·∫∫‡¥‘¡ πÈ”¬“‡¢â¡¢âπ®÷ß∂°Ÿ ·¬°‡ªìπ Õß™π‘¥§◊Õ A À√◊Õ Acid chloride salt ¢Õß‚´‡¥’¬¡ ‚ªμ— ‡´’¬¡ ·§≈‡´’¬¡ ·¡°π’‡´’¬¡·≈–Õ–´’‡μμ ·≈– “√ B ´÷Ë߇ªìπ‚´‡¥’¬¡‰∫§“√å∫Õ‡πμ·≈–‚´‡¥’¬¡ §≈Õ‰√¥å ‡Àμÿ∑’ËμâÕß·¬°°—π‡π◊ËÕß®“°·§≈‡´’¬¡·≈–·¡°π’‡´’¬¡Õ“®μ°μ–°Õπ‰¥â‡¡◊ËÕ®—∫°—∫§“√å∫Õ‡πμ °“√º ¡πÈ”¬“π—Èπ∑”‰¥â Õß≈—°…≥–3 §◊Õ fixed ratio mixing ·≈– servo controlled mixing (√Ÿª∑’Ë 5) ·∫∫ 25

Practical Dialysis in the Year 2009 Air vent Air trap Deaerated pump water out Pressure regulator Heated Negative water in pressure √ªŸ ∑’Ë 4 Dialysate deaeration A B Purified Heater and CM water deaerator Dialysate CS CS Purified CM Dialysate water CM Heater and deaerator √ªŸ ∑’Ë 5 °“√º ¡πÈ”¬“‡¢â¡¢πâ °∫— πÈ”∫√‘ ÿ∑∏å A. fixed mixing ratio B. servo-controlled CM §Õ◊ conductivity meter, CS §Õ◊ conductivity set point, ‡ πâ ª√–§◊Õ«ß®√§«∫§¡ÿ 26

Technology Insight of Hemodialysis Machine and Apparatus ·√°ππÈ— ¡ª’ ¡öí ¥¥Ÿ π”È ¬“‡¢¡â ¢πâ ∑ßÈ—  Õß™π¥‘ „π ¥—  «à π∑§Ë’ ß∑Ë’ ‚¥¬¡’ conductivity meter μ√«® Õ∫π”È ¬“∑ºË’  ¡ ·≈â«°àÕπ‡¢â“μ—«°√Õß ·∫∫∑’Ë Õßπ—Èπ¡’ conductivity meter μ√«® Õ∫πÈ”¬“∑’˺ ¡°—∫πÈ”∫√‘ ÿ∑∏‘χæ◊ËÕ„À≥⠧“à conductivity ∑μ’Ë Õâ ß°“√ ‚¥¬¡™’ ¥ÿ §«∫§¡ÿ ªÕÑ π°≈∫— °”Àπ¥°“√¥¥Ÿ πÈ”¬“‡¢¡â ¢πâ ·≈–¡’ conductivity meter ·¬°Õ’°μ—«Àπ÷Ë߇æ◊ËÕμ√«® Õ∫¢—Èπ ÿ¥∑⓬°àÕπ à߇¢â“μ—«°√Õß  —¥ à«π„π°“√º ¡·μ°μà“ß°—π‰ªμ“¡ º≈‘μ¿—≥±å ‡™àπ —¥ à«π¢ÕßπÈ”¬“‡¢â¡¢âπ™π‘¥°√¥:¥à“ß:πÈ”∫√‘ ÿ∑∏‘Ï ‡∑à“°—∫ 1:1.225:32.775, 1:1.83:34, 1:1.72:42.28 ‡ªìπμâπ °“√ª√—∫§«“¡‡¢â¡¢âπ¢Õß‚´‡¥’¬¡„π≈—°…≥–¢Õß sodium profiling dialysis π—Èπ„™â«‘∏’ °“√ª√—∫ —¥ à«π¢Õß°“√¥¥Ÿ πÈ”¬“ A ‡§√◊ËÕß∑’ˇªìπ fixed ratio mixing ®–∂Ÿ°ª√—∫ —¥ à«π°“√¥¥Ÿ 쓬엫¡“ ·≈«â  «à π·∫∫ servo controlled mixing ®–„™°â “√ª√∫— set point ¢Õß conductivity ‡æÕË◊ „À‰â ¥§â “à μ“¡μÕâ ß°“√ ‡π◊ËÕß®“° à«ππ’ȇªìπ°“√¥Ÿ¥πÈ”¬“°—∫¿“¬πÕ°‡§√◊ËÕß®÷ß¡’‚Õ°“ º‘¥æ≈“¥‰¥â‡™àπ¥Ÿ¥πÈ”¬“º‘¥∂—ß ·ºàπ °√Õß∑’Ë∑àÕ¥Ÿ¥Õÿ¥μ—π∑”„À⥟¥πÈ”¬“‰¡à¢÷Èπ‡ªìπμâπ ®÷ßμâÕß¡’√–∫∫μ√«® Õ∫πÈ”¬“Õ’°§√—ÈßÀπ÷Ëß°àÕπºà“π‡¢â“  àŸμ—«°√Õß 2.4 √–∫∫μ√«® Õ∫¢Õß«ß®√π”È ¬“ °àÕππÈ”¬“®–‡¢â“ àŸμ—«°√Õß¡’°“√μ√«® Õ∫ 3 Õ¬à“ß §◊Õ pH, Õÿ≥À¿Ÿ¡‘πÈ”¬“ ·≈– conductivity 2.4.1 pH ‡ªìπ°“√μ√«® —¥ à«π√–À«à“ß HCO3- ·≈– H2CO3 ¥â«¬‡§√◊ËÕß«—¥ ™à«ß∑’ˇÀ¡“– ¡ §◊Õ 6.8-7.6 2.4.2 Õ≥ÿ À¿¡Ÿ π‘ È”¬“‡ªπì °“√μ√«®¥«â ¬‡§√Õ◊Ë ßμ√«®®∫— Õ≥ÿ À¿¡Ÿ ∫‘ √‡‘ «≥„°≈°â ∫— μ«— °√Õß·≈–§«√ ¡’√–∫∫ªÑÕß°—π∑’ˉ«æÕ®–®—∫°“√‡ª≈’ˬπ·ª≈ߢÕßÕÿ≥À¿Ÿ¡‘‰¥â ± 0.5°C ™à«ßÕÿ≥À¿Ÿ¡‘∑’ˇÀ¡“– ¡§◊Õ 34-42°C Õ≥ÿ À¿¡Ÿ ∑‘ μË’ ”Ë ™«à ¬ªÕÑ ß°π— ¿“«–§«“¡¥π— ‚≈Àμ‘ μ”Ë √–À«“à ßøÕ°‡≈Õ◊ ¥ ·μÕà “®∑”„Àºâ ªŸâ «É ¬Àπ“« πË— ∂â“Õÿ≥À¿Ÿ¡‘μË”‡°‘π‰ª  à«π∂â“Õÿ≥À¿Ÿ¡‘ Ÿß®–∑”„À⇰‘¥ protein denaturation À√◊Õ¿“«–‡¡Á¥‡≈◊Õ¥·μ°‰¥â ¥—ßπ—Èπ∂â“Õÿ≥À¿¡Ÿ ‘πÈ”¬“‡°‘π¢’¥∑’Ëμ—È߉«â ‡§√◊ËÕß®–‡μ◊Õπ·≈–μ—¥‰¡à„ÀâπÈ”¬“‡¢â“ àŸμ—«°√Õß∑—π∑’ 2.4.3 Conductivity À√◊Õ°“√π”‰øøÑ“ °“√π”‰øø“Ñ ¢ÕßπÈ”¬“¢π÷È °∫—  “√≈–≈“¬∑¡’Ë ª’ √–®„ÿ ππÈ”¬“ ∂“â ¡¡’ “°®–∑”„À§â “à °“√π”‰øø“Ñ  ßŸ °“√μ√«® Õ∫§à“°“√π”‰øøÑ“‡ªìπ°“√μ√«®‡æ◊ËÕ¬◊π¬—π«à“πÈ”¬“ dialysate ¡’ à«πº ¡¢ÕßπÈ”∫√‘ ÿ∑∏‘Ï·≈– πÈ”¬“‡¢â¡¢âπμ“¡ à«π∑’Ë∂°Ÿ μâÕß §à“∑’ˇÀ¡“– ¡§◊Õ 12-16 millisiemens/cm ‡§√◊ËÕß∑—Ë«‰ª®–¡’°“√‡μ◊Õπ∂â“ §à“°“√π”‰øøÑ“·ª√‡ª≈’ˬπ√–À«à“ß ± 5% ª√–®ÿ à«π„À≠à∑’Ë∑”„À⇰‘¥§à“°“√π”‰øøÑ“§◊Õ ‚´‡¥’¬¡ ª√–®ÿ ÕπË◊ Ê ¡ª’ √¡‘ “≥πÕâ ¬¡“°®π·∑∫μ¥— ∑ßÈ‘ ‰ª‰¥â §“à °“√π”‰øø“Ñ ππÈ— ®ß÷ ·ª√ºπ— ‡ªπì ‡ πâ μ√ß°∫— ‚´‡¥¬’ ¡„ππ”È ¬“ dialysate §◊Õ §à“°“√π”‰øøÑ“¥—ß°≈à“«¢â“ßμâπ‡∑à“°—π§à“‚´‡¥’¬¡ 120-160 mEq/L °“√„™â sodium profiling „π°“√øÕ°‡≈◊Õ¥π—Èπ®÷ß„™â°“√ª√—∫§à“°“√π”‰øøÑ“·∑π°“√«—¥‚´‡¥’¬¡‚¥¬μ√ß ´÷Ëß∫“߇§√◊ËÕßμâÕß„™â«‘∏’ °“√‡∑’¬∫∫—≠≠—쑉μ√¬“ß»å ·μà∫“߇§√◊ËÕß®–§”π«≥ª√—∫‡ªìπ§à“‚´‡¥’¬¡„Àâ‡≈¬ „π°√≥’∑’褈ҡ“√π”‰øøÑ“ μ˔Փ®‡°‘¥®“°πÈ”¬“‡¢â¡¢âπÀ¡¥∂—ßÀ√◊Õ∑àÕ¥Ÿ¥πÈ”¬“‡¢â¡¢âπ∂Ÿ°Õÿ¥μ—π  à«π∂â“§à“°“√π”‰øøÑ“ ŸßÕ“®‡°‘¥ ®“°πÈ”∫√ ‘ ∑ÿ ∏∂‘Ï °Ÿ  ßà ¡“‰¡æà Շ欒 ß πÈ”∫√ ‘ ∑ÿ ∏¡‘Ï °’ “√ªπ‡ªÕóô π®“°ª√–®‡ÿ ™πà ·§≈‡´¬’ ¡À√Õ◊ „™πâ È”¬“dialysate ‡¢â¡¢âπº‘¥™π‘¥ ‡™àπ„™âπÈ”¬“ A ∑—Èß Õß∂—ß ‡¡◊ËÕ§à“ conductivity  ßŸ À√◊ÕμË”°«à“∑’Ëμ—È߉«â ‡§√◊ËÕß®– àß —≠≠“≥ ‡μÕ◊ π·≈–μ¥— π”È ¬“‰¡„à À â ßà ‰ª¬ß— μ«— °√Õß ‡æÕË◊ ‰¡„à À‡â ≈Õ◊ ¥ ¡— º — °∫— π”È ¬“∑ºË’ ¥‘ ª°μ‘ Õπ— Õ“®°Õà „À‡â °¥‘ ¿“«– hyper, hypoosmolality ‰¥â 27

Practical Dialysis in the Year 2009  «à πª√–°Õ∫∑„’Ë ™«â ¥— §“à °“√π”‰øø“Ñ ª√–°Õ∫¥«â ¬metal electrode  ÕßÕπ— Õ¬ÀàŸ “à ß°π— ª√–¡“≥ 1 ™.¡. ·≈–®ÿà¡≈߉ª„ππÈ”¬“ dialysate (√ªŸ ∑’Ë 6) °√–· ‰øøÑ“∂Ÿ° à߉ª„π∑’Ë electrode ∑—Èß Õß ·√ߥ—π‰øøÑ“ ∑’Ëμ°§√àÕ¡ electrode ®–·ª√‡ª≈’ˬπμ“¡ ¿“æª√–®ÿ„ππÈ”¬“ ‡π◊ËÕß®“°°“√‰À≈¢Õß°√–· ‰øøÑ“¢÷Èπ°—∫ Õÿ≥À¿¡Ÿ ‘¥â«¬ ¥—ßπ—Èπ§à“°“√π”‰øøÑ“¡—°®– correct ¥â«¬§à“¡“μ√∞“π∑’Ë 25°C 2.5 ·√ߥ—ππÈ”¬“, ªí¡ö ·≈–°“√§«∫§ÿ¡ ultrafiltration ·√ߥ—π¢ÕßπÈ”¬“„π√–∫∫§«√Õ¬àŸ„π™à«ß (-400) - (+350) ¡¡.ª√Õ∑ ‚¥¬¡’§à“§«“¡‡∑’ˬßμ√ß Õ¬àŸ√–À«à“ß ± 10% ·√ߥ—π∫«°¢ÕßπÈ”¬“‰¡à§«√‡°‘π venous pressure ‡æ◊ËÕªÑÕß°—π°“√·μ°¢Õ߇¬◊ËÕ°√Õß À√◊Õ backfiltration °“√§«∫§ÿ¡°“√¥÷ßπÈ”®“°ºâŸªÉ«¬ (ultrafiltration) ·μà‡¥‘¡π—Èπ∑”‰¥â‚¥¬°“√·ª√‡ª≈’ˬπ §à“ transmembrane pressure (TMP) TMP π—Èπ‡∑à“°—∫·√ߥ—π¢Õ߇≈◊Õ¥∑’ËÕÕ°®“°μ—«°√Õß≈∫¥â«¬·√ߥ—π πÈ”¬“∑¥’Ë π— ÕÕ°®“°μ«— °√Õß ·μ‡à §√Õ◊Ë ßøÕ°‡≈Õ◊ ¥„πª®í ®∫ÿ π— ‡ªπì ·∫∫ volumetric ∑ß—È À¡¥·≈«â ´ß÷Ë °“√§«∫§¡ÿ ¡’ 2 ·∫∫3 §◊Õ„™â flow sensor (√ªŸ ∑’Ë 7) ≈—°…≥–‡À¡◊Õπ°—ßÀ—π«—¥ª√‘¡“≥πÈ”¬“ dialysate ∑’ˇ¢â“·≈–ÕÕ° ®“°μ«— °√Õß ·≈–§”π«≥Õμ— √“°“√‰À≈°≈∫— ‡ªπì ª√¡‘ “μ√ ‚¥¬„™â micro processor ‡æÕ◊Ë °“√§«∫§¡ÿ ª√¡‘ “≥ ultrafiltration „À‰â ¥μâ “¡μÕâ ß°“√„π‡«≈“∑°Ë’ ”Àπ¥ μ«— Õ¬“à ߢÕ߇§√ÕË◊ ß∑„Ë’ ™â flow control §Õ◊ Baxter Õ°’ √–∫∫ ‡ªπì °“√«¥— ª√¡‘ “≥π”È ¬“‡¢“â ·≈–ÕÕ°®“°μ«— °√Õß‚¥¬μ√ß ‡√¬’ °«“à ·∫∫ balancing system °“√∑”ß“π‚¥¬ ¬Õà §Õ◊ √–∫∫®–¡À’ Õâ ß ”À√∫— °°— πÈ”¬“ (chamber) ∑ß—È °Õà π‡¢“â μ«— °√Õß·≈–∑Õ’Ë Õ°®“°μ«— °√Õß ‚¥¬‡ªπì ÀÕâ ß ‡¥¬’ «°π— ·μ¡à º’ πß— °πÈ— °≈“ß·∫ßà ª√¡‘ “μ√‡ªπì  Õß™Õà ߇∑“à Ê °π— ‡¡ÕË◊ ¡π’ ”È ¬“‡¢“â ‰ª ¥Ÿà “â πÀπßË÷ ºπß— π®È’ –∂°Ÿ ¥π— ‰ª¥â“πμ√ߢⓡ ∑”„Àâª√‘¡“μ√¢ÕßÀâÕßÕ’°¥â“πÀπ÷Ëß≈¥≈ß πÈ”¬“¢“ÕÕ°®–∂Ÿ°ªíö¡‡¢â“ ŸàÀâÕߥâ“ππ’È®π ∑”„Àâºπ—ß°—Èπ°≈—∫ Ÿà®ÿ¥°÷Ëß°≈“ßÕ’°§√—Èß ¥—Èßπ—ÈππÈ”¬“∑’ˇ¢â“·≈–ÕÕ°®“°μ—«°√Õß®–¡’ª√‘¡“μ√‡∑à“°—π ∂â“ μÕâ ß°“√„À¡â ’ ultrafiltration √–∫∫§«∫§¡ÿ ®– ßà  ≠— ≠“≥‰ª„Àªâ ¡öí π”È ¬“¢“‡¢“â ·≈–ÕÕ°®“°μ«— °√Õ߇æÕË◊ „Àâ ‰¥âª√‘¡“≥ ultrafiltration μ“¡μâÕß°“√ ‚¥¬∑—Ë«‰ª‡§√◊ËÕß®–¡’ balancing chamber 2 ÀâÕß∑”ß“π ≈—∫°—π ‡æ◊ËÕ Meter with Alarm setting Circuit and current source -+ Thermister Dialysate Conductivity cell √Ÿª∑Ë’ 6 Dialysate conductivity measurement 28

Technology Insight of Hemodialysis Machine and Apparatus „À⇰‘¥§«“¡μàÕ‡π◊ËÕߢÕß°“√ àßπÈ”¬“‡¢â“ÕÕ°®“°μ—«°√Õß μ—«Õ¬à“ߢÕ߇§√◊ËÕß∑’Ë„™â√–∫∫π’ȧ◊Õ Fresenius, Nikiso ‡ªìπμâπ (√ªŸ ∑’Ë 8) Inlet dialysate Flow meter dialyzer Controller Flow meter Dialysate pump Pressure control √ªŸ ∑Ë’ 7 °“√§«∫§ÿ¡ UF ·∫∫ flow sensor dialyzer Controller Outlet dialysate Dialysate pump UF pump Inlet dialysate √Ÿª∑Ë’ 8 °“√§«∫§ÿ¡ UF ·∫∫ balancing system 29

Practical Dialysis in the Year 2009 2.6 blood leak monitoring ‡ªπì °“√μ√«® Õ∫«“à ¡‡’ ≈Õ◊ ¥ªπ°∫— πÈ”¬“ dialysate À√Õ◊ ‰¡à ´ß÷Ë ∂“â ¡Õ’ “®¡°’ “√·μ°·¬°¢Õ߇¬Õ◊Ë °√Õß (membrane) ‚¥¬¡—°„™â infrared À√◊Õ°“√μ√«®®—∫¥â«¬· ß ‚¥¬ÕÕ°·∫∫„Àâμ—« àß· ß·≈–μ—«°√Õß √—∫‡ªìπ≈—°…≥–‡À¡◊Õπ∂⫬ ‡æ◊ËÕªÑÕß°—π°“√√∫°«π®“°øÕßÕ“°“»∑’ËÕ“®ªπ¡“ ´÷Ëß®–≈Õ¬Õ¬àŸ‡Àπ◊Õμ—« μ√«®®—∫ (√ªŸ ∑’Ë 9) ∂â“¡’‡¡Á¥‡≈◊Õ¥·¥ßªπ¡“°—∫πÈ”¬“®–∑”„Àâ°“√À—°‡À¢Õß· ß‡ª≈’Ë¬π‰ª ‚¥¬∑—Ë«‰ª√–∫∫ ®–¡’§«“¡‰«Õ¬àŸ„π™à«ß 0.25-0.35 ¡≈. ¢Õ߇≈◊Õ¥∑’Ëªπ¡“°—∫πÈ”¬“ 1 ≈‘μ√ ∂â“¡’°“√μ√«® Õ∫æ∫ blood leak ‡§√◊ËÕß®– à߇ ’¬ß‡μ◊Õπ·≈–‡°‘¥°“√∑”ß“π¢Õߪíö¡‡≈◊Õ¥ 3. ‡∑§‚π‚≈¬„’ À¡Êà „π°“√øÕ°‡≈◊Õ¥ πÕ°®“°√–∫∫æπ◊È ∞“π∑°’Ë ≈“à «¡“·≈«â „πª®í ®∫ÿ π— ‡√¡‘Ë ¡°’ “√„™‡â ∑§‚π‚≈¬„’ À¡Êà „π°“√øÕ°‡≈Õ◊ ¥ ¡“°¢÷Èπ  à«πÀπ÷ËßÕ“®¬—߇ªìπß“π«‘®—¬ ·μà∫“ß à«π°Á‡√‘Ë¡„™â„π°“√øÕ°‡≈◊Õ¥ª√–®”¥â«¬ °≈à“«§◊Õ online monitoring ¢Õß chemical/physical signal √–À«à“ß°“√øÕ°‡≈◊Õ¥·≈– feedback control ®ÿ¥ª√– ß§å„π°“√ ∑”§Õ◊ ‡æÕË◊ ≈¥ª≠í À“ hemodynamic instability ¢ÕߺªŸâ «É ¬´ßË÷ ‡ªπì ª≠í À“ ”§≠— ∑æË’ ∫‰¥∫â Õà ¬4 ‡πÕË◊ ß®“°°“√ øÕ°‡≈Õ◊ ¥∑«Ë— ‰ª‡¡ÕË◊ ¡¿’ “«–¢Õß hemodynamic ∑‡Ë’ ª≈¬Ë’ π·ª≈ß ‚¥¬‡©æ“– blood volume ∑≈Ë’ ¥≈ß·≈–§«“¡ ¥—π‚≈À‘μμË”π—Èπ ®–μ√«® Õ∫‰¥â°ÁμàÕ‡¡◊ËÕ‡ÀÁπ°“√‡ª≈’ˬπ·ª≈ߢÕßÕ“°“√À√◊Õ —≠≠“≥™’æ·≈â« ·≈–°“√ ·°â‰¢°ÁμâÕß„™â§π„π°“√ª√—∫·μàß ´÷ËßÕ“®‰¡à∑—π°—∫°“√‡ª≈’ˬπ·ª≈ߢÕߺ⟪ɫ¬ ·¡â«à“®–¡’°“√„™â profiling dialysis ∑—Èß‚´‡¥’¬¡ ·≈– ultrafiltration ·μà°Á‡ªìπ§à“∑’˪√—∫·μàß¡“·≈â« ‚¥¬‰¡à‰¥âÕÕ°·∫∫¡“ ”À√—∫ºâŸªÉ«¬ ·μà≈–√“¬ √–∫∫π’È®÷ߧ‘¥§âπ¢÷Èπ¡“‡æ◊Ëՙ૬„π°“√ª√—∫·μàß°“√√—°…“·∫∫Õ—μ‚π¡—μ‘À√◊Õ°÷ËßÕ—μ‚π¡—μ5‘ ‚¥¬ ª√–°Õ∫¥â«¬ online monitoring ´÷Ë߇ªìπ°“√μ√«® Õ∫ à«πª√–°Õ∫¢Õ߇≈◊Õ¥À√◊ÕπÈ”¬“≈â“߉μμ≈Õ¥‡«≈“ ·≈– àß —≠≠“≥‡μ◊Õπ„Àâ√–∫∫§«∫§ÿ¡‡ªìπ≈—°…≥–¢Õß°“√ªÑÕπ°≈—∫ ´÷Ëß°“√ª√—∫·μàß¡’‰¥âμ—Èß·μàª√—∫ Air bubbles Lamp Photocell √Ÿª∑Ë’ 9 blood leak monitor 30

Technology Insight of Hemodialysis Machine and Apparatus ‚¥¬º¥Ÿâ ·Ÿ ≈‡¡Õ◊Ë ‡§√Õ◊Ë ß ßà  ≠— ≠“≥‡μÕ◊ πª√∫— ·∫∫°ß÷Ë Õμ— ‚π¡μ— ‘À√Õ◊ ·∫∫Õμ— ‚π¡μ— ‚‘ ¥¬‡§√Õ◊Ë ßª√∫— ultrafiltration ·≈– conductivity ¢ÕßπÈ”¬“„Àâ‡À¡“– ¡ ´÷Ë߇√’¬°«à“ biofeedback control6 √–∫∫μ√«® Õ∫∑’Ë¡’„πªí®®ÿ∫—𠉥·â °à °“√‡ª≈¬Ë’ π·ª≈ߪ√¡‘ “≥‡≈Õ◊ ¥ (blood volume), °“√π”‰øø“Ñ ¢Õßπ”È ¬“ (dialysate conductivity), urea kinetic ·≈– thermal energy balance „π∑’Ëπ’È®–¢Õ¬°μ—«Õ¬à“߇©æ“– blood volume monitoring blood volume monitoring ‡ªìπ°“√μ√«® Õ∫°“√‡ª≈’ˬπ·ª≈ߪ√‘¡“≥‡≈◊Õ¥„π√à“ß°“¬‚¥¬°“√μ√«® Õ∫√–¥—∫ hemoglobin À√◊Õ hematocrit μ≈Õ¥‡«≈“ ∂â“ blood volume ≈¥≈ß hemoglobin °Á®– Ÿß¢÷Èπ °“√μ√«® Õ∫ „™âÀ≈—°¢Õß optical absorbance §◊Õ¡’·À≈àß°”‡π‘¥· ß·≈–μ—«√—∫· ßª√–°Õ∫°—∫ à«π arterial blood line ‚¥¬μ√«® Õ∫°“√À°— ‡À¢Õß· ß´ß÷Ë ®–‡ª≈’¬Ë π·ª≈߉ªμ“¡√–¥—∫§«“¡‡¢â¡¢πâ ¢Õ߇≈Õ◊ ¥ ·≈–§”π«≥°≈—∫ ¡“‡ªìπ°“√‡ª≈’ˬπ·ª≈ߢÕߪ√‘¡“≥‡≈◊Õ¥ ∂Ⓡªìπ√–∫∫ biofeedback ‡§√◊ËÕß®–≈¥ª√‘¡“≥ ultrafiltration ‡¡Õ◊Ë ª√¡‘ “≥‡≈Õ◊ ¥≈¥≈ßμË”°«“à §“à ∑μ’Ë ß—È ‰«â ®“°°“√»°÷ …“∑º’Ë “à π¡“æ∫«“à §«“¡ ¡— æπ— ∏√å –À«“à ß blood volume ∑’Ë≈¥≈ß°—∫°“√‡°‘¥§«“¡¥—π‚≈À‘μμË”π—Èπ‰¡à¥’¡“°π—° ‡π◊ËÕß®“°¡’ªí®®—¬À≈“¬Õ¬à“ß¡“‡°’ˬ«¢âÕß7,8 ‡™àπ vascular refilling ∑·Ë’ μ°μ“à ß°π— „π·μ≈à –∫§ÿ §≈ ª√¡‘ “≥‡≈Õ◊ ¥¢ÕߺªŸâ «É ¬ ·≈–√–¥∫— Õ≈— ∫¡Ÿ π‘ „π‡≈Õ◊ ¥ ‡ªπì μπâ ¢âÕ¥’¢Õß°“√„™â blood volume monitoring §◊Õ‡ªìπ non invasive test ·≈–‡ªìπÕÿª°√≥åª√–°Õ∫∑’ˉ¥â°—∫ ‡§√◊ËÕßøÕ°‡≈◊Õ¥‡°◊Õ∫∑ÿ°√ÿàπ ·μà§ÿ≥§à“¢Õß°“√„™âß“πª√–®”«—π§ßμâÕßÕ“»—¬°“√»÷°…“μàÕ‰ª9 4.  √ÿª °“√√®âŸ °— ·≈–‡¢“â „®°“√∑”ß“π¢Õ߇§√ÕË◊ ß¡Õ◊ ∑„Ë’ ™ßâ “π ¡§’ «“¡®”‡ªπì Õ¬“à ߬ßË‘ ‚¥¬‡©æ“–„π°“√ √—°…“∑’Ë ≈—∫´—∫´âÕ𠧫“¡º‘¥æ≈“¥∑’ˇ°‘¥®“°‡§√◊ËÕß¡◊Õ  “¡“√∂ªÑÕß°—π‰¥â¥â«¬°“√∫”√ÿß√—°…“·≈–ª√—∫ ·μà߇§√◊ËÕß¡◊ÕÕ¬à“ß ¡Ë”‡ ¡Õ‚¥¬ºŸâ™”π“≠°“√ ∂÷ß·¡â«à“‡§√◊ËÕßøÕ°‡≈◊Õ¥ ®–ÕÕ°·∫∫¡“„Àâ¡’√–∫∫„π °“√ªÑÕß°—πÕ—πμ√“¬À≈“¬Õ¬à“ß°Áμ“¡ °Á¬—ßÕ“®¡’§«“¡º‘¥æ≈“¥‡°‘¥¢÷Èπ®“°¡πÿ…¬å‚¥¬‡§√◊ËÕ߉¡àÕ“® μ√«®®—∫‰¥â∑—𠇙àπ¥Ÿ¥πÈ”¬“‡¢â¡¢âπº‘¥∂—ß ®π∑”„À⇰‘¥¿“«– hyperosmolar ‡¢Á¡¥â“πÀ≈Õ¥‡≈◊Õ¥¥”À≈ÿ¥ ®“°À≈Õ¥‡≈◊Õ¥ ´÷Ë߇§√◊ËÕßÕ“®‰¡à à߇ ’¬ß‡μ◊Õπ ‡π◊ËÕß®“° venous pressure ∑’Ë≈¥≈߉¡àæÕ∑’Ë®–∑”„À⇧√◊ËÕß μ√«®‰¥â À√◊Õ “¬ à߇≈◊Õ¥À—°ßÕ„πμ”·Àπàß√–À«à“ߪíö¡‡≈◊Õ¥ ·≈– venous pressure monitoring ∑”„À⇰‘¥ ·√ߥ—π Ÿß®π‡¡Á¥‡≈◊Õ¥·¥ß·μ° ∑’Ë ”§—≠§◊Õ‡¡◊ËÕ¡’ —≠≠“≥‡μ◊Õπ®“°‡§√◊ËÕß ®–μâÕßμ√«® Õ∫„Àâ·πà„® «à“¡’ªí≠À“∑’Ë®ÿ¥„¥ ·≈–·°â‰¢‡ ’¬°àÕπ ®÷ß®–¥”‡π‘π°“√√—°…“μàÕ‰ª ‡Õ° “√Õ“â ßÕß‘ 1. Misra M. The basics of hemodialysis equipment. Hemodial Int 2005; 9(1):30-6. 2. Polaschegg HD. Machines for hemodialysis. Contrib Nephrol 2005; 149:18-26. 3. Richard A Ward. Single-Patient Hemodialysis Machines. In: Nissenson AR, Fine RN, eds. Dialysis Therapy. 3rd ed. Philadelphia: Hanley and Belfus; 2002: 60-65. 4. Andrulli S, Colzani S, Mascia F et al. The role of blood volume reduction in the genesis of intradialytic hypotension. Am J Kidney Dis 2002; 40(6):1244-54. 31

Practical Dialysis in the Year 2009 5. Ward RA, Ronco C. Dialyzer and machine technologies: application of recent advances to clinical practice. Blood Purif 2006; 24(1):6-10. 6. Ronco C, Ghezzi PM, La Greca G. The role of technology in hemodialysis. J Nephrol 1999; 12 Suppl 2:S68-81. 7. Kim KE, Neff M, Cohen B et al. Blood volume changes and hypotension during hemodialysis. Trans Am Soc Artif Intern Organs 1970; 16:508-14. 8. Daugirdas, JT. Dialysis hypotension: a hemodynamic analysis. Kidney Int. 1991; 39(2):233-46. 9. Locatelli F, Buoncristiani U, Canaud B, Kohler H, Petitclerc T, Zucchelli P. Haemodialysis with on-line monitoring equipment: tools or toys? Nephrol Dial Transplant 2005; 20(1):22-33. 32

Know How! Know Why!! in Chronic Hemodialysis Prescription 4 Know How! Know Why!! in Chronic Hemodialysis Prescription ∑«’ ™“≠™—¬√®ÿ ‘√“ 1. ∫∑π” 2. ‡ªÑ“À¡“¬„π°“√ —Ëß°“√√—°…“øÕ°‡≈Õ◊ ¥ 3. §” ß—Ë °“√√—°…“ºŸªâ «É ¬øÕ°‡≈Õ◊ ¥ 4. Õߧåª√–°Õ∫∑μ’Ë âÕߧ”π÷ß„π°“√ Ëß— °“√√°— …“øÕ°‡≈◊Õ¥ 5. °“√ª√–‡¡π‘ º≈°“√μ√«®∑“ßÀâÕߪØ∫‘ —μ°‘ “√ 6. °“√ª√–‡¡‘πºŸªâ «É ¬°Õà π°“√øÕ°‡≈◊Õ¥ 7. °“√ª√–‡¡π‘ ºâŸªÉ«¬√–À«à“ß°“√øÕ°‡≈◊Õ¥ 8. °“√ª√–‡¡‘π·≈–·°â ‰¢°√≥∑’ ªË’ √‘¡“≥øÕ°‡≈Õ◊ ¥‰¡‡à æ’¬ßæÕ 9. °“√®¥— ∑”·ø¡Ñ ª√–«—μº‘ ⟪«É ¬ 10.  √ÿª 33

Practical Dialysis in the Year 2009 1. ∫∑π” °“√ ß—Ë √°— …“øÕ°‡≈Õ◊ ¥¡‡’ ª“Ñ À¡“¬À≈°— §Õ◊ „Àºâ ªŸâ «É ¬‰¥√â ∫— °“√øÕ°‡≈Õ◊ ¥∑‡’Ë æ¬’ ßæÕ‡æÕ◊Ë ≈¥Õμ— √“ °“√‡®Á∫ªÉ«¬·≈–Õ—μ√“°“√‡ ’¬™’«‘μ √«¡∂÷ß∑”„ÀâºâŸªÉ«¬¡’ ¡√√∂¿“æ√à“ß°“¬ (physical performance) ·≈–§ÿ≥¿“æ™’«‘μ∑’Ë¥’¢÷Èπ °“√¥Ÿ·≈ºâŸªÉ«¬øÕ°‡≈◊Õ¥§«√¡’∑’¡´÷Ëߪ√–°Õ∫¥â«¬ ·æ∑¬å 欓∫“≈«‘™“™’æ 欓∫“≈‡∑§π‘§ π—°‚¿™π“°“√·≈–π—° —ߧ¡ ß‡§√“–Àå ‡æ◊ËÕ∑’Ë®–‰¥â¥Ÿ·≈ºŸâªÉ«¬·∫∫Õߧå√«¡ ¢âÕ¡≈Ÿ μà“ßÊ ∑’ˉ¥â®“°°“√ª√–‡¡‘πºŸâªÉ«¬π”¡“ª√–¡«≈ ‡æ◊ËÕ∑’Ë®–‰¥â«“ß·ºπ°“√√—°…“√«¡∂÷ß°“√ —Ëß°“√√—°…“∑’Ë §√Õ∫§≈¡ÿ ∑°ÿ ª≠í À“¢ÕߺªŸâ «É ¬1  ”À√∫— „π∫∑§«“¡π®È’ –°≈“à «∂ß÷ ‡©æ“–°“√‡¢¬’ 𧔠ßË— °“√√°— …“·≈–Õß§å ª√–°Õ∫∑’ËμâÕߧ”π÷ß„π°“√ —Ëß°“√√—°…“„πºâŸªÉ«¬ chronic hemodialysis 2. ‡ª“Ñ À¡“¬„π°“√¥·Ÿ ≈√°— …“ºŸªâ É«¬øÕ°‡≈◊Õ¥ Õߧªå √–°Õ∫ ”§≠— ∑μË’ Õâ ߧ”πß÷ ∂ß÷ „π°“√¥·Ÿ ≈ºªâŸ «É ¬‡æÕË◊ „À∫â √√≈‡ÿ ª“Ñ À¡“¬„π°“√øÕ°‡≈Õ◊ ¥∑Ë’ ‡æ’¬ßæÕ¡’¥—ßπ’È 1) §«“¡‡æ’¬ßæÕ„π°“√¢®—¥ uremic toxins ‚¥¬Õ“»—¬¥—™π’™’È«—¥∑’Ë ”§—≠§◊Õ Kt/V ·≈– urea reduction ratio (URR) °“√ª√–‡¡‘π°“√øÕ°‡≈◊Õ¥∑’ˇ撬ßæÕ μâÕßμ‘¥μ“¡·≈–ª√–‡¡‘π delivered Kt/V Õ¬à“ß ¡Ë”‡ ¡Õ ·≈–μâÕߪ√–‡¡‘π ¿“æ∑—Ë«‰ª∑“ߧ≈‘π‘°§«∫§àŸ°—π¥â«¬ 2) °“√§«∫§ÿ¡ ¡¥ÿ≈πÈ”„π√à“ß°“¬ ¥ÿ≈‡°≈◊Õ·√à·≈–°√¥¥à“ß √–¥—∫·§≈‡´’¬¡·≈–øÕ ‡øμ „π‡≈◊Õ¥ √«¡∂÷ß√–¥—∫ parathyroid hormone „π‡≈◊Õ¥„ÀâÕ¬àŸ„π√–¥—∫∑’ˇÀ¡“– ¡ ´÷Ëß„π°“√ —Ëß°“√√—°…“ μâÕߧ”π÷ß∂÷ßªí®®—¬μàÕ‰ªπ’È - °“√°”Àπ¥πÈ”Àπ—°·Àâß (dry weight) ·≈–Õ—μ√“°“√¥÷ßπÈ” (ultrafiltration rate) - °“√°”Àπ¥ à«πª√–°Õ∫¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥ (dialysate solution composition) „Àâ‡À¡“–  ¡ ”À√—∫ ¿“«–¢Õߺ⟪ɫ¬·μà≈–√“¬ - °“√„™â phosphate binder ‡æ◊ËÕ§«“¡§ÿ¡ªí≠À“ hyperphosphatemia ·≈–°“√„™â«‘μ“¡‘π¥’ ‡æ◊ËÕ§«∫§ÿ¡ªí≠À“ hyperparathyroidism 3) ·°â‰¢¿“«–μà“ßÊ ∑’Ë¡—°æ∫„πºŸâªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß ‡™àπ ·°â‰¢¿“«–´’¥ °“√§«∫§ÿ¡√–¥—∫‰¢ ¡—π„π‡≈◊Õ¥§«∫§ÿ¡√–¥—∫§«“¡¥—π‚≈À‘μ„ÀâÕ¬àŸ„π‡°≥±å∑’ˇÀ¡“– ¡ 4) ¿“«–‚¿™π“°“√ ‚¥¬°“√«—¥ normalized protein catabolic rate (nPCR) À√◊Õ normalized protein nitrogen appearance (nPNA) √«¡∂÷ß°“√ª√–‡¡‘π¿“«–‚¿™π“°“√®“°°“√μ√«®√à“ß°“¬ (anthropometric measurement) ·≈–º≈∑“ßÀâÕߪؑ∫—μ‘°“√ (serum albumin, serum transferrin) 5) °“√√—°…“‚√§·∑√°´âÕπ∑’Ëæ∫√à«¡ (comorbid diseases) ‡™àπ °“√§«∫§ÿ¡√–¥—∫πÈ”μ“≈„π ‡≈◊Õ¥„πºŸâªÉ«¬‡∫“À«“π 6) °“√ªÑÕß°—π‰¡à‡°‘¥¿“«–·∑√°´âÕπ√–À«à“ß°“√øÕ°‡≈◊Õ¥ - °“√°”Àπ¥Õÿ≥À¿¡Ÿ ‘¢ÕߢÕß dialysate - Sodium profiling ·≈– Ultrafiltration profiling 34

Know How! Know Why!! in Chronic Hemodialysis Prescription - Blood volume monitoring 2.1 §«“¡‡æ¬’ ßæÕ„π°“√¢®—¥ uremic toxin °“√°”Àπ¥ª√‘¡“≥°“√øÕ°‡≈◊Õ¥ (hemodialysis dose) ∑’ˇ撬ßæÕ ªí®®ÿ∫—ππ‘¬¡„™âÕ—μ√“°“√ ¢®—¥¢Õß urea ‚¥¬„™â Kt/V ·≈– URR ‡ªìπ¥—™π’™’È«—¥ 2 2.1.1 Kt/V ‡ªìπ°“√«—¥ª√‘¡“≥°“√øÕ°‡≈◊Õ¥´÷Ëß„™â‡ª√’¬∫‡∑’¬∫ ”À√—∫ºŸâªÉ«¬·μà≈–√“¬ ‚¥¬ §à“ K §◊ÕÕ—μ√“°“√¢®—¥¢Õß urea ‚¥¬ dialyzer (dialyzer urea clearance) ·≈– t §◊Õ√–¬–‡«≈“∑’Ë„™â„π°“√ øÕ°‡≈◊Õ¥ ¥—ßπ—Èπº≈§≥Ÿ ¢Õß§à“ K ·≈– t (Kt) §◊Õª√‘¡“≥°“√øÕ°‡≈◊Õ¥∑’˺ŸâªÉ«¬‰¥â√—∫ §à“ V §◊Õ ª√‘¡“μ√ °“√°√–®“¬¢Õß urea (volume distribution ¢Õß urea) ¢Õߺ⟪ɫ¬ ´÷Ëß®–‡ªìπ —¥ à«π°—∫¢π“¥À√◊ÕπÈ”Àπ—° μ—«¢Õߺ⟪ɫ¬·μà≈–§π (V ¡’§à“‡∑à“°—∫ total body water) §à“ Kt/V ‡ªìπ§à“∑’ˉ¡à¡’Àπ૬ ‚¥¬§à“ Kt/V §◊Õ Õ—μ√“ à«π¢Õߪ√‘¡“μ√¢Õß urea ∑’Ë∂Ÿ°¢®—¥ÕÕ°‡∑’¬∫°—∫ª√‘¡“μ√¢Õß urea ∑—ÈßÀ¡¥„π√à“ß°“¬ ¥—ßπ—Èπ§à“ Kt/V ®÷߇ªìπ§à“∑’Ë· ¥ßª√– ‘∑∏‘¿“æÀ√◊Õª√‘¡“≥°“√øÕ°‡≈◊Õ¥μàÕ¢π“¥¢Õߺ⟪ɫ¬·μà≈–√“¬ „π°“√øÕ° ‡≈◊Õ¥·μà≈–§√—Èß °“√À“§“à Kt/V  “¡“√∂∑”‰¥Àâ ≈“¬«∏‘ ’ ·μ«à ∏‘ ∑’ ‰Ë’ ¥ºâ ≈·¡πà ¬”∑ Ë’ ¥ÿ §Õ◊ formal urea kinetic model (UKM) ´÷Ëß«‘∏’π’È®–‰¥â§à“ nPNA ¥â«¬ ·μà UKM ¡’ Ÿμ√§”π«≥∑’˧àÕπ¢â“ß´—∫´âÕπ·≈–®”‡ªìπμâÕßÕ“»—¬ ‚ª√·°√¡§Õ¡æ‘«‡μÕ√å™à«¬„π°“√§”π«≥ „π°√≥’∑’ˉ¡à¡’‚ª√·°√¡¥—ß°≈à“« (NKF-DOQI) ·π–π”„ÀâÀ“§à“ Kt/V ‚¥¬«‘∏’„™â μŸ √Õ¬à“ßßà“¬ (2nd generation Daugirdas formula)3 ¥—ß ¡°“√∑’Ë 1 ¢â“ß≈à“ß §à“ Kt/V ®“°  Ÿμ√π’Èæ∫«à“‰¥âº≈„°≈⇧’¬ß°—∫«‘∏’ formal urea kinetic model Kt/V = {-Ln(R - 0.008 × t)} + {(4 - 3.5 × R) X UF/W} .................................. ¡°“√∑’Ë 1 ‚¥¬∑’Ë Ln = natural logarithm À√◊Õ loge (log ∞“π e) R = post-dialysis BUN ÷ pre-dialysis BUN t = √–¬–‡«≈“¢Õß°“√øÕ°‡≈◊Õ¥∑—ÈßÀ¡¥∑’˺ŸâªÉ«¬‰¥â√—∫®√‘ß (Àπ૬‡ªìπ ™—Ë«‚¡ß) UF = ª√‘¡“≥ ultrafiltration (total ultrafiltration) (Àπ૬‡ªìπ ≈‘μ√) W = πÈ”Àπ—°μ—«À≈—ßøÕ°‡≈◊Õ¥ (Àπ૬‡ªìπ °‘‚≈°√—¡) §“à Kt/V ∑‰Ë’ ¥®â “°°“√„™§â “à BUN ∑‡Ë’ °∫Á ∑π— ∑À’ ≈ß— øÕ°‡≈Õ◊ ¥ (‚¥¬«∏‘ ’ slow flow) ‡√¬’ °«“à single- pool Kt/V (spKt/V) 2.1.2 ª√‘¡“≥°“√øÕ°‡≈Õ◊ ¥∑ˇ’ æ’¬ßæÕ (adequate hemodialysis dose) ª®í ®∫ÿ π— ¡¢’ Õâ ¡≈Ÿ ™¥— ‡®π«“à ª√¡‘ “≥°“√øÕ°‡≈Õ◊ ¥∑π’Ë Õâ ¬∑ ’Ë ¥ÿ ∑º’Ë ªâŸ «É ¬§«√‰¥√â ∫— (minimal delivered dose of hemodialysis) §«√‡ªìπ‡∑à“‰√ ´÷Ëß∂â“μË”°«à“π’È∂◊Õ«à“°“√øÕ°‡≈◊Õ¥‰¡à‡æ’¬ßæÕ  à«πª√‘¡“≥°“√ øÕ°‡≈◊Õ¥∑’Ë¡“°∑’Ë ÿ¥ (maximal delivered dose of hemodialysis) §◊Õª√‘¡“≥°“√øÕ°‡≈◊Õ¥∑’ˇæ‘Ë¡¡“° °«à“√–¥—∫π’È·≈â«®–‰¡à‰¥â≈¥Õ—μ√“°“√‡®Á∫ªÉ«¬À√◊ÕÕ—μ√“°“√‡ ’¬™’«‘μ≈ßÕ’° ´÷Ëß„πªí®®ÿ∫—π¬—߉¡à∑√“∫ ·πà™—¥«à“√–¥—∫‰Àπ∑’˺⟪ɫ¬®–‰¡à‰¥âª√–‚¬™πå‡æ‘Ë¡¢÷Èπ  ”À√—∫ª√‘¡“≥°“√øÕ°‡≈◊Õ¥‡æ’¬ßæÕ (adequate 35

Practical Dialysis in the Year 2009 hemodialysis dose) πà“®–‡ªìπ§à“∑’ËÕ¬Ÿà√–À«à“ß§à“ minimal ·≈– maximal π’È ‚¥¬§”π÷ß∂÷ß§à“„™â®à“¬·≈– ª√–‚¬™πå∑’˺⟪ɫ¬®–‰¥â√—∫ ßŸ  ÿ¥ (cost-effectiveness) ª√‘¡“≥°“√øÕ°‡≈◊Õ¥∑’ËπâÕ¬∑’Ë ÿ¥∑’˺⟪ɫ¬§«√‰¥â√—∫ (minimal delivered dose of hemodialysis) „π°√≥’∑’ËøÕ°‡≈◊Õ¥ 3 §√—ÈßμàÕ —ª¥“Àå 4 spKt/V = 1.2 ·≈– URR = 65%  ”À√—∫°“√ —Ëß°“√√—°…“ prescribed spKt/V §«√‡º◊ËÕ‡æ‘Ë¡¢÷Èπ‰«âª√–¡“≥√âÕ¬≈– 15 ¥—ßπ—Èπ prescribed spKt/V = 1.4 À√◊Õ URR 70% ¢Õâ ¡≈Ÿ ®“°°“√»°÷ …“æ∫«“à „πºªŸâ «É ¬‰¡¡à ª’  í  “«–À√Õ◊ Àπ“â ∑°Ë’ “√∑”ß“π¢Õ߉μ‡À≈Õ◊ πÕâ ¬¡“° „π°√≥’∑’ËøÕ°‡≈◊Õ¥ 3 §√—ÈßμàÕ —ª¥“Àå ∂⓪√‘¡“≥°“√øÕ°‡≈◊Õ¥´÷Ëß«—¥®“°§à“ spKt/V πâÕ¬°«à“ 1.2 (À√◊Õ URR πâÕ¬°«à“ 65%) Õ—μ√“°“√‡ ’¬™’«‘μ·≈–Õ—μ√“°“√‡®Á∫ªÉ«¬‡æ‘Ë¡¢÷ÈπÕ¬à“ß™—¥‡®π 5-8  ”À√—∫„π°√≥’∑’ËøÕ°‡≈◊Õ¥ 2 §√—ÈßμàÕ —ª¥“Àå ∂â“Àπâ“∑’Ë°“√∑”ß“π¢Õ߉μ∑’ˇÀ≈◊ÕÕ¬àŸπâÕ¬‡°‘𠉪 (urea clearance < 2 ¡≈./π“∑/’ 1.73 ¡.2) °“√øÕ°‡≈Õ◊ ¥‡æ¬’ ß 2 §√ßÈ— μÕà  ª— ¥“ÀÕå “®‰¡‡à 欒 ßæÕ ‡πÕË◊ ß®“° °“√øÕ°‡≈◊Õ¥·μà≈–§√—Èß®”‡ªìπμâÕ߉¥â§à“ spKt/V ª√–¡“≥ 2.0-2.1 (À√◊Õ double-pool Kt/V = 1.85)4,9,10 ´÷Ëß Õ“®∑”„Àâ∂÷߇ªÑ“À¡“¬‰¥â¬“°‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’πÈ”Àπ—°μ—«¡“°·≈–‡«≈“°“√øÕ°‡≈◊Õ¥ —Èπ  ”À√—∫ °“√»÷°…“„πª√–‡∑»‰∑¬æ∫«à“ 5 year survival „πºŸâªÉ«¬ 3,029 √“¬ ∑’ˉ¥â√—∫øÕ°‡≈◊Õ¥ 2 §√—ÈßμàÕ —ª¥“Àå æ∫«à“ºâŸªÉ«¬∑’ˉ¥â√—∫ spKt/V ≥ 1.8 ¡’Õ—μ√“°“√‡ ’¬™’«‘μμË”°«à“ºâŸªÉ«¬∑’ˉ¥â√—∫ spKt/V < 1.8 Õ¬à“ß™—¥‡®π „π ¢≥–∑’˺⟪ɫ¬∑’ˉ¥â√—∫ spKt/V 1.8-2.1 ¡’Õ—μ√“°“√‡ ’¬™’«‘μ‰¡à·μ°μà“ß°—∫ºâŸªÉ«¬∑’ˉ¥â√—∫ spKt/V > 2.111 ®÷ß·π–π”«à“ª√‘¡“≥°“√øÕ°‡≈◊Õ¥„πºâŸªÉ«¬‰∑¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥ 2 §√—ÈßμàÕ —ª¥“Àå §«√‰¥â√—∫ spKt/V ≥ 1.8 ‡ªìπÕ¬à“ßπâÕ¬  ”À√—∫ª√‘¡“≥°“√øÕ°‡≈◊Õ¥∑’ËπâÕ¬∑’Ë ÿ¥∑’˺ŸâªÉ«¬§«√‰¥â√—∫ ∑’˧«“¡∂’Ëμà“ßÊ ¢Õß°“√øÕ°‡≈◊Õ¥·≈–Àπâ“∑’ˉμ∑’ˬ—߇À≈◊ÕÕ¬Ÿà · ¥ß¥—ßμ“√“ß∑’Ë 1 2.1.3 Urea reduction ration (URR) Urea reduction ratio (URR) ‡ªìπ°“√«—¥Õ—μ√“°“√¢®—¥¢Õß urea ´÷Ë߇ªìπ«‘∏’§”π«≥∑’Ëßà“¬„π ª√–‡¡‘πª√‘¡“≥°“√øÕ°‡≈◊Õ¥∑’˺ŸâªÉ«¬‰¥â√—∫ ·≈–¡’¢âÕ¡Ÿ≈®“°°“√»÷°…“∫àß™’È«à“§à“ URR ¡’§«“¡ —¡æ—π∏å °—∫Õ—μ√“°“√‡ ’¬™’«‘μ¢Õߺ⟪ɫ¬øÕ°‡≈◊Õ¥4  Ÿμ√§”π«≥ URR ¥—ß ¡°“√∑’Ë 2 μ“√“ß∑’Ë 1 ª√¡‘ “≥°“√øÕ°‡≈Õ◊ ¥∑π’Ë Õâ ¬∑ ’Ë ¥ÿ ∑§’Ë «√‰¥√â ∫— „π°“√øÕ°‡≈Õ◊ ¥∑§’Ë «“¡∂μ’Ë “à ßÊ ·≈–Àπ“â ∑‰’Ë μ∑¬’Ë ß— ‡À≈Õ◊ Õ¬4Ÿà §«“¡∂¢Ë’ Õß°“√øÕ°‡≈◊Õ¥ Minimal spKt/V Kr < 2 ¡≈./π“∑’/1.73 ¡.2 Kr > 2 ¡≈./π“∑’/1.73 ¡.2 2 §√—ÈßμàÕ —ª¥“Àå ‰¡à·π–π” 2.0 3 §√—ÈßμàÕ —ª¥“Àå 1.2 0.9 4 §√—ÈßμàÕ —ª¥“Àå 0.8 0.6 6 §√—ÈßμàÕ —ª¥“Àå 0.5 0.4 Kr = residual renal urea clearance (Àπâ“∑’Ë°“√∑”ß“π¢Õ߉μ∑’ˬ—߇À≈◊ÕÕ¬àŸ ‚¥¬«—¥‡ªìπ clearance ¢Õß urea) 36

Know How! Know Why!! in Chronic Hemodialysis Prescription URR = 100 × (1 - R) (R = post-dialysis BUN / pre-dialysis BUN ) = 100 × [(pre − dialysisBUN) − (post − ]dialysisBUN) ............................. ¡°“√∑Ë’ 2 pre − dialysisBUN §à“ URR ¡’¢âÕ®”°—¥∑’ˉ¡à‰¥â§‘¥√«¡°“√¢®—¥¢Õ߇ ’¬∑’ˇ°‘¥®“° ultrafiltrataion (UF) ‡π◊ËÕß®“° urea ∑’Ë∂°Ÿ ¢®—¥ÕÕ°‚¥¬ UF ‡ªìπ¢∫«π°“√æ“ (convection) ´÷Ë߉¡à‰¥â∑”„Àâ§à“ BUN ‡ª≈’ˬπ·ª≈ß ¥—ßπ—È𠧫“¡·¡àπ¬”¢Õß URR „π°“√ª√–‡¡‘π°“√¢®—¥ urea ®÷ßπâÕ¬°«à“§à“ Kt/V μ—«Õ¬à“߇™àπ §à“ URR °—∫ Kt/V ¡’§«“¡ —¡æ—π∏å°—π¥—ß°√“ø„π√ªŸ ∑’Ë 1 ®–‡ÀÁπ«à“ UF ®–¡’º≈μàÕ spKt/V ‡™àπ URR 65% ‡∑à“°—∫ spKt/V 1.1 ∂Ⓣ¡à¡’ UF ·μà∂â“¡’ UF ª√–¡“≥ 10% ¢ÕßπÈ”Àπ—°μ—« ®–‰¥â spKt/V ª√–¡“≥ 1.35 ¥—ßπ—Èπ°“√·ª≈º≈ URR §«√„™ªâ √–°Õ∫√«à ¡°∫— §“à spKt/V  “¡“√∂À“§“à spKt/V ®“°§“à URR ‚¥¬„™°â √“ø· ¥ß§«“¡ ¡— æπ— ∏å √–À«à“ß spKt/V ·≈– URR ∑’Ë UF rate μà“ßÊ°—π12 (√Ÿª∑’Ë 1) ‚¥¬°√“ø‡ âπ∑·¬ß‡ªìπ§à“ total UF ‡∑’¬∫°—∫πÈ” Àπ—°μ—«ºŸâªÉ«¬À≈—ßøÕ°‡≈◊Õ¥ (UF/W) „Àâ≈“°‡ âπμ√ß®“°§à“ URR ∑’˧”π«≥‰¥â‰ªμ—¥°—∫‡ âπ°√“ø·π« ∑·¬ß∑’Ë· ¥ß§à“ UF/W À≈—ß®“°π—Èπ≈“°‡ âπμ√ߢπ“π·°π X ‰ªμ—¥°—∫§à“ spKt/V ∑’Ë·°π Y √Ÿª∑Ë’ 1 °√“ø· ¥ß§«“¡ —¡æ—π∏√å –À«à“ß Kt/V ·≈– URR ∑’Ë ultrafiltration rate μà“ßÊ °—π ‚¥¬°√“ø‡ πâ ∑·¬ß‡ªπì §à“ total ultrafiltration (UF) ‡∑¬’ ∫°—∫πÈ”Àπ—°μ«— ºªâŸ «É ¬À≈—ßøÕ°‡≈Õ◊ ¥ (UF/W) 37