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New Frontiers in Dialysis

Published by 1.patanrad, 2020-02-19 22:55:29

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10 Whatûs New in Conventional Hemodialysis? ™≈∏ª‘ æß» å °≈ÿ 1. Hypertension in hemodialysis 2. °“√§«∫§¡ÿ √–¥∫— πÈ”µ“≈„πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥

New Frontiers in Dialysis 190 ∏πµ‘ ®‘√ππ— ∑∏å «—™ ‘√¿‘ “ ™â“ß»√‘ °‘ ÿ≈™—¬ ∏π—π¥“ µ√–°“√«π™‘ « —πµå ‡ÿ ¡∏°≈ÿ 1. Hypertension in hemodialysis §«“¡¥π— ‚≈Àµ‘ ßŸ ‡ªπì ª®í ®¬— ‡ ¬’Ë ß¢Õß‚√§À«— „®À≈Õ¥‡≈Õ◊ ¥·≈–°“√‡ ¬’ ™«’ µ‘ Õ¬“à ß™¥— ‡®ππÕ°®“° π¬È’ ß— ‡ªπì ª®í ®¬— ”§≠— ∑∑Ë’ ”„À‰â µ‡ ÕË◊ ¡¡“°¢πÈ÷ „π‚√§‰µ‡√ÕÈ◊ √ß— ¡§’ ”·π–π”™¥— ‡®πÕ¬·Ÿà ≈«â „π°“√§¡ÿ §«“¡ ¥π— ‚≈Àµ‘ ¢ÕßºªâŸ «É ¬§«“¡¥π— ‚≈Àµ‘ ßŸ ·≈–ºªâŸ «É ¬‚√§‰µ‡√ÕÈ◊ √ß— ∑¬Ë’ ß— ‰¡‰à ¥øâ Õ°‡≈Õ◊ ¥ „πºâŸªÉ«¬∑’ËøÕ°‡≈◊Õ¥·≈â«¡’¢âÕ¡Ÿ≈„π‡√◊ËÕß§«“¡¥—π‚≈À‘µ°—∫Õ—µ√“°“√‡ ’¬™’«‘µ∑’Ëµà“ß‰ª ‡°≥±å „π°“√«‘π‘®©—¬·≈–§«∫§ÿ¡§«“¡¥—π‚≈À‘µ Ÿß°Á·µ°µà“ß®“°§πª°µ‘ „π à«πµàÕ‰ªπ’È®–¢Õ°≈à“«∂÷ßº≈ ¢Õß§«“¡¥π— ‚≈Àµ‘ ßŸ „πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ √«¡∂ß÷ ¥™— π∑’ §Ë’ «√„™„â π°“√√°— …“¿“«–πÈ’ §«“¡¥π— ‚≈Àµ‘ „πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥ππÈ— ¡§’ “à ‰¡§à ß∑Ë’ §Õ◊ ¡°— ßŸ „π™«à ß°Õà πøÕ°‡≈Õ◊ ¥ ‡πÕË◊ ß®“°¡’ ¿“«–πÈ”·≈–‡°≈◊Õ§—Ëß ·≈–®–≈¥À≈—ß°“√øÕ°‡≈◊Õ¥ ·µà„π∫“ß√“¬®–¡’≈—°…≥–°≈—∫°—π§◊Õ§«“¡¥—π Ÿß ¢÷Èπ„π¢≥–øÕ°‡≈◊Õ¥ ‰¡à§àÕ¬¡’°“√»÷°…“∂÷ßæ¬“°√≥å‚√§¢Õß§«“¡¥—π‚≈À‘µ Ÿß√–À«à“ß°“√øÕ°‡≈◊Õ¥ °∫— Õµ— √“°“√‡ ¬’ ™«’ µ‘ 1≈“à ¥ÿ ¡¢’ Õâ ¡≈Ÿ ®“°°“√»°÷ …“«“à „π°≈¡ÿà ∑§’Ë «“¡¥π— ‚≈Àµ‘ ‰¡‡à ª≈¬’Ë π·ª≈ßÀ√Õ◊ ‡æ¡‘Ë ¢π÷È À≈ß— °“√øÕ°¡Õ’ µ— √“°“√‡¢“â √°— …“„π‚√ßæ¬“∫“≈·≈–‡ ¬’ ™«’ µ‘ ßŸ °«“à °≈¡ÿà ∑§’Ë «“¡¥π— ≈¥≈ß2 °“√»°÷ …“º≈ ¢Õß§«“¡¥—π‚≈À‘µ∑’Ëºà“π¡“ à«π¡“°®–„™â§à“§«“¡¥—π‚≈À‘µ°àÕπÀ√◊ÕÀ≈—ßøÕ° ‡ªìπµ—«·ª√„π°“√ À“§«“¡ —¡æ—π∏å°—∫Õ—µ√“°“√‡ ’¬™’«‘µ ·µà„π™à«ß‰¡à°’Ëªï∑’Ëºà“π¡“ ‡√‘Ë¡¡’°“√ª√–‡¡‘π∂÷ß§ÿ≥§à“¢Õß°“√„™â §«“¡¥—π‚≈À‘µ∑’Ë«—¥®“°∑’Ë∫â“π ·≈–¡’¢âÕ¡Ÿ≈∑’ËÕ“®‡ªìπµ—«∫àß™’È∑’Ë¥’°«à“„π°“√∫Õ°∂÷ß¿“«–·∑√°´âÕπ¢Õß §«“¡¥π— ‚≈Àµ‘ ßŸ ∂“â „™‡â °≥±§å «“¡¥π— ‚≈Àµ‘ °Õà πøÕ°¡“°°«“à 150/85 ¡¡.ª√Õ∑ À√Õ◊ µÕâ ß„™¬â “≈¥§«“¡¥π— ‚≈Àµ‘ æ∫«“à §«“¡™°ÿ ¢Õß§«“¡¥π— ‚≈Àµ‘ ßŸ „πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ππÈ— ßŸ ∂ß÷ 70-80 ‡ªÕ√‡å ´πÁ µ3å 4 §«“¡ ¡— æπ— ∏¢å Õß §«“¡¥—π‚≈À‘µ°—∫Õ—µ√“°“√‡ ’¬™’«‘µ à«π„À≠à‰¥â¡“®“°°“√»÷°…“·∫∫ cohort ‚¥¬¡—°√«∫√«¡¡“®“° °“√≈ß∑–‡∫’¬πºâŸªÉ«¬øÕ°‡≈◊Õ¥ ´÷ËßÕ“®‰¡à‰¥â√“¬≈–‡Õ’¬¥¥â“π™π‘¥¢Õß¬“§«“¡¥—π∑’Ë„™â À√◊Õ‚√§√à«¡ ∫“ßÕ¬“à ß∑Õ’Ë “® ßà º≈µÕà Õµ— √“°“√‡ ¬’ ™«’ µ‘ §«“¡¥π— ‚≈Àµ‘ ßŸ π”¡“´ß÷Ë ¿“«–À«— „®ÀÕâ ß≈“à ß´“â ¬‚µ¡°’ “√»°÷ …“´ß÷Ë æ∫«“à À«— „®ÀÕâ ß≈“à ß´“â ¬‚µ ‚¥¬ª√–‡¡π‘ ®“° echocardiogram ∑”π“¬°“√‡ ¬’ ™«’ µ‘ ‰¥¥â °’ «“à §“à §«“¡¥π— ‚≈Àµ‘ ‚¥¬ Silberberg æ∫«“à À«— „®‚µ„πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥ ‡æ¡Ë‘ §«“¡‡ ¬Ë’ ß¢Õß°“√‡ ¬’ ™«’ µ‘ ∂ß÷ 3.2 ‡∑“à 5 Õ°’ °“√»°÷ …“ÀπßË÷ ¢Õß Foley æ∫ «“à §«“¡¥π— ‚≈Àµ‘ µ«— ∫π∑ Ë’ ßŸ ¢πÈ÷ ∑°ÿ 10 ¡¡.ª√Õ∑ ‡æ¡Ë‘ left ventricular mass index 2.2 gm/m2 ·≈–‡æ¡‘Ë §«“¡‡ ¬Ë’ ß¢Õß°“√‡°¥‘ À«— „®«“¬§√ßÈ— ·√° 2.07 ‡∑“à 6 ·µæà ∫«“à §«“¡¥π— ‚≈Àµ‘ µ”Ë °‡Á ªπì ª®í ®¬— ‡ ¬Ë’ ß¢Õß°“√ ‡ ’¬™’«‘µ ´÷ËßÕ“®‡π◊ËÕß¡“®“°§«“¡¥—π‚≈À‘µ∑’ËµË”∫àß∂÷ß°“√∑”ß“π¢ÕßÀ—«„®∑’Ë‰¡àª°µ‘ °“√»÷°…“∑—Èß„π ≠ª’Ë πÿÉ 7-9 ·≈–Õ‡¡√°‘ “10 ∑ßÈ— incident ·≈– prevalent cohort °æÁ ∫§«“¡ ¡— æπ— ∏√å –À«“à ß§«“¡¥π— ‚≈Àµ‘ µ«— ∫π°—∫°“√‡ ’¬™’«‘µ‡ªìπ·∫∫ reverse J shape À√◊Õ reverse epidemiology ¥—ßµ—«Õ¬à“ß„π√Ÿª∑’Ë 1 ´÷Ëß ‡ªπì °“√µ¥‘ µ“¡ºªŸâ «É ¬°«“à À’Ë ¡π◊Ë §π‡ªπì ‡«≈“ 15 ‡¥Õ◊ π11æ∫«“à Õµ— √“°“√‡ ¬’ ™«’ µ‘ ‡æ¡‘Ë ¢π÷È „π°≈¡ÿà ∑§’Ë «“¡¥π— ‚≈À‘µª°µ‘À√◊ÕµË” ·µàÕ—µ√“°“√‡ ’¬™’«‘µµË”°«à“„π°≈ÿà¡∑’Ë§«“¡¥—π‚≈À‘µ ßŸ ‡≈Á°πâÕ¬ ´÷Ëß°“√«‘‡§√“–Àå‰¥â¡’ °“√ª√—∫µ—«·ª√æ◊Èπ∞“π∑’Ë¡’º≈µàÕ°“√√Õ¥™’«‘µ ‡™àπ ‡æ» Õ“¬ÿ ¿“«–‡∫“À«“π ·≈–‰¥â¡’√“¬ß“π°“√ «‘‡§√“–Àå∑—Èß§«“¡ —¡æ—π∏å¢Õß§«“¡¥—π‚≈À‘µµ—Èßµâπ·≈–§«“¡¥—π‚≈À‘µ‡©≈’Ë¬„π™à«ß∑’Ëµ‘¥µ“¡°“√√—°…“

Whatûs New in Conventional Hemodialysis? ™≈∏‘ª æß» å °ÿ≈ 191 √ªŸ ∑Ë’ 1 §«“¡ ¡— æπ— ∏√å –À«“à ß§«“¡¥π— ‚≈Àµ‘ °∫— °“√‡ ¬’ ™«’ µ‘ ®“°‚√§À«— „®·≈–À≈Õ¥‡≈Õ◊ ¥„π™«à ß 15 ‡¥Õ◊ π ®“°ºªŸâ «É ¬„π Dialysis Clinic Inc. ¢Õß À√∞— Õ‡¡√°‘ “°«“à 16000 √“¬°∫— Õµ— √“°“√‡ ¬’ ™«’ µ‘ ·≈«â ´ßË÷ „Àºâ ≈ ‰ª„π∑“ß‡¥’¬«°—π §◊Õ§«“¡¥—π‚≈À‘µµ—«∫π°àÕπøÕ°‡≈◊Õ¥∑’ËπâÕ¬°«à“ 140 ¡¡.ª√Õ∑‡æ‘Ë¡§«“¡‡ ’Ë¬ßµàÕ °“√‡ ¬’ ™«’ µ‘ ·µ∂à “â ¡“°°«“à 160 ¡¡.ª√Õ∑°≈∫— ≈¥§«“¡‡ ¬’Ë ß12§”Õ∏∫‘ “¬¢Õß ß‘Ë ∑æ’Ë ∫π¬’È ß— ‰¡™à ¥— ‡®π§«“¡ ¥π— ‚≈Àµ‘ ∑µË’ ”Ë Õ“®‡ªπì º≈®“°‚√§À«— „®∑√Ë’ πÿ ·√ß °“√¢“¥Õ“À“√·≈–°“√Õ°— ‡ ∫ (malnutrition-inflammation complex) À√◊Õ¬“∑’Ë‰¥â√—∫ ´÷Ëß à«π„À≠à‰¡à¡’¢âÕ¡Ÿ≈π’È ‘Ëß‡À≈à“π’È∑”„Àâ§«“¡¥—π‚≈À‘µµË”·≈–‡ªìπªí®®—¬∑’Ë ‡æ¡Ë‘ §«“¡‡ ¬Ë’ ß¢Õß°“√‡ ¬’ ™«’ µ‘ ¡„‘ ™§à «“¡¥π— ‚≈Àµ‘ Õ¬“à ß‡¥¬’ «∑‡Ë’ ªπì º≈∑”„À‡â ¬’ ™«’ µ‘ §«“¡¥π— ‚≈Àµ‘ ∑§’Ë «√§«∫§¡ÿ „πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥¡§’ ”·π–π”¢ÕßK/DOQI„πªï2005´ß÷Ë ‡ªπì √–¥∫— C §Õ◊ ‡ªπì §«“¡‡ÀπÁ ·≈–°“√»°÷ …“¬Õâ πÀ≈ß— ·π–π”„À§â ¡ÿ §«“¡¥π— ‚≈Àµ‘ °Õà πøÕ°‡≈Õ◊ ¥ 140/90 ¡¡.ª√Õ∑ ·≈–À≈ß— øÕ°‡≈Õ◊ ¥ 130/80 ¡¡.ª√Õ∑13Õ¬“à ß‰√°µÁ “¡¬ß— ‰¡¡à À’ ≈°— ∞“π™¥— ‡®π«“à °“√§«∫§¡ÿ §«“¡¥π— ‚≈Àµ‘ µ“¡‡ªÑ“À¡“¬π’È®– “¡“√∂≈¥Õ—µ√“°“√‡ ’¬™’«‘µ ·µà¡’¢âÕ¡Ÿ≈∫àß∫Õ°«à“°“√æ¬“¬“¡§ÿ¡§«“¡¥—π„Àâ‰¥â µ“¡‡ª“Ñ ¡‚’ Õ°“ ‡°¥‘ ¿“«–§«“¡¥π— ‚≈Àµ‘ µË”¢≥–øÕ°‡≈Õ◊ ¥¡“°¢π÷È 14 ®π∂ß÷ ª®í ®∫ÿ π— ¬ß— ¡¢’ Õâ ‚µ·â ¬ßâ „π°“√§¡ÿ §«“¡¥π— ‚≈Àµ‘ ¢ÕßºªŸâ «É ¬øÕ°‡≈Õ◊ ¥«“à ®–«¥— ∑®Ë’ ¥ÿ „¥ ·≈– „™§â “à ‡∑“à ‰√ °“√«¥— ∑ÀË’ π«à ¬‰µ∂“â ‰¡‰à ¥„â ™«â ∏‘ ¡’ “µ√∞“πÕ“®∑”„À§â «“¡¥π— ‚≈Àµ‘ ßŸ °«“à §«“¡‡ªπì ®√ß‘ ∂ß÷ 10 ¡¡. ª√Õ∑15 ¡°’ “√∑∫∑«π∫∑§«“¡µ“¡√–∫∫ (systematic review) „π‡√Õ◊Ë ß§«“¡ ¡— æπ— ∏¢å Õß§«“¡¥π— ‚≈Àµ‘

New Frontiers in Dialysis 192 ∏π‘µ ®‘√ππ— ∑å∏«™— √‘ ¿‘ “ ™“â ß»‘√°‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « —πµå ÿ‡¡∏°ÿ≈ °Õà π·≈–À≈ß— øÕ°‡≈Õ◊ ¥°∫— §«“¡¥π— √–À«“à ß™«à ß∑‰’Ë ¡øà Õ°‡≈Õ◊ ¥ (interdialytic) ¥«â ¬ ambulatory blood pressure monitoring æ∫«“à §«“¡¥π— ‚≈Àµ‘ °Õà π·≈–À≈ß— øÕ° ‰¡‰à ¥‡â ªπì µ«— ·∑π∑¥Ë’ ¢’ Õß§«“¡¥π— ∑∫Ë’ “â π §«“¡¥π— °Õà πøÕ° «à π„À≠¡à §’ “à ¡“°°«“à §«“¡¥π— ™«à ß∑ÕË’ ¬∑àŸ ∫Ë’ “â π «à π§«“¡¥π— À≈ß— øÕ° «à π„À≠¡à §’ “à πÕâ ¬°«“à 16 ¥—ßπ—Èπ®÷ß§«√¡’«‘∏’°“√«—¥§«“¡¥—π‚≈À‘µ∑’Ë “¡“√∂∫Õ°°“√æ¬“°√≥å‰¥â¥’°«à“π’È ‚¥¬‡©æ“–§«“¡¥—π ‚≈Àµ‘ ∑ ’Ë ¡— æπ— ∏°å ∫— °“√‡°¥‘ ¿“«–À«— „®ÀÕâ ß≈“à ß´“â ¬‚µ®ß÷ ‡ªπì µ«— ·ª√∑ ’Ë ¡— æπ— ∏°å ∫— Õµ— √“°“√‡ ¬’ ™«’ µ‘ ∑¥’Ë °’ «“à „π™«à ßª∑ï º’Ë “à π¡“‡√¡‘Ë ¡°’ “√√“¬ß“π«“à °“√«¥— §«“¡¥π— ∑∫’Ë “â π‰¡«à “à ®–‡ªπì °“√„™‡â §√Õ◊Ë ßÕµ— ‚π¡µ— «‘ ¥— (Ambulatory blood pressure monitoring) À√◊Õ„Àâ«—¥‡Õß∑’Ë∫â“π¥â«¬‡§√◊ËÕß¥‘®‘µÕ≈«—π≈– 3 §√—Èß ¡’§«“¡ ¡— æπ— ∏°å ∫— ¿“«–À«— „®ÀÕâ ß≈“à ß´“â ¬‚µ‰¥¥â °’ «“à 17 ¥ß— ππ—È ®ß÷ π“à ®–‡ªπì µ«— ∫ßà ™∂’È ß÷ °“√√°— …“∑¥’Ë ’·≈–homeblood pressure monitoring “¡“√∂∑”‰¥„â π∑“ßªØ∫‘ µ— ‘ ¡§’ «“¡ ¡— æπ— ∏∑å ¥’Ë °’ ∫— Ambulatory blood pressure monitory ´÷ËßµâÕß„™â‡§√◊ËÕß¡◊Õ∑’Ë¡’√“§“·æß §«“¡ —¡æ—π∏å√–À«à“ß home blood pressure monitoring °—∫°“√‡ ’¬ ™«’ µ‘ ®“°‚√§À«— „®À≈Õ¥‡≈Õ◊ ¥ππ—È ™¥— ‡®π°«“à °“√„™§â «“¡¥π— ‚≈Àµ‘ °Õà πÀ√Õ◊ À≈ß— °“√øÕ°‡≈Õ◊ ¥18 ·≈–¬ß— ‡ªπì ‰ª„π·π«∑“ß‡¥’¬«°—∫ºâŸ∑’Ë‰¡à‰¥âøÕ°‡≈◊Õ¥§◊Õ §«“¡¥—π‚≈À‘µ¬‘Ëß Ÿß ¬‘Ëß‡æ‘Ë¡Õ—µ√“°“√‡ ’¬™’«‘µ (√ªŸ ∑Ë’ 2) §«“¡¥π— ‚≈Àµ‘ ∑‡Ë’ À¡“– ¡„π¢≥–∑ÕË’ ¬∫Ÿà “â π§Õ◊ §«“¡¥π— µ«— ∫ππÕâ ¬°«“à 125 ¡¡.ª√Õ∑ ∂÷ß·¡â¡’°“√»÷°…“°“√„™â§«“¡¥—π‚≈À‘µ∑’Ë∫â“π„πºŸâªÉ«¬øÕ°‡≈◊Õ¥¬—ß¡’πâÕ¬ ·µà°Áπà“ π„®·≈– ∑”‰¥â®√‘ß Õ“®‡≈◊Õ°„™â„πºâŸªÉ«¬∑’Ë¡’§«“¡¥—π‚≈À‘µ°àÕπøÕ° Ÿß¡“°·≈–‡ª≈’Ë¬π·ª≈ß¡“°‡¡◊ËÕøÕ°‡≈◊Õ¥ ‡æÕË◊ ∑®Ë’ –‰¥¡â §’ “à §«“¡¥π— ·∑®â √ß‘ ∑∫Ë’ “â π §“à ∑§Ë’ «√‡ªπì Õ“®„™µâ “¡‡°≥±¢å Õß JNC 7 ‡™πà §πª°µ°‘ ‰Á ¥1â 9 √ªŸ ∑’Ë 2 Hazard ratio ¢Õß°“√‡ ¬’ ™«’ µ‘ ®“°∑°ÿ “‡Àµÿ ·∫ßà µ“¡ quartile ¢Õß§«“¡¥π— ‚≈Àµ‘ µ«— ∫π

Whatûs New in Conventional Hemodialysis? ™≈∏‘ª æß»å °≈ÿ 193 2. °“√§«∫§¡ÿ √–¥∫— π”È µ“≈„πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ „πºŸâªÉ«¬‡∫“À«“π∑’Ë¬—ß‰¡à¡’¿“«–·∑√°´âÕπ ¡’¢âÕ¡≈Ÿ Õ¬à“ß™—¥‡®π«à“°“√§«∫§ÿ¡√–¥—∫πÈ”µ“≈ „π‡≈Õ◊ ¥ªÕÑ ß°π— °“√‡°¥‘ ¿“«–·∑√°´Õâ π‚¥¬‡©æ“–∑“ß‰µ‰¥2â 0-24‡∫“À«“π‡ªπì “‡Àµ ÿ ”§≠— ¢Õß‚√§‰µ‡√Õ◊È √ß— ºâŸªÉ«¬øÕ°‡≈◊Õ¥ª√–¡“≥§√÷ËßÀπ÷Ëß¡’ “‡Àµÿ¡“®“°‡∫“À«“π à«πÀπ÷Ëß¢ÕßºâŸªÉ«¬øÕ°‡≈◊Õ¥ “¡“√∂ À¬¥ÿ ¬“≈¥πÈ”µ“≈„π‡≈Õ◊ ¥‰¥‡â πÕ◊Ë ß®“°πÈ”µ“≈„π‡≈Õ◊ ¥‰¡ à ßŸ π°— ªí≠À“§◊Õ°“√§«∫§ÿ¡πÈ”µ“≈„π‡≈◊Õ¥„πºŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥·≈â«¡’§«“¡®”‡ªìπ‡æ’¬ß„¥ √–¥—∫ ∑§Ë’ «√®–‡ªπì §Õ◊ ‡∑“à ‰√·≈–æ¬“°√≥‚å √§„πº∑âŸ §Ë’ ¡ÿ √–¥∫— π”È µ“≈‰¥¥â ·’ µ°µ“à ß°∫— º∑âŸ §Ë’ ¡ÿ ‰¡‰à ¥Õâ ¬“à ß‰√ ®π∂÷ßªí®®ÿ∫—π ¬—ß‰¡à¡’°“√»÷°…“‰ª¢â“ßÀπâ“∑’Ë‡°’Ë¬«¢âÕß°—∫°“√§«∫§ÿ¡√–¥—∫πÈ”µ“≈„πºŸâ∑’Ë øÕ°‡≈Õ◊ ¥ ¢Õâ ¡≈Ÿ ∑‰Ë’ ¥¡â “®“°°“√»°÷ …“·∫∫ ß— ‡°µ (observational study) ‡ªπì À≈°— °“√»°÷ …“∑„’Ë À≠ à ¥ÿ ¡“®“°≠ª’Ë πÿÉ 25 ‚¥¬‡ªπì ºªŸâ «É ¬„π°≈¡àÿ °“√»°÷ …“ DOPPS ´ßË÷ ‡ªπì °“√»°÷ …“ ·∫∫ —ß‡°µ„πÀ≈“¬ª√–‡∑»‚¥¬¡’«—µ∂ÿª√– ß§å‡æ◊ËÕª√–‡¡‘π·∫∫·ºπ°“√√—°…“´÷ËßÕ“®·µ°µà“ß°—π‰ª °∫— º≈¢Õß°“√√°— …“°“√»°÷ …“„π≠ª’Ë πÿÉ π‡’È ªπì °“√ª√–‡¡π‘ √–¥∫— HbA1Cæπ◊È ∞“π°∫— °“√‡ ¬’ ™«’ µ‘ ‚¥¬æ¬“¬“¡ ª√∫— ª®í ®¬— ‡ ¬Ë’ ßæπÈ◊ ∞“π∑¡Ë’ º’ ≈ ·µ‰à ¡‰à ¥ªâ √–‡¡π‘ §“à HbA1C √–À«“à ß°“√»°÷ …“ æ∫«“à ‡¡ÕË◊ ·∫ßà §“à HbA1C ‡ªπì 5 °≈¡àÿ °≈¡àÿ ∑¡Ë’ §’ “à HbA1C „π quintile ∑Ë’ 5 §Õ◊ ¡“°°«“à 7.3 ‡ªÕ√‡å ´πÁ µå ¡§’ «“¡‡ ¬Ë’ ßµÕà °“√‡ ¬’ ™«’ µ‘ 2.36 ‡∑“à (95% CI=1.02-5.4) ·≈–°“√§¡ÿ π”È µ“≈∑‰Ë’ ¡¥à π’ πÈ— ‰¡¡à §’ «“¡ ¡— æπ— ∏°å ∫— ª®í ®¬— ‡ ¬Ë’ ßæπÈ◊ ∞“πÕπË◊ Ê ·µ‰à ¡‰à ¥√â “¬ß“π∂ß÷ ¿“«–·∑√°´Õâ π„π°≈¡ÿà ∑§’Ë ¡ÿ πÈ”µ“≈‰¥¥â °’ «“à Õ°’ °“√»°÷ …“„π≠ªË’ πÉÿ ‡™πà °π— ¡ª’ √–™“°√πÕâ ¬°«“à ·µµà ¥‘ µ“¡ºªâŸ «É ¬∂ß÷ 7 ª2ï 6 æ∫«“à °≈¡àÿ ∑§Ë’ ¡ÿ π”È µ“≈‰¥‰â ¡¥à §’ Õ◊ HbA1C ¡“°°«“à 8 ‡ªÕ√‡å ´πÁ µå ¡Õ’ µ— √“°“√√Õ¥™æ’ µ”Ë ¥ÿ (√ªŸ ∑Ë’ 3) ·µ‰à ¡¡à √’ “¬ß“π¿“«– ·∑√°´Õâ π‡™πà °π— √ªŸ ∑’Ë 3 Õµ— √“°“√√Õ¥™æ’ ·∫ßà µ“¡√–¥∫— HBA1c

New Frontiers in Dialysis 194 ∏π‘µ ®√‘ π—π∑∏å «™— ‘√‘¿“ ™â“ß»‘√°‘ ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå ÿ‡¡∏°ÿ≈ ‚¥¬ √ªÿ §Õ◊ °“√§¡ÿ √–¥∫— πÈ”µ“≈„πª«É ¬‡∫“À«“π∑ø’Ë Õ°‡≈Õ◊ ¥‚¥¬ª√–‡¡π‘ ®“°√–¥∫— HbA1C π“à ®–¡ª’ √–‚¬™π°å ∫— ºªŸâ «É ¬ ·µµà Õâ ßæß÷ √–«ß— ¿“«–·∑√°´Õâ π§Õ◊ π”È µ“≈„π‡≈Õ◊ ¥µ”Ë ¥«â ¬ ‡Õ° “√Õ“â ßÕß‘ 1. Chen J, Gul A, Sarnak MJ. Management of intradialytic hypertension: the ongoing challenge. Semin Dial 2006;19:141-5. 2. Inrig JK, Oddone EZ, Hasselblad V et al. Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients. Kidney Int 2007; 71(5):454-61. 3. Agarwal R, Nissenson AR, Batlle D, Coyne DW, Trout JR, Warnock DG. Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States. Am J Med 2003; 115:291-7. 4. Salem MM. Hypertension in the hemodialysis population: a survey of 649 patients. Am J Kidney Dis 1995; 26:461-8. 5. Silberberg JS, Barre PE, Prichard SS, Sniderman AD. Impact of left ventricular hypertrophy on survival in end-stage renal disease. Kidney Int 1989; 36:286-90. 6. Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996; 49:1379-85. 7. Tomita J, Kimura G, Inoue T et al. Role of systolic blood pressure in determining prognosis of hemodialyzed patients. Am J Kidney Dis 1995; 25:405-12. 8. Kimura G, Tomita J, Nakamura S, Uzu T, Inenaga T. Interaction between hypertension and other cardiovascular risk factors in survival of hemodialyzed patients. Am J Hypertens 1996; 9(10 Pt 1):1006-12. 9. Iseki K, Miyasato F, Tokuyama K et al. Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients. Kidney Int 1997; 51:1212-7. 10. Foley RN, Herzog CA, Collins AJ. Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study. Kidney Int 2002; 62:1784-90. Notes: CORPORATE NAME: United States Renal Data System 11. Kalantar-Zadeh K, Kilpatrick RD, Kopple JD. Reverse epidemiology of blood pressure in dialysis patients. Kidney Int 2005; 67:2067; author reply 2067-8. 12. Li Z, Lacson E Jr, Lowrie EG et al. The epidemiology of systolic blood pressure and death risk in hemodialysis patients. Am J Kidney Dis 2006; 48:606-15. 13. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am JKidney Dis 2005; 45(4 Suppl 3):S1-153.Notes: CORPORATE NAME: K/DOQI Workgroup 14. Davenport A, Cox C, Thuraisingham R. Achieving blood pressure targets during dialysis improves control but increases intradialytic hypotension. Kidney Int 2007 Dec 26. 15. Rahman M, Griffin V, Kumar A, Manzoor F, Wright JT Jr, Smith MC. A comparison of standardized versus çusualé blood pressure measurements in hemodialysis patients. Am J Kidney Dis 2002; 39:1226-30. 16. Agarwal R, Peixoto AJ, Santos SF, Zoccali C. Pre- and postdialysis blood pressures are imprecise estimates

Whatûs New in Conventional Hemodialysis? ™≈∏ª‘ æß»å °≈ÿ 195 of interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2006;1:389-98. 17. Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is a superior determinant of left ventricular hypertrophy. Hypertension 2006; 47:62-8. 18. Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin J Am Soc Nephrol 2007; 2:1228-34. 19. Chobanian AV, Bakris GL, Black HR et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42:1206-52. 20. The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329:977-86. 21. Effect of intensive therapy on the development and progression of diabetic nephropathyin the Diabetes Control and Complications Trial. The Diabetes Control and Complications (DCCT) Research Group. Kidney Int 1995; 47:1703-20. 22. Effect of intensive blood-glucose control with metformin on complications in overweightpatients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:854-65. 23. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837-53. 24. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317:703-13. 25. Hayashino Y, Fukuhara S, Akiba T et al. Diabetes, glycaemic control and mortality risk in patients on haemodialysis: the Japan Dialysis Outcomes and Practice Pattern Study. Diabetologia 2007; 50:1170-7. 26. Oomichi T, Emoto M, Tabata T et al. Impact of glycemic control on survival of diabetic patients on chronic regular hemodialysis: a 7-year observational study. Diabetes Care 2006; 29:1496-500.

11 Whatûs New in Online Hemodiafiltration? »¿ÿ ƒ°…å ®µ‘ µ°‘ “ππ∑å 1. ∫∑π” 2. Online hemodiafiltration 3. Predilution and postdilution online hemodiafiltration 4. Mixed dilution hemodiafiltration 5. Mid-dilution hemodiafiltration 6. Reverse mid-dilution hemodiafiltration 7. Paired hemodiafiltration 8. Hemodiafiltration with endogenous reinfusion 9. √ªÿ

New Frontiers in Dialysis 198 ∏πµ‘ ®‘√π—π∑å∏«™— √‘ ¿‘ “ ™“â ß»‘√°‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå ‡ÿ ¡∏°≈ÿ 1. ∫∑π” „πªï §.». 19671‰¥¡â °’ “√æ≤— π“°“√∫”∫¥— ∑¥·∑π‰µ·∫∫„À¡´à ß÷Ë Õ“»¬— °“√°√ÕßπÈ”·≈–„À â “√ π”È ∑¥·∑π¢πÈ÷ ‚¥¬‡√¬’ °«∏‘ π’ «È’ “à çdiafiltrationé ´ßË÷ µÕà ¡“∂°Ÿ ‡√¬’ °«“à çhemodiafiltrationé (HDF) ‚¥¬§”«“à hemodiafiltration ∂°Ÿ „™§â √ßÈ— ·√°„πªï §.». 1978 ‚¥¬ Leber ·≈–§≥–2 HDF ‰¥√â «¡‡Õ“¢Õâ ¥¢’ Õß°“√∑” hemodialysis §◊Õ°“√°”®—¥ “√¢π“¥‡≈Á°‚¥¬«‘∏’°“√·æ√à (diffusion) ·≈–¢âÕ¥’¢Õß°“√∑” hemofiltration §◊Õ°“√°”®—¥ “√¢π“¥„À≠à‚¥¬«‘∏’°“√æ“ (convection) ‡¢â“‰«â¥â«¬°—π HDF ®÷ß “¡“√∂°”®—¥¢Õß‡ ’¬ ∑—Èß∑’Ë¡’¢π“¥‡≈Á°·≈–¢π“¥„À≠à‰¥â¥’ °“√°”®—¥ “√‚¥¬¢∫«π°“√æ“ ∑”‰¥â‚¥¬°“√°√ÕßπÈ”„πæ≈“ ¡à“ (ultrafiltration) ÕÕ°¡“®”π«π¡“° ‚¥¬Õ“»¬— ‡¡¡‡∫√π∑¡Ë’ √’ °Ÿ √Õß¢π“¥„À≠à (high-flux membrane) ‡ªπì µ—«°√Õß (hemodiafilter) ·≈–„Àâ “√πÈ”∑’Ë¡’∫—ø‡øÕ√å‡¢â“‰ª∑¥·∑ππÈ”∑’Ë°√ÕßÕÕ°¡“ ‚¥¬Õ“®‡µ‘¡‡¢â“‰ª „π‡≈◊Õ¥°àÕπ∑’Ë‡≈◊Õ¥®–ºà“πµ—«°√Õß (predilution) À√◊ÕÀ≈—ß®“°‡≈◊Õ¥ºà“πµ—«°√Õß·≈â« (postdilution) ¡’ √“¬ß“π«“à Õµ— √“°“√≈¥≈ß¢Õß√–¥∫— β2-microglubulin „π°“√∑” HDF ßŸ °«“à °“√∑” hemodialysis ( ßŸ ∂ß÷ √Õâ ¬≈– 79 ‡∑¬’ ∫°∫— √Õâ ¬≈– 45-50) ¢≥–∑ªË’ √– ∑‘ ∏¿‘ “æ„π°“√°”®¥— ¬‡Ÿ √¬’ §√Õ’ “µπ‘ π’ ·≈–øÕ øÕ√ — ‡∑“à °π— À√Õ◊ ¡“°°«“à 3-7 Online HDF À¡“¬∂ß÷ °“√∑” HDF ∑ Ë’ “√π”È ∑¥·∑π‡µ√¬’ ¡¡“®“°π”È ¬“øÕ°‡≈Õ◊ ¥∑ºË’ “à π°“√ °√Õß‚¥¬µ—«°√ÕßÀ≈“¬µ—«∑’Ë‡µ‘¡‡¢â“‰ª„π “¬ àßπÈ”¬“øÕ°‡≈◊Õ¥®π‰¥âπÈ”¬“∑’Ë¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß „™â ·∑π “√πÈ”∑¥·∑π¥—Èß‡¥‘¡∑’Ë∫√√®ÿÕ¬àŸ„π∂ÿß·≈–¡’√“§“ Ÿß ¥—ßπ—Èπ°“√∑” online HDF ®÷ß “¡“√∂∑”°“√ ·≈°‡ª≈’Ë¬π “√πÈ”‰¥â¡“°¢÷Èπ ‚¥¬§à“„™â®à“¬‰¡à‡æ‘Ë¡¡“°¢÷Èπ ªí≠À“∑’Ë ”§—≠¢Õß online HDF §◊Õ§«“¡ °ß— «≈„®‡°¬’Ë «°∫— §«“¡‰¡∫à √ ‘ ∑ÿ ∏¢‘Ï Õß “√πÈ”∑¥·∑π∑‡’Ë µ√¬’ ¡‰¥â„πª®í ®∫ÿ π— ®ß÷ ¡°’ “√æ≤— π“√ªŸ ·∫∫¢Õßonline HDF ‰ªÀ≈“¬√Ÿª·∫∫ ‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ„π°“√·≈°‡ª≈’Ë¬π “√πÈ”·≈–°“√°”®—¥¢Õß‡ ’¬ ·≈–‡æ◊ËÕ °”®—¥§«“¡°—ß«≈„®‡°’Ë¬«°—∫§«“¡‰¡à∫√‘ ÿ∑∏‘Ï¢Õß “√πÈ”∑¥·∑π „π∫∑π’È®–°≈à“«∂÷ß∫“ß‡∑§π‘§∑’Ë¡’ §«“¡π“à π„®À√Õ◊ ‰¥√â ∫— °“√æ≤— π“¢π÷È ¡“„À¡à 2. Online hemodiafiltration „π√–¬–·√°¢Õß°“√∑” HDF (classic HDF) “√πÈ”∑¥·∑π∂°Ÿ ∫√√®„ÿ π∂ßÿ 4.5 ≈µ‘ √ ‚¥¬„™â lactate ‡ªπì ∫ø— ‡øÕ√å ·≈–„À·â ∫∫ postdilution ‡∑“à ππÈ— ´ßË÷ ∑”„Àªâ √¡‘ “≥°“√·≈°‡ª≈¬Ë’ π “√π”È ∂°Ÿ ®”°¥— Õ¬∑àŸ Ë’ 4.5-9 ≈‘µ√ (1-2 ∂ÿß) ‡π◊ËÕß®“° “√πÈ”∑¥·∑π¥—ß°≈à“«¡’√“§“§àÕπ¢â“ß ßŸ ·≈–¡’§«“¡¬ÿàß¬“°„π°“√‡ª≈’Ë¬π∂ÿß πÈ”¬“À“°µÕâ ß°“√·≈°‡ª≈¬’Ë π “√πÈ”ª√¡‘ “≥¡“°¢π÷È µÕà ¡“„π™«à ßªï §.». 1980 ‰¥¡â °’ “√æ≤— π“√–∫∫ online HDF ¢÷Èπ ‚¥¬‡µ√’¬¡πÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß (ultrapure dialysate solution) ·≈–„™â‡ªìπ “√ π”È ∑¥·∑π‡µ¡‘ ‡¢“â ‰ª„π‡≈Õ◊ ¥∑π— ∑’ ∑”„À°â “√·≈°‡ª≈¬Ë’ π “√π”È ∑”‰¥¡â “°¢πÈ÷ Õ“® ßŸ ∂ß÷ 3-12 ≈µ‘ √/™«Ë— ‚¡ß ‚¥¬∑§Ë’ “à „™®â “à ¬‰¡‡à æ¡Ë‘ ¢πÈ÷ ·µ¥à «â ¬§«“¡°ß— «≈¥“â π§«“¡ª≈Õ¥¿¬— ¢Õß°“√„À â “√π”È ∑¥·∑π∑‡Ë’ µ√¬’ ¡·∫∫ online ∑”„À°â “√√°— …“·∫∫ online HDF ‰¡·à æ√Àà ≈“¬‡∑“à ∑§Ë’ «√ „πª√–‡∑»·∂∫¬‚ÿ √ª¡º’ ªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√ øÕ°‡≈Õ◊ ¥‡√Õ◊È √ß— ·∫∫ online HDF ‰¡‡à °π‘ √Õâ ¬≈– 108 «à π„π À√∞— Õ‡¡√°‘ “·≈–≠ª’Ë πÿÉ ¡¢’ Õâ ®”°¥— ∑“ß°ÆÀ¡“¬

Whatûs New in Online Hemodiafiltration? »¿ÿ ƒ°…å ®‘µµ‘°“ππ∑å 199 ∑”„Àâ online HDF «à π„À≠∂à °Ÿ ®”°¥— ‡©æ“–„πß“π«®‘ ¬— ‡∑“à ππÈ— ‡π◊ËÕß®“°°“√∑” online HDF “¡“√∂∑”°“√·≈°‡ª≈’Ë¬π “√πÈ”‰¥â‡ªìπª√‘¡“≥¡“° §«“¡ ª≈Õ¥¿—¬¢Õß°“√∑”®÷ß¢÷ÈπÕ¬àŸ°—∫§«“¡∫√‘ ÿ∑∏‘Ï¢Õß “√πÈ”∑¥·∑π∑’Ë„Àâ ·≈–‡§√◊ËÕß‰µ‡∑’¬¡∑’Ë§«∫§ÿ¡°“√ ·≈°‡ª≈’Ë¬π “√πÈ”‰¥âÕ¬à“ß·¡àπ¬” πÈ”∑’Ë„™â„π°“√‡µ√’¬¡πÈ”¬“øÕ°‡≈◊Õ¥µâÕß‡ªìππÈ”∑’Ë¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß (ultrapure water) ‚¥¬¡§’ ≥ÿ ¡∫µ— §‘ Õ◊ ¡·’ ∫§∑‡’ √¬’ πÕâ ¬°«“à 0.1 colony forming units/¡≈. ¡’ endotoxin ´ßË÷ µ√«®‚¥¬«∏‘ ’ Limulus amoebocyte lysate assay πÕâ ¬°«“à 0.03 IU/¡≈. ·≈–¡§’ «“¡µ“â π∑“π‰øø“Ñ Õ¬àŸ „πæ ‘ ¬— 0.1-5.0 MΩ/¡≈.πÈ”¬“øÕ°‡≈Õ◊ ¥∑‰’Ë ¥®â –º“à π°“√°√Õß‚¥¬µ«— °√ÕßÀ≈“¬µ«— ∑‡’Ë æ¡‘Ë ‡¢“â ‰ª„π “¬ ßà π”È ¬“øÕ°‡≈Õ◊ ¥ (multiple ultrafilters) ‚¥¬µ«— °√Õßµ«— ¥ÿ ∑“â ¬®–µ¥‘ µßÈ— Õ¬°Ÿà Õà π∑®Ë’ –‡µ¡‘ “√π”È ‡¢“â ‡àŸ ≈Õ◊ ¥ µ—«°√Õß∑—ÈßÀ¡¥µâÕß‰¥â√—∫°“√¶à“‡™◊ÈÕ·≈–‡ª≈’Ë¬πµ“¡√–¬–‡«≈“ πÈ”¬“øÕ°‡≈◊Õ¥ à«πÀπ÷Ëß®–∂Ÿ°ªíö¡„π “¬ àß “√πÈ”∑¥·∑π¥÷ß·¬°¡“‡ªìπ “√πÈ”∑¥·∑π‡µ‘¡‡¢â“‰ª„π‡≈◊Õ¥¢ÕßºŸâªÉ«¬‚¥¬µ√ß ‡§√◊ËÕß‰µ ‡∑’¬¡∑’Ë„™âµâÕß¡’√–∫∫‡æ◊ËÕ§«∫§ÿ¡°“√·≈°‡ª≈’Ë¬π “√πÈ”Õ¬à“ß·¡àπ¬” (fluid balancing chamber) ‡¡◊ËÕ π”È ¬“øÕ°‡≈Õ◊ ¥ª√¡‘ “≥ÀπßË÷ ∂°Ÿ ¥ß÷ ¡“‡ªπì “√π”È ∑¥·∑π°®Á –∂°Ÿ ∑¥·∑π‚¥¬ fluid balancing system ´ßË÷ ∑”„À‡â °¥‘ °“√°√ÕßπÈ”ÕÕ°®“°‡≈Õ◊ ¥„πª√¡‘ “≥‡∑“à °π— °“√∑” online HDF ®”‡ªπì µÕâ ß„™µâ «— °√Õß high-flux ‡ªπì µ«— °√Õß „™°â “√‰À≈¢Õß‡≈Õ◊ ¥ ßŸ (350- 450 ¡≈./π“∑)’ ·≈–„™°â “√‰À≈¢Õßπ”È ¬“øÕ°‡≈Õ◊ ¥ ßŸ (600-800 ¡≈./π“∑)’ ª√¡‘ “≥π”È ∑∂Ë’ °Ÿ °√ÕßÕÕ°¡“ ®“°æ≈“ ¡“à „π°“√∑” HDF ∂°Ÿ ®”°¥— ‚¥¬Õµ— √“°“√‰À≈¢Õß‡≈Õ◊ ¥ Œ¡’ “‚µ§√µ‘ ·≈– transmembrane pressure (TMP) ´÷Ëß‰¥â√—∫Õ‘∑∏‘æ≈®“°Õ—µ√“°“√°√ÕßπÈ”Õ’°¢—ÈπÀπ÷Ëß ‚¥¬∑—Ë«‰ª®–µ—ÈßÕ—µ√“°“√„Àâ “√πÈ”∑¥·∑π ‡∑à“°—∫Àπ÷Ëß„π “¡¢ÕßÕ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥¢“‡¢â“µ—«°√Õß „π°“√∑”·∫∫ postdilution HDF ·≈– ‡∑“à °∫— §√ßË÷ ÀπßË÷ ¢ÕßÕµ— √“°“√‰À≈¢Õß‡≈Õ◊ ¥¢“‡¢“â µ«— °√Õß „π°“√∑”·∫∫ predilution HDF À√Õ◊ µßÈ— Õµ— √“ °“√„À â “√π”È ∑¥·∑π‡∑“à °∫— 100 ¡≈./π“∑’ (24 ≈µ‘ √/4 ™«Ë— ‚¡ß) ·≈– 200 ¡≈./π“∑’ (48 ≈µ‘ √/4 ™«Ë— ‚¡ß) „π°“√∑”·∫∫ postdilution ·≈– predilution µ“¡≈”¥∫— 3. Predilution and postdilution online hemodiafiltration „π°“√∑” predilution HDF “√πÈ”∑¥·∑π∑∂’Ë °Ÿ ‡µ¡‘ ‡¢“â ‰ª„π‡≈Õ◊ ¥°Õà π∑®’Ë –º“à π‡¢“â µàŸ «— °√Õß ®– ‰ª‡®Õ◊ ®“ß§«“¡‡¢¡â ¢πâ ¢Õß‡≈Õ◊ ¥·≈– “√µ“à ßÊ∑≈’Ë –≈“¬„πæ≈“ ¡“à ‡ªπì ‡Àµ„ÿ À§â «“¡‡¢¡â ¢πâ ¢Õß “√≈¥≈ß §«“¡·µ°µà“ß¢Õß§«“¡‡¢â¡¢âπ√–À«à“ßæ≈“ ¡à“·≈–πÈ”¬“øÕ°‡≈◊Õ¥®÷ß≈¥≈ß ∑”„Àâ°“√°”®—¥ “√ ¢π“¥‡≈Á°‚¥¬«‘∏’°“√·æ√à≈¥≈ß‰ª¥â«¬ Õ¬à“ß‰√°Á¥’„π°“√√—°…“·∫∫ online HDF ª√– ‘∑∏‘¿“æ∑’Ë≈¥≈ß Õ“®∂Ÿ°∑¥·∑π‚¥¬°“√‡æ‘Ë¡ª√‘¡“≥¢Õß°“√·≈°‡ª≈’Ë¬π “√πÈ”‰¥â¡“°¢÷Èπ ∑”„Àâ°“√°”®—¥ “√‚¥¬«‘∏’ °“√æ“¡“°¢πÈ÷ ‰¥â ‡πÕË◊ ß®“°Œ¡’ “‚µ§√µ‘ ·≈–‚ª√µπ’ „π‡≈Õ◊ ¥∂°Ÿ ‡®Õ◊ ®“ß‚¥¬ “√π”È ∑¥·∑π∑„Ë’ À‡â ¢“â ‰ª ®ß÷ “¡“√∂°√Õßπ”È ‰¥¡â “°°«“à «∏‘ ’ postdilution °“√∑” postdilution HDF “√π”È ∑¥·∑π®–∂°Ÿ ‡µ¡‘ ‡¢“â ‰ª„π‡≈Õ◊ ¥∑ºË’ “à π°“√°√Õßπ”È ÕÕ°‚¥¬ µ—«°√Õß·≈â« ®÷ßπà“®–‡ªìπ«‘∏’∑’Ë¡’ª√– ‘∑∏‘¿“æ„π°“√°”®—¥¢Õß‡ ’¬ Ÿß∑’Ë ÿ¥ ‡π◊ËÕß®“°‰¡à¡’°“√‡®◊Õ®“ß ¢Õß “√µà“ßÊ „πæ≈“ ¡à“‡À¡◊Õπ„π«‘∏’ predilution HDF ·µà«‘∏’π’È¡’¢âÕ®”°—¥§◊Õ ‰¡à “¡“√∂‡æ‘Ë¡Õ—µ√“

New Frontiers in Dialysis 200 ∏πµ‘ ®√‘ π—π∑å∏«—™ ‘√¿‘ “ ™â“ß»‘√°‘ ÿ≈™¬— ∏π—π¥“ µ√–°“√«π™‘ « π— µå ‡ÿ ¡∏°≈ÿ °“√°√ÕßπÈ”‰¥âµ“¡µâÕß°“√ ‡π◊ËÕß®“°®–∑”„Àâ§«“¡‡¢â¡¢âπ¢Õß‚ª√µ’π ·≈–Œ’¡“‚µ§√‘µ¿“¬„πµ—«°√Õß Ÿß¢÷Èπ®“°°“√°√ÕßπÈ”ÕÕ°®“°æ≈“ ¡à“ Õ“®∑”„Àâ‡°‘¥≈‘Ë¡‡≈◊Õ¥¢÷Èπ„πµ—«°√Õß À√◊ÕÕ“®∑”„Àâ‚ª√µ’π ‡ Õ◊Ë ¡ ¿“æ·≈–‡°¥‘ ¿¬π— µ√“¬µÕà ‡¡¥Á ‡≈Õ◊ ¥·¥ß9 ·≈–§«“¡‡¢¡â ¢πâ ¢Õß‚ª√µπ’ „π‡≈Õ◊ ¥∑ ’Ë ßŸ ¢π÷È ∑”„Àâ oncotic pressure ‡æ¡Ë‘ ¢πÈ÷ ´ß÷Ë Õ“®‡ªπì º≈„À§â «“¡¬Õ¡„Àπâ ”È º“à π¢Õß‡¡¡‡∫√π≈¥≈ß10 πÕ°®“°π®È’ –∑”„À‡â °¥‘ °“√ √â“ß™—Èπ‚ª√µ’π‡§≈◊Õ∫º‘«‡¡¡‡∫√π¥â“π„π ‡°‘¥°“√Õÿ¥µ—π¢Õß√Ÿ°√Õß ´÷Ëß™—Èπ‚ª√µ’ππ’È∑”„Àâ§«“¡¬Õ¡„Àâ ºà“π¢Õß‡¡¡‡∫√π≈¥≈ß‚¥¬∂“«√ ∑”„Àâª√– ‘∑∏‘¿“æ¢Õßµ—«°√Õß·≈–°“√√—°…“≈¥≈ß ·≈–Õ“®µâÕß„™â transmembrane pressure (TMP) ∑ ’Ë ßŸ ¡“° ‡æÕ◊Ë „À‡â °¥‘ °“√°√ÕßπÈ”µ“¡µÕâ ß°“√ ‚¥¬∑«—Ë ‰ª ¥— «à π°“√°√Õß (filtration fraction) ‰¡§à «√‡°π‘ 0.45-0.511À√Õ◊ „™°â “√§”π«≥„À§â “à Œ¡’ “‚µ§√µ‘ À≈ß— µ«— °√Õß‰¡‡à °π‘ √Õâ ¬≈–50 12 À“°¡“°°«“à §“à πÕÈ’ “®∑”„À§â “à TMP ßŸ ¡“° ·≈–√–∫∫¡ª’ √– ∑‘ ∏¿‘ “æ≈¥≈ß®“°‡Àµºÿ ≈¢“â ßµπâ ¥ß— ππ—È «∏‘ ’predilutionHDFÕ“®¡º’ ≈¥„’ π¥“â π°“√‰À≈·≈–§«“¡Àπ¥◊ ¢Õß‡≈Õ◊ ¥¿“¬„πµ«— °√Õß¥°’ «“à ®÷ß “¡“√∂°√ÕßπÈ”ÕÕ°‰¥â¡“°°«à“«‘∏’ postdilution HDF ·¡âª√– ‘∑∏‘¿“æ„π°“√°”®—¥¢Õß‡ ’¬¢π“¥ ‡≈Á°®–¥âÕ¬°«à“ ´÷ËßÕ“®¡’ª√–‚¬™πå„πºŸâªÉ«¬∑’Ë¡’Œ’¡“‚µ§√‘µ Ÿß ·≈–‡¡◊ËÕµâÕß°“√∑”°“√·≈°‡ª≈’Ë¬π “√ πÈ”„πª√‘¡“≥ Ÿß °“√º ¡º “π∑—Èß predilution ·≈– postdilution Õ“®™à«¬·°âªí≠À“∑’Ëª√– ∫®“°°“√ √°— …“·µ≈à –«∏‘ ‰’ ¥â 4. Mixed dilution hemodiafiltration Mixed dilution hemodiafiltration ¡À’ ≈°— °“√§Õ◊ °“√·¬°„À â “√π”È ∑¥·∑π‡¢“â ‰ª„π‡≈Õ◊ ¥∑ßÈ— °Õà π (predilution) ·≈–À≈ß— µ«— °√Õß (postdilution) ‡æÕË◊ ≈¥ª≠í À“‡√ÕË◊ ß°“√‰À≈·≈–§«“¡Àπ¥◊ ¢Õß‡≈Õ◊ ¥¿“¬„π µ«— °√Õß®“°°“√∑”postdilution·≈–‰¡∑à ”„Àªâ √– ∑‘ ∏¿‘ “æ„π°“√°”®¥— ¢Õß‡ ¬’ ≈¥≈ß¡“°‡°π‘ ‰ª®“°°“√∑” predilution ´ßË÷ ·π«§¥‘ π‡È’ °¥‘ ¢πÈ÷ µßÈ— ·µªà ï §.». 1978 «‘∏’π’È∑”‰¥â‚¥¬„™â∑àÕ àß “√πÈ”∑¥·∑π∑’Ë¡’µ—«·¬°‡ªìπ√Ÿªµ—« Y ·≈–‡æ‘Ë¡ªíö¡Õ’°µ—«„π∑àÕ∑’Ë·¬° ÕÕ°¡“‡æÕ◊Ë ∑®’Ë –π” “√πÈ”∑¥·∑π «à πÀπß÷Ë ®“° «à π∑®’Ë –„À·â ∫∫ postdilution ‰ª„À·â ∫∫ predilution ·≈–„™â feedback system „π°“√§«∫§¡ÿ TMP ·≈–ª√∫— ¥— «à π¢Õß predilution/postdilution „À‡â À¡“– ¡µ≈Õ¥ ‡«≈“ ‚¥¬„ÀÕâ µ— √“°“√„À â “√πÈ”∑¥·∑π§ß∑µ’Ë ≈Õ¥‡«≈“ °“√°√–∑”¥ß— °≈“à «‡æÕ◊Ë ∑®’Ë –‰¥§â “à filtration fraction Ÿß∑’Ë ÿ¥‡æ◊ËÕ„Àâ¡’°“√·≈°‡ª≈’Ë¬π “√πÈ”·≈–°“√°”®—¥ “√‚¥¬¢∫«π°“√æ“ Ÿß∑’Ë ÿ¥ ‚¥¬¡’ ¿“æ§«“¡ Àπ¥◊ ·≈–°“√‰À≈¢Õß‡≈Õ◊ ¥¿“¬„πµ«— °√Õß‡À¡“– ¡∑ Ë’ ¥ÿ ·≈–Õµ— √“°“√°√Õßπ”È ‰¡‡à ª≈¬Ë’ π·ª≈ß °“√„Àâ “√πÈ”∑¥·∑π·∫∫ mixed dilution µâÕßÕ“»—¬√–∫∫ TMP feedback control ´÷Ëß®–¡’ ¡“µ√«¥— §«“¡¥π— ∑∑Ë’ “ß‡¢“â ·≈–∑“ßÕÕ°¢Õß‡≈Õ◊ ¥·≈–π”È ¬“øÕ°‡≈Õ◊ ¥ software ®–π”¡“§“à §«“¡¥π— ∑Ë’ «¥— ‰¥¡â “§”π«≥‡ªπì §“à TMP ·≈–§Õ¬ª√∫— Õµ— √“ «à π√–À«“à ß predilution ·≈– postdilution ‡æÕ◊Ë ®–§ß„À§â “à TMP Õ¬àŸ„π™à«ß∑’Ëª≈Õ¥¿—¬·≈–‡À¡“– ¡µ≈Õ¥‡«≈“ (250-300 ¡¡.ª√Õ∑) ‚¥¬‰¡à‰ª‡ª≈’Ë¬π·ª≈ßÕ—µ√“ °“√„Àâ “√πÈ”∑¥·∑π√«¡·≈–Õ—µ√“°“√°√ÕßπÈ” ∂â“§à“ TMP ≈¥µË”≈ß°«à“§à“µË” ÿ¥ “√πÈ”∑¥·∑π ª√¡‘ “≥‡≈°Á πÕâ ¬ (5-10 ¡≈./π“∑)’ ®–∂°Ÿ ¥ß÷ ®“° predilution ¡“‡ªπì postdilution ‚¥¬°“√‡æ¡‘Ë §«“¡‡√«Á ¢Õßª¡íö postdilution ‡ªìπº≈„Àâ TMP ·≈– filtration fraction ‡æ‘Ë¡¢÷Èπ „π∑“ß°≈—∫°—π À“°§à“ TMP Ÿß‡°‘π§à“

Whatûs New in Online Hemodiafiltration? »¿ÿ ƒ°…å ®µ‘ µ‘°“ππ∑å 201 ßŸ ¥ÿ ∑®’Ë –µ“â π∑“π‰¥â “√πÈ”∑¥·∑πpostdilution„πª√¡‘ “≥‡∑“à °π— ®–∂°Ÿ ¥ß÷ ¡“‡ªπì predilution‡ªπì º≈„À§â “à TMP ·≈– filtration fraction ≈¥≈ß ‡§√ÕË◊ ß‰µ‡∑¬’ ¡∑¡Ë’ √’ –∫∫¥ß— °≈“à «‰¥·â °à ‡§√ÕË◊ ß Fresenius 4008E, 5008E ‡¡¡‡∫√π™π¥‘ high flux ‚¥¬∑«Ë— ‰ª®–¬Õ¡„À â “√∑¡Ë’ ¢’ π“¥‚¡‡≈°≈ÿ ‡≈°Á °«“à 20 °‚‘ ≈¥“≈µπ— º“à π ®÷ßÕ“®¡’°“√ Ÿ≠‡ ’¬‚ª√µ’π¢÷Èπ ‚¥¬‡©æ“–‡¡◊ËÕ„™â§«“¡¥—π„π°“√°√Õß ŸßÊ „π™à«ß·√°Ê ¢Õß°“√√—°…“ ‚¡‡≈°ÿ≈¢π“¥„À≠à ‡™àπ Õ—≈∫Ÿ¡‘π °ÁÕ“®∂Ÿ°º≈—°ºà“π√Ÿ°√Õß¢Õß‡¡¡‡∫√π ´÷ËßÕ“®∑”„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬ Õ—≈∫Ÿ¡‘π‰ª„ππÈ”¬“øÕ°‡≈◊Õ¥ À√◊ÕÕ—≈∫Ÿ¡‘πÕ“®∂Ÿ°°—°Õ¬Ÿà¿“¬„π√Ÿ°√Õß´÷Ëß∑”„Àâ§«“¡¬Õ¡„Àâºà“π¢Õß ‡¡¡‡∫√π≈¥≈ßÕ¬à“ß∂“«√ ·µà∂â“„™â§«“¡¥—π„π°“√°√ÕßµË”Ê ‡©æ“–‡ªª‰µ¥å·≈–‚ª√µ’π¢π“¥‡≈Á°Ê ‡∑à“π—Èπ∑’Ë®–‰ªÕÿ¥Õ¬Ÿà„π√°Ÿ √Õß·≈–®—∫Õ¬àŸ„πºπ—ß¥â“π„π ∑”„Àâ¢π“¥√°Ÿ √Õß‡≈Á°≈ß ´÷Ëß√°Ÿ √Õß∑’Ë‡≈Á°≈ßπ’È‰¡à ¬Õ¡„À‚â ¡‡≈°≈ÿ ¢π“¥„À≠‡à ™πà Õ≈— ∫¡Ÿ π‘ º“à π ·µ§à «“¡¬Õ¡„Àºâ “à π¢Õß “√∑¡Ë’ ‚’ ¡‡≈°≈ÿ ¢π“¥°≈“ß ‡™πà β2- microglobulin ‰¡à‡ª≈’Ë¬π·ª≈ß ®÷ß‰¡à‡°‘¥°“√ Ÿ≠‡ ’¬Õ—≈∫Ÿ¡‘π‚¥¬¬—ß “¡“√∂°”®—¥ “√∑’Ë¡’‚¡‡≈°ÿ≈¢π“¥ °≈“ß‰¥â·≈–™à«¬§ß§ÿ≥ ¡∫—µ‘¢Õß‡¡¡‡∫√π‰¡à„Àâ‡ª≈’Ë¬π·ª≈ß‰ª¡“° ®“°¢âÕ —ß‡°µ¥—ß°≈à“« ®÷ß¡’ °“√π”¡“ª√–¬°ÿ µ„å ™‚â ¥¬µßÈ— §“à filtration fraction (´ß÷Ë ¡§’ «“¡ ¡— æπ— ∏°å ∫— TMP ·∫∫ exponential) „Àµâ ”Ë „π™«à ß·√°¢Õß°“√∑” HDF (ª√–¡“≥ 0.35-0.45) ®“°ππ—È §Õà ¬Ê ‡æ¡‘Ë TMP ¢π÷È ∑≈’ –πÕâ ¬®π∂ß÷ §“à ∑‡’Ë À¡“– ¡ ‚¥¬ TMP feedback control ‚¥¬‰¡¡à °’ “√‡ª≈¬’Ë π·ª≈ßÕµ— √“°“√°√Õß·µÕà ¬“à ß„¥ (Transmembrane Pressure Profiling) «∏‘ ’ mixed dilution “¡“√∂°”®¥— “√¢π“¥‡≈°Á ‰¥¥â °’ «“à °“√∑” predilution online HDF ·≈– „°≈‡â §¬’ ß°∫— °“√∑” postdilution online HDF13 «à π°“√°”®¥— “√¢π“¥°≈“ß ‡™πà β2-microglobulin æ∫«“à mixed dilution ¡ª’ √– ∑‘ ∏¿‘ “æ¥°’ «“à ∑ßÈ— predilution ·≈– postdilution online HDF14 ·≈–Õ“®¥°’ «“à «∏‘ ’ mid dilution15,16 «à π°“√„™â TMP profiling ‚¥¬µßÈ— filtration pressure „Àâµ”Ë „π™«à ß·√° ·≈«â §Õà ¬Ê ‡æ¡Ë‘ ¢πÈ÷ ®π∂ß÷ §“à ‡ª“Ñ À¡“¬¿“¬„π§√ß÷Ë ™«—Ë ‚¡ß·√°¢Õß°“√√°— …“∑”„À°â “√ ≠Ÿ ‡ ¬’ Õ≈— ∫¡Ÿ π‘ – ¡πÕâ ¬≈ß·≈–°“√°”®¥— β2- microglobulin – ¡‡æ¡Ë‘ ¢πÈ÷ 17 πÕ°®“°ππÈ— ¬ß— ™«à ¬√°— …“ ¿“æ§«“¡¬Õ¡„Àºâ “à π¢Õß‡¡¡‡∫√π ∑”„Àªâ √– ∑‘ ∏¿‘ “æ¢Õß‡¡¡‡∫√π¬ß§ßÕ¬µŸà ≈Õ¥™«à ß°“√√°— …“ 5. Mid-dilution hemodiafiltration Õ°’ ·π«§¥‘ ÀπßË÷ „π°“√°”®¥— ¢Õâ ‡ ¬’ ¢Õß predilution ·≈– postdilution HDF §Õ◊ °“√√«¡∑ßÈ— Õß«∏‘ ’ ‡¢â“¥â«¬°—π ‚¥¬‡√‘Ë¡µâπ®“°°“√„™âµ—«°√Õß Õßµ—«µàÕ°—π·∫∫Õπÿ°√¡ ·≈–„Àâ “√πÈ”∑¥·∑π‡¢â“‰ª √–À«“à ßµ«— °√Õß∑ß—È Õß ¥ß— ππ—È µ«— °√Õßµ«— ·√°§Õ◊ °“√∑” postdilution HDF ·≈–µ«— ∑ ’Ë Õß§Õ◊ predilution HDF (√ªŸ ∑’Ë1)®“°ππ—È ®ß÷ ¡°’ “√¥¥— ·ª≈ß„À∑â ß—È Õß«∏‘ ‡’ °¥‘ ¢π÷È „πµ«— °√Õßµ«— ‡¥¬’ «°π— ‚¥¬°“√ÕÕ°·∫∫µ«— °√Õß„À¡¢à π÷È Olpur 190MD hemodiafilter (Nephros, Inc., New York, NY, USA) ‡ªπì µ«— °√Õß∑ÕË’ “»¬— À≈°— °“√¥ß— °≈“à « ‚¥¬°“√∑”„Àâ postdilution ·≈– predilution HDF ‡°¥‘ ¢π÷È ¿“¬„πµ«— °√Õßµ«— ‡¥¬’ « Olpur 190MD ª√–°Õ∫¥«â ¬ polyethersulphone fiber ∑¡Ë’ æ’ πÈ◊ ∑ºË’ «‘ √«¡ 1.90 µ“√“ß‡¡µ√ ‚¥¬ fiber ¿“¬„π®–·∫ßà ‡ªπì Õß «à π∑µ’Ë ¥‘ µÕà °π— §Õ◊ «à π∑’Ë 1 ‡ªπì fiber ∑«’Ë ß‘Ë Õ¬√Ÿà Õ∫πÕ°¢Õßµ«— °√Õß ¡æ’ π◊È ∑º’Ë «‘ √«¡ 1.00-1.10 µ“√“ß‡¡µ√ ·≈– «à π∑Ë’ 2 ∑«Ë’ ßË‘ Õ¬µŸà √ß°≈“ß ¡æ’ πÈ◊ ∑ºË’ «‘ √«¡ 0.80-0.90 µ“√“ß‡¡µ√ ∑ªË’ ≈“¬µ«— °√Õß¥“â πÀπßË÷ ®–¡’ two-

New Frontiers in Dialysis 202 ∏πµ‘ ®‘√π—π∑å∏«™— ‘√¿‘ “ ™â“ß»√‘ °‘ ≈ÿ ™—¬ ∏π—π¥“ µ√–°“√«π‘™ « π— µå ÿ‡¡∏°ÿ≈ port header cap ´ßË÷ „™‡â ªπì ∑“ß‡¢“â ·≈–∑“ßÕÕ°¢Õß‡≈Õ◊ ¥ «à πª≈“¬Õ°’ ¢“â ßÀπßË÷ ®–¡’ single-port header cap ´ßË÷ „™‡â ªπì ∑“ß‡¢“â ¢Õß “√π”È ∑¥·∑π ‡¡ÕË◊ ‡≈Õ◊ ¥«ßË‘ ‡¢“â µŸà «— °√Õß∑“ß¥“â π two-port header cap ‡≈Õ◊ ¥ ®–‰À≈‡¢“â àŸ fiber «à π∑Ë’ 1 ∑ÕË’ ¬√Ÿà Õ∫πÕ° ·≈–«ßË‘ ‰ª¬ß— ª≈“¬µ«— °√ÕßÕ°’ ¥“â πÀπßË÷ ∑¡Ë’ ’ single-port header cap ∑’Ë∫√‘‡«≥π’È‡≈◊Õ¥∑’Ë¡’§«“¡‡¢â¡¢âπ Ÿß®“°¢∫«π°“√°√Õß∑’Ë‡°‘¥¢÷Èπ¿“¬„π fiber à«π∑’Ë 1 ®–º ¡°—∫ “√πÈ”∑¥·∑π ®“°ππ—È ®–‰À≈‡¢“â Ÿà fiber «à π∑’Ë 2 ´ß÷Ë Õ¬µàŸ √ß°≈“ßµ«— °√Õß «ß‘Ë °≈∫— ‰ª¬ß— ª≈“¬¥“â π∑¡’Ë ’ two- port header cap ·≈–‰À≈ÕÕ°®“°µ«— °√Õß «à ππ”È ¬“øÕ°‡≈Õ◊ ¥®–‰À≈®“°¥“â πª≈“¬¥“â π∑¡Ë’ ’ single-port ‰ª¬ß— ¥“â π two-port header cap π”È ¬“øÕ°‡≈Õ◊ ¥®–«ßË‘ «π∑“ß°∫— ‡≈Õ◊ ¥„π fiber «à π∑Ë’ 1 ·≈–«ßË‘ ‰ª„π ∑»‘ ∑“ß‡¥¬’ «°∫— ‡≈Õ◊ ¥„π fiber «à π∑Ë’ 2 ¥ß— ππÈ— „π fiber «à π∑Ë’ 1 ®–‡°¥‘ ¢∫«π°“√ postdilution HDF «à π„π fiber «à π∑Ë’ 2 ®–‡°¥‘ ¢∫«π°“√ predilution HDF (√ªŸ ∑Ë’ 2) √ªŸ ∑’Ë 1 ·π«§¥‘ „π°“√∑” mid-dilution HDF ®“°°“√„™µâ «— °√Õß 2 µ«— µÕà °π— ·∫∫Õπ°ÿ √¡19 √ªŸ ∑’Ë 2 · ¥ß Olpur 190MD hemodiafilter18

Whatûs New in Online Hemodiafiltration? »¿ÿ ƒ°…å ®µ‘ µ‘°“ππ∑å 203 °“√„™âµ—«°√Õß™π‘¥π’È ‰¡à®”‡ªìπµâÕß‡§√◊ËÕß‰µ‡∑’¬¡æ‘‡»…„¥Ê ·≈– “¡“√∂·≈°‡ª≈’Ë¬π “√ π”È ‰¥¡â “°°«“à «∏‘ ’ postdilution HDF ‚¥¬Õ“® ßŸ ∂ß÷ 10-12 ≈µ‘ √/™«Ë— ‚¡ß ·≈– “¡“√∂°”®¥— “√¢π“¥‡≈°Á ·≈–¢π“¥°≈“ß‰¥¥â ’ æ∫«“à °“√°”®¥— “√∑¡Ë’ ¢’ π“¥‡≈°Á Õ“®¡¥’ Õâ ¬°«“à °“√∑” postdilution HDF ‡πÕË◊ ß®“° mid-dilution HDF ‡ªπì °“√√«¡ predilution ·≈– postdilution HDF ‡¢“â ¥«â ¬°π— «à π°“√°”®¥— “√∑¡’Ë ¢’ π“¥°≈“ß æ∫«à“ mid-dilution ¡’ª√– ‘∑∏‘¿“æ‡Àπ◊Õ°«à“ postdilution HDF ‡π◊ËÕß®“° “¡“√∂‡æ‘Ë¡Õ—µ√“°“√°√Õß ‰¥¡â “°°«“à °“√∑” postdilution ¡“° ∑”„À°â “√°”®¥— “√‚¥¬«∏‘ °’ “√æ“¡“°¢πÈ÷ µ“¡Õµ— √“°“√°√Õß18-20 ª≠í À“„π°“√∑” mid-dilution HDF ∑ ’Ë ”§≠— §Õ◊ §«“¡¥π— ¿“¬„πµ«— °√Õß‰¡§à ß∑’Ë ‡πÕ◊Ë ß®“°Õµ— √“ °“√°√ÕßπÈ”∑ ’Ë ßŸ ∑”„À§â «“¡µ“â π∑“π¿“¬„πµ«— °√Õß ßŸ ¢π÷È ‚¥¬‡©æ“–„π¥“â π∑¡’Ë ‡’ ≈Õ◊ ¥Õ¬Ÿà‡ªπì º≈„À§â “à TMP Ÿß¡“°‚¥¬‡©æ“–„π à«π∑’Ë‡°‘¥ postdilution HDF ®πÕ“®µâÕß≈¥Õ—µ√“°“√°√Õß≈ß ∑”„Àâ°“√·≈° ‡ª≈¬’Ë π “√πÈ”‰¡ à ßŸ µ“¡§«“¡§“¥À«ß— ¢ÕßºÕâŸ Õ°·∫∫µ«— °√ÕßÕ¬“à ß‰√°¥Á ’Potier°≈“à ««“à ®“°ª√– ∫°“√≥å 2 ªï „π°“√∑” mid-dilution HDF „πÀ≈“¬»πŸ ¬å ¬ß— ‰¡æà ∫º≈√“â ¬¢Õß§«“¡¥π— ∑ Ë’ ßŸ ¢πÈ÷ ·µÕà ¬“à ß„¥20 ‰¥¡â °’ “√æ≤— π“µ«— °√Õß Olpur MD220 ¢πÈ÷ ‚¥¬¡æ’ πÈ◊ ∑ºË’ «‘ ‡æ¡Ë‘ ¢πÈ÷ ‡ªπì 2.2 µ“√“ß‡¡µ√ ·≈–‡æ¡Ë‘ æπÈ◊ ∑ºË’ «‘ ¢Õß fiber ∑ÕË’ ¬µàŸ √ß°≈“ß‡ªπì 1.0 µ“√“ß‡¡µ√ ‚¥¬°“√‡æ¡Ë‘ ª√¡‘ “≥ fiber ¢πÈ÷ ‡™ÕË◊ «“à ®–™«à ¬„Àâ §«“¡¥π— ≈¥≈ß ·≈–¡ª’ √– ∑‘ ∏¿‘ “æ„π°“√°”®¥— ¢Õß‡ ¬’ ¡“°¢πÈ÷ 6. Reverse mid-dilution hemodiafiltration ¥ß— ∑‰Ë’ ¥°â ≈“à «·≈«â «“à ª≠í À“∑ Ë’ ”§≠— „π°“√∑” mid-dilution HDF ∑ Ë’ ”§≠— §Õ◊ §«“¡¥π— ∑ Ë’ ßŸ ¢πÈ÷ ®ß÷ ¡º’ §âŸ ¥‘ «∏‘ ·’ °ªâ ≠í À“πÈ’ ‚¥¬°“√ ≈∫— ∑“ß‡¢“â ·≈–∑“ßÕÕ°¢Õß‡≈Õ◊ ¥ ∑”„Àâ fiber µ√ß°≈“ß «à π∑‡Ë’ §¬‡°¥‘ predilution °≈“¬‡ªπì postdilution ·≈– fiber «à π√¡‘ ∑‡Ë’ §¬‡°¥‘ postdilution °≈“¬‡ªπì predilution ‡√¬’ ° «∏‘ π’ «È’ “à reverse mid-dilution HDF ´ßË÷ “¡“√∂≈¥§«“¡¥π— ¿“¬„πµ«— °√Õß≈¥≈ß‰¥â (√ªŸ ∑Ë’ 3) Santoro ·≈–§≥–‰¥∑â ”°“√»°÷ …“‡ª√¬’ ∫‡∑¬’ ∫«∏‘ ’ mid-dilution °∫— «∏‘ ’ reverse mid-dilution HDF æ∫«à“°“√°”®—¥ “√∑’Ë¡’¢π“¥‡≈Á°·≈–¢π“¥°≈“ß‰¡à·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠ ·µà§«“¡¥—π„π√–∫∫ reverse mid-dilution µË”°«à“Õ¬à“ß¡’π—¬ ”§—≠ ‰¡à«à“®–‡ªìπ§«“¡¥—π∑’Ë∑“ß‡¢â“·≈–∑“ßÕÕ°¢Õß‡≈◊Õ¥ §«“¡¥π— ∑∑Ë’ “ß‡¢“â ¢Õß “√π”È ∑¥·∑π TMP „π «à π∑‡Ë’ °¥‘ postdilution, predilution ·≈–§“à TMP ‡©≈¬Ë’ 21 7. Paired hemodiafiltration Paired hemodiafiltration (PHF; Bellco) ‡ªπì √ªŸ ·∫∫ÀπßË÷ ¢Õß°“√∑” online HDF ∑æË’ ≤— π“¢πÈ÷ ‡æÕË◊ ≈¥ª≠í À“§«“¡‰¡∫à √ ‘ ∑ÿ ∏¢Ï‘ Õß “√π”È ∑¥·∑π ∑”‰¥‚â ¥¬„™µâ «— °√Õß high-flux 2 µ«— ¢∫«π°“√°”®¥— “√‚¥¬°“√·æ√à·≈–°“√æ“‡°‘¥¢÷Èπ„πµ—«°√Õßµ—«·√°´÷Ëß¡’¢π“¥„À≠à°«à“ (1.9 µ“√“ß‡¡µ√) ·≈–πÈ”¬“ øÕ°‡≈◊Õ¥ à«πÀπ÷Ëß®–∂Ÿ°¥÷ßÕÕ°¡“‡ªìπ “√πÈ”∑¥·∑π‚¥¬„™âªíö¡„π∑àÕ àß “√πÈ”∑¥·∑π ‚¥¬‡µ‘¡‡¢â“ Ÿà ‡≈Õ◊ ¥‚¥¬¢∫«π°“√ back filtration „πµ«— °√Õßµ«— ∑ Ë’ Õß´ßË÷ ¡¢’ π“¥‡≈°Á °«“à (0.7 µ“√“ß‡¡µ√) °“√‡°¥‘ back filtration ¢Õß “√πÈ”∑¥·∑π‡¢â“‰ª„π‡≈◊Õ¥‡ªìπ°“√¬◊π¬—π«à“ “√πÈ”∑’Ë®–‡¢â“ Ÿàµ—«ºâŸªÉ«¬¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß (√ªŸ ∑’Ë 4)

New Frontiers in Dialysis 204 ∏πµ‘ ®‘√ππ— ∑å∏«—™ √‘ ‘¿“ ™“â ß»√‘ °‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « —πµå ÿ‡¡∏°≈ÿ √ªŸ ∑’Ë 3 3A · ¥ß mid-dilution HDF, 3B · ¥ß reverse mid-dilution HDF21 √ªŸ ∑Ë’ 4 · ¥ß«ß®√ Paired hemodiafiltration. BLD = Blood leak detector; UF = ultrafiltrate37

Whatûs New in Online Hemodiafiltration? »¿ÿ ƒ°…å ®µ‘ µ°‘ “ππ∑å 205 Paired hemodiafiltration ¡≈’ °— …≥–‡¥πà 2 ª√–°“√ §Õ◊ 1. “√π”È ∑¥·∑π®–º“à π¢∫«π°“√ back filtration „πµ«— °√Õßµ«— ∑Ë’ 2 ‡¢“â ‡àŸ ≈Õ◊ ¥∑π— ∑’ ®ß÷ µ¥— ‚Õ°“ ‡°¥‘ °“√ªπ‡ªÕôó π„π∑Õà ßà À√Õ◊ ¢Õâ µÕà µ“à ßÊ ∑„Ë’ ™ â ßà “√π”È ∑¥·∑πÕ¬“à ß∑„Ë’ ™„â π«∏‘ ’ online HDF ∑«Ë— ‰ª 2. “¡“√∂µ√«®°“√√—Ë«¢Õß‡¡¡‡∫√π„πµ—«°√Õßµ—«∑’Ë 2 ‰¥â ‚¥¬°“√°≈—∫∑‘»∑“ß¢Õßªíö¡„π ∑Õà ßà “√π”È ∑¥·∑π ∑”„À‡â °¥‘ °“√°√Õß‡≈Õ◊ ¥¿“¬„πµ«— °√Õß∑Ë’ 2 ·∑π∑°Ë’ “√„À â “√π”È ∑¥·∑π Õªÿ °√≥å ¡“µ√∞“π∑’Ë„™âµ√«®°“√√—Ë«¢Õß‡≈◊Õ¥ “¡“√∂µ√«®‡¡Á¥‡≈◊Õ¥·¥ß„π “√πÈ”∑’Ë°√Õß‰¥â °“√µ√«®°“√√—Ë« ¢Õß‡¡Á¥‡≈◊Õ¥·¥ß¡’§«“¡‰« Ÿß·¡â®–¡’°“√·µ°¢Õß fiber ‡æ’¬ß‡≈Á°πâÕ¬ ·≈–‡™◊ËÕ∂◊Õ‰¥â ‡π◊ËÕß®“°‡¡Á¥ ‡≈◊Õ¥·¥ß∑’Ë√—Ë«ÕÕ°¡“‰¡à‰¥âº ¡Õ¬àŸ„ππÈ”¬“øÕ°‡≈◊Õ¥·µàª–ªπÕ¬àŸ„ππÈ”∑’Ë∂Ÿ°°√ÕßÕÕ°¡“®“°°“√°≈—∫ ∑‘»∑“ß¢Õßªíö¡ °“√∑”‡™àππ’È‡æ◊ËÕ‡ªìπ°“√¬◊π¬—π«à“‡¡¡‡∫√π„πµ—«°√Õßµ—«∑’Ë 2 ‰¡à√—Ë« ‡æ◊ËÕ§«“¡¡—Ëπ„®«à“ “√π”È ∑¥·∑π®–¡§’ «“¡∫√ ‘ ∑ÿ ∏ Ï‘ ßŸ °“√µ√«®°“√√«Ë— ¢Õß‡¡¡‡∫√π®–∑”‡¡ÕË◊ ‡√¡Ë‘ µπâ °“√∑” PHF ®“°ππÈ— °®Á –∑”°“√µ√«®‡ªπì √–¬–µ≈Õ¥™«à ß°“√∑” PHF ¡°’ “√»°÷ …“∑“ß§≈π‘ °‘ æ∫«“à °“√∑” PHF ¡§’ «“¡§≈“â ¬§≈ß÷ °∫— °“√∑” online HDF «∏‘ Õ’ πË◊ „π ·ß°à “√°”®¥— β2-microglobulin ·≈–‰¡°à √–µπâÿ „À√â “à ß°“¬º≈µ‘ cytokines22,23 8. Hemodiafiltration with endogenous reinfusion ‡π◊ËÕß®“°¡’ºâŸ§”π÷ß∂÷ßªí≠À“¢Õß°“√∑” online HDF §◊Õ§«“¡∫√‘ ÿ∑∏‘Ï¢Õß “√πÈ”∑¥·∑π∑’ËºâŸ ªÉ«¬‰¥â√—∫‡ªìπª√‘¡“≥¡“° ·≈–Õ“®¡’°“√ Ÿ≠‡ ’¬ “√∫“ßÕ¬à“ß∑’Ë¡’§«“¡ ”§—≠∑“ß √’√«‘∑¬“ÕÕ°‰ª ∑“ßπ”È ∑∂Ë’ °Ÿ °√ÕßÕÕ°¡“ (ultrafiltrate) ‡™πà °√¥Õ–¡‚‘ π «µ‘ “¡π‘ ŒÕ√‚å ¡π ·≈– growth factors ®ß÷ ¡º’ §âŸ ¥‘ «∏‘ ’ hemodiafiltration with endogenous reinfusion ‚¥¬π”πÈ”∑’Ë∂Ÿ°°√ÕßÕÕ°¡“‰ª∫”∫—¥‚¥¬π”‰ªºà“π °√–∫Õ°∑¡’Ë ’ “√¥¥Ÿ ´∫— ¢Õß‡ ¬’ ®“°ππ—È ®ß÷ ‡µ¡‘ °≈∫— ‡¢“â ‰ª„π‡≈Õ◊ ¥‡ªπì “√πÈ”∑¥·∑π(endogenousreinfusion fluid) ‚¥¬ ultrafiltrate ∑’Ë‰¥â√—∫°“√∫”∫—¥®–¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß·≈–¡’°√¥Õ–¡‘‚π ·≈–‰∫§“√å∫Õ‡πµ‡ªìπ «à πª√–°Õ∫‡À¡Õ◊ π„πæ≈“ ¡“à æ∫«“à °“√ ≠Ÿ ‡ ¬’ °√¥Õ–¡‚‘ π‚¥¬«∏‘ π’ ®’È –‡∑¬’ ∫‡∑“à °∫— °“√„™µâ «— °√Õß low flux §Õ◊ ª√–¡“≥√Õâ ¬≈– 10-11 πÕâ ¬°«“à °“√∑” high flux hemodialysis À√Õ◊ HDF «∏‘ Õ’ πË◊ Ê ∑¡Ë’ °’ “√ ≠Ÿ ‡ ¬’ °√¥Õ–¡‚‘ π∂ß÷ √Õâ ¬≈– 25-33 ´ßË÷ Õ“®§¥‘ ‡ªπì ª√¡‘ “≥‡©≈¬Ë’ 3-4 °√¡— /§√ßÈ— °“√√°— …“24-26 „π™«à ßµπâ ªï §.». 1990 ‰¥‡â √¡Ë‘ ¡°’ “√„™â noncoated mineral carbon 130 ¡≈. µÕà ‡¢“â °∫— ∑Õà ßà π”È ∑Ë’ ∂°Ÿ °√ÕßÕÕ°¡“‡æÕË◊ ‡ªπì “√¥¥Ÿ ´∫— ¢Õß‡ ¬’ ‡√¬’ °«∏‘ π’ «È’ “à hemofiltrate reinfusion (HFR)27,28 µÕà ¡“„π™«à ßªï §.». 1999-2000 ‰¥‡â √¡‘Ë ¡°’ “√„™°â √–∫Õ°∑∫’Ë √√®ÿ hydrophobic styrenic resin 40 ¡≈. ´ß÷Ë “¡“√∂¥¥Ÿ ´∫— uremic toxins ‰¥Àâ ≈“¬™π¥‘ ‡™πà β2-microglobulin, homocysteine, parathyroid hormone, chemokines ·≈– cytokines À≈“¬™π¥‘ 29,30 ·µ‰à ¡¥à ¥Ÿ ´∫— ¬‡Ÿ √¬’ §√Õ’ “µπ‘ π’ °√¥¬√Ÿ °‘ ‚´‡¥¬’ ¡ ‚ª·µ ‡´¬’ ¡ øÕ øÕ√ — ·≈–‰∫§“√∫å Õ‡πµ ¥ß— ππ—È °“√°”®¥— “√¢π“¥‡≈°Á ∑‰’Ë ¡∂à °Ÿ ¥¥Ÿ ´∫— ®–‡°¥‘ ¢π÷È „πµ«— °√Õßµ«— ∑ ’Ë Õß∑¡’Ë °’ “√°”®¥— “√¥«â ¬°“√·æ√à ‚¥¬À≈°— °“√ HFR ‡ªπì √–∫∫°“√∫”∫¥— ∑¥·∑π‰µ∑Õ’Ë “»¬— °“√·æ√à °“√æ“ ·≈–°“√¥¥Ÿ ´∫— (√ªŸ ∑’Ë 5) ª√–°Õ∫¥«â ¬µ«— °√Õß 2 µ«— µ«— ·√°‡ªπì high flux polyethersulphone ·≈–‰¡¡à π’ ”È ¬“øÕ°‡≈Õ◊ ¥‰À≈º“à π ¥—ßπ—Èπ®÷ß‡°‘¥°“√°”®—¥ “√‚¥¬¢∫«π°“√æ“®“°°“√°√ÕßπÈ”‡∑à“π—Èπ µ—«°√Õßµ—«∑’Ë 2 ‡ªìπ low flux

New Frontiers in Dialysis 206 ∏πµ‘ ®‘√ππ— ∑å∏«™— √‘ ‘¿“ ™“â ß»√‘ ‘°ÿ≈™¬— ∏π—π¥“ µ√–°“√«π‘™ « —πµå ÿ‡¡∏°ÿ≈ polyethersulphone ´÷Ëß¡’πÈ”¬“øÕ°‡≈◊Õ¥‰À≈ºà“π„π∑‘»∑“ß «π°—∫∑‘»∑“ß°“√‰À≈¢Õß‡≈◊Õ¥ πÈ”∑’Ë‰¥â ®“°°“√°√Õß„πµ«— °√Õßµ«— ·√°®–‰À≈º“à π°√–∫Õ°∑∫Ë’ √√®ÿ hydrophobic styrenic resin ∑¡Ë’ ™’ Õà ß«“à ß·≈– √Ÿæ√ÿπ¡“°¡“¬∑”„Àâ¡’æ◊Èπ∑’Ëº‘« Ÿß∂÷ß 700 µ“√“ß‡¡µ√/°√—¡ ‡¡◊ËÕºà“π°“√¥Ÿ¥´—∫„π°√–∫Õ°·≈â«®–∂Ÿ° àß °≈—∫‡¢â“‰ª√«¡°—∫‡≈◊Õ¥∑’ËÕÕ°¡“®“°µ—«°√Õßµ—«·√° °àÕπ®–√«¡°—π‰À≈‡¢â“µ—«°√Õßµ—«∑’Ë 2 ¥—ßπ—Èπ ‡≈◊Õ¥∑’Ëºà“π¢∫«π°“√°√Õß®“°µ—«°√Õßµ—«·√°·≈–¢∫«π°“√¥Ÿ¥´—∫®–‰¡à∂Ÿ°°”®—¥πÈ”ÕÕ°‡≈¬ à«πµ—« °√Õßµ—«∑’Ë 2 ®–∑”Àπâ“∑’Ë‡À¡◊Õπ°“√∑” low flux hemodialysis ∑—Ë«‰ª ´÷Ëß°“√°”®—¥ “√ à«π„À≠à‡°‘¥ ®“°¢∫«π°“√·æ√à ·≈–®–¡°’ “√¥ß÷ π”È «à π‡°π‘ ÕÕ°®“°‡≈Õ◊ ¥∑µË’ «— °√Õßµ«— πÈ’ ‡Àµÿ∑’Ë‡≈◊Õ°∑”°“√°√ÕßπÈ”ÕÕ°¡“®“°‡≈◊Õ¥‡æ◊ËÕ‰ªºà“π “√¥Ÿ¥´—∫ ·∑π∑’Ë®–π”‡≈◊Õ¥‰ªºà“π °√–∫Õ°¥Ÿ¥´—∫‚¥¬µ√ß (hemoperfusion) ‡π◊ËÕß®“°Õ—µ√“°“√‰À≈¢ÕßπÈ”∑’Ë∂Ÿ°°√ÕßÕÕ°¡“ºà“π°√–∫Õ° ¥¥Ÿ ´∫— ®–µ”Ë °«“à Õµ— √“°“√‰À≈¢Õß‡≈Õ◊ ¥º“à π°√–∫Õ°¥¥Ÿ ´∫— ∑”„À¡â ‡’ «≈“„π°“√ ¡— º — “√¥¥Ÿ ´∫— π“π°«“à °“√¥¥Ÿ ´∫— ®ß÷ ‡°¥‘ ‰¥¥â °’ «“à ª√–°“√µÕà ¡“§Õ◊ ªÕÑ ß°π— °“√°√–µπâÿ ªØ°‘ √‘ ¬‘ “„π√“à ß°“¬ ®“°°“√ ¡— º — ¢Õß ‡´≈≈Õå °— ‡ ∫·≈–‡°≈¥Á ‡≈Õ◊ ¥°∫— “√¥¥Ÿ ´∫— ‡§√Õ◊Ë ß‰µ‡∑¬’ ¡∑¡’Ë °’ “√„™∑â ” HFR ‰¥·â °à ‡§√Õ◊Ë ß Formula Plus (Bellco- Sorin) ´ßË÷ ¡’ software „π°“√§”π«≥Õµ— √“°“√°√Õß„πµ«— °√Õßµ«— ·√°‡æÕË◊ „À°â “√¥¥Ÿ ´∫— ‡°¥‘ ¢πÈ÷ ¡“°∑ Ë’ ¥ÿ ‚¥¬¢π÷È °∫— ¢π“¥¢Õß°√–∫Õ°∫√√® ÿ “√¥¥Ÿ ´∫— ª√¡‘ “≥ “√¥¥Ÿ ´∫— πÕ°®“°ππ—È ‡§√Õ◊Ë ß¬ß— „™§â “à Œ¡’ “‚µ§√µ‘ ·≈– √ªŸ ∑Ë’ 5 · ¥ß«ß®√ hemodiafiltration with endogenous reinfusion. QBi = blood flow at the dialyzer inlet; QBo = blood flow at the dialyzer outlet; QDi = dialysate flow at the dialyzer inlet, QDo = dialysate flow at the dialyzer outlet; UF = ultrafiltrate; QUF = ultrafiltrate flow; QR = reinfusate flow24

Whatûs New in Online Hemodiafiltration? »¿ÿ ƒ°…å ®‘µµ°‘ “ππ∑å 207 TMP ¡“§”π«≥Õ—µ√“°“√°√Õß¥â«¬ ‚¥¬Õ—µ√“°“√°√Õß¡—°®– Ÿß„π™à«ß·√° ·≈–Õ“®ª√—∫≈¥≈ß ‡πÕ◊Ë ß®“°‡≈Õ◊ ¥¡§’ «“¡‡¢¡â ¢πâ ¢π÷È ®“°°“√»°÷ …“∑“ß§≈π‘ °‘ À≈“¬°“√»°÷ …“æ∫«“à HFR “¡“√∂°”®¥— ¬‡Ÿ √¬’ , β2-microglobulin, cytokines ‡™πà interleukin-6 ·≈– tumor necrosis factor α31 32 ·≈– “¡“√∂¥¥Ÿ ´∫— homocysteine ‚¥¬‰¡à ¥¥Ÿ ´∫— «µ‘ “¡π‘ ∫’ 12 ·≈– folate ´ßË÷ Õ“®¡ª’ √–‚¬™π„å π°“√≈¥§«“¡‡ ¬Ë’ ßµÕà ‚√§À«— „®·≈–À≈Õ¥‡≈Õ◊ ¥33 ¡’ °“√»°÷ …“æ∫«“à C-reactive protein „πºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√∑” HFR ≈¥≈ß‡¡ÕË◊ ‡∑¬’ ∫°∫— ºªâŸ «É ¬øÕ°‡≈Õ◊ ¥∑«Ë— ‰ª √«à ¡°∫— æ∫«“à bone turnover ≈¥≈ß æ√Õâ ¡°∫— °“√≈¥≈ß¢Õß total ·≈– bone alkaline phosphatase34 Panichi ‰¥»â °÷ …“‡ª√¬’ ∫‡∑¬’ ∫ HFR °∫— online HDF ‚¥¬∑”°“√»°÷ …“·∫∫ crossover æ∫«“à ∑ß—È Õß«∏‘ ’ “¡“√∂≈¥√–¥∫— C-reactive protein ·≈– interleukin-6 ‡¡ÕË◊ ‡∑¬’ ∫°∫— °“√∑” hemodialysis ·≈–¬ß— æ∫«“à √–¥∫— interleukin-10 ‡æ¡‘Ë ¢π÷È ¥«â ¬35 Calo ‰¥â»÷°…“º≈√–¬–¬“«¢Õß°“√∑” HFR ‡∑’¬∫°—∫°“√∑” hemodialysis ‚¥¬»÷°…“·∫∫ crossover ·≈–¥°Ÿ “√‡ª≈¬Ë’ π·ª≈ß¢Õß°“√· ¥ßÕÕ°¢Õß gene æ∫«“à „π™«à ß∑∑Ë’ ” HFR °“√ √“â ß mRNA ·≈–°“√· ¥ßÕÕ°¢Õß‚ª√µπ’ p22phox ·≈– plasminogen activator inhibitor 1 (PAI-1) ≈¥≈ß36 ´ßË÷ ‚ª√µπ’ ∑ßÈ— Õß™π¥‘ ¡ ’ «à π‡°¬Ë’ «¢Õâ ß„π¢∫«π°“√Õ°— ‡ ∫ ·≈–¿“«– oxidative stress ·≈–¡ ’ «à π‡°¬Ë’ «¢Õâ ß°∫— °“√ ‡°¥‘ ‚√§À«— „®·≈–À≈Õ¥‡≈Õ◊ ¥„πºªŸâ «É ¬‡∫“À«“π·≈–ºªâŸ «É ¬‚√§‰µ 9. √ªÿ ª®í ®∫ÿ π— §«“¡√‡Ÿâ °¬Ë’ «°∫— uremic toxins ·≈–æ¬“∏°‘ ”‡π¥‘ ¢Õß¿“«–¬√Ÿ ‡’ ¡¬’ ‡®√≠‘ °“â «Àπ“â ‰ª¡“° ∑”„À¡â °’ “√æ≤— π“‡∑§‚π‚≈¬„’ π°“√∫”∫¥— ∑¥·∑π‰µ„À â “¡“√∂∑¥·∑π°“√∑”ß“π¢Õß‰µ‰¥„â °≈‡â §¬’ ß∑ ’Ë ¥ÿ °“√øÕ°‡≈Õ◊ ¥·∫∫ª°µ‘ ‰¡ à “¡“√∂°”®¥— ¢Õß‡ ¬’ ∑¡Ë’ ¢’ π“¥„À≠‰à ¥‡â æ¬’ ßæÕ °“√∑” online HDF ®ß÷ ‡ªπì ∑“ß‡≈◊Õ°Àπ÷Ëß∑’Ë®–™à«¬·°âªí≠À“π’È‰¥â ªí®®ÿ∫—π·¡â®–¢“¥¢âÕ¡Ÿ≈®“°°“√»÷°…“∑’Ë¡’§ÿ≥¿“æ Ÿß∂÷ß ª√–‚¬™πå¢Õß°“√∑” online HDF µàÕ°“√√Õ¥™’«‘µ¢ÕßºŸâªÉ«¬ ·µà°Á¡’¢âÕ¡Ÿ≈∂÷ß§«“¡ª≈Õ¥¿—¬ ·≈– ª√–‚¬™π„å π°“√∫√√‡∑“¿“«–´¥’ °“√§«∫§¡ÿ §«“¡¥π— ‚≈Àµ‘ ·≈–§«“¡§ß∑∑’Ë “ß hemodynamic ¢Õß°“√∑” online HDF ¢Õâ ®”°¥— „π°“√∑” online HDF §Õ◊ √“§“∑ Ë’ ßŸ °«“à °“√øÕ°‡≈Õ◊ ¥‚¥¬∑«Ë— ‰ª ·≈–§«“¡°ß— «≈ ‡°’Ë¬«°—∫§«“¡∫√‘ ÿ∑∏‘Ï¢Õß “√πÈ”∑¥·∑π∑’Ë„Àâ·°àºâŸªÉ«¬ ´÷Ëß°Á¡’°“√æ—≤π“‡∑§π‘§µà“ßÊ ‡æ◊ËÕ·°â‰¢ªí≠À“ π’È·≈–¡’¢âÕ¡≈Ÿ ‡°’Ë¬«°—∫°“√ª≈Õ¥¿—¬Õ¬Ÿà¡“°¡“¬ ‡√“§ßµâÕß√Õ¢âÕ¡≈Ÿ ®“°°“√»÷°…“∑’Ë¡’§ÿ≥¿“æµàÕ‰ª„π Õπ“§µ √«¡∂ß÷ °“√»°÷ …“∂ß÷ ‡∑§π§‘ „À¡Êà ‡æÕË◊ ‡æ¡Ë‘ ª√– ∑‘ ∏¿‘ “æ„π°“√°”®¥— “√‚¥¬¢∫«π°“√æ“µÕà ‰ª ‡Õ° “√Õ“â ßÕß‘ 1. Henderson LW, Besarab A, Michaels A, Bluemle LW Jr. Blood purification by UF and fluid replacement (diafiltration). Trans Am Soc Artif intern Organs 1967;17:216-221. 2. Leber H, Wizemann V, Goubeaud G, et al. Hemodiafiltration: a new alternative to hemofiltration and conventional hemodialysis. Artif Organs 1978;2:150-153.

New Frontiers in Dialysis 208 ∏πµ‘ ®√‘ π—π∑å∏«—™ ‘√¿‘ “ ™â“ß»‘√‘°≈ÿ ™¬— ∏π—π¥“ µ√–°“√«π™‘ « π— µå ÿ‡¡∏°ÿ≈ 3. Floege J, Granolleras C, Descholdt G, et al. High flux synthetic versus cellulosic membranes for beta2- microglobulin removal during hemodialysis, hemodiafiltration and hemofiltration. Nephrol Dial Transplant 1989;4:653-657. 4. Kerr PB, Argiles a, Flavier JL, et al. Comparison of hemodialysis and hemofiltration: A long-term longitudinal study. Kidney Int 1992;41:1035-1040. 5. Lornot W, Because I, Billiouw JM, et al. Remarkable removal of beta2-microglobulin by on-line hemodiafiltration. Am J Nephrol 1998;18:105-108. 6. Shinzato T, Miwa M, Nakai S, et al. On-line HDF: A safe and efficient way to increase beta2-m removal. Blood Purif 1995: 13(Suppl 1):50-51. 7. Canaud B, Bosc JY, Leray H, et al. On-line hemodiafiltration: state of the art. Nephrol Dial Transplant 1998;13(Suppl 5):3-11. 8. Canaud B, Morena M, Leray-Moragues H, et al. Overview of clinical studies in hemodiafiltration: what do we need now? Hemodialysis Int 2006;10:S5-12. 9. Henderson LW. Biophysics of ultrafiltration and hemofiltration. In: Maher JF, ed. Replacement of Renal Function by Dialysis. Dordrecht, the Netherlands: Kluwer Academic Publishers, 1989;300-326. 10. Rockel A, Hertel J, Fiegel P, et al. Permeability and secondary membrane formation of a high flux polysulfone hemofilter. Kidney Int 1986;30:429-32. 11. Baldamus AC: Problems in hemofiltration. Contrib Nephrol 1985;44:212-222. 12. Jenkins RD, Funk JE, Chen B, Golper T. Operational instability in extracorporeal filtration of blood. Blood Purif 1992;10:292-297. 13. Pedrini LA, De Cristofaro V, Pagliari B, Sama F. Mixed predilution and postdilution online hemodiafiltration compared with the traditional infusion modes. Kidney Int 2000;58:2155-2165. 14. Pedrini LA, De Cristofaro V. On-line mixed hemodiafiltration with a feedback for ultrafiltration control. Effect on middle molecule removal. Kidney Int 2003;64:1505-1513. 15. Krieter DH, Falkenhain S, Chalabi L, et al. Clinical cross-over comparison of mid-dilution hemodiafiltration using a novel dialyzer concept and post-dilution hemodiafiltration. Kidney Int 2005;67:349-356. 16. Feliciani a, Riva MA, Zerbi S, et al. New strategies in hemodiafiltration (HDF): prospective comparative analysis between on-line mixed HDF and mid-dilution HDF. Nephrol Dial Transplant 2007.DOI:10.1093/ndt/ gfm023. 17. Petras D, Fortunato A, Soffiati G, et al. Transmembrane pressure modulation in high-volume mixed hemodiafiltration to optimize efficiency and minimize protein loss. Kidney Int 2006;69:573-579. 18. Krieter DH, Collins G, Summerton J, et al. Mid-dilution online hemodiafiltration in a standard dialyser configuration. Nephrol Dial Transplant 2005;20:155-160. 19. Krieter DH, Falkenhain S, Chalabi L, et al. Clinical cross-over comparison of mid-dilution hemofiafiltration using a novel dialyzer concept and post-dilution hemodiafiltration. Kidney Int 2005;67:349-356. 20. Potier J. Mid-Dilution: an innovative high-quality and safe haemodiafiltration approach; in Ronco C, Canaud B, P Aljama (eds): Hemodiafiltration. Contrib Nephrol. Basel, Karger, 2007, vol 158, pp 153-160.

Whatûs New in Online Hemodiafiltration? »ÿ¿ƒ°…å ®‘µµ‘°“ππ∑å 209 21. Santoro A, Ferramosca E, Mancini E, et al. Reverse mid-dilution: new way to remove small and middle molecules as well as phosphate with high intrafilter convective clearance. Nephrol Dial Transplant 2007;22:2000- 2005. 22. Pizzarelli F, Tetta C, Cerrai T, Maggiore Q. Double chamber online hemodiafiltration: a novel technique with intra-treatment monitoring of dialysate ultrafilter integrity. Blood Purif 2000;18:237-241. 23. Pizzarelli F, Cerrai T, Etta C. Paired hemodiafiltration: technical assessment and preliminary clinical results; in Locatelli F, Ronco C, Tetta C (eds): Polyethersulfone: Membranes for Multiple Clinical Applications. Contrib Nephrol. Basel, Karger, 2003, vol 138, pp 99-105. 24. Wratten ML, Ghezzi PM. Hemodiafiltration with endogenous reinfusion; in Ronco C, Canaud B, P Aljama (eds): Hemodiafiltration. Contrib Nephrol. Basel, Karger, 2007, vol 158, pp 94-102. 25. Ikizler TA, Flakoll PJ, Parker RA, Hakim RM. Amino acid and albumin losses during hemodialysis. Kidney Int 1994;46:830-837. 26. Prado de Negreiros Nogueira Maduro I, Elias NM, Nonino Borges CB. Total nitrogen and free amino acid losses and protein calorie malnutrition of hemodialysis patients: do they really matter? Nephron Clin Pract 2007;105:c9-c17. 27. Ghezzi PM, Gervasio R, Tessore V, et al. Hemodiafiltration without replacement fluid: experimental study. Trans Am Soc artif Intern Organs 1992;38:61-65. 28. Ghezzi PM, et al. Use of the ultrafiltrate obtained in two-chamber hemodiafiltration as replacement fluid. Int J Artif Organs 1991;14:227-234. 29. De Nitti C, Giordano R, Gervasio R, et al. Choosing new adsorbents for endogenous ultrapure infusion fluid: performances, safety and flow distribution. Int J Artif Organs 2001;24:765-776. 30. Tetta C, Ghezzi PM, De Nitti C, et al. New options for on-line hemodiafiltration; in Ronco C, La Greca G (eds): Hemodialysis Technology. Contrib Nephrol. Karger, Basel, 2002, vol 137, pp 212-220. 31. Meloni C, Ghezzi PM, Cipriani S, et al. One year of experience in postdilution hemofiltration with online reinfusion of regenerated ultrafiltrate. Blood Purif 2004;22:505-509. 32. Meloni C, Ghezzi PM, Cipriani S, et al. Hemodiafiltration with post-dilution reinfusion of the regenerated ultrafiltrate: a new on-line technique. Clin Nephrol 2005;63:106-112. 33. Splendiani G, De Angelis S, Tullio T, et al. Selective adsorption of homocysteine using an HFR online technique. Artif Organs 2004;28:592-595. 34. Bolasco PG, Ghezzi PM, Ferrara R, et al. Effect of on-line hemodiafiltration with endogenous reinfusion (HFR) on the calcium-phosphorus metabolism: medium-term effects. Int J Artif Organs 2006;29:1042-1052. 35. Panichi V, Manca-Rizza G, Paoletti S, et al. Effects on inflammatory and nutritional markers of hemodiafiltration with online regeneration of ultrafiltrate (HFR) vs online hemodiafiltration: a cross-over randomized multicentre trial. Nephrol Dial Transplant 2006;21:756-762. 36. Calo LA, Naso A, Carraro G, et al. Effect of hemodiafiltration with online regeneration of ultrafiltrate on oxidative stress in dialysis patients. Nephrol Dial transplant 2007;22:1413-1419. 37. Pizzarelli F. Paired hemodiafiltration; in Ronco C, Canaud B, P Aljama (eds): Hemodiafiltration. Contrib Nephrol. Basel, Karger, 2007, vol 158, pp 131-137.

12 Dialysis in Acute Kidney Injury ≥∞— ™¬— »√ ’ « — ¥‘Ï ¢®√ µ√’ ≥∏π“°≈ÿ 1. ∫∑π” 2. ‡«≈“∑‡’Ë √¡Ë‘ µπâ ·≈–¢Õâ ∫ßà ™È’„π°“√√°— …“∫”∫¥— ∑¥·∑π‰µ 3. ™π¥‘ °“√√°— …“∫”∫¥— ∑¥·∑π‰µ„π¿“«–‰µ«“¬©∫— æ≈π— 4. ¢π“¥¢Õß°“√∫”∫¥— ∑¥·∑π‰µ (dialysis dosing) 5. ∫∑∫“∑¢Õß peritoneal dialysis „π acute kidney injury

New Frontiers in Dialysis 212 ∏π‘µ ®√‘ π—π∑∏å «—™ ‘√¿‘ “ ™“â ß»√‘ °‘ ÿ≈™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå ‡ÿ ¡∏°≈ÿ 1. ∫∑π” „πª®í ®∫ÿ π— ‡√“¡°— „™§â ”«“à ¿“«–‰µ«“¬©∫— æ≈π— (acute kidney injury) ·∑π°“√„™§â ”«“à acute renal failure, acute kidney injury ‡°¥‘ ®“°°“√ ≠Ÿ ‡ ¬’ §«“¡ “¡“√∂¢Õß‰µÕ¬“à ß©∫— æ≈π— „π°“√¢®¥— ¢Õß ‡ ¬’ ‡™πà urea √«¡∑ßÈ— °“√ ≠Ÿ ‡ ¬’ §«“¡ “¡“√∂„π°“√§«∫§¡ÿ “√π”È ·≈– electrolyte º≈∑µË’ “¡¡“®“° ¿“«–‰µ«“¬©∫— æ≈π— ∑æ’Ë ∫‰¥∫â Õà ¬‡™πà volume overload, metabolic acidosis, hyperkalemia, hypo-hypernatremia ·≈–°“√ – ¡ nitrogen waste products µà“ßÊ „π‡≈◊Õ¥ ∂÷ß·¡â„πªí®®ÿ∫—π‡√“¡’§«“¡√Ÿâ§«“¡‡¢â“„®¡“° ¢πÈ÷ „π‡√ÕË◊ ßæ¬“∏ ‘ ¿“æ¢Õß°“√‡°¥‘ ‚√§·µ„à π·ß¢à Õß°“√√°— …“°≈∫— æ∫«“à ‡√“¬ß— ‰¡¡à §’ «“¡°“â «Àπ“â ¡“°π°— ¬“µ“à ßÊ ∑∂Ë’ °Ÿ ∑¥ Õ∫«“à “¡“√∂„™√â °— …“‰¥¥â „’ π µ— «∑å ¥≈Õß ·µ°à ≈∫— ‰¡‰à ¥ºâ ≈‡¡ÕË◊ π”¡“„™„â π¡π…ÿ ¬å ¥ß— π—ÈπÀ≈—°„π°“√√—°…“ºŸâªÉ«¬‰µ«“¬©—∫æ≈—π §◊Õ °“√°”®—¥ “‡Àµÿ∑’Ë∑”„Àâ‡°‘¥¿“«–‰µ«“¬·≈–°“√√—°…“ ·∫∫ª√–§—∫ª√–§Õß (supportive therapy) ‡æ◊ËÕ√Õ„Àâ¿“«–‰µ«“¬°≈—∫øóôπµ—«¡“ àŸ¿“«–ª°µ‘ °“√√—°…“ À≈°— „π°“√√°— …“·∫∫ª√–§∫— ª√–§Õß§Õ◊ °“√√°— …“∫”∫¥— ∑¥·∑π‰µ (renal replacement therapy, RRT) ‡π◊ËÕß®“°§«“¡·µ°µà“ß„π‡°≥±å°“√«‘π‘®©—¬¿“«–‰µ«“¬©—∫æ≈—π∑”„Àâ¡’§«“¡¬“°≈”∫“° „π°“√»÷°…“Õÿ∫—µ‘°“√≥å¢Õß‚√§ √«¡∂÷ß°“√‡ª√’¬∫‡∑’¬∫∂÷ßª√– ‘∑∏‘¿“æ¢Õß¡“µ√°“√„π°“√ªÑÕß°—π ·≈–√—°…“¿“«–π’È „πªí®®ÿ∫—π®÷ß‰¥â¡’°“√√‘‡√‘Ë¡°“√„™â‡°≥±å¡“µ√∞“π„π°“√«‘π‘®©—¬¿“«–‰µ«“¬©—∫ æ≈π— √«à ¡°π— ‡√¬’ °«“à RIFLE criteria1 (√ªŸ ∑Ë’ 1) ‚¥¬¡°’ “√„™∑â ßÈ— §“à GFR ·≈–ª√¡‘ “≥ª í “«–„π°“√®¥— °≈¡àÿ ºâŸ ªÉ«¬µ“¡§«“¡√ÿπ·√ß¢Õß‚√§ ·≈–„™â√–¬–‡«≈“¢Õß°“√ Ÿ≠‡ ’¬°“√∑”ß“π¢Õß‰µ„π°“√∫àß∫Õ°∂÷ß º≈≈æ— ∏¢å Õß‚√§ À≈ß— ®“°∑Ë’ RIFLE criteria ÕÕ°¡“ ‰¥¡â °’ “√π”‰ª„™»â °÷ …“„πºªâŸ «É ¬‰µ«“¬©∫— æ≈π— „πÀÕ ºŸâªÉ«¬Àπ—° ·≈–„πºâŸªÉ«¬∑’Ë‰¥â√—∫°“√ºà“µ—¥ coronary artery bypass surgery æ∫«à“ “¡“√∂∑’Ë®–„™â„π °“√∑”π“¬Õµ— √“°“√µ“¬ §«“¡®”‡ªπì ∑µË’ Õâ ß‰¥√â ∫— °“√√°— …“∫”∫¥— ∑¥·∑π‰µ ‰¥‡â ªπì Õ¬“à ß¥’ √ªŸ ∑Ë’ 1 · ¥ß‡°≥±°å “√«π‘ ®‘ ©¬— ¿“«–‰µ«“¬©∫— æ≈π— µ“¡ RIFLE criteria1

Dialysis in Acute Kidney Injury ≥—∞™—¬ »√ ’ «— ¥Ï‘ ¢®√ µ√’ ≥∏π“°≈ÿ 213 ≈“à ¥ÿ „πªï æ.». 2550 Molitoris2 ·≈–§≥– ‰¥‡â πÕ√“¬ß“π‡°≥±°å “√«π‘ ®‘ ©¬— ¿“«–‰µ«“¬©∫— æ≈π— ´ßË÷ ¥¥— ·ª≈ß¡“®“° RIFLE criteria (µ“√“ß∑Ë’ 1) „π modified RIFLE criteria „À¡πà È’ ‰¥‡â ª≈¬Ë’ π™ÕË◊ ¢Õß √–¬–µ“à ßÊ „π¿“«–‰µ«“¬©∫— æ≈π— ®“° Risk, Injury, Failure ‡ªπì stage 1, 2 ·≈– 3 µ“¡≈”¥∫— ·∑π ·≈–‰¥âµ—¥√–¬– Loss ·≈– end stage kidney disease ÕÕ°®“° criteria §ßµâÕß√Õ°“√»÷°…“∂÷ß ª√– ∑‘ ∏¿‘ “æ¢Õß criteria „À¡πà µÈ’ Õà ‰ª „πª®í ®∫ÿ π— “¡“√∂∑”°“√√°— …“∫”∫¥— ∑¥·∑π‰µ (renal replacement therapy) ‰¥Àâ ≈“¬«∏‘ ’ ‡™πà °“√øÕ°‰µ‚¥¬„™‡â §√Õ◊Ë ß‰µ‡∑¬’ ¡™π¥‘ intermittent hemodialysis (IHD), °“√∑” continuous renal replacement therapies (CRRT), °“√∑” sustained low efficiency dialysis (SLED) À√Õ◊ °“√øÕ°‰µ∑“ßºπß— Àπ“â ∑Õâ ß (acute peritoneal dialysis) ∂÷ß·¡â‡√“®–¡’«‘∏’°“√µà“ßÊ ¡“°¡“¬‡æ◊ËÕ™à«¬„π°“√∫”∫—¥∑¥·∑π‰µ ·µà„πªí®®ÿ∫—π Õµ— √“µ“¬„πºªâŸ «É ¬∑¡Ë’ ¿’ “«–‰µ«“¬©∫— æ≈π— ¬ß— §ßÕ¬„àŸ π√–¥∫— ∑ Ë’ ßŸ (¡“°°«“à √Õâ ¬≈– 50) „πºªŸâ «É ¬∑¡Ë’ Õ’ “°“√ √πÿ ·√ß3 2. ‡«≈“∑‡Ë’ √¡‘Ë µπâ ·≈–¢Õâ ∫ßà ™È’„π°“√√°— …“∫”∫¥— ∑¥·∑π‰µ ‡«≈“∑’Ë‡À¡“– ¡„π°“√‡√‘Ë¡µâπ √—°…“∫”∫—¥∑¥·∑π‰µ·°àºŸâªÉ«¬‰µ«“¬©—∫æ≈—π¡’§«“¡ ”§—≠ Õ¬“à ß¬ßË‘ °“√‡√¡Ë‘ °“√√°— …“∑¥·∑π∑‡Ë’ √«Á ‡°π‘ ‰ª Õ“® ßà º≈„Àºâ ªâŸ «É ¬∫“ß «à π‰¥√â ∫— °“√√°— …“‚¥¬‰¡®à ”‡ªπì ‡πÕ◊Ë ß®“°‰µ “¡“√∂øπóô µ«— ‰¥‡â Õß·≈–ºªâŸ «É ¬ «à πÀπß÷Ë µÕâ ß‡ ¬’Ë ß°∫— º≈¢“â ß‡§¬’ ß¢Õß°“√√°— …“∑¥·∑π‰µ‰¥·â °à ¿“«–§«“¡¥π— ‚≈Àµ‘ µË”´ß÷Ë ¡º’ ≈∑”„À°â “√øπóô µ«— ¢Õß‰µ™“â ≈ß°“√·¢ßÁ µ«— ¢Õß‡≈Õ◊ ¥º¥‘ ª°µ‘·≈–°“√‡ ¬’ ‡≈Õ◊ ¥ ¢Õâ ∫ßà ™‚È’ ¥¬∑«Ë— ‰ª„π°“√√°— …“∫”∫¥— ∑¥·∑π‰µ ‰¥·â °à 2.1) ¿“«– intractable volume overload 2.2) ¿“«– intractable hyperkalemia 2.3) ¿“«– intractable acidosis 2.4) ¿“«– uremia µ“√“ß∑Ë’ 1 Urine output criteria · ¥ß√“¬≈–‡Õ¬’ ¥¢Õß modified RIFLE criteria2 <0.5 ml/kg/h for >6 h Stage Serum creatinine criteria <0.5 ml/kg/h for >12 h 1 Increase of ≥ 26.4 µmol/l (0.3 mg/dl) OR to 150-200% of <0.3 ml/kg/h for 24 h baseline (1.5-2.0-fold) or anuria for 12 h 2 Increase to >200-300% of baseline (>2-3-fold) 3 Increase to >300% of baseline (>3-fold; or serum creatinin ≥354 µmol/l [4.0 mg/dl] with an acute rise of at least 44 µmol/l [0.5 mg/dl])

New Frontiers in Dialysis 214 ∏π‘µ ®√‘ π—π∑∏å «—™ √‘ ¿‘ “ ™“â ß»‘√‘°≈ÿ ™¬— ∏π—π¥“ µ√–°“√«π™‘ « —πµå ‡ÿ ¡∏°ÿ≈ 2.1) Intractable volume overload ¿“«–πÈ”‡°π‘ ‡ªπì ¢Õâ ∫ßà ™À’È πß÷Ë „π°“√√°— …“‚¥¬«∏‘ °’ “√∫”∫¥— ∑¥·∑π‰µ„π¿“«–‰µ«“¬©∫— æ≈π— «∏‘ ’ °“√∫”∫¥— ∑¥·∑π‰µµ“à ßÊ ¢“â ßµπâ ≈«â π‡ªπì «∏‘ °’ “√∑ Ë’ “¡“√∂≈¥ “√π”È ¿“¬„πÀ≈Õ¥‡≈Õ◊ ¥ (intravascular volume) ‰¥¥â ’ °“√„™â subjective criteria „π°“√‡√¡Ë‘ µπâ °“√√°— …“ª√–°Õ∫¥«â ¬ °“√ ≠Ÿ ‡ ¬’ §«“¡ “¡“√∂„π °“√∑”ß“π¢Õß√–∫∫À«— „®·≈–ªÕ¥ (cardiopulmonary function) ‚¥¬∑”„À‡â °¥‘ pulmonary vascular congestion À√◊Õ°“√À“¬¢Õß·º≈∑’Ë≈à“™â“®“°¿“«–∫«¡πÈ” (edema) „π¥â“π objective criteria “¡“√∂∑”°“√«—¥ ª√¡‘ “≥ “√πÈ”„π√“à ß°“¬‰¥Àâ ≈“¬«∏‘ ’ ‡™πà °“√«¥— central venous pressure (CVP) °“√«¥— pulmonary capillary wedge pressure (PCWP) ·µ¬à ß— ‰¡¡à §’ “à µ«— ‡≈¢∑·Ë’ ππà Õπ„π°“√µ¥— π‘ „®‡√¡Ë‘ µπâ °“√∫”∫¥— ∑¥·∑π‰µ ¬—ß§ß‡ªìπ∑’Ë∂°‡∂’¬ß°—π∂÷ß‡√◊ËÕß°“√„™â¬“¢—∫ªí  “«–°àÕπ∑’Ë®–‡√‘Ë¡°“√∫”∫—¥∑¥·∑π‰µ«à“ ‡À¡“– ¡À√Õ◊ ‰¡à Metha ·≈–§≥–4 ‰¥∑â ”°“√»°÷ …“ retrospective study „πºªâŸ «É ¬¿“«–«°‘ ƒµ∑‘ ¡Ë’ ‰’ µ«“¬ ©∫— æ≈π— ®”π«π 522 √“¬ √Õâ ¬≈– 59 ¢ÕßºªŸâ «É ¬°≈¡àÿ π‰È’ ¥√â ∫— °“√√°— …“¥«â ¬¬“¢∫— ª í “«– æ∫«“à Õµ— √“ °“√‡ ¬’ ™«’ µ‘ √«¡∑ßÈ— °“√‰¡øà πôó §π◊ ¢Õß°“√∑”ß“π¢Õß‰µ‡æ¡Ë‘ ¢πÈ÷ (odds ratio, 1.77; 95% confidence interval [CI] = 1.14-2.76) Õ¬“à ß‰√°µÁ “¡æ∫«“à Õ∫ÿ µ— °‘ “√≥∑å ‡Ë’ æ¡Ë‘ ¢πÈ÷ πÈ’ «à π¡“°‡°¥‘ „πºªâŸ «É ¬∑‰Ë’ ¡µà Õ∫ πÕßµÕà ¬“ ¢∫— ª í “«– ´ßË÷ ∫ßà ™«È’ “à Õ“®‡°¥‘ °“√‡≈Õ◊ °„™¬â “¢∫— ª í “«– ‡©æ“–„π°≈¡àÿ ºªŸâ «É ¬∑¡Ë’ Õ’ “°“√¢Õß‚√§√πÿ ·√ß Uchino ·≈–§≥–5 ‰¥∑â ”°“√«‡‘ §√“–À¢å Õâ ¡≈Ÿ ºªâŸ «É ¬ 1743 √“¬ ®“° 54 centers „π 23 ª√–‡∑» æ∫«“à Odds ratio ”À√∫— Õµ— √“°“√µ“¬ ¡— æπ— ∏°å ∫— °“√„™¬â “¢∫— ª í “«–‡æ¬’ ß 1.21 (95% CI = 0.96-1.50; P = 0.10) °“√»°÷ …“µÕà ¡“·∫∫ randomized controlled trial ‚¥¬„™¬â “¢∫— ª í “«–¢π“¥ ßŸ „πºªŸâ «É ¬‰µ«“¬ ©∫— æ≈π— °≈∫— ‰¡æà ∫«“à °“√„™¬â “¢∫— ª í “«–®–¡º’ ≈„π°“√‡æ¡‘Ë Õ∫ÿ µ— °‘ “√≥°å “√‡ ¬’ ™«’ µ‘ ‡¡Õ◊Ë ‡ª√¬’ ∫‡∑¬’ ∫°∫— ¬“À≈Õ°6 ‰¡‰à ¥∂â Õ◊ ‡ªπì ¢Õâ À“â ¡„π°“√∑¥≈Õß„™¬â “¢∫— ª í “«–°Õà π∑®’Ë –æ®‘ “√≥“°“√∫”∫¥— ∑¥·∑π‰µ·µà ∂“â À“°«“à ‡¡ÕË◊ ‰¥„â ™¬â “¢∫— ª í “«–„π¢π“¥∑ Ë’ ßŸ ·≈«â ‡™πà 160 ¡°. ¢Õß furosemide À√Õ◊ ‡∑¬’ ∫‡∑“à ·≈«â ‰¡à‰¥âº≈À√◊Õ¬—ß§ß¡’ªí  “«–ÕÕ°πâÕ¬Õ¬Ÿà Õ“®‰¡à¡’§«“¡®”‡ªìπµâÕß„™â¬“¢—∫ªí  “«–‡æ◊ËÕ™à«¬„π°“√¢—∫ ª í “«–Õ°’ µÕà ‰ª 2.2) Intractable hyperkalemia or rapid rising potassium levels ¿“«– hyperkalemia ¡º’ ≈µÕà §«“¡º¥‘ ª°µ¢‘ Õß§≈πË◊ ‰øø“Ñ À«— „® °“√√°— …“∑“ß¬“ ‡™πà °“√„™â intravenous calcium ‡æÕ◊Ë µ“â πƒ∑∏¢‘Ï Õß hyperkalemia ∑¡’Ë º’ ≈µÕà myocardial cell membrane °“√„™â intravenous insulin ·≈– intravenous À√Õ◊ inhaled β-adrenergic agonists ‡æÕË◊ π” potassium ‡¢“â ‡Ÿà ´≈≈å ∂Õ◊ °“√„™¬â “ ¢—∫ªí  “«–·≈–°“√„Àâ potassium binding resins ‡ªìπ°“√√—°…“‡∫◊ÈÕßµâπ ·µà„π°√≥’¿“«–‰µ«“¬©—∫ æ≈π— √πÿ ·√ß °“√„À¬â “¢∫— ª í “«–‡æÕË◊ ¢∫— potassium ÕÕ°®“°√“à ß°“¬¡°— ‰¡‰à ¥ºâ ≈ ∂ß÷ ·¡°â “√„Àâ potassium bindingresins “¡“√∂¢∫— potassiumÕÕ°‰¥â·µ°à ¡Á ¢’ Õâ ®”°¥— „π°√≥∑’ º’Ë ªâŸ «É ¬‰¥√â ∫— °“√º“à µ¥— ∑“ß™Õà ß∑Õâ ßÀ√Õ◊ ileus À√Õ◊ bowel ischemia ∂Õ◊ °“√∫”∫¥— ∑¥·∑π‰µ‡ªπì ¢Õâ ∫ßà ™„È’ π°“√√°— …“ºªŸâ «É ¬‰µ«“¬©∫— æ≈π— ∑¡Ë’ ¿’ “«– intractable hyperkalemia ´ßË÷ À“°‰¡‰à ¥√â ∫— °“√√°— …“Õ“®∑”„Àºâ ªŸâ «É ¬‡ ¬’ ™«’ µ‘ ©∫— æ≈π— ‰¥â

Dialysis in Acute Kidney Injury ≥—∞™—¬ »√’ « — ¥Ï‘ ¢®√ µ√’ ≥∏π“°≈ÿ 215 °“√∑” dialysis ‡ªπì «∏‘ °’ “√∑™Ë’ «à ¬≈¥√–¥∫— potassium „π‡≈Õ◊ ¥‰¥‡â √«Á ∑ Ë’ ¥ÿ ·µ‡à πÕË◊ ß¥«â ¬§«“¡ À≈“°À≈“¬¢Õß°“√»°÷ …“ ·≈–°“√„™‡â ∑§π§‘ „π°“√∑” dialysis „À¡Êà ∑”„À‡â ªπì °“√¬“°∑®Ë’ –ª√–¡“≥ °“√¢®¥— potassium µÕà °“√∑” dialysis ÀπßË÷ §√ßÈ— 7 Õµ— √“°“√¢®¥— potassium ‚¥¬ peritoneal dialysis ·≈– CRRT®–µË”°«“à °“√∑”hemodialysis¥ß— ππ—È „π°√≥∑’ ¡’Ë √’ –¥∫— ´√’ ¡—Ë potassium ßŸ ¡“°·≈–µÕâ ß°“√≈¥√–¥∫— ´√’ ¡—Ë potassium ≈ßÕ¬“à ß√«¥‡√«Á §«√‡≈Õ◊ °„™°â “√∑” hemodialysis °Õà π‡ªπì Õπ— ¥∫— ·√° ·µ‡à πÕË◊ ß®“° “¡“√∂∑” peritoneal dialysis ·≈– CRRT „π√–¬–‡«≈“∑πË’ “π°«“à ∑”„À§â «∫§¡ÿ √–¥∫— ´√’ ¡Ë— potassium §ß∑·Ë’ ≈–≈¥ ¿“«– post dialysis potassium rebound ‡™πà ‡¥¬’ «°∫— volume status ‰¡¡à µ’ «— ‡≈¢∑·Ë’ ππà Õπ«“à √–¥∫— ´√’ ¡Ë— potassium ‡∑“à „¥∑§Ë’ «√®–‡√¡Ë‘ RRT ¿“«– myocardial toxicity ®“° heperkalemia ¡°— ‰¡‡à °¥‘ ¢π÷È ‡¡ÕË◊ √–¥∫— ´√’ ¡Ë— potassium µ”Ë °«“à 6.5 mEql/≈µ‘ √7 ¥ß— ππÈ— °“√µ¥— π‘ „®∑®Ë’ –‡√¡Ë‘ µπâ °“√∑” dialysis ¢πÈ÷ Õ¬°àŸ ∫— √–¥∫— ·≈–Õµ— √“°“√‡æ¡Ë‘ ¢πÈ÷ ¢Õß√–¥∫— ´√’ ¡Ë— potassium ¿“«–‚¥¬√«¡¢ÕßºªŸâ «É ¬ ·≈–º≈¢Õß°“√„™¬â “„π√°— …“ 2.3) ¿“«– intractable acidosis ¬ß— §ß‰¡¡à ¢’ Õâ √ªÿ ∑™Ë’ ¥— ‡®π∂ß÷ ∫∑∫“∑¢Õß°“√„™¥â “à ß„π°“√√°— …“¿“«– metabolic acidosis ‚¥¬ ‡©æ“–Õ¬“à ß¬ß‘Ë lactic acidosis8,9 °“√„™â RRT ‡ªπì Õ°’ ∑“ß‡≈Õ◊ °Àπß÷Ë ∑„’Ë ™·â ∑π¥“à ß„π°“√√°— …“¿“«– metabolic acidosis ‡æÕË◊ À≈°’ ‡≈¬Ë’ ßº≈‡ ¬’ ∑ÕË’ “®‡°¥‘ ®“°°“√„™¥â “à ß ‡™πà ¿“«– volume overload ·≈– hypernatremia ∂ß÷ ·¡«â “à ¿“«– progressive metabolic acidosis ‡ªπì ¢Õâ ∫ßà ™¢È’ Õß°“√∑” RRT ·µ¬à ß— ‰¡¡à °’ “√»°÷ …“∑∫Ë’ Õ°‰¥â ™¥— ‡®π«“à √–¥∫— pH À√Õ◊ serum bicarbonate ‡∑“à „¥∑§Ë’ «√®–‡√¡Ë‘ ∑” RRT ∑®Ë’ –™«à ¬„Àºâ ªâŸ «É ¬¥¢’ πÈ÷ ‡™πà °π— 2.4) ¿“«– uremia (pericarditis, neuropathy, unexplained decline in mental status, etc) Õ“°“√·≈–Õ“°“√· ¥ß¢Õß¿“«– uremia ‡ªπì ¢Õâ ∫ßà ™™È’ ¥— ‡®π„π°“√∑” RRT „πºªâŸ «É ¬¿“«–‰µ «“¬©∫— æ≈π— Õ“°“√· ¥ß‡√¡Ë‘ µπâ ¢Õß¿“«– uremia ‡™πà Õ“°“√§≈πË◊ ‰ Õâ “‡®¬’ π ‡∫ÕË◊ Õ“À“√ Õ“°“√§π— ¡°— ‰¡®à ”‡æ“–·≈–¬“°∑®’Ë –·¬°ÕÕ°®“°¿“«–Õπ◊Ë Ê „πºªâŸ «É ¬∑Õ’Ë ¬„Ÿà π¢π—È «°‘ ƒµ‘ °“√‡ª≈¬’Ë π·ª≈ß∑“ß mental status Õ“®∫ßà ∫Õ°∂ß÷ ¿“«– uremic encephalopathy ·µ‡à ªπì °“√¬“°∑®Ë’ –·¬°ÕÕ°®“°¿“«– delirium ¿“«– uremic pericarditis ‡ªìπ¿“«–·∑√°´âÕπ√–¬–∑â“¬ ·µàµâÕß°“√°“√√—°…“∑’Ë‡√àß¥à«π ‡πÕË◊ ß®“°¡Õ’ µ— √“‡ ¬Ë’ ß ßŸ µÕà °“√‡°¥‘ intrapericardial hemorrhage ·≈– cardiac tampanade ‰¥¡â °’ “√·π–π”°“√∑” RRT °Õà π∑®Ë’ –¡Õ’ “°“√· ¥ß¢Õß¿“«– uremia (prophylactic dialysis) ¡“µßÈ— ·µà æ.». 2503 ‚¥¬ Teschan ·≈–§≥–10 ·µ®à π°√–∑ßË— ª®í ®∫ÿ π— ¬ß— ‰¡¡à ¢’ Õâ µ°≈ß∑·Ë’ ππà Õπ«“à §«√®– ‡√¡Ë‘ RRT ‡¡ÕË◊ „À√à °“√»°÷ …“∑‰’Ë ¥∂â °Ÿ µæ’ ¡‘ æ„å π™«à ßªï æ.». 2503 ∂ß÷ æ.». 2513 æ∫«“à °“√‡√¡‘Ë °“√√°— …“ hemodialysis ∑’Ë√–¥—∫ BUN 90-100 ¡°/¥≈. „Àâº≈°“√√—°…“¥’°«à“°“√√Õ®π°√–∑—Ëß√–¥—∫ BUN ¡“°°«à“ 150-200 ¡°/¥≈. 11-14 Õ¬“à ß‰√°µÁ “¡°“√»°÷ …“ prospective study ∑‰Ë’ ¥√â “¬ß“π„πªæï .». 2529 ‰¡æà ∫«“à ¡§’ «“¡·µ° µ“à ß°π— „πÕµ— √“°“√√Õ¥™«’ µ‘ √–À«“à ßº∑âŸ ‡Ë’ √¡Ë‘ ∑” dialysis ‡¡ÕË◊ √–¥∫— BUN 60 ¡°/¥≈. °∫— º∑âŸ ‡Ë’ √¡Ë‘ ∑” ‡¡ÕË◊ ¡’

New Frontiers in Dialysis 216 ∏π‘µ ®√‘ π—π∑å∏«™— ‘√‘¿“ ™â“ß»√‘ ‘°≈ÿ ™¬— ∏π—π¥“ µ√–°“√«π™‘ « —πµå ÿ‡¡∏°≈ÿ √–¥∫— BUN 100 ¡°/¥≈.15 °“√»°÷ …“„πª®í ®∫ÿ π— ∑‰Ë’ ¥»â °÷ …“§«“¡ ¡— æπ— ∏√å –À«“à ß√–¬–‡«≈“‡√¡Ë‘ µπâ ∑∑Ë’ ” CRRT °∫— º≈∑‰Ë’ ¥â ∑“ß§≈π‘ °‘ æ∫«“à º≈°“√√°— …“¥¢’ πÈ÷ √«¡∑ßÈ— Õµ— √“°“√√Õ¥™«’ µ‘ ∑¡Ë’ “°°«“à „π°≈¡àÿ ∑∑Ë’ ” early dialysis 16-17 ≈“à ¥ÿ ®“°¢Õâ ¡≈Ÿ ¢Õß PICARD study (The Program to Improve Care in Acute Renal Disease )18 ´ßË÷ ‡ªπì retrospective study „πºªâŸ «É ¬ 243 √“¬∑¡Ë’ ¿’ “«–‰µ«“¬©∫— æ≈π— ‚¥¬·∫ßà ºªâŸ «É ¬‡ªπì 2 °≈¡àÿ °≈¡àÿ ·√°§Õ◊ °≈¡àÿ ∑‡Ë’ √¡Ë‘ ∑” dialysis ∑’√Ë –¥∫— BUN > 76 ¡°./¥≈. °≈¡àÿ ∑Ë’ 2 ‡√¡Ë‘ ∑” dialysis ∑√Ë’ –¥∫— BUN ≤ 76 ¡°./ ¥≈. æ∫«“à °≈¡àÿ ∑Ë’ 1 ¡§’ “à Õµ— √“°“√‡ ¬’ ™«’ µ‘ ∑Ë’ 60 «π— ßŸ °«“à °≈¡àÿ ∑Ë’ 2 Õ¬“à ß¡π’ ¬— ”§≠— ∑“ß ∂µ‘ ‘ (RR 1.97, 95% CI = 1.21-3.2) ∂÷ß·¡â«à“°“√»÷°…“π’È®–æ∫«à“Õÿ∫—µ‘°“√≥å¢Õß°“√‡ ’¬™’«‘µ®–≈¥≈ß„πºâŸªÉ«¬∑’Ë∑”°“√øÕ°‰µ ·µà‡π‘ËπÊ ·µà°“√»÷°…“π’È¡’¢âÕ®”°—¥‡π◊ËÕß®“°‡ªìπ°“√»÷°…“∑’Ë‰¡à‰¥â¡’°“√ ÿà¡·∫àß°≈ÿà¡ ∑”„Àâ¡’‚Õ°“ ‡ªìπ ‰ª‰¥∑â ·Ë’ µ≈à –°≈¡àÿ ¡¢’ Õâ ∫ßà ™¢È’ Õß°“√øÕ°‰µ∑·Ë’ µ°µ“à ß°π— ·≈–‰¡‰à ¥«â ‡‘ §√“–À°å ≈¡àÿ ºªŸâ «É ¬ acute kidney injury ∑‰’Ë ¡‰à ¥√â ∫— °“√øÕ°‰µ‡πÕ◊Ë ß®“°°“√∑”ß“π¢Õß‰µ¥¢’ π÷È À√Õ◊ ºªŸâ «É ¬‡ ¬’ ™«’ µ‘ °Õà π ‚¥¬ √ÿª ªí®®ÿ∫—π¬—ß¡’¢âÕ¡Ÿ≈‰¡à‡æ’¬ßæÕ∑’Ë∫àß∫Õ°∂÷ß‡«≈“∑’Ë‡À¡“– ¡„π°“√‡√‘Ë¡°“√√—°…“ ∑¥·∑π‰µ„πºªŸâ «É ¬‰µ«“¬©∫— æ≈π— ¢Õâ ¡≈Ÿ «à π„À≠´à ß÷Ë ‡ªπì retrospective study π∫— ππÿ °“√∑” prophylactic dialysis °àÕπ∑’ËºâŸªÉ«¬®–¡’Õ“°“√ uremia ‚¥¬Õ“®‡√‘Ë¡∑”‡¡◊ËÕ√–¥—∫ BUN ª√–¡“≥ 80-100 ¡°./¥≈. §ß®–µÕâ ß√Õ°“√»°÷ …“¢π“¥„À≠∑à ‡Ë’ ªπì multicenter randomized controlled study µÕà ‰ª ‰¥â √ÿª°“√»÷°…“‡°’Ë¬«°—∫‡«≈“∑’Ë‡À¡“– ¡„π°“√‡√‘Ë¡∫”∫—¥√—°…“∑¥·∑π‰µ„π¿“«–‰µ«“¬ ©∫— æ≈π— ‰«„â πµ“√“ß∑Ë’ 2 µ“√“ß∑’Ë 2 √ªÿ °“√»°÷ …“‡°¬’Ë «°∫— ‡«≈“∑‡’Ë À¡“– ¡„π°“√‡√¡‘Ë ∫”∫¥— √°— …“∑¥·∑π‰µ„π¿“«–‰µ«“¬©∫— æ≈π— Author æ.». Mode of RRT Study design N BUN at initiation of RRT Survival (mg/dl) (%) Yes Parsons11 2504 IHD Retrospective 33 > 200 vs 120-150 Yes Yes Fischer12 2509 IHD Retrospective 162 200 vs 150 Yes No Kleinknecht13 2515 IHD Retrospective 500 > 163 vs < 93 Yes No Conger14 2518 IHD Prospective 18 150 vs 70 Yes Gillum15 2529 IHD Prospective 34 150 vs 60 Gettings16 2542 CRRT Retrospective 100 94 ± 28 vs 42 ± 13 Bouman17 2545 CRRT Prospective 106 105 vs 47 Liu18 2549 IHD Retrospective 243 >76 vs > 76 Yes: early dialysis better than late dialysis No: late dialysis better than early dialysis IHD: intermittent hemodialysis

Dialysis in Acute Kidney Injury ≥—∞™—¬ »√’ « — ¥Ï‘ ¢®√ µ’√≥∏π“°≈ÿ 217 3. ™π¥‘ °“√√°— …“∫”∫¥— ∑¥·∑π‰µ„π¿“«–‰µ«“¬©∫— æ≈π— 3.1) ™π¥‘ ·≈–°“√‡≈Õ◊ °«∏‘ °’ “√√°— …“∫”∫¥— ∑¥·∑π‰µ “¡“√∂·∫ßà °“√√°— …“∫”∫¥— ∑¥·∑π‰µ„πºªâŸ «É ¬‰µ«“¬©∫— æ≈π— ∑¡’Ë „’ ™Õâ ¬„àŸ πª®í ®∫ÿ π— ‰¥‡â ªπì °≈¡ÿà „À≠Êà ¥ß— π§È’ Õ◊ (√ªŸ ∑Ë’ 4) 1. °“√√—°…“∑¥·∑π‰µ·∫∫‰¡àµàÕ‡π◊ËÕß (intermittent) §◊Õ°“√√—°…“∑’Ë¡’™à«ß‡«≈“À¬ÿ¥æ—°„π ·µ≈à –«π— ‰¡‰à ¥∑â ”°“√√°— …“µÕà ‡πÕË◊ ßµ≈Õ¥ 24 ™¡. ´ßË÷ Õ“®∑”„πÀÕâ ß‰µ‡∑¬’ ¡À√Õ◊ ÀÕºªŸâ «É ¬«°‘ ƒµ°‘ ‰Á ¥â - Intermittent hemodialysis (IHD) §◊Õ°“√∑” hemodialysis ∑’Ë„™âÕÿª°√≥å ·≈–¡’«‘∏’°“√ ‡À¡◊Õπ°—∫°“√∑” hemodialysis „πºâŸªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß „™â√–¬–‡«≈“ª√–¡“≥ 4-6 ™¡./§√—Èß ·≈–¡—°∑” „πÀÕâ ß‰µ‡∑¬’ ¡ ‚¥¬Õ“»¬— ·æ∑¬·å ≈–æ¬“∫“≈‰µ‡∑¬’ ¡‡ªπì º¥Ÿâ ·Ÿ ≈ - Sustained low-efficiency dialysis (SLED) §Õ◊ °“√√°— …“∑¡Ë’ ≈’ °— …≥–‡ªπì ≈°Ÿ º ¡√–À«“à ß IHD °∫— CRRT °≈“à «§Õ◊ ®–„™Õâ ªÿ °√≥·å ≈–«∏‘ °’ “√‡À¡Õ◊ π IHD ·µ≈à ¥Õµ— √“°“√‰À≈¢Õß‡≈Õ◊ ¥·≈–πÈ”¬“‰µ‡∑¬’ ¡≈ß ·≈–‡æ¡Ë‘ √–¬–‡«≈“„π°“√∑” dialysis ‡ªπì ‡«≈“ 8-12 ™¡. ‚¥¬Õ“®∑”„π‡«≈“°≈“ß§π◊ ‰¥â ‚¥¬∑«Ë— ‰ª¡°— ∑”„πÀÕºªŸâ «É ¬«°‘ ƒµ‘ √ªŸ ∑Ë’ 4 · ¥ß™π¥‘ ¢Õß«∏‘ °’ “√√°— …“∫”∫¥— ∑¥·∑π‰µ (Renal replacement modalities for acute renal failure). CRRT, continuous renal replacement therapy; CAVH, continuous arteriovenus hemofiltration; CAVHD, continuous arteriovenous hemo-dialysis; CAVHDF, continuous arteriovenous hemodiafiltration; CVVH, continuous venovenous hemofiltration; CVVHD, continuous venovenous hemodialysis; CVVHDF, continuous venovenous hemodiafiltration; EDD, extended daily dialysis; IHD, intermittent hemodialysis; PD, peritoneal dialysis; RRT, renal replacement therapy; SCUF, slow continuous ultrafiltration; SLED, sustained low-efficiency dialysis.

New Frontiers in Dialysis 218 ∏π‘µ ®‘√ππ— ∑∏å «—™ ‘√‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå ‡ÿ ¡∏°≈ÿ 2. °“√√—°…“∑¥·∑π‰µ·∫∫µàÕ‡π◊ËÕß (continuous) §◊Õ°“√√—°…“∑’Ë∑”µàÕ‡π◊ËÕßµ≈Õ¥ 24 ™¡.‡ªìπ‡«≈“À≈“¬«—π ‚¥¬∑”°“√√—°…“„πÀÕºâŸªÉ«¬«‘°ƒµ‘ Õ¬àŸ„π§«“¡¥Ÿ·≈¢Õß‡®â“Àπâ“∑’Ë„πÀÕºŸâªÉ«¬ «‘°ƒµ‘‚¥¬¡’·æ∑¬åÀ√◊Õæ¬“∫“≈‰µ‡∑’¬¡„Àâ§”ª√÷°…“ ‚¥¬∏√√¡™“µ‘¢Õß°“√√—°…“·∫∫µàÕ‡π◊ËÕß´÷Ëß¡’°“√ ·≈°‡ª≈’Ë¬π “√‡°‘¥¢÷ÈπÕ¬à“ß™â“Ê ·≈–µàÕ‡π◊ËÕß ¥—ßπ—ÈπºâŸªÉ«¬®–¡’§«“¡§ß∑’Ë∑“ß hemodynamics ¡¥ÿ≈ π”È ·≈–‡¡µ“∫Õ≈´‘ ¡÷ ¡“°°«“à IHD - Continuous renal replacement therapy (CRRT) ‡ªìπ°“√√—°…“∑¥·∑π‰µ∑’Ë¡’°“√æ—≤π“ Õ¬à“ßµàÕ‡π◊ËÕß ¡’§«“¡π‘¬¡‡æ‘Ë¡ Ÿß¢÷Èπ·≈–¡’°“√»÷°…“¡“°¢÷Èπ‡√◊ËÕ¬Ê ‡π◊ËÕß®“°‡™◊ËÕ«à“¡’ª√– ‘∑∏‘¿“æ„π °“√°”®¥— ¢Õß‡ ¬’ ‡∑¬’ ∫‡∑“à À√Õ◊ ¥°’ «“à IHD ·≈–¡§’ «“¡§ß∑∑Ë’ “ß¥“â π hemodynamics ¡“°°«“à IHD ‰¥â √ÿª¢âÕ¥’·≈–¢âÕ¥âÕ¬¢Õß CRRT ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ IHD ‰«â„πµ“√“ß∑’Ë 3 ®–‰¥â°≈à“«∂÷ß√“¬≈–‡Õ’¬¥ ¢Õß°“√∑” CRRT „πÀ«— ¢Õâ ∂¥— ‰ª - Peritoneal dialysis (PD) ‡¥‘¡π‘¬¡„™â PD ‡ªìπ°“√√—°…“∑¥·∑π‰µ„πºŸâªÉ«¬∑’Ë¡’¿“«–∑“ß hemodynamics ‰¡§à ß∑Ë’ ·µÀà ≈ß— ®“°∑¡Ë’ °’ “√æ≤— π“ CRRT ¢πÈ÷ Õ¬“à ßµÕà ‡πÕË◊ ß °“√„™â PD ®ß÷ ≈¥≈ßÕ¬“à ß¡“° “‡ÀµÀÿ ≈°— π“à ®–‡°¥‘ ®“°§«“¡‡™Õ◊Ë ∑«’Ë “à ª√– ∑‘ ∏¿‘ “æ„π°“√°”®¥— ¢Õß‡ ¬’ ¢Õß PD ¥Õâ ¬°«“à IHD ·≈– CRRT µ“√“ß∑’Ë 3 √ªÿ ¢Õâ ¥·’ ≈–¢Õâ ¥Õâ ¬¢Õß°“√∑” intermittent hemodialysis ‡¡ÕË◊ ‡∑¬’ ∫°∫— continuous renal replacement therapy Intermittent hemodialysis Continuous renal replacement therapy ¢Õâ ¥’ - §«“¡‡ ¬Ë’ ßµÕà °“√µ°‡≈Õ◊ ¥µ”Ë °«“à - Hemodynamic §ß∑°Ë’ «“à - ¡‡’ «≈“ ”À√∫— °“√√°— …“À√Õ◊ °“√«π‘ ®‘ ©¬— ÕπË◊ Ê - ¡¿’ “«– cardiac arrhythmia πÕâ ¬°«“à - ‡À¡“–°∫— ¿“«– hyperkalemia ∑√Ë’ πÿ ·√ß - ª√–§∫— ª√–§Õß¿“«–∑“ß‚¿™π“°“√‰¥â - §“à „™®â “à ¬µ”Ë °«“à ¥°’ «“à - °“√·≈°‡ª≈¬Ë’ π°“ä ´„πªÕ¥¥°’ «“à - §«∫§¡ÿ ¡¥≈ÿ π”È ¥°’ «“à - §«∫§¡ÿ ¿“«–∑“ß™«’ ‡§¡¥’ °’ «“à ¢Õâ ¥Õâ ¬ - µÕâ ß„™‡â ®“â Àπ“â ∑æË’ ¬“∫“≈‰µ‡∑¬’ ¡ - §«“¡‡ ¬Ë’ ßµÕà °“√µ°‡≈Õ◊ ¥ ßŸ °«“à - §«∫§¡ÿ hemodynamics ‰¥¬â “°°«“à - °“√‡§≈ÕË◊ π¬“â ¬ºªâŸ «É ¬‰¡ à –¥«° - ¢π“¥°“√∑” dialysis ‰¡‡à æ¬’ ßæÕ - ª≠í À“‡°¬Ë’ «°∫— µ«— °√Õß - §«∫§¡ÿ ª√¡‘ “≥ “√π”È ‰¥‰â ¡‡à æ¬’ ßæÕ (·µ° ‡°¥‘ ≈¡Ë‘ ‡≈Õ◊ ¥) - ª√–§∫— ª√–§Õß¿“«–∑“ß‚¿™π“°“√‰¥â - §“à „™®â “à ¬ ßŸ °«“à ‰¡‡à æ¬’ ßæÕ - ‰¡‡à À¡“–°∫— ºªâŸ «É ¬∑¡Ë’ §’ «“¡¥π— „π °–‚À≈°»√’ …– ßŸ - ‰¡ à “¡“√∂°”®¥— cytokines - Õ“®‡°¥‘ °“√°√–µπâÿ √–∫∫ complement ®“°°“√„™µâ «— °√Õß∑‡Ë’ ªπì bio-incompatibility

Dialysis in Acute Kidney Injury ≥∞— ™—¬ »√’ « — ¥‘Ï ¢®√ µ’√≥∏π“°ÿ≈ 219 ‰¥ â √ªÿ ™π¥‘ ¢Õß°“√√°— …“∫”∫¥— ∑¥·∑π‰µ„π√ªŸ ∑Ë’ 4 °“√‡≈Õ◊ °«∏‘ °’ “√∫”∫¥— √°— …“∑¥·∑π‰µ ‚¥¬∑«—Ë ‰ª·æ∑¬¡å °— Õ“»¬— ≈°— …≥–∑“ß§≈π‘ °‘ ¢ÕßºªâŸ «É ¬‡ªπì ª®í ®¬— À≈°— ∑„’Ë ™„â π°“√µ¥— π‘ „®‡≈Õ◊ ° ª√–‡¿∑¢Õß°“√√°— …“∑¥·∑π‰µ „πºªŸâ «É ¬∑¡’Ë ¿’ “«– hemodynamics ‰¡§à ß∑’Ë ·æ∑¬¡å °— æ®‘ “√≥“‡≈Õ◊ ° CRRT, SLED À√Õ◊ PD ‡πÕË◊ ß®“°ºªâŸ «É ¬¡°— ∑πµÕà °“√√°— …“‰¥¥â °’ «“à IHD «à πºªâŸ «É ¬∑ÕË’ ¬„Ÿà π√–¬– hypercatabolism ®–¡’°“√ ≈“¬‚ª√µ’π¡“°¢÷Èπ ¡’°“√ – ¡¢Õß‡ ’¬„π√à“ß°“¬Õ¬à“ß√«¥‡√Á« ºŸâªÉ«¬¡’§«“¡µâÕß°“√√—°…“ ª√–§∫— ª√–§Õß∑“ß‚¿™π“°“√¡“° °“√√°— …“∑‡’Ë À¡“– ¡„πºªâŸ «É ¬°≈¡ÿà ππ’È “à ®–‡ªπì CRRT, SLED À√Õ◊ IHD ‡πÕ◊Ë ß®“°¡ª’ √– ∑‘ ∏¿‘ “æ„π°“√§«∫§¡ÿ ¡¥≈ÿ πÈ”·≈–‡¡µ“∫Õ≈´‘ ¡÷ ·≈– “¡“√∂°”®¥— ¢Õß‡ ¬’ ‰¥¥â °’ «“à PD πÕ°®“°ª®í ®¬— ¥ß— °≈“à « ª®í ®¬— ∑“ß¥“â πª√– ∫°“√≥¢å Õß·µ≈à – ∂“∫π— ·≈–§“à „™®â “à ¬ √«¡∂ß÷ ¢Õâ ∫ßà ™Õ’È π◊Ë Ê °Á‡ªìπªí®®—¬ ”§—≠∑’Ë„™â„π°“√µ—¥ ‘π„®‡≈◊Õ°«‘∏’°“√√—°…“∑¥·∑π‰µ ‰¥â √ÿª°“√‡≈◊Õ°«‘∏’°“√∫”∫—¥√—°…“ ∑¥·∑π‰µ‰«„â πµ“√“ß∑Ë’ 4 À≈°— °“√·≈–√“¬≈–‡Õ¬’ ¥¢Õß«∏‘ °’ “√∫”∫¥— √°— …“∑¥·∑π‰µ·∫∫µÕà ‡πÕË◊ ß™π¥‘ µ“à ßÊ - Slow Continuous Ultrafiltration (SCUF) Slow continuous ultrafiltration (SCUF) ∂°Ÿ ÕÕ°·∫∫¡“‡æÕË◊ „™°â ”®¥— π”È ÕÕ°ª√–¡“≥ 6-7 ≈µ‘ √ µÕà «π— ‚¥¬‰¡µà Õâ ß‡µ¡‘ replacement fluid (√ªŸ ∑Ë’ 5) πÕ°®“° hyperalimentation ¥«â ¬‡∑§π§‘ πÈ’ solute ®– ∂°Ÿ °”®¥— ÕÕ°Õ¬“à ß™“â Ê ‡πÕË◊ ß®“°°“√∑¡Ë’ ’ low ultrafiltration ·≈– lack of dialysis ´ßË÷ ª√¡‘ “≥°“√¢®¥— ¢Õß urea ·≈– small solute ®–‡∑“à °∫— ultrafiltration rate ‡æ¬’ ß 4-5 ¡≈./π“∑’ ¥ß— ππÈ— SCUF ®ß÷ ‡ªπì «∏‘ ∑’ ‰Ë’ ¡à µ“√“ß∑Ë’ 4 √ªÿ °“√‡≈Õ◊ °«∏‘ °’ “√∫”∫¥— √°— …“∑¥·∑π‰µ Primary therapeutic goal Clinical condition Renal replacement therapy Solute removal Stable, hypercatabolic IHD Unstable, hypercatabolic CAVHD, CVVHD, CVVH, SCUF+IHD Unstable, non-hypercatabolic CAVH, CVVH, SCUF+IHD, CEPD Fluid removal Stable IIUF Unstable IIUF, SCUF Solute and fluid removal Stable IHD Unstable CAVHD, CVVH, CVVHD, CAVH+HD, IIUF+IHD Blood detoxification Unstable CVVH, CVVHD, CAVH, TPE?? IHD: intermittent hemodialysis, CAVHD: continue arteriovenous hemodialysis, CAVH: continuous venovenous hemodialysis, CVVH: continue venovenous hemofiltration, TPE: therapeutic plamaexchange, IIUF: intermittent isolated ultrafiltration

New Frontiers in Dialysis 220 ∏π‘µ ®√‘ ππ— ∑∏å «™— √‘ ‘¿“ ™“â ß»√‘ ‘°ÿ≈™—¬ ∏π—π¥“ µ√–°“√«π™‘ « —πµå ‡ÿ ¡∏°≈ÿ ‡À¡“–∑®Ë’ –∑”„πºªâŸ «É ¬∑¡Ë’ ¿’ “«– uremia À√Õ◊ hyperkalemia ‡°¥‘ ¢πÈ÷ ·≈«â - Continuous Venovenous Hemofiltration (CVVH) À≈°— °“√∑” CVVH (√ªŸ ∑Ë’ 6) ‡À¡Õ◊ π°∫— °“√∑” continuous arteriovenous hemofiltration (CAVH) ¬°‡«πâ µÕâ ß„™â extracorporeal blood pump ‡æÕË◊ §«∫§¡ÿ flow rate „π√–∫∫ °“√∑¡Ë’ ’ blood pump ∑”„Àâ Õµ— √“°“√‰À≈¢Õß‡≈Õ◊ ¥∑‰’Ë ¥¡â §’ “à §ß∑1’Ë 9 ‡™πà ∂“â ºªŸâ «É ¬¡√’ –¥∫— hematrocrit ª√–¡“≥ 33% plasma flow rate 167 ¡≈./π“∑’ ∑§’Ë “à filtration fraction √Õâ ¬≈– 10 ®–¡º’ ≈„À§â “à UFR ‡∑“à °∫— 16.7 ¡≈./π“∑’ À√Õ◊ ª√–¡“≥ 1 ≈µ‘ √/™¡. À√Õ◊ 24 ≈µ‘ √/«π— (¡“°°«“à SCUF ª√–¡“≥ 4 ‡∑“à ) ´ß÷Ë ºªŸâ «É ¬®”‡ªπì ®–µÕâ ß‰¥√â ∫— fluid replacement ´ßË÷ ∂“â À“°‡√“„À‡â ªπì predilution ®–∑”„Àâ urea clearance ≈¥≈ßÕ°’ ª√–¡“≥√Õâ ¬≈– 15 ‚¥¬∑«Ë— ‰ª water exchange ª√–¡“≥ 20-30 ≈µ‘ √/«π— ®–‡æ¬’ ßæÕ ·µ∂à “â ºªŸâ «É ¬¡¿’ “«– hypercatabolism ∑”„À¡â ’ urea load ‡æ¡Ë‘ ¢πÈ÷ ·≈–Õ“®®–µÕâ ß°“√ water exchange ‡æ¡Ë‘ ‡ªπì 40 ≈µ‘ √/«π— ®“°°“√∑‡Ë’ √“ “¡“√∂µßÈ— §“à blood flow rate ·≈– “¡“√∂∑”„À¡â °’ “√‡æ¡Ë‘ ultrafiltration rate ∑”„Àâπ‘¬¡∑” CVVH ¡“°°«à“ CAVH ‡¡◊ËÕµâÕß°“√°“√¢®—¥ solute ‡ªìπ ”§—≠ ‚¥¬‡©æ“–ºâŸªÉ«¬∑’Ë¡’ hypercatabolic stage À√Õ◊ ¡√’ –¥∫— BUN ∑ Ë’ ßŸ √ªŸ ∑’Ë 5 · ¥ßÀ≈°— °“√¢Õß slow continuous ultrafiltration (SCUF). QB, blood flow rate; Quf , ultrafiltration rate √ªŸ ∑Ë’ 6 · ¥ßÀ≈°— °“√¢Õß continuous venovenous hemofiltration. QB, blood flow rate; QE, effluent flow rate; QR, replacement fluid flow rate; QUF, ultrafiltration flow rate

Dialysis in Acute Kidney Injury ≥—∞™¬— »√’ « — ¥Ï‘ ¢®√ µ√’ ≥∏π“°≈ÿ 221 - Continuous Venovenous Hemodialysis (CVVHD) CVVHD µ“à ß®“° CVVH µ√ß∑Ë’ CVVHD ®–¡’ dialysate ‰À≈º“à πµ«— °√Õß¥“â π dialysate part ´ßË÷ ®– ∑”„À‡â °¥‘ °“√·æ√¢à Õß “√À√◊Õ¢Õß‡ ¬’ µà“ßÊºà“π dialysis membrane §“à ª√– ∑‘ ∏¿‘ “æ¢Õß CVVHD ®– ¢πÈ÷ Õ¬°àŸ ∫— blood flow rate (Qb) Õ¬“à ß‰√°µÁ “¡ §“à UFR ¢Õß°“√∑” CVVHD ®–‰¡ à ßŸ ‡À¡Õ◊ π°∫— °“√∑” CVVH ¥ß— ππÈ— °“√¢®¥— π”È „π√“à ß°“¬¢ÕßºªŸâ «É ¬®–µ”Ë °«“à °“√∑” CVVH „π¢≥–∑®Ë’ –‰¥â solute clearance ∑¡’Ë “°°«“à Clearance rates ¢Õß CVVHD ¢πÈ÷ Õ¬°àŸ ∫— blood flow ·≈– dialysate flow rate ´ßË÷ ®–‡ªπì µ«— ∫Õ°§«“¡‡¢¡â ¢πâ ∑·Ë’ µ°µ“à ß°π— ¢Õß “√√–À«“à ß 2 compartment ∑Ë’ Qb ¡“°°«“à 80 ¡≈./π“∑’ §«“¡‡¢¡â ¢πâ ¢Õß solute „π¥“â π dialysate ®–∂ß÷ ®¥ÿ Õ¡‘Ë µ«— (§«“¡‡¢¡â ¢πâ ¢Õß solute „π dialysate ®–‡∑“à °∫— „π plasma) ‚¥¬«∏‘ π’ °È’ “√∑‡Ë’ √“µÕâ ß°“√∑®Ë’ –‡æ¡Ë‘ clearance ¢Õß solute ‡√“µÕâ ß‡æ¡Ë‘ dialysate flow rate (Qd) ®“° 1 ‡ªπì 2 ≈µ‘ √/™¡.20,21 ‡¡ÕË◊ ‡√“‡æ¡Ë‘ Qb ‰¥∂â ß÷ 2 ≈µ‘ √/™¡. ‡√“®ß÷ “¡“√∂∑®Ë’ –‡æ¡Ë‘ Qb ‡æÕË◊ ‡æ¡Ë‘ clearance rates ‰¥â (√ªŸ ∑Ë’ 7) - Continuous Venovenous Hemodiafiltration (CVVHDF) CVVHDF ®–„™∑â ßÈ— ¢∫«π°“√ diffusion ·≈– convection „π°“√°”®¥— ¢Õß‡ ¬’ «∏‘ °’ “√∑”§≈“â ¬°∫— °“√∑” CVVH ´ßË÷ µÕâ ß„™â blood pump ‡æÕË◊ ¥ß÷ ‡≈Õ◊ ¥‡¢“â Ÿà extracorporeal circuit ‚¥¬∑«Ë— ‰ª°“√∑”«∏‘ π’ ®È’ –‡ª¥î blood flow (Qb) µßÈ— ·µà 150-300 ¡≈./π“∑’ ·≈– dialysate flow 1-2 ≈µ‘ √/™¡. (√ªŸ ∑Ë’ 8) Õªÿ °√≥∑å „Ë’ ™„â π°“√∑” CVVHDF ‰¡¬à ßàÿ ¬“° ‡æ¬’ ß·§¡à ’ blood pump √«à ¡°∫— separate infusion pump πÕ°®“°ππÈ— „πª®í ®∫ÿ π— ¬ß— ¡‡’ §√ÕË◊ ß„π√–∫∫ intergrated system ∑ Ë’ “¡“√∂∑”‰¥‡â ™πà ‡§√ÕË◊ ß Aquarius (Edward), Prisma (Hospal) ·≈– Acu-men (Fresenius) Continuous Renal Replacement Therapy (CRRT) CRRT ‡ªìπ°“√√—°…“∫”∫—¥∑¥·∑π‰µ∑’Ë “¡“√∂∑”‰¥âµàÕ‡π◊ËÕßµ≈Õ¥‡«≈“·≈–∂Ÿ°π”¡“„™â„π √ªŸ ∑Ë’ 7 · ¥ßÀ≈°— °“√∑”ß“π¢Õß CVVHD. QB, blood flow rate; QD, dialysate flow rate; QE, effluent rate; QUF, ultrafiltration rate

New Frontiers in Dialysis 222 ∏πµ‘ ®√‘ ππ— ∑å∏«—™ ‘√¿‘ “ ™“â ß»‘√°‘ ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå ÿ‡¡∏°≈ÿ √ªŸ ∑’Ë 8 · ¥ßÀ≈°— °“√∑”ß“π¢Õß CVVHDF. QB, blood flow rate; QD, dialysate flow rate; QE, effluent flow rate; QR, replacement fluid flow rate; QUF, ultrafiltration flow rate °“√√—°…“ºâŸªÉ«¬‰µ«“¬©—∫æ≈—π ‚¥¬ “¡“√∂∑”‰¥â “¡«‘∏’§◊Õ continuous hemofiltration, continuous hemodialysis ·≈– continuous hemodiafiltration ´ßË÷ ª√–°Õ∫¥«â ¬°≈‰°„π°“√°”®¥— ¢Õß‡ ¬’ ‚¥¬°“√π” (convective) ·≈–°“√·æ√à (diffusion) ∂ß÷ ·¡«â “à °“√¢®¥— “√ middle ·≈– large molecules ¡— æπ— ∏°å ∫— °“√„™â convective therapy (hemofiltration) ¡“°°«“à °“√∑” diffusive therapy (hemodialysis) ·µªà ®í ®∫ÿ π— ¬ß— ‰¡¡à ’ °“√»÷°…“∑’Ë∫Õ°‰¥â«à“°“√∑” convective therapy ®–‰¥âº≈°“√√—°…“∑’Ë¥’°«à“°“√∑” diffusive therapy °“√‡≈Õ◊ °ª√–‡¿∑¢Õß CRRT ®ß÷ ¢πÈ÷ Õ¬°Ÿà ∫— ª√– ∫°“√≥·å ≈–‡∑§‚π‚≈¬∑’ ¡Ë’ Õ’ ¬Ÿà ≥ ∂“∫π— ππÈ— Ê ‡ªπì ”§≠— °“√‡ª√¬’ ∫‡∑¬’ ∫ CRRT °∫— IHD ‚¥¬∑—Ë«‰ª CRRT ¡’¢âÕ¥’‡Àπ◊Õ°«à“ IHD „πºâŸªÉ«¬‰µ«“¬©—∫æ≈—π‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’¿“«– hemodynamic instability À√Õ◊ „πºªâŸ «É ¬∑Õ’Ë ¬„Ÿà π¿“«– hypercatabolism ´ß÷Ë ¡Õ’ µ— √“°“√ √“â ß¢Õß‡ ¬’ ¡“° °“√∑” CRRT „πºªŸâ «É ¬°≈¡àÿ π È’ “¡“√∂∫√√≈‡ÿ ª“Ñ À¡“¬„π°“√°”®¥— ¢Õß‡ ¬’ ¢π“¥‡≈°Á ‰¥¥â °’ «“à ºªŸâ «É ¬∑¡Ë’ ª’ √¡‘ “≥ ªí  “«–πâÕ¬Õ“®¡’§«“¡®”‡ªìπµâÕß°”®—¥ “√πÈ” à«π‡°‘π‡ªìπª√‘¡“≥¡“° ‡æ◊ËÕ§«∫§ÿ¡ ¡¥ÿ≈πÈ” ´÷ËßºâŸ ªÉ«¬Õ“®∑πµàÕ°“√∑” CRRT ‰¥â¥’°«à“ IHD „π°“√°”®—¥ “√πÈ”ª√‘¡“≥¡“°ÕÕ°®“°√à“ß°“¬ πÕ°®“°ππÈ— ¡√’ “¬ß“π°“√∑” IHD „πºªŸâ «É ¬«°‘ ƒµ‘ ®–‡æ¡Ë‘ °“√„™Õâ Õ°´‡‘ ®π ·≈–∑”„À¿â “«– acidosis „π ‡¬◊ËÕ∫ÿ≈”‰ â‡æ‘Ë¡¢÷Èπ ´÷ËßÕ“®∑”„Àâ‡°‘¥¿“«–·∑√°´âÕπ„π√–∫∫∑“ß‡¥‘πÕ“À“√·≈–°“√µ‘¥‡™◊ÈÕ‡æ‘Ë¡¢÷Èπ‰¥â º≈°“√√—°…“À≈—° 3 ¥â“π∑’Ë∂Ÿ°π”¡“„™â‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√∑” CRRT ·≈– IHD §◊Õ º≈∑“ß¥â“π §«“¡§ß∑¢Ë’ Õß hemodynamics, Õµ— √“°“√√Õ¥™«’ µ‘ (survival) ·≈–°“√øπôó §π◊ °“√∑”ß“π¢Õß‰µ (recovery of renal function) 1) º≈∑“ß¥“â π§«“¡§ß∑¢’Ë Õß hemodynamics (hemodynamic stability) Misset ·≈–§≥–23 ‰¡æà ∫§«“¡·µ°µ“à ß∑“ß¥“â π hemodynamic stability √–À«“à ß°“√∑” CRRT ‡∑¬’ ∫°∫— IHD „πºªŸâ «É ¬‰µ«“¬©∫— æ≈π— 27 √“¬ ‚¥¬ºªŸâ «É ¬·µ≈à –√“¬‰¥√â ∫— °“√∑” CAVH ·≈– IHD ‚¥¬ √–¬–√–À«“à ß°“√√°— …“∑ßÈ— Õß 24 ™¡. æ∫«“à ª√– ∑‘ ∏¿‘ “æ„π°“√§«∫§¡ÿ ‡¡µ–∫Õ≈ ‘ ¡ §«“¡¥π— ‚≈Àµ‘ ‡©≈¬’Ë °“√„™¬â “æ¬ßÿ §«“¡¥π— ‚≈Àµ‘ ·≈–°“√‡ª≈¬’Ë π·ª≈ßπÈ”Àπ°— µ«— ‰¡·à µ°µ“à ß°π— „π√–À«“à ß°“√∑”CAVH

Dialysis in Acute Kidney Injury ≥—∞™¬— »√ ’ « — ¥‘Ï ¢®√ µ’√≥∏π“°≈ÿ 223 ·≈– IHD Õ¬à“ß‰√°Áµ“¡°“√»÷°…“π’È∑”„πºŸâªÉ«¬∑’Ë¡’™’«‘µ√Õ¥Õ¬àŸÀ≈“¬«—π ¥—ßπ—Èπ®÷ß‡ªìπ°“√‡≈◊Õ°ºŸâªÉ«¬ ®“°°≈¡àÿ ∑¡Ë’ ¿’ “«–∑“ß hemodynamics §Õà π¢“â ß§ß∑Ë’ πÕ°®“°π„È’ π°“√∑” IHD ¬ß— „™Õâ µ— √“°“√‰À≈¢Õß ‡≈Õ◊ ¥‡æ¬’ ß 200 ¡≈./π“∑’ ´ßË÷ ‡ªπì ‰ª‰¥¬â “°∑®Ë’ –‰¥§â “à °“√øÕ°‡≈Õ◊ ¥∑‡Ë’ æ¬’ ßæÕ Davenport ·≈–§≥–24æ∫«“à °“√∑”CRRT„πºªâŸ «É ¬«°‘ ƒµ∑‘ ¡’Ë ¿’ “«–‰µ·≈–µ∫— «“¬©∫— æ≈π— ¡§’ «“¡ §ß∑∑Ë’ “ß¥“â πÀ«— ‰®·≈–À≈Õ¥‡≈Õ◊ ¥¥°’ «“à °“√∑” IHD ºªâŸ «É ¬∑∑Ë’ ” IHD ®–¡’ cardiac index ∑™Ë’ «Ë— ‚¡ß·√° ≈¥≈ß´ßË÷ ¡— æπ— ∏°å ∫— §“à §«“¡¥π— ‚≈Àµ‘ ‡©≈¬Ë’ , pulmonary capillary wedge pressure ·≈–°“√„™Õâ Õ°´‡‘ ®π ¢Õß‡πÕ◊È ‡¬Õ◊Ë ∑≈’Ë ¥≈ßπÕ°®“°ππ—È ¬ß— æ∫«“à §“à §«“¡¥π— „π°–‚À≈°»√’ …–¢ÕßºªâŸ «É ¬∑¡’Ë ’hepaticencephalopathy ßŸ ¢πÈ÷ „π¢≥–∑∑Ë’ ” IHD «à π§«“¡¥π— „π°–‚À≈°»√’ …–¢ÕßºªŸâ «É ¬∑∑Ë’ ” CRRT ‰¡‡à æ¡Ë‘ ¢πÈ÷ 2) Õµ— √“°“√√Õ¥™«’ µ‘ (survival) °“√»÷°…“ à«π¡“°∑’Ë‡ª√’¬∫‡∑’¬∫°“√∑” CRRT ·≈– IHD à«π¡“°‡ªìπ retrospective case series25-29 À≈ß— ®“°°“√ª√∫— (adjust) ‡√ÕË◊ ß§«“¡√πÿ ·√ß¢Õß‚√§·≈«â æ∫«“à ‰¡¡à §’ «“¡·µ°µ“à ß°π— „πÕµ— √“ √Õ¥™«’ µ‘ ¢Õß∑ß—È Õß°≈¡ÿà °“√»°÷ …“¢Õß Mehta ·≈–§≥–30 »°÷ …“ºªŸâ «É ¬ 166 √“¬ ∑¡Ë’ ’ acute kidney injury ‚¥¬·∫ßà ºªŸâ «É ¬ ÕÕ°‡ªπì Õß°≈¡àÿ §Õ◊ °≈¡àÿ ∑‰Ë’ ¥√â ∫— °“√√°— …“¥«â ¬ CRRT ·≈–°≈¡àÿ ∑‰Ë’ ¥√â ∫— °“√√°— …“¥«â ¬ IHD æ∫«“à °≈¡àÿ ∑‰Ë’ ¥√â ∫— °“√√°— …“¥«â ¬ CRRT ¡Õ’ µ— √“°“√‡ ¬’ ™«’ µ‘ (all cause mortality) ∑Ë’ 28 «π— ·≈–¡Õ’ µ— √“°“√‡ ¬’ ™«’ µ‘ „π‚√ßæ¬“∫“≈ ßŸ °«“à °≈¡ÿà ∑‰’Ë ¥√â ∫— °“√√°— …“¥«â ¬ IHD (√Õâ ¬≈– 59.5 ‡ª√¬’ ∫‡∑¬’ ∫°∫— 41.5, p < 0.02, √Õâ ¬≈– 65.5 ‡ª√¬’ ∫‡∑¬’ ∫°∫— 47.6, p < 0.02, µ“¡≈”¥∫— ) Õ¬“à ß‰√°µÁ “¡∂ß÷ ·¡«â “à °“√»°÷ …“π®’È –‡ªπì °“√»°÷ …“·∫∫ ¡ÿà ºªŸâ «É ¬∑∂Ë’ °Ÿ ¡àÿ „À°â “√√°— …“¥«â ¬ CRRT ¡’ APACHE III scores ·≈–¿“«–µ∫— «“¬ (liver failure) ∑ Ë’ ßŸ °«“à °≈ÿà¡∑’Ë‰¥â√—∫ IHD ·µàÀ≈—ß®“°‰¥â∑”°“√ª√—∫ªí®®—¬∑’ËÕ“®¡’º≈µàÕº≈°“√»÷°…“π’ÈÕÕ°‰ª·≈â« ‰¡àæ∫Õ—µ√“ µ“¬∑‡Ë’ æ¡Ë‘ ¢πÈ÷ „π°≈¡àÿ ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“¥«â ¬ CRRT (adjusted odds of death = 1.58, CI 0.7-3.3) °“√»°÷ …“·∫∫‰ª¢“â ßÀπ“â Õ°’ 2 °“√»°÷ …“ ‰¥·â °°à “√»°÷ …“¢Õß Guerin ·≈–§≥– ´ßË÷ ∑”°“√ »°÷ …“·∫∫ ß— ‡°µ (observational study) „πºªâŸ «É ¬ 587 √“¬ (CRRT 354 √“¬·≈– IHD 233 √“¬) ·≈–°“√ »÷°…“¢Õß Augustine ·≈–§≥– ´÷Ëß∑”°“√»÷°…“·∫∫ ÿà¡„πºŸâªÉ«¬ 80 √“¬ °“√»÷°…“∑—Èß 2 π’Èæ∫«à“ Õ—µ√“°“√‡ ’¬™’«‘µ„πºâŸªÉ«¬∑’Ë∑” CRRT ßŸ °«à“ºâŸªÉ«¬∑’Ë∑” IHD ·µà‡¡◊ËÕ°”®—¥ªí®®—¬Õ◊ËπÊÕÕ°‰ª·≈â« æ∫ «“à Õµ— √“°“√‡ ¬’ ™«’ µ‘ „πºªŸâ «É ¬∑ßÈ— 2 °≈¡àÿ ‰¡¡à §’ «“¡·µ°µ“à ß°π— Õ¬“à ß¡π’ ¬— ”§≠— ∑“ß ∂µ‘ ‘ ¡°’ “√»°÷ …“·∫∫ meta-analyses31,322°“√»°÷ …“∑‡’Ë ª√¬’ ∫‡∑¬’ ∫º≈°“√√°— …“√–À«“à ß°“√∑”CRRT ·≈– °“√∑” IHD °“√»°÷ …“·√°∑”‚¥¬ Kellum ·≈–§≥– ‚¥¬√«∫√«¡ 13 °“√»°÷ …“ √«¡ºªâŸ «É ¬°«“à 1,400 √“¬ ·µà¡’‡æ’¬ß 3 °“√»÷°…“∑’Ë‡ªìπ°“√»÷°…“·∫∫ ÿà¡‰ª¢â“ßÀπâ“ æ∫«à“ºŸâªÉ«¬∑’Ë∑” CRRT ¡’§«“¡‡ ’Ë¬ß µÕà °“√‡ ¬’ ™«’ µ‘ „°≈‡â §¬’ ß°∫— IHD (relative risk = 0.93, 95% CI = 0.79-1.09, p = 0.29) ‡¡ÕË◊ °”®¥— ª®í ®¬— ∑“ß¥â“π§ÿ≥¿“æ¢Õßß“π«‘®—¬ ·≈–§«“¡√ÿπ·√ß¢Õß§«“¡‡®Á∫ªÉ«¬ÕÕ°‰ª æ∫«à“ºŸâªÉ«¬∑’Ë∑” CRRT ¡’ §«“¡‡ ¬Ë’ ßµÕà °“√‡ ¬’ ™«’ µ‘ πÕâ ¬°«“à IHD (relative risk = 0.92, 95% CI = 0.60-0.87, p < 0.01) º‡âŸ ¢¬’ π √ªÿ «“à ‡πÕ◊Ë ß®“°§≥ÿ ¿“æ°“√»°÷ …“µË”¢Õâ ¡≈Ÿ ¥ß— °≈“à «®ß÷ ‰¡‡à æ¬’ ßæÕ∑®’Ë –À“¢Õâ √ªÿ ∑™’Ë ¥— ‡®π·µ®à “°¢Õâ ¡≈Ÿ ™«’È “à ºªŸâ «É ¬∑∑’Ë ” CRRT ¡·’ π«‚π¡â ∑®’Ë –¡Õ’ µ— √“°“√√Õ¥™«’ µ‘ ¡“°°«“à (√ªŸ ∑’Ë 9) °“√»°÷ …“∑’Ë 2 ∑”‚¥¬ Tonelli ·≈–§≥– √«∫√«¡ 6 °“√»°÷ …“‡©æ“–∑‡Ë’ ªπì °“√»°÷ …“·∫∫ ¡àÿ ·≈–¡°’ ≈¡àÿ §«∫§¡ÿ (√«¡°“√»°÷ …“¢Õß Mehta) ‰¡à

New Frontiers in Dialysis 224 ∏π‘µ ®‘√π—π∑∏å «™— √‘ ‘¿“ ™“â ß»√‘ °‘ ≈ÿ ™—¬ ∏π—π¥“ µ√–°“√«π‘™ « —πµå ‡ÿ ¡∏°ÿ≈ √ªŸ ∑’Ë 9 · ¥ß°“√‡ª√¬’ ∫º≈°“√√°— …“√–À«“à ß°“√∑” CRRT ·≈– °“√∑” IHD æ∫«“à ºªŸâ «É ¬∑∑Ë’ ” CRRT ¡§’ «“¡ ‡ ¬Ë’ ßµÕà °“√‡ ¬’ ™«’ µ‘ πÕâ ¬°«“à IHD (relative risk = 0.92, 95% CI = 0.60-0.87, p < 0.01) ‡¡ÕË◊ °”®¥— ª®í ®¬— ∑“ß¥“â π§≥ÿ ¿“æ¢Õßß“π«®‘ ¬— ·≈–§«“¡√πÿ ·√ß¢Õß§«“¡‡®∫Á ª«É ¬ÕÕ°‰ª æ∫§«“¡·µ°µ“à ß¢ÕßÕµ— √“°“√√Õ¥™«’ µ‘ ‰¡«à “à ®–‡≈Õ◊ °«∏‘ °’ “√∫”∫¥— ∑¥·∑π‰µ·∫∫„¥°µÁ “¡ (√ªŸ ∑Ë’ 10) Õ¥§≈âÕß°—∫°“√»÷°…“ HEMODIAFE study ´÷Ëß‡ªìπ°“√»÷°…“≈à“ ÿ¥‚¥¬ Vinsonneau ·≈– §≥– °“√»°÷ …“π‡È’ ªπì randomized controlled trial ∑∂Ë’ Õ◊ ‰¥«â “à „À≠∑à Ë’ ¥ÿ „πª®í ®∫ÿ π— 33 ¡º’ ªâŸ «É ¬∑ßÈ— πÈ‘ 360 √“¬ ·≈–∑°ÿ √“¬¡¿’ “«–‰µ«“¬©∫— æ≈π— ·≈– multi-organ dysfunction syndrome ‚¥¬°“√ ¡ÿà „À‰â ¥√â ∫— °“√√°— …“·∫∫ IHD À√Õ◊ CVVHDF ‚¥¬¡’ primary endpoint §Õ◊ Õµ— √“°“√√Õ¥™«’ µ‘ ∑Ë’ 60 «π— æ∫«“à ºªâŸ «É ¬∑ßÈ— 2 °≈¡àÿ ¡’ §«“¡√πÿ ·√ß¢Õß‚√§‡∑“à °π— ·≈–¡Õ’ µ— √“°“√‡ª≈¬Ë’ π°“√√°— …“®“° CRRT ‰ª‡ªπì IHD µ”Ë (√Õâ ¬≈– 3.3) º≈°“√»°÷ …“æ∫«“à Õµ— √“°“√√Õ¥™«’ µ‘ ∑Ë’ 60 «π— ‡∑“à °π— ∑ßÈ— Õß°≈¡àÿ (√Õâ ¬≈– 31.5 ·≈– 32.6 „π IHD ·≈– CRRT µ“¡≈”¥—∫, p = 0.98) πÕ°®“°π’È‰¡àæ∫«à“¡’Õ—µ√“°“√‡°‘¥§«“¡¥—π‚≈À‘µµË”·≈–¿“«–√–∫∫‰À≈ ‡«’¬π‚≈À‘µ‰¡à§ß∑’Ë ·µ°µà“ß°—π„π°“√√—°…“∑—Èß Õß«‘∏’ ·µà¢âÕ √ÿª∑’Ë‰¥â®“°°“√»÷°…“π’È¬—ß§ß¡’¢âÕ®”°—¥ ‡π◊ËÕß®“°√–‡∫’¬∫«‘∏’«‘®—¬ ∑’Ë™—¥∑’Ë ÿ¥§◊Õ¢π“¥°“√√—°…“ (dialysis dosing) ∑’Ëæ∫«à“µË”°«à“∑’Ë§«√®–‡ªìπ„π

Dialysis in Acute Kidney Injury ≥—∞™—¬ »√ ’ « — ¥Ï‘ ¢®√ µ’√≥∏π“°ÿ≈ 225 √ªŸ ∑’Ë 10 · ¥ß°“√‡ª√¬’ ∫º≈°“√√°— …“√–À«“à ß°“√∑” CRRT ·≈– °“√∑” IHD ‰¡æà ∫«“à ºªâŸ «É ¬∑∑Ë’ ” CRRT ¡’ §«“¡‡ ¬Ë’ ßµÕà °“√‡ ¬’ ™«’ µ‘ ·µ°µ“à ß®“°ºªâŸ «É ¬∑∑Ë’ ” IHD ∑ßÈ— Õß°≈¡àÿ °“√»°÷ …“ °“√„™â heparin ¡“°°«“à °“√„™â regional anti-coagulant √–À«“à ß°“√∑” CRRT ´ßË÷ Õ“® —¡æ—π∏å°—∫°“√‡°‘¥¿“«–‡≈◊Õ¥ÕÕ°„π à«πµà“ßÊ ¢Õß√à“ß°“¬À√◊Õ¿“«–°“√·¢Áßµ—«¢Õß‡≈◊Õ¥∑’Ë extracorporeal circuit πÕ°®“°π√È’ –¬–‡«≈“∑„Ë’ ™„â π°“√»°÷ …“∑πË’ “π‡°π‘ ‰ª Õµ— √“°“√‡ ¬’ ™«’ µ‘ „π°≈¡àÿ ∑‰Ë’ ¥â √—∫°“√∑” IHD ≈¥≈ß‡¡◊ËÕ‡«≈“ºà“π‰ª„π¢≥–∑’ËÕ—µ√“°“√‡ ’¬™’«‘µ„π°≈ÿà¡∑’Ë‰¥â√—∫°“√√—°…“¥â«¬ CRRT ¬—ß§ß∑’Ëµ≈Õ¥‡«≈“ Õ“®®–π”º≈∑’Ë‰¥â®“°°“√»÷°…“π’È¡“ √ÿª‚¥¬√«¡‰¡à‰¥â ·µàÕ“®®–æÕ∫Õ°·π«‚πâ¡ ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“·∫∫ IHD ‰¥‡â ¡ÕË◊ ‡«≈“º“à π‰ª ‘ßË ”§≠— ∑°Ë’ “√»°÷ …“π‰È’ ¥·â ¥ß„À‡â ÀπÁ «“à ¡§’ «“¡ ‡ªìπ‰ª‰¥â∑’Ë‡√“ “¡“√∂∑’Ë®–∑” IHD ‰¥â„πºâŸªÉ«¬‰µ«“¬©—∫æ≈—π‚¥¬∑’ËÕ—µ√“°“√‡°‘¥§«“¡¥—π‚≈À‘µµË”‰¡à ‰¥â·µ°µà“ß®“°°≈ÿà¡∑’Ë‰¥â√—∫°“√√—°…“¥â«¬ CRRT ·≈–πÕ°®“°π’Èæ∫«à“°“√∑” IHD ‡ ’¬§à“„™â®à“¬πâÕ¬ °«“à °“√∑” CRRT Õ¬“à ß™¥— ‡®π 3) °“√øπóô °“√∑”ß“π¢Õß‰µ (recovery of renal function) °“√øπôó °“√∑”ß“π¢Õß‰µ (recovery of renal function) ¬ß— §ß‡∑“à °π— ‰¡«à “à ®–‰¥√â ∫— °“√∑” CRRT À√Õ◊ °“√∑” IHD ·µ¡à ∫’ “ß°“√»°÷ …“∑∫Ë’ Õ°«“à °“√∑” CRRT ¡º’ ≈¢Õß°“√√°— …“¥°’ «“à 34-36 °“√»°÷ …“‡À≈“à π’È‰¥â∑”°“√«—¥‡©æ“–°“√øóôπ§◊π¢Õß°“√∑”ß“π¢Õß‰µ „πºâŸªÉ«¬∑’Ë¬—ß¡’™’«‘µÕ¬àŸ‚¥¬∑’Ë‰¡à‰¥âπ”ºâŸªÉ«¬∑’Ë‡ ’¬ ™’«‘µ¡“§‘¥¥â«¬ ‡¡◊ËÕπ”¡“«‘‡§√“–Àå‚¥¬√«¡‡Õ“ºŸâ∑’Ë‡ ’¬™’«‘µ·≈–ºâŸ∑’Ë°“√∑”ß“π¢Õß‰µ∑’Ë‰¡àøóôπ¡“§‘¥¥â«¬ æ∫«“à ∑ß—È Õß°≈¡ÿà ¡Õ’ µ— √“°“√øπóô §π◊ ¢Õß°“√∑”ß“π¢Õß‰µ‰¡·à µ°µ“à ß°π— 37 °“√»°÷ …“·∫∫ ¡ÿà ‰¡æà ∫§«“¡ ·µ°µ“à ß„π·ß¢à Õß°“√øπôó §π◊ °“√∑”ß“π¢Õß‰µ √–À«“à ß°“√∑” CRRT ·≈– IHD33,37-38

New Frontiers in Dialysis 226 ∏π‘µ ®√‘ ππ— ∑∏å «™— ‘√¿‘ “ ™â“ß»√‘ °‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå ‡ÿ ¡∏°≈ÿ ‚¥¬ √ªÿ ®“°¢Õâ ¡≈Ÿ ∑¡Ë’ Õ’ ¬„àŸ πª®í ®∫ÿ π— ¬ß— §ß‰¡‡à æ¬’ ßæÕ∑®Ë’ – √ªÿ «“à °“√∑” CRRT ¡ª’ √– ∑‘ ∏¿‘ “æ ∑’Ë‡Àπ◊Õ°«à“ IHD ·¡â®–¡’·π«‚πâ¡«à“ºâŸªÉ«¬∑’Ë∑” CRRT ®–¡’¿“«– hemodynamics ∑’Ë§ß∑’Ë°«à“ ¡’Õ—µ√“ °“√√Õ¥™«’ µ‘ ßŸ °«“à ·≈–¡°’ “√øπôó °“√∑”ß“π¢Õß‰µ¥°’ «“à ºªâŸ «É ¬∑∑Ë’ ” IHD √ªÿ ¢Õâ ·π–π”„π°“√„™â CRRT ∑ÕË’ “®®–¥°’ «“à °“√∑” IHD ¥ß— πÈ’ 1. „πºâŸªÉ«¬∑’Ë¡’¿“«–√–∫∫‰À≈‡«’¬π‚≈À‘µ∑’Ë‰¡à§ß∑’ËÀ√◊ÕºâŸªÉ«¬∑’ËÕ“®‡°‘¥¿“«–§«“¡¥—π‚≈À‘µ µ”Ë ‰¥„â π¢≥–∑∑Ë’ ” IHD ¥ß— √ªŸ ∑Ë’ 11 ·≈– 1237 2. °“√∑”CRRTÕ“®™«à ¬¢®¥— ‡°≈Õ◊ ·≈–πÈ” «à π‡°π‘ ¢Õß√“à ß°“¬‰¥¥â °’ «“à √«¡∑ß—È “¡“√∂„À â “√ Õ“À“√‰¥µâ “¡§«“¡µÕâ ß°“√¢ÕßºªâŸ «É ¬37 3. ™à«¬¢®—¥ inflammatory mediator µà“ßÊ ´÷ËßÕ“®‰¥âº≈¥’„πºŸâªÉ«¬∑’Ë¡’¿“«– sepsis ‚¥¬ ‡©æ“–°“√∑” convection modes „π CRRT38-40 4. „πºªŸâ «É ¬∑¡Ë’ ’ acute brain injury À√Õ◊ fulminant hepatic failure °“√∑” CRRT Õ“®¥°’ «“à „π·ßà ¢Õß°“√‰À≈‡«¬’ π‚≈Àµ‘ ‡æÕË◊ ‰ªÀ≈Õà ‡≈¬È’ ß ¡Õß (cerebral perfusion)41 ª√–‚¬™πå∑’Ë‰¥â®“°¢âÕ·π–π”¥—ß°≈à“«¢â“ßµâπ¬—ßÕ“®‰¡à™—¥‡®π ‡π◊ËÕß®“°‰¡àæ∫Õ—µ√“°“√√Õ¥ ™«’ µ‘ ∑·Ë’ µ°µ“à ß°π— „π∑ßÈ— °“√∑” CRRT À√Õ◊ °“√∑” IHD ‡Àµºÿ ≈ª√–°“√ÀπßË÷ §Õ◊ °“√∑” convective therapy ‰¡‡à æ¬’ ß·µ°à ”®¥— pro-inflammatory mediator µ“à ßÊ ∑‡Ë’ ªπì “√°Õà ‚√§ ·µ¬à ß— Õ“®°”®¥— anti-inflammatory mediator Õπ◊Ë Ê ∑¡’Ë ª’ √–‚¬™πÕå Õ°‰ª®“°√“à ß°“¬¥«â ¬ πÕ°®“°π’È Õµ— √“„π°“√°”®¥— ‚¥¬«∏‘ ’ convective therapy Õ“®‰¡ à “¡“√∂°”®¥— pro-inflammatory mediator ‰¥∑â π— ‡¡ÕË◊ ‡∑¬’ ∫°∫— pro-inflammatory mediator µ“à ßÊ ∑√’Ë “à ß°“¬º≈µ‘ ¢π÷È ¡“ °“√‡ª√¬’ ∫‡∑¬’ ∫°“√√°— …“ RRT ¥«â ¬«∏‘ Õ’ π◊Ë Ê ªí®®ÿ∫—π¡’¢âÕ¡Ÿ≈°“√»÷°…“‡æ’¬ß‡≈Á°πâÕ¬∑’Ë‡ª√’¬∫‡∑’¬∫«‘∏’°“√√—°…“µà“ßÊ ¢Õß°“√∑” RRT „πºªâŸ «É ¬ ‰µ«“¬©∫— æ≈π— - °“√»°÷ …“‡ª√¬’ ∫‡∑¬’ ∫°“√∑” PD °∫— °“√∑” CVVH °“√»°÷ …“¢Õß Phu ·≈–§≥–42 ‰¥∑â ”°“√»°÷ …“·∫∫ prospective study „πºªâŸ «É ¬ 70 √“¬ ∑¡Ë’ ’ ¿“«–‰µ«“¬©∫— æ≈π— ®“° malaria À√Õ◊ sepsis (48 ·≈– 22 √“¬µ“¡≈”¥∫— ) ∑ªË’ √–‡∑»‡«¬’ ¥π“¡ ‚¥¬ ÿà¡„Àâ‰¥â√—∫°“√√—°…“¥â«¬«‘∏’ PD À√◊Õ CVVH º≈°“√»÷°…“æ∫«à“Õ—µ√“°“√‡ ’¬™’«‘µ„π°≈ÿà¡∑’Ë‰¥â√—∫°“√ √°— …“‚¥¬ PD ¡“°°«“à °≈¡àÿ ∑‰Ë’ ¥√â ∫— °“√√°— …“‚¥¬°“√∑” CVVH (√Õâ ¬≈– 47 ‡¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— √Õâ ¬≈– 15, odds ratio = 5.1, 95% CI = 1.6-16) (√ªŸ ∑Ë’ 13) “‡Àµ∑ÿ ∑Ë’ ”„Àºâ ªŸâ «É ¬°≈¡àÿ ∑‰Ë’ ¥√â ∫— °“√√°— …“‚¥¬ PD ‡ ¬’ ™«’ µ‘ ¡“°°«“à ª√–°Õ∫¥«â ¬ overall creatinine clearance ∑µË’ ”Ë °«“à °“√„™â acetate (‰¡„à ™â bicarbonate) „π πÈ”¬“ PD dialysate ·≈–ªí®®—¬Õ◊ËπÊ ∑’Ë¬—ß‰¡à∑√“∫„πªí®®ÿ∫—π πÕ°®“°π’ÈπÈ”¬“ dialysate „π°“√»÷°…“ ‡ªπì π”È ¬“∑ºË’ ≈µ‘ ¢πÈ÷ ‡Õß∑‚Ë’ √ßæ¬“∫“≈∑∑Ë’ ”°“√»°÷ …“ „π¢≥–∑Ë’ commercial peritoneal dialysate „πª√– ‡∑»Õπ◊Ë Ê ¡°— ¡ ’ «à πª√–°Õ∫‡ªπì lactate ·∑π∑®’Ë –‡ªπì acetate ¬ß— ‰¡¡à °’ “√»°÷ …“‡ª√¬’ ∫‡∑¬’ ∫√–À«“à ß°“√∑” peritoneal dialysis °∫— °“√∑” intermittent hemodialysis - °“√»÷°…“‡ª√’¬∫‡∑’¬∫°“√∑” sustained low efficiency dialysis (SLED) ·≈– extended daily dialysis (EDD) °∫— °“√∑” CVVH

Dialysis in Acute Kidney Injury ≥—∞™¬— »√ ’ «— ¥Ï‘ ¢®√ µ’√≥∏π“°ÿ≈ 227 °“√∑” SLED ‡ªπì °“√π”‡Õ“¢Õâ ¥¢’ Õß∑ßÈ— °“√∑” IHD ·≈– CRRT ¡“„™â ®ß÷ ¡°— ∂°Ÿ ‡√¬’ °«“à ‡ªπì hybrid therapy °“√√°— …“π‰È’ ¡µà Õâ ß°“√‡§√ÕË◊ ß¡Õ◊ „À¡‡à æ¬’ ß·µªà √–¬°ÿ µ‡å §√ÕË◊ ß¡Õ◊ ∑„Ë’ ™„â π°“√∑” hemodialysis ´ßË÷ “¡“√∂∑”‰¥„â π‚√ßæ¬“∫“≈∑¡Ë’ ¢’ Õâ ®”°¥— „π°“√∑” CRRT ‚¥¬°“√‡ª¥î dialysate flow ™“â Ê ‡æ¬’ ß 100 ¡≈./π“∑’ ·≈–„™‡â «≈“ª√–¡“≥ 8-24 ™¡./«π— Marshall ·≈–§≥–43 ‰¥∑â ”°“√»°÷ …“°“√∑” SLED „πºªŸâ «É ¬«°‘ ƒµ‘ 37 √“¬ ∑‰Ë’ ¡ à “¡“√∂∑π µÕà °“√∑” IHD ‰¥‡â πÕË◊ ß®“°‡°¥‘ §«“¡¥π— ‚≈Àµ‘ µ”Ë À√Õ◊ ‰¡ à “¡“√∂‡æ¡Ë‘ ¢π“¥¢Õß dialysis ‚¥¬«∏‘ ’ IHD „Àâ‰¥âµ“¡‡ªÑ“À¡“¬ æ∫«à“°“√∑” SLED „πºâŸªÉ«¬°≈ÿà¡π’È “¡“√∂°”®—¥ “√πÈ” à«π‡°‘π·≈–°”®—¥¢Õß ‡ ¬’ ÕÕ°®“°µ«— ºªâŸ «É ¬‰¥µâ “¡‡ª“Ñ À¡“¬∑µ’Ë Õâ ß°“√ §“à double pool Kt/V urea ∑º’Ë ªâŸ «É ¬‰¥√â ∫— ‡∑“à °∫— 1.36±0.38 µàÕ§√—Èß ºâŸªÉ«¬¡’Õ—µ√“°“√‡ ’¬™’«‘µ„π‚√ßæ¬“∫“≈ √âÕ¬≈– 62 ´÷Ëß‰¡à·µ°µà“ß®“°ºâŸªÉ«¬∑’Ë¡’§à“§–·ππ §«“¡√πÿ ·√ß¢Õß§«“¡‡®∫Á ª«É ¬ (APACHE II score) ‡¥¬’ «°π— Kumar44 ·≈–§≥– ‰¥∑â ”°“√»°÷ …“„πºªŸâ «É ¬«°‘ ƒµ‡‘ ª√¬’ ∫‡∑¬’ ∫°“√∑” SLED (n=17) °∫— °“√∑” CVVH (n=25) ‡¡ÕË◊ °”®¥— “√π”È ÕÕ°®“°ºªŸâ «É ¬„πª√¡‘ “≥„°≈‡â §¬’ ß°π— (3,000 ¡≈./«π— ·≈– 3,028 ¡≈./«π— ) ‰¡æà ∫§«“¡·µ°µ“à ß¢Õß§«“¡¥π— ‚≈Àµ‘ ‡©≈¬Ë’ ·≈–°“√„™â catecholamine „π°“√√°— …“∑ßÈ— 2 ·∫∫ °“√∑” SLED „™ â “√µ“â π°“√·¢ßÁ µ«— ¢Õß‡≈Õ◊ ¥πÕâ ¬°«“à °“√∑” CVVH (heparin 4,000 ¬πŸ µ‘ /«π— ) ‡∑¬’ ∫°∫— 21,000 ¬πŸ µ‘ /«π— ) Kielstein45 ·≈–§≥– ‰¥∑â ”°“√»°÷ …“·∫∫ ¡àÿ ¡°’ ≈¡àÿ §«∫§¡ÿ „πºªŸâ «É ¬«°‘ ƒµ∑‘ ÕË’ “»¬— ‡§√ÕË◊ ß™«à ¬ À“¬„®·≈–¡¿’ “«–‰µ«“¬©∫— æ≈π— ∑¡’Ë ª’ √¡‘ “≥ª í “«–πÕâ ¬‡ª√¬’ ∫‡∑¬’ ∫°∫— °“√√°— “‚¥¬°“√∑”SLED(n=20) °—∫°“√∑” CVVH (n=19) æ∫«à“°“√°”®—¥ urea „π∑—Èß 2 °≈ÿà¡¡’§à“„°≈â‡§’¬ß°—π ·≈–º≈°“√µ√«®∑“ß hemodynamics °‰Á ¡¡à §’ «“¡·µ°µ“à ß°π— ·¡§â “à systemic vascular resistance „π°≈¡àÿ ∑∑Ë’ ” SLED ®–¡’ ·π«‚π¡â ∑ Ë’ ßŸ °«“à °≈¡àÿ ∑∑Ë’ ” CRRT Berbece46 ·≈–§≥– ‰¥∑â ”°“√»°÷ …“·∫∫ ß— ‡°µ‰ª¢“â ßÀπ“â ‡ª√¬’ ∫‡∑¬’ ∫°“√∑” SLED (n=23) °∫— °“√∑” CRRT (n=11) „πºªâŸ «É ¬«°‘ ƒµ‘ æ∫«“à ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√∑” SLED «à π„À≠∑à πµÕà °“√√°— …“‰¥¥â ’ ‡°‘°¿“«–§«“¡¥—π‚≈À‘µµË” 17 ®“° 165 §√—Èß °“√∑” SLED „™â§à“„™â®à“¬πâÕ¬°«à“ CRRT ·≈–¡’°“√ °”®¥— ¢Õß‡ ¬’ ¢π“¥‡≈°Á ¡“°°«“à CRRT (Kt/V urea µÕà ª— ¥“Àå 8.4 ± 1.8 ‡∑¬’ ∫°∫— 7.1 ± 2.1. p < 0.001) ·≈– §“à time average serum creatinine ¡§’ “à 95 ± 49 ‡∑¬’ ∫°∫— 136 ± 49 µmol/≈µ‘ √, p = 0.03 ®“°°“√»÷°…“¥—ß°≈à“«æÕ √ÿª‰¥â«à“°“√∑” SLED „πºŸâªÉ«¬‰µ«“¬©—∫æ≈—π¡’§«“¡§ß∑’Ë∑“ß hemodynamics ·≈–¡’ª√– ‘∑∏‘¿“æÕ¬à“ßπâÕ¬∑’Ë ÿ¥„°≈â‡§’¬ß°—∫°“√∑” CRRT ‚¥¬„™â‡∑§π‘§∑’Ëßà“¬°«à“ √–¬–‡«≈“πÕâ ¬°«“à ·≈–°“√¥·Ÿ ≈‚¥¬∫§ÿ ≈“°√πÕâ ¬°«“à ·≈–ºªŸâ «É ¬∑∑Ë’ ” SLED ®–‰¥√â ∫— “√µ“â π°“√·¢ßÁ µ«— ¢Õß‡≈Õ◊ ¥πÕâ ¬°«“à °“√∑” CRRT ¥ß— ππÈ— ®ß÷ ¡ª’ √–‚¬™π„å π°≈¡àÿ ºªâŸ «É ¬∑¡Ë’ §’ «“¡‡ ¬Ë’ ßµÕà °“√µ°‡≈Õ◊ ¥ „π ªí®®ÿ∫—π¬—ß‰¡à¡’°“√»÷°…“‡ª√’¬∫‡∑’¬∫∂÷ßº≈∑“ß¥â“πÕ—µ√“°“√√Õ¥™’«‘µ ·≈–°“√øóôπµ—«¢Õß°“√∑”ß“π ¢Õß‰µ√–À«“à ß°“√∑” SLED °∫— IHD À√Õ◊ CRRT ‰¥√â «∫√«¡°“√»°÷ …“°“√„™â SLED ·≈– extended nocturnal dialysis „πºªŸâ «É ¬‰µ«“¬©∫— æ≈π— „πÀÕºªŸâ «É ¬«°‘ ƒµ‘ ‰«„â πµ“√“ß∑Ë’ 5

New Frontiers in Dialysis 228 ∏πµ‘ ®‘√ππ— ∑∏å «—™ √‘ ‘¿“ ™“â ß»√‘ °‘ ≈ÿ ™—¬ ∏π—π¥“ µ√–°“√«π™‘ « π— µå ÿ‡¡∏°ÿ≈ µ“√“ß∑Ë’ 5 √ªÿ °“√»°÷ …“°“√„™â SLED ·≈– extended nocturnal dialysis „πºªâŸ «É ¬‰µ«“¬©∫— æ≈π— „πÀÕºªâŸ «É ¬«°‘ ƒµ4‘ 7 Author Dialysis machine Blood/dialysate Treatment Nocturnal Fiaccadori48 AK 200 Ultra flow (ml/min) time (h) treatment Kielstein45 Genius 200/100 8-9 No 200/100 12 Yes Kielstein Genius 150-200/150-200 8 Yes Kumar44 2008H 200/300 6-8 No Lonnemann Genius 70/70 18 Not reported Marshall43 2008H 200/100 12 Yes Marshall 2008H 200/100 12 Not reported Marshall 4008SArRT-PlusS 250-350/200 8 No Morgera Genius 180-200/180-200 4-6 No Naka Not reported 100/200 6-8 Not reported Ratanarat Not reported 200-250/67-150 6-12 Not reported Schlaeper 2008H 100-200/100-300 8-24 Yes ‚¥¬ √ÿª ¬—ß‰¡à¡’¢âÕ¡Ÿ≈∑’Ë‡æ’¬ßæÕ„π°“√∑’Ë®– √ÿª«à“°“√„™â RRT ·∫∫‰Àπ∑’Ë®–¥’°«à“À√◊Õ¥’ ∑’Ë ÿ¥„π°“√√—°…“ºâŸªÉ«¬ acute kidney injury ©–π—Èπ„π°“√√—°…“ºŸâªÉ«¬‚¥¬ à«π„À≠à®÷ß¢÷ÈπÕ¬Ÿà°—∫¿“«– ¢ÕßºŸâªÉ«¬„π·µà≈–√“¬ §«“¡™”π“≠¢ÕßºâŸ„Àâ°“√√—°…“·≈–ªí®®—¬∑“ß¥â“πÕÿª°√≥å√«¡∑—Èß§à“„™â®à“¬ µ«— Õ¬“à ß‡™πà „π°√≥º’ ªŸâ «É ¬∑¡Ë’ ¿’ “«– acute brain injury À√Õ◊ fulminant hepatic failure °“√√°— …“·∫∫ CRRT Õ“®¡ª’ √–‚¬™π¡å “°°«“à „π·ß¢à Õß°“√‰À≈‡«¬’ π¢Õß‚≈Àµ‘ ‡æÕ◊Ë ‰ªÀ≈Õà ‡≈¬’È ß ¡Õß ¢π“¥¢Õß°“√√°— …“∑‡’Ë À¡“– ¡ (optimal dosing) - Optimal dosing of intermittent hemodialysis ¢π“¥¢Õß°“√√°— …“IHD¢π÷È Õ¬°Ÿà ∫— ¢π“¥∑„’Ë À°â “√√°— …“„π·µ≈à –§√ß—È √«à ¡°∫— §«“¡∂¢’Ë Õß°“√√°— …“ ¥ß— ππÈ— º≈∑‰Ë’ ¥Õâ “®®–·µ°µ“à ß°π— „π·µ≈à –§√ßÈ— ∑∑Ë’ ”°“√√°— …“‡¡ÕË◊ ‡√“°”Àπ¥™«à ß‡«≈“∑‡Ë’ √“®–∑”°“√√°— …“ (fixed treatment schedule) À√◊ÕÕ“®·µ°µà“ß°—π„π™à«ß¢Õß°“√√—°…“‡¡◊ËÕ‡√“°”Àπ¥¢π“¥¢Õß°“√ √—°…“„π·µà≈–§√—Èß (fixed dose per session) ¬—ß‰¡à¡’°“√»÷°…“¢âÕ·µ°µà“ß¢Õß¢π“¥∑’Ë„Àâ°“√√—°…“„π ·µ≈à –§√ßÈ— „πºªŸâ «É ¬∑∑Ë’ ” IHD ‚¥¬°“√°”Àπ¥™«à ß‡«≈“∑·Ë’ ππà Õπ (fixed schedule) ‡™πà 3 §√ßÈ— µÕà ª— ¥“Àå ¡’¢âÕ¡Ÿ≈∑’Ë∫àß∫Õ°«à“¢π“¥¢Õß°“√√—°…“¡’º≈µàÕºâŸªÉ«¬„π°≈ÿà¡∑’Ë¡’Õ“°“√√ÿπ·√ßª“π°≈“ß ‡™πà √“¬ß“π¢Õß Paganini ·≈–§≥–50 ‰¥∑â ”°“√»°÷ …“·∫∫ retrospective study ºªŸâ «É ¬®”π«π 844 √“¬∑¡Ë’ ’ ¿“«–‰µ«“¬©∫— æ≈π— „πÀÕºªâŸ «É ¬«°‘ ƒµ‚‘ ¥¬„™â Kt/V ‡ªπì µ«— ·∑π¢π“¥¢Õß°“√√°— …“·∫∫ acute intermittent hemodialysis æ∫«“à Õµ— √“°“√√Õ¥™«’ µ‘ ‡æ¡Ë‘ ¢πÈ÷ „πºªŸâ «É ¬∑¡Ë’ ’ Kt/V ¡“°°«“à 1 ‚¥¬‡©æ“–ºªâŸ «É ¬∑¡Ë’ Õ’ “°“√

Dialysis in Acute Kidney Injury ≥—∞™¬— »√ ’ «— ¥‘Ï ¢®√ µ’√≥∏π“°ÿ≈ 229 √ÿπ·√ßª“π°≈“ß ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ºâŸªÉ«¬∑’Ë¡’Õ“°“√√ÿπ·√ß¡“°À√◊ÕºŸâªÉ«¬∑’Ë‰¡à¡’Õ“°“√√ÿπ·√ß ´÷Ëß Õß °≈¡ÿà À≈ß— ‰¡æà ∫«“à ¢π“¥„π°“√√°— …“¡º’ ≈µÕà Õµ— √“°“√√Õ¥™«’ µ‘ ¢ÕßºªâŸ «É ¬ √“¬ß“πº≈°“√»°÷ …“¢Õß Schiffl ·≈–§≥–34 ∑”°“√»°÷ …“ºªâŸ «É ¬ 160 √“¬∑¡Ë’ ¿’ “«–‰µ«“¬©∫— æ≈π— ‚¥¬·∫ßà ºªŸâ «É ¬ÕÕ°‡ªπì Õß°≈¡àÿ °≈¡àÿ ·√°‰¥√â ∫— °“√√°— …“‚¥¬°“√∑” hemodialysis «π— ‡«πâ «π— °≈¡àÿ ∑’Ë Õß‰¥â√—∫°“√∑” hemodialysis ∑ÿ°«—π à«π¡“°¢ÕßºŸâªÉ«¬∑’ËÕ¬àŸ„π°“√»÷°…“π’È¡’Õ“°“√¢Õß‚√§√ÿπ·√ß ª“π°≈“ß‚¥¬¥Ÿ®“° APACHE scores æ∫«à“°“√∑” hemodialysis ∑ÿ°«—π¡’Õÿ∫—µ‘°“√≥å°“√‡ ’¬™’«‘µµË” °«“à °≈¡àÿ ∑‰Ë’ ¥√â ∫— °“√√°— …“‚¥¬°“√∑” hemodialysis «π— ‡«πâ «π— (√Õâ ¬≈– 28 ‡¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— √Õâ ¬≈– 46) æ∫Õÿ∫—µ‘°“√≥å¢Õß§«“¡¥—π‚≈À‘µµË”∑’ËπâÕ¬°«à“ ·≈–ºŸâªÉ«¬À“¬®“°¿“«–‰µ«“¬©—∫æ≈—π‰¥â‡√Á«°«à“ (9 «π— ‡¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— 16 «π— ) §“à single pool Kt/V §Õà π¢“â ßµ”Ë §Õ◊ 0.94 µÕà °“√∑” dialysis ·µ≈à –§√ßÈ— „π¢≥–∑’Ë°≈ÿà¡∑’Ë∑” hemodialysis ∑ÿ°«—π°Á¡’§à“ single pool Kt/V ∑’Ë„°≈â‡§’¬ß°—π·µà∑”∫àÕ¬°«à“ º≈∑’Ë‰¥â ®“°°“√»°÷ …“π·’È ¥ß„À‡â ÀπÁ «“à °“√√°— …“‚¥¬°“√∑”dialysis∑‰’Ë ¡‡à æ¬’ ßæÕ ¡— æπ— ∏°å ∫— Õµ— √“°“√µ“¬∑‡’Ë æ¡‘Ë ¢π÷È ª®í ®∫ÿ π— ¬ß— ‰¡¡à ’ evidence-based ∑·Ë’ π–π”‡°¬Ë’ «°∫— ¢π“¥°“√√°— …“∑‡Ë’ À¡“– ¡„πºªâŸ «É ¬ acute kidney injury ¢Õâ ·π–π”¢Õß°≈¡ÿà acute dialysis initiative51 ‡°¬’Ë «°∫— ¢π“¥°“√√°— …“‚¥¬°“√∑” hemodialysis „πºŸâªÉ«¬¿“«–‰µ«“¬©—∫æ≈—π ·π–π”«à“¢π“¥°“√√—°…“∑’ËπâÕ¬∑’Ë ÿ¥∑’ËºŸâªÉ«¬§«√®–‰¥â√—∫§«√®–‡∑à“°—∫ °≈ÿà¡ºâŸªÉ«¬∑’Ë‰¥â√—∫°“√∑” chronic hemodialysis ´÷Ëß§«√¡’§à“ Kt/V ¡“°°«à“ 1.2 µàÕ°“√∑” dialysis „π ·µ≈à –§√ßÈ— „πºªâŸ «É ¬∑∑Ë’ ” dialysis 3 §√ßÈ— µÕà ª— ¥“Àå À√Õ◊ §«√¡§’ “à Kt/V ¡“°°«“à 1 „πºªâŸ «É ¬∑∑Ë’ ” dialysis Õ¬à“ßπâÕ¬ 6 §√—ÈßµàÕ —ª¥“Àå Õ¬à“ß‰√°Áµ“¡‡π◊ËÕß®“°§à“√—°…“∑’Ë Ÿß·≈–§«“¡®”‡ªìπ∑’ËµâÕß„™â∫ÿ§≈“°√ ‡ªπì ®”π«π¡“°„πºªŸâ «É ¬∑µË’ Õâ ß∑” hemodialysis ∫Õà ¬§√—ßÈ ∑”„À°â “√√°— …“‚¥¬°“√∑” hemodialysis ∑°ÿ «π— ‰¡‰à ¥√â ∫— §«“¡π¬‘ ¡ - Optimal dosing of continuous renal replacement therapy ‰¥¡â °’ “√»°÷ …“·∫∫ randomized controlled trial18,52-53 À≈“¬°“√»°÷ …“‡°¬Ë’ «°∫— °“√‡æ¡Ë‘ ¢π“¥ °“√√—°…“¢Õß CRRT º≈°“√»÷°…“∑’Ë‡°’Ë¬«°—∫Õ—µ√“°“√√Õ¥™’«‘µ¢ÕßºâŸªÉ«¬„π·µà≈–°“√»÷°…“¬—ß§ß·µ° µ“à ß°π— ¥ß— ‡™πà °“√»°÷ …“¢Õß Ronco ·≈–§≥–52 ‰¥∑â ”°“√»°÷ …“ºªŸâ «É ¬®”π«π 425 √“¬∑¡’Ë ’ acute kidney injury ‚¥¬·∫ßà ºªŸâ «É ¬ÕÕ°‡ªπì “¡°≈¡àÿ ·µ≈à –°≈¡àÿ „À°â “√√°— …“‚¥¬°“√∑” CVVH ¥«â ¬¢π“¥ ultrafiltration rates ∑·Ë’ µ°µ“à ß°π— §Õ◊ 20, 35 À√Õ◊ 45 ¡≈./°°./™¡. ∑Ë’ 15 «π— À≈ß— ®“°À¬¥ÿ ∑” CVVH æ∫«“à „π°≈¡àÿ ºªŸâ «É ¬∑Ë’ ‰¥â√—∫°“√√—°…“„π¢π“¥∑’ËµË” (20 ¡≈./°°./™¡.) ¡’Õ—µ√“°“√√Õ¥™’«‘µµË”°«à“Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ „π°≈¡àÿ ºªŸâ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“„π¢π“¥∑ªË’ “π°≈“ß (35 ¡≈./°°./™¡.) À√Õ◊ ßŸ (45¡≈./°°./™¡.) (√Õâ ¬≈– 41 ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ √âÕ¬≈– 57 ·≈–√âÕ¬≈– 58 „πºâŸ∑’Ë‰¥â√—∫°“√√—°…“„π¢π“¥°≈“ß·≈–¢π“¥ Ÿß µ“¡≈”¥∫— ) (√ªŸ ∑Ë’ 11) °“√»°÷ …“¢Õß Bouman ·≈–§≥–18 ‰¥∑â ”°“√»°÷ …“ºªŸâ «É ¬®”π«π 106 √“¬∑¡Ë’ ¿’ “«– oliguria ‚¥¬ ¡àÿ ºªâŸ «É ¬„À‰â ¥√â ∫— °“√√°— …“ 3 ·∫∫§Õ◊ early high-volume CVVH, early low-volume CVVH ·≈– late low-volume CVVH ∑Ë’ 28 «π— Õµ— √“°“√√Õ¥™«’ µ‘ ¢ÕßºªâŸ «É ¬∑ßÈ— “¡°≈¡àÿ ‰¡·à µ°µ“à ß°π— (√Õâ ¬– 74, 69, ·≈– 75 µ“¡≈”¥—∫) Õ¬à“ß‰√°Áµ“¡°“√»÷°…“π’È¬—ß‰¡à¡’πÈ”Àπ—°‡æ’¬ßæÕ∑’Ë®–·¬°¢âÕ·µ°µà“ß¢ÕßÕ—µ√“°“√√Õ¥

New Frontiers in Dialysis 230 ∏πµ‘ ®√‘ ππ— ∑∏å «™— ‘√¿‘ “ ™â“ß»√‘ °‘ ÿ≈™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « —πµå ÿ‡¡∏°ÿ≈ √ªŸ ∑’Ë 11 °√“ø Kaplan Meier estimation of survival rates „πºªŸâ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“‚¥¬°“√∑” CRRT ∑ÕË’ µ— √“ °“√°√Õßµ“à ßÊ: Group 1; 20 ¡≈./°°./™¡., Group 2; 35 ¡≈./°°./™¡., Group 3; 45 ¡≈./°°./™¡. ™’«‘µ„πºâŸªÉ«¬∑—Èß “¡°≈ÿà¡π’È‰¥â πÕ°®“°π’ÈÕ—µ√“°“√√Õ¥™’«‘µ∑’Ë Ÿß„πºŸâªÉ«¬∑—Èß “¡°≈ÿà¡∫àß∫Õ°«à“ºŸâªÉ«¬∑’Ë ‡¢“â √∫— °“√»°÷ …“„π§√ß—È π¡’È Õ’ “°“√¢Õß‚√§∑Õ’Ë “®‰¡√à πÿ ·√ß´ß÷Ë ‰¡‡à À¡Õ◊ π°≈¡ÿà ºªâŸ «É ¬¿“«–«°‘ ƒµ∑‘ ¡’Ë a’ cutekidney injury ∑µË’ Õâ ß°“√°“√∑” RRT ‚¥¬∑«Ë— ‰ª °“√»°÷ …“¢Õß Saudan ·≈–§≥–53 ‰¥∑â ”°“√»°÷ …“ºªŸâ «É ¬®”π«π 206 √“¬ ‚¥¬ ¡ÿà „À°â “√√°— …“ ∑ßÈ— CVVH (hemofiltration rate 25±5 ¡≈./°°./™¡. ¢Õß replacement fluid) À√Õ◊ CVVHDF (hemofiltration rate 24±6 ¡≈./°°./™¡. √«à ¡°∫— 18±5 ¡≈./°°./™¡. ¢Õß dialysate flow) ®–‡ÀπÁ ‰¥«â “à °“√»°÷ …“π‰È’ ¥‡â æ¡Ë‘ °“√°“√ „™â dialysate flow ‡¢“â ‰ª„πº∑âŸ ∑Ë’ ” CVVH ∑”„À¡â °’ “√‡æ¡Ë‘ °“√¢®¥— ¢Õß‡ ¬’ ‚¥¬°“√ diffusion ‡æ¡Ë‘ ¢πÈ÷ º≈ °“√»÷°…“æ∫«à“Õ—µ√“°“√√Õ¥™’«‘µ Ÿß°«à“„π°≈ÿà¡ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√∑” CVVHDF ∑’Ë 28 «—π (√âÕ¬≈– 59 ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫√âÕ¬≈– 34) Õ¬à“ß‰√°Áµ“¡§«√·ª≈º≈°“√»÷°…“π’È¥â«¬§«“¡√–¡—¥√–«—ß‡π◊ËÕß®“° ‡ªπì °“√»°÷ …“∑‡Ë’ ªπì ·∫∫™π¥‘ unblinded ·≈–¬ß— ‡ªπì °“√»°÷ …“∑‡Ë’ ªπì single center study ß“π«®‘ ¬— À≈“¬™π‘È °”≈ß— Õ¬„àŸ π°“√»°÷ …“‡æÕ◊Ë „À‰â ¥§â ”µÕ∫‡°¬’Ë «°∫— optimaldose¢Õß°“√∑”CRRT ·≈– IHD „πºªŸâ «É ¬‰µ«“¬©∫— æ≈π— 54,55 The United States VA/NIH acute renal trial network study (ATN)54 ‰¥∂â °Ÿ ÕÕ°·∫∫¡“‡æÕ◊Ë ‡ª√¬’ ∫ ‡∑¬’ ∫ ºªŸâ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“ 2 ¢π“¥ ‚¥¬°“√∑” IHD, CRRT À√Õ◊ SLED ¢πÈ÷ Õ¬°Ÿà ∫— hemodynamic status ¢ÕßºªâŸ «É ¬·µ≈à –√“¬ ¢π“¥¢Õß°“√√°— …“ 2 ¢π“¥ §Õ◊ Intensive therapy - hemodialysis ·≈– SLED ∂°Ÿ ÕÕ°·∫∫„À‰â ¥√â ∫— °“√√°— …“ 6 §√ß—È µÕà ª— ¥“Àå ·≈– target Kt/V §Õ◊ 1.2-1.4 µÕà °“√√°— …“·µ≈à –§√ß—È „π¢≥–∑’Ë CRRT °”Àπ¥„À‰â ¥â effluent flow rate 35 ¡≈./°°./™¡. ·≈– Less intensive therapy - hemodialysis ·≈–

Dialysis in Acute Kidney Injury ≥∞— ™¬— »√’ « — ¥Ï‘ ¢®√ µ’√≥∏π“°ÿ≈ 231 SLED ∂°Ÿ ÕÕ°·∫∫„À‰â ¥√â ∫— °“√√°— …“ 3 §√ßÈ— µÕà ª— ¥“Àå „π¢≥–∑Ë’ CRRT °”Àπ¥„À‰â ¥â effluent flow rate 20 ¡≈./°°./™¡. °“√»°÷ …“π®È’ – πÈ‘ ¥ÿ „πªï æ.». 2551 „πª√–‡∑»ÕÕ ‡µ√‡≈¬’ ·≈–π«‘ ´·’ ≈π¥å ¡°’ “√»°÷ …“∑™Ë’ ÕË◊ the Randomized Evaluation of Normal versus Augmented Level of RRT (RENAL) study55 ‰¥Õâ Õ°·∫∫°“√√°— …“‚¥¬°“√ ¡àÿ „Àºâ ªŸâ «É ¬‰¥√â ∫— °“√ √°— …“‚¥¬ CVVHDF „π¢π“¥ effluent flow 25 À√Õ◊ 40 ¡≈./°°./™¡. °“√»°÷ …“π®È’ – πÈ‘ ¥ÿ „πªï æ.». 2551 ‡™πà ‡¥¬’ «°π— §ßµÕâ ß√Õº≈°“√»°÷ …“‡À≈“à π‡’È æÕ◊Ë ∑®’Ë –π”¡“‡ªπì ·π«∑“ß„π°“√√°— …“ºªâŸ «É ¬‰µ«“¬©∫— æ≈π— µÕà ‰ª °≈“à «‚¥¬ √ªÿ 1. ºªâŸ «É ¬∑¡Ë’ ’ life threatening complication ¢Õß acute kidney injury §«√‰¥√â ∫— °“√‡√¡Ë‘ µπâ °“√ √°— …“‚¥¬ RRT 2. ¬ß— ‰¡¡à ¢’ Õâ √ªÿ ∑·’Ë ππà Õπ«“à °“√√°— …“ºªâŸ «É ¬°Õà π∑®’Ë –¡Õ’ “°“√∑“ß§≈π‘ °‘ (earlyorprophylactic dialysis) ®–¡’Õ—µ√“°“√√Õ¥™’«‘µ∑’Ë¥’¢÷Èπ ·µàºâŸ‡™’Ë¬«™“≠À≈“¬∑à“π·π–π”„Àâ‡√‘Ë¡°“√√—°…“ºâŸªÉ«¬°àÕπ∑’Ë®– ¡’Õ“°“√À√◊ÕÕ“°“√· ¥ß¢Õß¿“«–‰µ«“¬©—∫æ≈—π ‡ªìπ‰ª‰¥â¬“°∑’Ë®–¡’√–¥—∫∑’Ë·πàπÕπ¢Õß§à“ BUN ∑’Ë §«√®–‡√¡Ë‘ °“√√°— …“‚¥¬ RRT ·π«∑“ßªØ∫‘ µ— ‚‘ ¥¬∑«Ë— ‰ª ®–‡√¡Ë‘ ∑” RRT ‡¡ÕË◊ ¡√’ –¥∫— BUN 80-100 ¡°/¥≈ ∂ß÷ ·¡®â –¬ß— ‰¡¡à ¢’ Õâ µ°≈ß∑·’Ë ππà Õπ°µÁ “¡ 3. ®“°¢Õâ ¡≈Ÿ „πª®í ®∫ÿ π— ¬ß— ‰¡¡à ¢’ Õâ √ªÿ ∑·Ë’ ππà Õπ«“à °“√∑” IHD À√Õ◊ CRRT ®–‰¥ªâ √–‚¬™πå ¡“°°«“à °π— ·≈–‰¡¡à ¢’ Õâ ¡≈Ÿ ∑‡Ë’ æ¬’ ßæÕ‡°¬Ë’ «°∫— hybrid therapy ·≈–°“√∑” acute peritoneal dialysis ¥ß— π—Èπ°“√∑’Ë®–‡≈◊Õ°∑” RRT ™π‘¥„¥®÷ß¢÷ÈπÕ¬àŸ°—∫§«“¡™”π“≠¢Õß·µà≈–·Ààß·≈–ª√– ∫°“√≥å√à«¡°—∫ §«“¡µÕâ ß°“√„π°“√√°— …“ºªŸâ «É ¬·µ≈à –√“¬ À“°‡≈Õ◊ °„™â CRRT º‡Ÿâ ™¬Ë’ «™“≠·π–π”„À‡â ≈Õ◊ °°“√∑” CVVH ¡“°°«“à °“√∑” CAVH 4. ¢π“¥°“√√°— …“‚¥¬°“√∑” RRT ¬ß— ‰¡™à ¥— ‡®π „π°“√∑” IHD º‡âŸ ™¬Ë’ «™“≠·π–π”„À„â ™¢â π“¥°“√√°— …“ delivered Kt/V > 1.2 µÕà °“√√°— …“ ·µ≈à –§√ßÈ— ∂“â ∑”°“√øÕ°‰µ ª— ¥“À≈å – 3 §√ßÈ— À√Õ◊ Õ¬“à ßµ”Ë delivered Kt/V > 1 À“°∑”°“√øÕ°‰µÕ¬“à ßµ”Ë 6 §√ßÈ— µÕà ª— ¥“Àå „π°√≥’ CRRT º‡âŸ ™¬Ë’ «™“≠·π–π”„À„â ™â effluence flow rate (º≈√«¡¢Õß hemofiltration rate ·≈– dialysate flow rate) Õ¬“à ßµ”Ë 35 ¡≈./°°./™¡. 5. ∫∑∫“∑¢Õß peritoneal dialysis „π acute kidney injury 5.1 §«“¡√æâŸ πÈ◊ ∞“π §«“¡√æâŸ π◊È ∞“πperitonealdialysis(PD)‡ªπì Õ°’ ∑“ß‡≈Õ◊ °Àπß÷Ë ∑„’Ë ™„â π°“√√°— …“·∫∫ª√–§∫— ª√–§Õß „πºªâŸ «É ¬‰µ«“¬©∫— æ≈π— ‚¥¬À≈°— ·≈«â ¡°— „™â peritoneal dialysis „π°“√√°— …“ºªŸâ «É ¬‰µ«“¬‡√ÕÈ◊ √ß— πÕ°®“°πÈ’ acute PD ¬—ß‡ªìπ∑“ß‡≈◊Õ°Àπ÷Ëß∑’Ë„™â√—°…“ºŸâªÉ«¬‰µ«“¬©—∫æ≈—π∑’Ë¡’¿“«–√–∫∫‰À≈‡«’¬π‚≈À‘µ∑’Ë‰¡à§ß∑’Ë À√Õ◊ ºªâŸ «É ¬∑¡Ë’ §’ «“¡º¥‘ ª°µ¢‘ Õß°“√·¢ßÁ µ«— ¢Õß‡≈Õ◊ ¥ 56,57

New Frontiers in Dialysis 232 ∏πµ‘ ®‘√ππ— ∑å∏«™— √‘ ¿‘ “ ™“â ß»‘√°‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå ÿ‡¡∏°≈ÿ ¢Õâ ‰¥‡â ª√¬’ ∫¢Õß°“√∑” acute PD „πºªâŸ «É ¬‰µ«“¬©∫— æ≈π— ‡¡Õ◊Ë ‡∑¬’ ∫°∫— °“√∑” RRT ‚¥¬«∏‘ Õ’ π◊Ë Ê §Õ◊ 1. ‡ªπì «∏‘ °’ “√∑”∑ßË’ “à ¬ ®ß÷ “¡“√∂∑®Ë’ –‡≈Õ◊ °„™‰â ¥Õâ ¬“à ß°«“â ß¢«“ß„π‚√ßæ¬“∫“≈À≈“¬Ê·Àßà ·≈– “¡“√∂∑”‰¥‚â ¥¬æ¬“∫“≈∑¥’Ë ·Ÿ ≈ºªŸâ «É ¬¿“«–«°‘ ƒµ∑‘ ‰’Ë ¥√â ∫— °“√Ω°ñ Ωπ¡“ 2. ª√‘¡“≥¢Õß “√πÈ”·≈– solute ®”π«π¡“° “¡“√∂¢®—¥ÕÕ°‰¥âßà“¬„πºâŸªÉ«¬∑’Ë¡’√–∫∫ ‰À≈‡«¬’ π‚≈Àµ‘ ∑‰Ë’ ¡§à ß∑Ë’ ‡πÕË◊ ß®“°‡ªπì °“√¢®¥— ‡Õ“ “√π”È ·≈– solute ÕÕ°¡“Õ¬“à ß™“â Ê ‰¥5â 8 3. ‰¡‡à °¥‘ ¿“«– disequilibrium ‡πÕË◊ ß®“°‡ªπì «∏‘ °’ “√¢®¥— solute ÕÕ°‰ª®“°√“à ß°“¬Õ¬“à ß™“â Ê 4. ß“à ¬µÕà °“√§«∫§¡ÿ ¿“«– acid-base ·≈– electrolyte imbalance 5. ∑”°“√«“ß “¬ PD ‰¥ßâ “à ¬‚¥¬‡©æ“–„π‡¥°Á °“√«“ß “¬ PD “¡“√∂∑”‰¥‰â ¡¬à “°‚¥¬„™â semi-rigid catheter À√Õ◊ „™â single- cuff tenckhoff catheter semi-rigid catheter “¡“√∂«“ß “¬‰¥¢â “â ß ‡µ’¬ß‚¥¬Õ“¬ÿ√·æ∑¬å‚√§‰µÀ√◊Õ»—≈¬·æ∑¬å à«π Tenckhoff catheter “¡“√∂«“ß‰¥â∑’ËÀâÕßºà“µ—¥‚¥¬ »—≈¬å·æ∑¬å ·≈–‡π◊ËÕß®“° “¬ catheter ∑’Ë„™â¡’§«“¡¬◊¥À¬ÿàπ ºâŸªÉ«¬®÷ß¡’§«“¡√âŸ ÷°∑’Ë ∫“¬·≈–∫“ß§√—Èß ¬—ß “¡“√∂∑’Ë®–‡§≈◊ËÕπ‰À«‰¥â√Õ∫Ê ‡µ’¬ß °“√ºà“µ—¥¬—ß‡ªìπ°“√À≈’°‡≈’Ë¬ß°“√‡°‘¥¿“«–≈”‰ â∑–≈ÿ®“° °“√„ à “¬‚¥¬«‘∏’ blinded technique Õ“¬ÿ√·æ∑¬å‚√§‰µÀ≈“¬∑à“π‰¥â„ à catheter ‚¥¬„™â fluoroscope √à«¡°—∫°“√„ à guidewire ‚¥¬µ√ß À√◊Õ„™â°“√ àÕß°≈âÕß (peritoneoscope) ´÷Ëß∑—Èß Õß«‘∏’ “¡“√∂∑”‰¥â ¢“â ß‡µ¬’ ßºªâŸ «É ¬ 6. ‰¡à®”‡ªπì µâÕß‡®“–‡ âπ‡≈◊Õ¥·¥ßÀ√Õ◊ ‡≈πâ ‡≈◊Õ¥¥” ·≈–‰¡à®”‡ªìπµÕâ ß„™â “√°π— °“√·¢ßÁ µ—« ¢Õß‡≈Õ◊ ¥ ‡æ√“–©–ππÈ— ®ß÷ ·π–π”„À„â ™„â πºªŸâ «É ¬¥ß— µÕà ‰ªπ5È’ 8 ë º∑âŸ ¡Ë’ ’ bleeding diathesis ë ºªŸâ «É ¬¿“¬À≈ß— °“√º“à µ¥— ë ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— Õ∫ÿ µ— ‡‘ Àµÿ (trauma) ë ºªâŸ «É ¬∑¡’Ë ¿’ “«–‡≈Õ◊ ¥ÕÕ°„π ¡Õß 7. ¡’ biocompatibility ∑ Ë’ ßŸ 8. °“√ ßË— °“√√°— …“ß“à ¬‚¥¬‡©æ“–„π‡¥°Á acute PD ∂°Ÿ „™Õâ ¬“à ß·æ√Àà ≈“¬„π°“√√°— …“ºªŸâ «É ¬ ‡¥Á°∑’Ë¡’¿“«–‰µ«“¬©—∫æ≈—π ‡π◊ËÕß®“°‡ªìπ«‘∏’°“√∑’Ëßà“¬·≈–ª≈Õ¥¿—¬‚¥¬‡©æ“–°“√„ à “¬ PD πÕ°®“°π°’È “√∑”PD‰¡µà Õâ ß°“√‡®“–º“à π‡ πâ ‡≈Õ◊ ¥®ß÷ ∑”‰¥ßâ “à ¬·≈–‰¥√â ∫— §«“¡√«à ¡¡Õ◊ ®“°‡¥°Á ‰¥ßâ “à ¬°«“à 5.2 ¢Õâ ∫ßà ™„È’ π°“√∑” PD 1. absolute indication „π°“√∑” acute PD §Õ◊ °“√∑®Ë’ ”‡ªπì ®–µÕâ ß∑” dialysis ‚¥¬∑‰Ë’ ¡ à “¡“√∂ ∑”°“√√°— …“‰¥‚â ¥¬°“√∫”∫¥— ∑¥·∑π‰µÕ¬“à ßÕπ◊Ë ‰¥â 2. relative indication „π°“√∑” acute PD „πº„Ÿâ À≠5à 8 ª√–°Õ∫¥«â ¬ ë hemodynamically unstable patients ë bleeding diathesis or hemorrhagic conditions ë difficulty in obtaining blood access

Dialysis in Acute Kidney Injury ≥—∞™—¬ »√’ « — ¥Ï‘ ¢®√ µ√’ ≥∏π“°≈ÿ 233 ë removal of high molecular weight toxins (>10 kD) ë clinically significant hypothermia and hyperthermia ë heart failure refractory to medical management 5.3 ¢Õâ À“â ¡∑” acute PD ¢Õâ À“â ¡„π°“√∑” acute PD «à π„À≠‡à ªπì ‡æ¬’ ß relative contraindication58 ´ßË÷ ª√–°Õ∫¥«â ¬ 1. recent abdominal and/or cardiothoracic surgery 2. diaphragmatic peritoneal-pleural connections 3. levere respiratory failure 4. life-threatening hyperkalemia 5. extremely high catabolism 6. severe volume overload in a patient not on a ventilator 7. severe gastroesophageal reflux disease 8. low peritoneal clearances 9. fecal or fungal peritonitis 10. abdominal wall cellulitis 11. acute renal failure in pregnancy 5.4 ‡∑§π§‘ „π°“√∑” acute PD “¡“√∂∑” acute PD ‰¥∑â ßÈ— ·∫∫ intermittent À√Õ◊ continuous (¢πÈ÷ Õ¬°Ÿà ∫— §«“¡µÕâ ß°“√„π°“√ ¢®¥— π”È À√Õ◊ solute «à π‡°π‘ ÕÕ°®“°√“à ß°“¬) √«¡∑ßÈ— °“√∑”·∫∫ manual À√Õ◊ °“√„™‡â §√ÕË◊ ß automated PD59 Acute manual PD «à π¡“°¥”‡ππ‘ °“√‚¥¬æ¬“∫“≈ ´ßË÷ ‚¥¬ª°µ°‘ “√∑”«∏‘ π’ µÈ’ Õâ ß°“√º¥Ÿâ ·Ÿ ≈∑®Ë’ – §Õ¬µ√«® Õ∫ª√‘¡“≥ PD fluid ∑’Ë‡¢â“ ŸàºâŸªÉ«¬¥â«¬Õ—µ√“‡√Á«∑’Ë‡À¡“– ¡ ‡«≈“∑’Ë„™â„π°“√æ—°πÈ”¬“‰«â„π ™àÕß∑âÕß·≈–√–¬–‡«≈“∑’Ëª≈àÕ¬πÈ”¬“ÕÕ°¡“ æ¬“∫“≈ºâŸ™à«¬§Õ¬∑”Àπâ“∑’Ë®¥∫—π∑÷°ª√‘¡“≥πÈ”¬“∑’Ë„Àâ ‡¢“â ‰ª·≈–ª≈Õà ¬ÕÕ°¡“ √«¡∑ßÈ— §”π«≥ net ultrafiltration ∑‰Ë’ ¥√â ∫— ¥«â ¬ „π¢≥–∑’Ë°“√∑” automated PD °“√∑”ß“π¢â“ßµâπ®–∂Ÿ°·∑π∑’Ë¥â«¬‡§√◊ËÕßøÕ°‰µÕ—µ‚π¡—µ‘ ∑“ßÀπâ“∑âÕß √«¡∑—Èß°“√∑’Ë‰¡àµâÕß‡ ’¬‡«≈“¡“§Õ¬‡ª≈’Ë¬ππÈ”¬“·≈–πÈ”¬“∑’Ë„™â°—∫‡§√◊ËÕßøÕ°‰µÕ—µ‚π¡—µ‘ ∑“ßÀπâ“∑âÕß “¡“√∂‡µ√’¬¡‰¥â„π¢π“¥∑’Ë¡“° (ª°µ‘πÈ”¬“∑’Ë„™â™π‘¥ manual ®–¡’ª√‘¡“≥πÈ”¬“∂ÿß≈– ª√–¡“≥ 2,000 ¡≈. „π¢≥–∑πË’ ”È ¬“ automated PD ¡∂’ ßÿ ≈–ª√–¡“≥ 5,000 ¡≈.) 5.4.1 Acute intermittent peritoneal dialysis “¡“√∂„™‡â ∑§π§‘ π‰È’ ¥∑â ßÈ— °“√∑”·∫∫ manual À√Õ◊ automate PD ‚¥¬ª°µ®‘ – ßË— °“√√°— …“‚¥¬ „™â short dwell times ª√¡‘ “≥π”È ¬“ 2,000 ¡≈. ·≈– dialysate flow rate 2 ∂ß÷ 6 ≈µ‘ √/™¡. 5.4.2 Chronic equilibrated peritoneal dialysis

New Frontiers in Dialysis 234 ∏πµ‘ ®√‘ ππ— ∑å∏«™— ‘√‘¿“ ™“â ß»√‘ °‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå ‡ÿ ¡∏°≈ÿ Chronic equilibrated peritoneal dialysis (CEPD) ‡À¡Õ◊ π°∫— chronic ambulatory peritoneal dialysis ¬°‡«πâ ∑” CEPD „πºªâŸ «É ¬∑‰’Ë ¡ à “¡“√∂‡§≈Õ◊Ë π‰À«‰¥â ‡∑§π§‘ π ’È “¡“√∂§ß¿“«– (maintain) fluid ·≈– solute balance ·≈–¬ß— “¡“√∂∑” manual ‰¥¥â «â ¬‚¥¬∑”ª√–¡“≥ 4 §√ß—È µÕà «π— §“â ßπÈ”¬“‰«πâ “π§√ß—È ≈–ª√–¡“≥ 4-6 ™¡. “¡“√∂∑” CEPD ‰¥‚â ¥¬„™â automated machine60 ´ßË÷ “¡“√∂µßÈ— √–¬–‡«≈“µ“¡∑µË’ Õâ ß°“√‰¥â ‚¥¬ ‰¡àµâÕßÀ¬ÿ¥°“√∑”°“√øÕ°‰µ‡æ◊ËÕ‡ª≈’Ë¬ππÈ”¬“·≈–™à«¬≈¥‚Õ°“ ‡°‘¥°“√µ‘¥‡™◊ÈÕ®“°°“√‡ª≈’Ë¬π∂à“¬ π”È ¬“∫Õà ¬§√ßÈ— ¬ß— “¡“√∂ª√∫— ¢π“¥°“√√°— …“ CEPD ‡æÕË◊ §«∫§¡ÿ ª√¡‘ “≥ “√π”È ·≈– nitrogen wastes product ‰¥¥â «â ¬ 5.4.3 Tidal peritoneal dialysis Tidal peritoneal dialysis (TPD) ‡ªπì Õ°’ √ªŸ ·∫∫ÀπßË÷ ¢Õß°“√ ßË— °“√√°— …“ peritoneal dialysis ´ßË÷ ‚¥¬ª°µ®‘ –∑”°“√§“â ßπÈ”‰«„â π™Õà ß∑Õâ ß1,000¡≈.À≈ß— ®“°„ πà È”‡¢“â ‰ª„π™Õà ß∑Õâ ß2,000¡≈.«∏‘ π’ ®’È –™«à ¬‡æ¡‘Ë solute clearance ‰¥6â 1 5.4.4 Continuous flow peritoneal dialysis Continuous flow peritoneal dialysis (CFPD) ‡ªπì ‡∑§π§‘ ‡°“à ∑∂Ë’ °Ÿ π”¡“„™„â π°“√√°— …“ºªŸâ «É ¬‰µ «“¬©—∫æ≈—π CFPD „™â 2 accesses ‚¥¬ access ·√°‡ªìπ∑“ß‡¢â“¢ÕßπÈ”¬“ dialysis ·≈–Õ’° access ‡ªπì ∑“ßÕÕ°¢ÕßπÈ”¬“ dialysis ‚¥¬πÈ”¬“®–∂°Ÿ ª≈Õà ¬‡¢“â ·≈–ÕÕ°µ≈Õ¥‡«≈“´ß÷Ë Õ“®®–„™‡â ªπì single pass À√Õ◊ „™â external dialyzer ‡æÕË◊ regenerate sterile dialysis „À¡à ¥«â ¬‡∑§π§‘ π È’ “¡“√∂‡æ¡Ë‘ dialysate flow ∂ß÷ 300 ¡≈/π“∑’ ·≈– urea clearance 30-50 ¡≈/π“∑’ ª®í ®∫ÿ π— ¡°’ “√ÕÕ°·∫∫ catheter „À¡Àà ≈“¬·∫∫ ”À√∫— CFPD ‡æÕË◊ ™«à ¬„À¡â ’ adequate mixing ¢Õß intraperitoneal dialysate62,63 5.4.5 Peritoneal access ÀπßË÷ „π§«“¡ ”‡√®Á ¢Õß°“√∑” acute PD §Õ◊ °“√∑¡Ë’ ’ peritoneal access ∑„Ë’ ™‰â ¥¥â 5’ 9 ‚¥¬Õ“®„™â ‡ªπì semi-rigid acute catheter À√Õ◊ single-cuff Tenckhoff catheter ´ßË÷ ¡¢’ Õâ ¥¢’ Õâ ‡ ¬’ µ“à ß°π— ¥ß— πÈ’ - Semi-rigid acute catheter ¢Õâ ¥∑’ ™Ë’ ¥— ‡®π¢Õß simi-rigid acute catheter §Õ◊ “¡“√∂„ ‰à ¥ßâ “à ¬·≈– –¥«°‚¥¬ Õ“¬√ÿ ·æ∑¬å ‚√§‰µ∑¢’Ë “â ß‡µ¬’ ßºªŸâ «É ¬‚¥¬‰¡®à ”‡ªπì µÕâ ßÕ“»¬— »≈— ¬·æ∑¬6å 4 ·≈–„π¢≥–∑∑’Ë ”„™‡â æ¬’ ß·§°à “√©¥’ ¬“™“‚¥¬ ‰¡µà Õâ ß‡ ¬’Ë ßµÕà °“√¥¡¬“ ≈∫‡æÕ◊Ë À≈°’ ‡≈¬’Ë ßº≈¢“â ß‡§¬’ ß∑Õ’Ë “®‡°¥‘ ¢π÷È „πºªâŸ «É ¬∑Õ’Ë ¬„àŸ π¿“«–«°‘ ƒµ‘ Õ¬à“ß‰√°Áµ“¡æ∫«à“¡’¢âÕ‡ ’¬À≈“¬ª√–°“√®“°°“√„™â semi-rigid catheter ‘Ëß∑’Ë ”§—≠∑’Ë ÿ¥ §Õ◊ °“√¡§’ «“¡‡ ¬Ë’ ßµÕà °“√µ¥‘ ‡™ÕÈ◊ ßŸ ‡πÕË◊ ß®“° catheter ™π¥‘ π‰È’ ¡¡à ’ cuff ´ßË÷ ®–‡ªπì µ«— ™«à ¬„π°“√ªÕÑ ß°π— °“√µ¥‘ ‡™Õ◊È Õ∫ÿ µ— °‘ “√≥°å “√µ¥‘ ‡™Õ◊È ®– ßŸ ¡“°∂“â ∑ß‘È catheter‰«πâ “π‡°π‘ 72™¡.64,65 πÕ°®“°π°’È “√„™â semirigid catheter ¬—ß¡’‚Õ°“ ‡ ’Ë¬ßµàÕ¿“«– bowel perforation Õ’°¥â«¬ ¥—ßπ—Èπ„π°“√„™â catheter ™π‘¥π’È®–µâÕß ‡Õ“ “¬ÕÕ°À≈ß— ®“°„  à “¬ catheter ‡¢“â ‰ª·≈«â 72 ™¡. ®ß÷ ‰¡‡à À¡“–∑®Ë’ –„™„â π√“¬∑ºË’ ªŸâ «É ¬¬ß— √ Ÿâ °÷ µ«— Õ¬àŸ - Cuffed permanent catheter ¢Õâ ¥®’ “°°“√„™â Cuffed permanent catheter56,59,66-67 1. “¡“√∂„™ßâ “π‰¥∑â π— ∑À’ ≈ß— „ à 2. Õ∫ÿ µ— °‘ “√≥¢å Õß°“√µ¥‘ ‡™ÕÈ◊ µ”Ë °«“à °“√„™â semi-rigid catheter

Dialysis in Acute Kidney Injury ≥∞— ™—¬ »√ ’ « — ¥Ï‘ ¢®√ µ’√≥∏π“°ÿ≈ 235 3. À≈°’ ‡≈¬Ë’ ß°“√«“ß “¬´”È „π°√≥∑’ ®Ë’ –µÕâ ß∑” intermittent hemodialysis µ“à ß®“° semi-rigid catheter ´÷ËßÕ“®µâÕß°“√«“ß “¬´È”‡π◊ËÕß®“°ºâŸªÉ«¬‰µ«“¬©—∫æ≈—πÕ“®µâÕß°“√∑”°“√øÕ°‰µ∑’Ë‰¡à ¡”Ë ‡ ¡Õ·≈–‰¡ à “¡“√∂„ à semirigid catheter ‰«πâ “π‡°π‘ 3 «π— 4. “¬ catheter ™π¥‘ π‡È’ ªπì “¬ÕÕà π ®ß÷ ‰¡§à Õà ¬ trauma µÕà bowel À√Õ◊ intraperitoneal organs ÕπË◊ Ê ·≈–ºªâŸ «É ¬®–√ Ÿâ °÷ ∫“¬°«“à °“√„  à “¬ catheter ™π¥‘ semi-rigid catheter 5. “¬ catheter ™π¥‘ π‰È’ ¥√â ∫— °“√ÕÕ°·∫∫¡“„À„â ™‰â ¥°â ∫— ‡§√ÕË◊ ß automated PD „π¢≥–∑ Ë’ “¬ semi-rigid catheter ∫“ß§√ßÈ— ®– trigger „À‡â §√ÕË◊ ß alarm ∑”„Àµâ Õâ ßÀ¬¥ÿ °“√∑”ß“π¢Õß‡§√ÕË◊ ß‡ªπì æ°— Ê ¢Õâ ¥∑’ °’Ë ≈“à «¡“§«√®–µÕâ ßπ”¡“™ß—Ë πÈ”Àπ°— °∫— ª®í ®¬— ‡ ¬’Ë ß∑Õ’Ë “®®–‡°¥‘ ¢π÷È √«¡∑ß—È complication·≈–morbidity ∑ ’Ë ¡— æπ— ∏°å ∫— °“√º“à µ¥— ·≈–°“√¥¡¬“ ≈∫(∂“â ‰¡‰à ¥„â   à “¬‚¥¬°“√∑”¢“â ß‡µ¬’ ßºªŸâ «É ¬‚¥¬„™âpercutaneous technique) 5.5 Acute peritoneal dialysis prescription Standard acute peritoneal dialysis prescription ª√–°Õ∫¥«â ¬ 1. length of the dialysis section √–¬–‡«≈“„π°“√∑” acute PD session ‡©≈¬Ë’ ª√–¡“≥ 48-72 ™¡. ‚¥¬®”π«π¢Õß session «à π ¡“°®–„™â 48-72 exchanges ´ßË÷ ‡©≈¬Ë’ ·≈«â µÕà ÀπßË÷ session ®–„™‡â «≈“ 1 ™¡.65 Õ¬“à ß‰√°µÁ “¡√–¬–‡«≈“„π °“√∑” PD session “¡“√∂¬◊¥À¬ÿàπ‰¥â¢÷ÈπÕ¬Ÿà°—∫ “‡Àµÿ·≈–√–¬–‡«≈“¢Õß°“√‡°‘¥‰µ«“¬©—∫æ≈—π ª√¡‘ “≥ “√πÈ”·≈– solute ∑µ’Ë Õâ ß°“√¢®¥— ÕÕ° Õ∫ÿ µ— °‘ “√≥¢å Õß°“√µ¥‘ ‡™Õ◊È ‚¥¬‡©æ“–Õ¬“à ß¬ß‘Ë rigid catheter ®“°°“√∑‰’Ë ¡ à “¡“√∂ª√–‡¡π‘ °“√¥”‡ππ‘ ‚√§¢Õß¿“«–‰µ«“¬©∫— æ≈π— ·≈–°“√¥”‡ππ‘ ‚√§¢ÕßºªâŸ «É ¬∑‰’Ë ¡§à ß∑’Ë ®÷ß‰¡à§«√ —Ëß°“√√—°…“‰«âπ“π‡°‘π°«à“ 24 ™—Ë«‚¡ß ·æ∑¬å§«√ª√–‡¡‘πÕ“°“√·≈–º≈°“√µ√«®∑“ßÀâÕß ªØ∫‘ µ— °‘ “√µ≈Õ¥‡«≈“Õ¬“à ßπÕâ ¬«π— ≈– 1 §√ßÈ— ‡æÕ◊Ë ®–‰¥ â ßË— °“√√°— …“„Àºâ ªŸâ «É ¬‰¥‡â À¡“– ¡ 2. dialysate component πÈ”¬“peritonealdialysate∑‡’Ë ªπì ¡“µ√∞“π∑¡’Ë ®’ ”Àπ“à ¬Õ¬„àŸ πª®í ®∫ÿ π— ®–¡¢’ π“¥§«“¡‡¢¡â ¢πâ ¢Õß dextrose √Õâ ¬≈– 1.5, 2.5 ·≈– 4.25 ‚¥¬§«√®–Õπàÿ π”È ¬“ dialysate ∑ÕË’ ≥ÿ À¿¡Ÿ ‡‘ ∑“à °∫— √“à ß°“¬°Õà π∑®Ë’ – ª≈àÕ¬πÈ”¬“‡¢â“‰ª„π™àÕß∑âÕßºŸâªÉ«¬ ‡æ◊ËÕÀ≈’°‡≈’Ë¬ß§«“¡‡¬Áπ¢ÕßπÈ”¬“∑’Ë∑”„ÀâºâŸªÉ«¬√âŸ ÷°‰¡à ∫“¬∑âÕß ·≈–¬ß— ™«à ¬„π‡√ÕË◊ ß solute transport „À¥â ¢’ πÈ÷ ¥«â ¬ ‡æÕË◊ ™«à ¬„À°â “√∑” dialysis ¡’ ultrafiltration ¥¢’ πÈ÷ °“√„™πâ ”È ¬“ dilaysate §«√‡√¡Ë‘ ∑Ë’ 2.5% dextrose °“√„™â¢π“¥πÈ”¬“‡¢â¡¢âπ 1.5% dextrose ‡À¡“–∑’Ë®–„™â„πºŸâªÉ«¬∑’Ë¡’¿“«–πÈ”‡°‘π‰¡à¡“°·≈–„πºâŸªÉ«¬∑’Ë ¡’¿“«–√–∫∫‰À≈‡«’¬π‚≈À‘µ∑’Ë‰¡à§ß∑’Ë À√◊Õ„™â‡¡◊ËÕºŸâªÉ«¬∑’ËÕ¬Ÿà„π¿“«– euvolumia ·≈â«À≈—ß®“°„™â 2.5% dextrose solution 3. exchange volume ª®í ®¬— ∑¡Ë’ º’ ≈µÕà ª√¡‘ “≥ exchange volume ª√–°Õ∫¥«â ¬ - Peritoneal cavity size “¡“√∂ª√–‡¡π‘ ‰¥®â “°¢π“¥µ«— ¢ÕßºªŸâ «É ¬ ‚¥¬∑«Ë— ‰ªºªâŸ «É ¬∑¡Ë’ π’ ”È Àπ°— 60-80 °°. “¡“√∂„ πà È”¬“‡¢“â ‰ª„π™Õà ß∑Õâ ß‰¥§â √ß—È ≈–ª√–¡“≥ 2 ≈µ‘ √ ‚¥¬∑º’Ë ªâŸ «É ¬‰¡√à Ÿâ °÷ «“à ‰¡ à ∫“¬∑Õâ ß

New Frontiers in Dialysis 236 ∏πµ‘ ®‘√ππ— ∑å∏«™— √‘ ‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™¬— ∏π—π¥“ µ√–°“√«π‘™ « π— µå ‡ÿ ¡∏°≈ÿ ºªâŸ «É ¬∑¡’Ë π’ È”Àπ°— πÕâ ¬°«“à πÕ’È “®æ®‘ “√≥“ª√∫— ≈¥ª√¡‘ “≥πÈ”¬“∑®’Ë –„ ‡à ¢“â ‰ª„π™Õà ß∑Õâ ß¢ÕßºªâŸ «É ¬‰¥â - Respiratory insufficiency ºªŸâ «É ¬∑¡Ë’ ‚’ √§ªÕ¥‡™πà pneumonia, COPD, ºªâŸ «É ¬∑¡Ë’ ¿’ “«–À“¬„® ≈â¡‡À≈«∑’ËµâÕß„™â‡§√◊ËÕß™à«¬À“¬„® Õ“®µâÕß„ àπÈ”¬“ dialysate ‡¢â“‰ª„π™àÕß∑âÕß„πª√‘¡“≥∑’Ë≈¥≈ß ‡πÕË◊ ß®“°ª√¡‘ “≥π”È ®–¡º’ ≈µÕà °“√‡§≈ÕË◊ π‰À«¢Õß°√–∫ß— ≈¡∑”„Àâ tidal volume ¢ÕßºªŸâ «É ¬≈¥≈ß - hernia ª√¡‘ “≥ exchange volume §«√®–≈¥≈ß‡æÕË◊ ≈¥ intraabdominal pressure - leakage ·æ∑¬ å «à π¡“°π¬‘ ¡°“√‡ª≈¬Ë’ π∂“à ¬π”È ¬“ dialysate „πª√¡‘ “≥πÕâ ¬Ê „π™«à ß«π— ·√°Ê ¢Õß°“√«“ß “¬ catheter ·≈–§àÕ¬Ê ª√—∫ª√‘¡“≥πÈ”¬“‡æ‘Ë¡¢÷ÈπÀ≈—ß 3-4 «—π ‡¡◊ËÕºâŸªÉ«¬‰¡à¡’ªí≠À“„π °“√„ πà È”¬“ 4. inflow and outflow (drain) period Inflow time ‡ªπì ™«à ß‡«≈“∑ª’Ë ≈Õà ¬πÈ”¬“ dialysate ‡¢“â ™Õà ß∑Õâ ßºªŸâ «É ¬ ‚¥¬πÈ”¬“®–‰À≈µ“¡ gravity ´ßË÷ ‚¥¬ª°µ®‘ –„™‡â «≈“ª√–¡“≥ 10-15 π“∑5’ 9 ª®í ®¬— ∑¡Ë’ º’ ≈µÕà °“√„À≈‡¢“â ¢Õßπ”È ¬“ª√–°Õ∫¥«â ¬ 4.1 ª√¡‘ “≥¢Õßπ”È ¬“ dialysis 4.2 §«“¡ ßŸ ¢Õß∂ßÿ π”È ¬“ dialysate ∑‡Ë’ ÀπÕ◊ µÕà ™Õà ß∑Õâ ß¢ÕßºªŸâ «É ¬ 4.3 °“√∑¡Ë’ À’ √Õ◊ ‰¡¡à ·’ √ßµ“â π∑“π®“°°“√¢¥ßÕ¢Õß “¬ peritoneal catheter À√Õ◊ ®“°°“√≈¥≈ß ¢Õß°“√‡§≈◊ËÕπ‰À«¢Õß≈”‰ â ‡æ◊ËÕ„Àâ‰¥â maximum efficiency ¢Õß°“√∑” dialysis ®”‡ªìπ®–µâÕß≈¥ √–¬–‡«≈“¢Õß inflow time „À â πÈ— ∑ Ë’ ¥ÿ Outflow time ‡ªìπ™à«ß‡«≈“∑’Ëª≈àÕ¬πÈ”¬“ dialysate ÕÕ°®“°™àÕß∑âÕßºŸâªÉ«¬ ´÷Ëß‡ªìπ‰ªµ“¡ ·√ß‚π¡â ∂«à ß „™‡â «≈“ª√–¡“≥ 20-30 π“∑5’ 9 ª®í ®¬— ∑¡Ë’ º’ ≈µÕà outflow time ª√–°Õ∫¥«â ¬ 1. ª√¡‘ “≥π”È ¬“ dialysate ∑∂Ë’ °Ÿ ª≈Õà ¬ÕÕ°¡“ 2. Outflow resistant ∑‡’Ë °¥‘ ®“°°“√À°— ßÕ¢Õß “¬ °“√≈¥≈ß¢Õß°“√‡§≈Õ◊Ë π‰À«¢Õß≈”‰ â ·≈– fibrin „ππ”È ¬“ dialysate 3. §«“¡ ßŸ √–À«“à ßµ«— ºªâŸ «É ¬·≈–∂ßÿ ∑√Ë’ Õß√∫— π”È ¬“ dialysate ‡À¡Õ◊ π°∫— inflow time ‡æÕË◊ „À‰â ¥â maximum efficiency ¢Õß°“√∑” dialysis ®”‡ªπì ®–µÕâ ß≈¥√–¬–‡«≈“¢Õß inflow time „À â πÈ— ∑ Ë’ ¥ÿ ·≈– §«√„Àπâ È”¬“ dialysate ª≈Õà ¬ÕÕ°„ÀÀâ ¡¥ ∂“â ‰¡Àà ¡¥®–‡°¥‘ °“√ – ¡¢ÕßπÈ”¬“ dialysis ∑”„À‡â °¥‘ abdominal discomfort ·≈–¡º’ ≈µÕà √–∫∫À“¬„®¢ÕßºªŸâ «É ¬µ“¡¡“ 4. dwell time dwell time ‡ªπì ™«à ß‡«≈“∑πË’ ”È ¬“§“â ßÕ¬„Ÿà π™Õà ß∑Õâ ßÀ√Õ◊ √–¬–‡«≈“∑‡Ë’ √¡Ë‘ µßÈ— ·µ à πÈ‘ ¥ÿ °“√ª≈Õà ¬ πÈ”¬“‡¢“â ™Õà ß∑Õâ ß∂ß÷ ‡«≈“∑‡’Ë √¡‘Ë ª≈Õà ¬πÈ”¬“ÕÕ°®“°™Õà ß∑Õâ ß dwell time ª°µ∑‘ „’Ë ™„â π acute PD §Õ◊ 30 π“∑’ ´ßË÷ ‡ªπì √–¬–‡«≈“∑¡Ë’ °’ “√¢®¥— urea ·≈–π”È «à π‡°π‘ ∑‡Ë’ À¡“– ¡∑ Ë’ ¥ÿ 66 ∂“â √–¬–‡«≈“πÕâ ¬°«“à 30 π“∑°’ “√ øÕ°‰µ®–‰¡‡à æ¬’ ßæÕ65 «à π„π acute CEPD ®–„™â dwell time ª√–¡“≥ 3 ∂ß÷ 6 ™¡.59 „πºªâŸ «É ¬°≈¡àÿ πÈ’ Õ“®ª√∫— dwell time „À â πÈ— ≈ß‡æÕË◊ ‡æ¡Ë‘ ®”π«π√Õ∫¢Õß°“√øÕ°‰µ‡æÕË◊ ™«à ¬„π°“√ clearance ¢Õß solute „À‡â æ¡‘Ë ¢π÷È „πºªâŸ «É ¬∑¡’Ë ’ peritonitis ¡§’ «“¡®”‡ªπì ®–µÕâ ß≈¥ dwell time „À â π—È ≈ß‡πÕ◊Ë ß®“°°“√·æ√¢à Õß solute º“à π peritoneum membrane ‡√«Á ¢πÈ÷ „π°√≥∑’ °Ë’ “√Õ°— ‡ ∫¢Õß peritoneum

Dialysis in Acute Kidney Injury ≥—∞™¬— »√’ «— ¥Ï‘ ¢®√ µ√’ ≥∏π“°≈ÿ 237 5. number of exchanges ®”π«π§√ßÈ— ¢Õß°“√‡ª≈¬Ë’ ππ”È ¬“®–‡ªπì µ«— ∫ßà ∫Õ°∂ß÷ ª√¡‘ “≥¢Õß “√π”È ·≈– solute ∑∂Ë’ °Ÿ ¢®¥— ÕÕ°„πºªâŸ «É ¬·µ≈à –√“¬´ß÷Ë ª°µ·‘ ≈«â „π acute PD ®–∑”°“√‡ª≈¬’Ë π∂“à ¬πÈ”¬“∑ß—È À¡¥ 24 §√ß—È µÕà «π— „π¢≥–∑’Ë CEPD ®–‡ª≈¬Ë’ ππ”È ¬“ª√–¡“≥ 4 ∂ß÷ 6 §√ßÈ— µÕà «π— 6. dialysate additives °“√º ¡¬“‡¢“â ‰ª„ππÈ”¬“ dialysate “¡“√∂„™‰â ¥Àâ ≈“¬°√≥’ °“√º ¡¬“‡¢“â ‰ª„π·µ≈à –∂ßÿ §«√ ∑”‚¥¬∂°Ÿ «∏‘ ·’ ≈–ª√“»®“°‡™Õ◊È ¬“∑¡’Ë °— ®–∂°Ÿ „ ‡à ¢“â ‰ª„ππÈ”¬“ dialysate §Õ◊ heparin, insulin ·≈– potassium 6.1 Heparin “¡“√∂∑®Ë’ –‡µ¡‘ ‡¢“â ‰ª„ππ”È ¬“ dialysate ¢π“¥ 200 ∂ß÷ 500 units µÕà ≈µ‘ √ ‡æÕË◊ ªÕÑ ß°π— °“√‡°¥‘ fibrin clot ´ßË÷ ®–‰ªÕ¥ÿ µπ— “¬ peritoneal catheter65 ∂ß÷ ·¡«â “à ‚¥¬ª°µ·‘ ≈«â ®–„ à heparin ‡¡ÕË◊ æ∫«“à ¡’ fibrin „ππ”È ¬“ dialysate ∑ªË’ ≈Õà ¬ÕÕ°¡“ ·µ®à –¥°’ «“à ∂“â „ à heparin ‡æÕË◊ ªÕÑ ß°π— °“√‡°¥‘ fibrin °Õà π∑®Ë’ –æ∫«“à ¡’ fibrin „ππÈ”¬“∑ªË’ ≈Õà ¬ÕÕ°¡“ ‡æ√“–«“à À“°‡°¥‘ fibrin ·≈«â heparin ®–‰¡‰à ¥‡â ªπì µ«— ∑Ë’ ®–∑”„Àâ fibrin ≈“¬‰ª πÕ°®“°π’È heparin ‰¡à “¡“√∂∑’Ë®–∂Ÿ°¥Ÿ¥´÷¡ºà“πºπ—ß™àÕß∑âÕß‰¥â ®÷ß‰¡à¡’º≈ µÕà √–∫∫°“√·¢ßÁ µ«— ¢Õß‡≈Õ◊ ¥„π√“à ß°“¬ 6.2 Insulin “¡“√∂„À∑â “ß intraperitoneum „πºªâŸ «É ¬‡∫“À«“π‰¥â °“√„™â hypertonic dextrose- containing dialysate solution „πºªâŸ «É ¬‡∫“À«“π∑”„À‡â °¥‘ glucose load ∑”„À°â “√§«∫§¡ÿ √–¥∫— π”È µ“≈ „π‡≈Õ◊ ¥∑”‰¥¬â “°¢πÈ÷ ‚¥¬ª°µ‡‘ √“®–„ à insulin ‡¢“â ‰ª„ππ”È ¬“ dialysate °Õà π∑®Ë’ –ª≈Õà ¬π”È ¬“‡¢“â ‰ª„π ™Õà ß∑Õâ ß¢ÕßºªŸâ «É ¬·≈–ª√∫— ¢π“¥¢Õß insulin µ“¡√–¥∫— πÈ”µ“≈„π‡≈Õ◊ ¥ (‚¥¬ª°µ®‘ –‡®“–√–¥∫— π”È µ“≈ „π‡≈Õ◊ ¥∑°ÿ 6 ™«Ë— ‚¡ß) 6.3 Potassium ‚¥¬ª°µπ‘ È”¬“ dialysate ®–‰¡¡à ’ potassium ‡√“ “¡“√∂∑®’Ë –„ à potassium chloride ‡¢“â ‰ª„ππ”È ¬“ dialysate ‰¥â (‚¥¬ª°µ®‘ –„ ªà √–¡“≥ 3-4 mmol/≈µ‘ √) „πºªŸâ «É ¬∑¡Ë’ ¿’ “«– hypokalemia ‚¥¬‡©æ“–Õ¬“à ß¬ß‘Ë ºªâŸ «É ¬‚√§À«— „®∑‰’Ë ¥√â ∫— ¬“ digoxin §«√®–¡°’ “√«¥— √–¥∫— serum potassium „π‡≈Õ◊ ¥∫Õà ¬Ê ·≈–§«√®–„Àâ potassium ‡¢“â ‰ª„ππ”È ¬“ dialysis ‡æÕË◊ „À√â –¥∫— serum potassium „π‡≈Õ◊ ¥‰¡πà Õâ ¬°«“à 4 meq/≈µ‘ √65 7. monitoring fluid balance §«√¡°’ “√®¥∫π— ∑°÷ ª√¡‘ “≥ “√π”È ‡¢“â ·≈–ÕÕ° √«¡∑ßÈ— net ultrafiltration „πºªŸâ «É ¬∑∑Ë’ ” acute PD √«¡∑ßÈ— °“√®¥∫π— ∑°÷ π”È Àπ°— ¢ÕßºªâŸ «É ¬ ¢Õâ ¡≈Ÿ ∑’Ë‰¥â®–‡ªìπ¢âÕ¡≈Ÿ ∑™’Ë «à ¬„Àâ‡√“ ßË— °“√√°— …“ºªâŸ «É ¬‰¥∂â °Ÿ µÕâ ß¬ß‘Ë ¢π÷È 5.6 ¿“«–·∑√°´Õâ π¢Õß°“√∑” acute PD °“√∑”acutePDÕ“®‡°¥‘ ¿“«–·∑√°´Õâ π‰¥·â ≈–∫“ß§√ß—È Õ“®‡ªπì Õπ— µ√“¬∂ß÷ ™«’ µ‘ ‰¥6â 9,70 µ«— Õ¬“à ß ¢Õß¿“«–·∑√°´Õâ π∑æË’ ∫‰¥„â π°“√∑” acute PD ‡™πà 1. Mechanical complication «à π¡“°‰¡‰à ¥‡â ªπì Õπ— µ√“¬∂ß÷ ™«’ µ‘ ·µÕà “®¡º’ ≈µÕà °“√≈¥≈ß¢Õß dialysis efficiency ´ßË÷ ª√–°Õ∫¥«â ¬ 1.1 Abdominal pain À√◊Õ discomfort Õ“°“√πâÕ¬¡—° —¡æ—π∏å°—∫ Abdominal distension ∂â“

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New Frontiers in Dialysis

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