New Frontiers in Dialysis

New Frontiers in Dialysis 238 ∏π‘µ ®√‘ ππ— ∑å∏«—™  ‘√¿‘ “ ™â“ß»‘√°‘ ÿ≈™—¬ ∏π—𥓠µ√–°“√«π™‘ « —πµå  ÿ‡¡∏°ÿ≈ Õ“°“√ª«¥√ÿπ·√ß¡“°¡—° —¡æ—π∏å°—∫ catheter-related infection ´÷Ëߧ«√‰¥â√—∫°“√µ√«®‡æ◊ËÕ«‘π‘®©—¬·≈– √°— …“µÕà ‰ª 1.2 Intraabdominal hemorrhage Õ“°“√‡≈Õ◊ ¥ÕÕ°‰¡¡à “°¡°—  ¡— æπ— ∏°å ∫— °“√„  à “à ¬ catheters ·µ∂à “â ‡≈Õ◊ ¥ÕÕ°¡“°¡°—  ¡— æπ— ∏°å ∫— °“√„™ â “¬ semi-rigid catheter 1.3 Leakage ‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬  “¡“√∂·°â‰¢‰¥â‚¥¬°“√„ àπÈ”¬“„πª√‘¡“≥∑’Ë≈¥≈ß À√Õ◊ °“√æ°— ∑Õâ ߉«™â «Ë— §√“«°Õà π‡√¡Ë‘ „ πà ”È ¬“ dialysate 1.4 Inadequate dialysate ¡—°‡°‘¥®“°°“√≈¥≈ߢÕß°“√‡§≈◊ËÕπ‰À«¢Õß≈”‰ â ∫“ߧ√—ÈßÕ“® ®”‡ªπì µÕâ ß manipulate catheter ‡æÕË◊ „À°â “√ drainage ¥¢’ πÈ÷ 1.5 Bowel perforation ¡°— ‡°¥‘ ®“°°“√„ à semi-rigid catheter ºªâŸ «É ¬¡°— ¡Õ’ “°“√ª«¥∑Õâ ß æ∫ ¡‡’ ≈Õ◊ ¥ÕÕ°®“°πÈ”¬“ dialysate ∑’Ë drain ÕÕ°¡“ ·≈–¿“«– shock √°— …“‚¥¬ À¬¥ÿ °“√∑” peritoneal dialysis ‡Õ“ “¬ catheter ÕÕ° „Àâ antibiotic ·≈– ‡¬∫Á ´Õà ¡≈”‰ â 2. Infectious complication ‡ªìπ¿“«–∑Ë’æ∫∫àÕ¬‚¥¬‡©æ“– peritonitis ªÑÕß°—π‚¥¬°“√√—°…“ §«“¡ –Õ“¥√–À«à“ß°“√„ à·≈–°“√‡ª≈’ˬπ∂à“¬πÈ”¬“ dialysis ∫“ߧ√—ÈßÕ“®‡°‘¥ abscess „πµ”·Àπàß∑’Ë «“ß “¬‰¥∂â “â ∑”°“√«“ß “¬∑¢’Ë “â ߇µ¬’ ß·≈–‰¡√à –¡¥— √–«ß— √°— …“§«“¡ –Õ“¥ 3. Pulmonary complication Basal lung atelectasis, pneumonia, pleural effusion, aspiration 4. Cardiovascular complication Hypovolemia, cardiac arrhythmia 5. Metabolic complication Hyperglycemia, hypoglycemia ¡°— ‡°¥‘ ¿“¬À≈ß— °“√À¬¥ÿ ∑” PD, hypernatremia ®“°°“√ ≠Ÿ ‡ ¬’ π”È ‚¥¬°“√„™â hypertonic exchange, hypokalemia ®“°°“√∑πË’ ”È ¬“ dialysate ‚¥¬∑«Ë— ‰ª‰¡¡à ’ potassium ·°‰â ¢‚¥¬°“√‡µ¡‘ potassium „ππÈ”¬“ dialysate, protein losses ‚¥¬∑«—Ë ‰ª®–¡°’ “√ ≠Ÿ  ¬’ ‚ª√µπ’ ‰ª„ππÈ”¬“ dialysate ¡“°°«“à 5 g/day 5.7 effect on mortality ‰¡à¡’¢âÕ¡≈Ÿ ‡æ’¬ßæÕ∑’Ë®–∫Õ°«à“°“√∑” acute PD °“√∑” IHD À√◊Õ°“√∑” CRRT Õ¬à“߉Àπ ®–¥°’ «“à °π— „π·ß¢à Õß°“√≈¥Õµ— √“°“√µ“¬„πºªâŸ «É ¬‰µ«“¬©∫— æ≈π— ‡Õ° “√Õ“â ßÕß‘ 1. Bellomo R, Ronco C, Kellum JA, et al. The ADQI workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.Crit Care. 2004; 8:R204-12. 2. Molitoris BA, Levin A, Warnock DG, et al. Improving outcomes of acute kidney injury: report of an initiative. Nat Clin Pract Nephrol. 2007 Aug; 3(8):439-42. 3. Liano F, Pascual J, Madrid Acute Renal Failure Study Group. Epidemiology of acute renal failure: a prospective,

Dialysis in Acute Kidney Injury ≥—∞™¬— »√ ’ « — ¥‘Ï ¢®√ µ√’ ≥∏π“°ÿ≈ 239 multicenter, community-based study. Kidney Int 1996; 50:811-8. 4. Mehta RL, Pascual MT, Soroko S, et al. Diuretics, mortality, and non recovery of renal function in acute renal failure. JAMA 2002; 288:2547-53. 5. Uchino S, Doig GS, Bellomo R, et al. Diuretics and mortality in acute renal failure. Crit Care Med 2004; 32:1669-77. 6. Cantarovich F, Rangoonwala B, Lorenz H, et al. High-dose furosemide for established ARF: a prospective, randomized, double-blind, placebo-controlled, multi-center trial. Am J Kidney Dis 2004; 44:402- 9. 7. Greenberg A. Hyperkalemia: treatment options. Semin Nephrol 1998; 18:46 -57. 8. Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest 2000; 117:260-7. 9. Cuhaci B, Lee J, Ahmed Z. Sodium bicarbonate controversy in lactic acidosis. Chest 2000; 118:882-3 [letter]. 10. Teschan PE, Baxter CR, OûBrien TF, et al. Prophylactic hemodialysis in the treatment of acute renal failure. Ann Intern Med 1960; 53:992-1016. 11. Parsons, FM, Hobson, SM, Blagg, CR, et al. Optimum time for dialysis in acute reversible renal failure. Description and value of an improved dialyser with large surface area. Lancet 1961; 21:129-34. 12. Fischer, RP, Griffen, WOJ, Reiser, M, Clark, DS. Early dialysis in the treatment of acute renal failure. Surg Gynecol Obstet 1966; 123:1019-23. 13. Kleinknecht, D, Jungers, P, Chanard, J, et al. Uremic and nonuremic complications in acute renal failure: evaluation of early and frequent dialysis on prognosis. Kidney Int 1972; 1:190-6. 14. Conger, JD. A controlled evaluation of prophylactic dialysis in post-traumatic acute renal failure. J Trauma 1975; 15:1056-63. 15. Gillum, JD, Dixon, BS, Yanover, MJ, et al The role of intensive dialysis in acute renal failure. Clin Nephrol 1986; 25:249-55. 16. Gettings, LG, Reynolds, HN, Scalea, T. Outcome in posttraumatic acute renal failure when continuous renal replacement therapy is applied early vs. late. Intensive Care Med 1999; 25:805-13. 17. Bouman, CSC, Oudemans-van Straaten, HM, Tijssen, JG, et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med 2002; 30:2205-11. 18. Liu, KD, Himmelfarb, J, Paganini, E, et al Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol 2006; 1:915-9. 19. Macias, WL, Mueller, BA, Scarim, SK, et al. Continous venovenous hemofiltration: An alternative to continuous arteriovenous hemofiltration and hemodiafiltration in acute renal failure. Am J Kidney Dis 1991; 18:451-8. 20. Sigler, MH, Teehan, B. Solute transport in continuous hemodialysis: A new treatment for acute renal failure. Kidney Int 1987; 32:562-71. 21. Van Geelen, JA, Vincent, HH, Schalekamp, MA. Continuous arteriovenous haemofiltration and haemodiafiltration in acute renal failure. Nephrol Dial Transplant 1988; 3:181-6.

New Frontiers in Dialysis 240 ∏π‘µ ®√‘ π—π∑å∏«—™  ‘√‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™¬— ∏π—𥓠µ√–°“√«π™‘ « —πµå  ‡ÿ ¡∏°ÿ≈ 22. Bellomo, R, Parkin, G, Love, J, Boyce, N. A prospective comparative study of continuous arteriovenous hemodiafiltration and continuous venovenous hemodiafiltration in critically ill patients. Am J Kidney Dis 1993; 21:400-4. 23. Misset B, Timsit JF, Chevret S, et al. A randomized cross-over comparison of the hemodynamic response to intermittent hemodialysis and continuous hemofiltration in ICU patients with acute renal failure. Intensive Care Med. 1996 Aug; 22(8):742-6. 24. Davenport A, Will EJ, Davidson AM. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med. 1993 Mar; 21(3):328-38. 25. Van Bommel, EFH, Ponssen, HH. Intermittent versus continuous treatment for acute renal failure: where do we stand? Am J Kidney Dis 1997; 30 (Suppl 4):S72-9. 26. Lameire, N, Van Biesen, W, Vanholder, R. Dialysing the patient with acute renal failure in the ICU: the emperorûs clothes? Nephrol Dial Transplant 1999; 14:2570-3. 27. Bellomo, R, Boyce, N. Acute continuous hemodiafiltration: a prospective study of 110 patients and a review of the literature. Am J Kidney Dis 1993; 21:508-18. 28. Bellomo, R, Farmer, M, Parkin, G, et al. Severe acute renal failure: a comparison of acute continuous hemodiafiltration and conventional dialytic therapy. Nephron 1995; 71:59-64. 29. Van Bommel, E, Bouvy, ND, So, KL, et al Acute dialytic support for the critically ill: intermittent hemodialysis versus continuous arteriovenous hemodiafiltration. Am J Nephrol 1995; 15:192-200. 30. Mehta, R, McDonald, B, Gabbai, F, et al. A randomized clinic trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 2001; 60:1154-63. 31. Kellum, JA, Angus, DC, Johnson, JP, et al. Continuous versus intermittent renal replacement therapy: a meta-analysis. Intensive Care Med 2002; 28:29-37. 32. Tonelli, M, Manns, B, Feller-Kopman, D. Acute renal failure in the intensive care unit: a systematic review of the impact of dialytic modality on mortality and renal recovery. Am J Kidney Dis 2002; 40:875-85. 33. Vinsonneau, C, Camus, C, Combes, A, et al. Continuous venovenous hemodiafiltration versus intermittent hemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre, randomized trial. Lancet 2006; 368:379-85. 34. Schiffl, H, Lang, SM, Fischer, R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 2002; 346:305-10. 35. Manns, B, Doig, CJ, Lee, H, et al. Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Crit Care Med 2003; 31:449-55. 36. Jacka, MJ, Ivancinova, X, Gibney, RT. Continuous renal replacement therapy improves renal recovery from acute renal failure. Can J Anaesth 2005; 52:327-32. 37. Palevsky, PM, Baldwin, I, Davenport, A, et al. Renal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure. Curr Opin Crit Care 2005; 11:548-54.

Dialysis in Acute Kidney Injury ≥∞— ™—¬ »√ ’ « — ¥Ï‘ ¢®√ µ’√≥∏π“°≈ÿ 241 38. Augustine, JJ, Sandy, D, Seifert, TH, Paganini, EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 2004; 44:1000-7. 39. Uehlinger, DE, Jakob, SM, Ferrari, P, et al. Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 2005; 20:1630-7. 40. Ronco, C, Tetta, C, Mariano, F, et al. Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs 2003; 27:792-801. 41. Sanchez-Izquierdo, JA, Perez Vela, JL, Lozano Quintana, MJ, et al Cytokines clearance during venovenous hemofiltration in the trauma patient. Am J Kidney Dis 1997; 30:483-8. 42. Phu, NH, Hien, TT, Mai, NT, et al. Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. N Engl J Med 2002; 347:895-902. 43. Marshall MR, Golper TA, Shaver MJ, et al. Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int. 2001 Aug; 60(2):777-85. Erratum in: Kidney Int 2001; 60(4):1629. 44. Kumar VA, Craig M, Depner TA, et al. Extended daily dialysis: A new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis.2000 Aug;36(2):294-300. 45. Kielstein JT, Kretschmer U, Ernst T, Hafer C, et al. Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: a randomized controlled study. Am J Kidney Dis. 2004 Feb; 43:342-9. 46. Berbece AN, Richardson RM. Sustained low-efficiency dialysis in the ICU: cost, anticoagulation, and solute removal. Kidney Int. 2006 Sep; 70(5):963-8. 47. Fliser D, Kielstein JT. Technology Insight: treatment of renal failure in the intensive care unit with extended dialysis. Nat Clin Pract Nephrol. 2006 Jan;2(1):32-9. Review. 48. Fiaccadori E, Maggiore U, Parenti E, et al. Sustained low-efficiency dialysis (SLED) with prostacyclin in critically ill patients with acute renal failure. Nephrol Dial Transplant. 2007 Feb; 22(2):529-37. 49. Golper TA, Cigarran-Guldris S, Jenkins RD, et al. The role of convection during simulated continuous arteriovenous hemodialysis. Contrib Nephrol. 1991; 93:146-8. 50. Paganini, EP, Tapolyai, M, Goormastic, M, et al. Establishing a dialysis therapy/patient outcome link in intensive care unit acute dialysis for patients with acute renal failure. Am J Kidney Dis 1996; 28(Suppl 3):S81-9. 51. Kellum, JA, Johnson, JP, Kramer, D, et al. Diffusive vs. convective therapy: effects on mediators of inflammation in patient with severe systemic inflammatory response syndrome. Crit Care Med 1998; 26:1995-2000. 52. Ronco, C, Bellomo, R, Homel, P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26-30. 53. Saudan, P, Niederberger, M, De Seigneux, S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 2006; 70:1312-7. 54. Palevsky, PM, OûConnor, T, Zhang, JH, et al. Design of the VA/NIH Acute Renal Failure Trial Network (ATN) study: intensive versus conventional renal support in acute renal failure. Clin Trials 2005; 2:423-35.

New Frontiers in Dialysis 242 ∏𵑠®‘√π—π∑å∏«™—  ‘√‘¿“ ™â“ß»‘√°‘ ÿ≈™—¬ ∏π—𥓠µ√–°“√«π™‘ « —πµå  ‡ÿ ¡∏°≈ÿ 55. Bellomo, R. Do we know the optimal dose for renal replacement therapy in the intensive care unit?. Kidney Int 2006; 70:1202-7. 56. Ash, SR, Bever, SL. Peritoneal dialysis for acute renal failure: the safe, effective, and low-cost modality. Adv Ren Replace Ther 1995; 2:160-3. 57. Passadakis, P, Oreopoulos D. Peritoneal dialysis in acute renal failure. Int J Artif Organs 2003; 26: 265-77. 58. Nolph, KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54-5. 59. Lamiere, N. Principles of peritoneal dialysis and its application in acute renal failure. In: Critical Care Nephrology, Ronco, C, Bellomo, R (Eds), Kluwer Academic Publishers, Dordrecht 1998. p.1357-71. 60. Steiner, RW. Continuous equilibration peritoneal dialysis. Perit Dial Int 1989; 9:5-7. 61. Juergensen, PH, Murphy, AL, Pherson, KA, et al. Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients. Adv Perit Dial 1999; 15:125-6. 62. Amerling, R, Glezerman, I, Savransky, E, et al. Continuous flow peritoneal dialysis: principles and applications. Semin Dial 2003; 16:335-40. 63. Ash, SR. Peritoneal dialysis in acute renal failure of adults: the under-utilized modality. Contrib Nephrol 2004; 144:239-54. 64. Wong, SN, Geary, DF. Comparison of temporary and permanent catheters for acute peritoneal dialysis. Arch Dis Child 1988; 63:827-31. 65. Kronfol, NO. Acute Peritoneal Dialysis Prescription. In: Handbook of Dialysis, 2nd ed, Daugirdas, JT, Ing, TS (Eds), Little, Brown and Company. 1994. p.301-9. 66. Twardowski, ZJ, Nolph, KD. Blood purification in acute renal failure. Ann Intern Med 1984; 100:447-9. 67. Chadha, V, Warady, VA, Blowey, DL, et al. Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis. Am J Kidney Dis 2000; 35:1111-6. 68. Rubin, J, Adair, C, Barnes, T, Bower, J. Dialysate flow rate and peritoneal clearance. Am J Kidney Dis 1984; 4:260-7. 69. Vaamonde, CA, Michael, UF, Metzger, RA, Carroll, KE Jr. Complications of acute peritoneal dialysis. J Chronic Dis 1975; 28:637-59. 70. Gault, MH, Ferguson, EL, Sidhu, JS, Corbin, RP. Fluid and electrolyte complications of peritoneal dialysis. Choice of dialysis solutions. Ann Intern Med 1971; 75:253-62. 71. Passadakis, P, Malliara, M, Thodis, E, et al. Arterial hypotension in patients on peritoneal dialysis. Int J Artif Organs 2002; 25:489-95.

13 Frontiers in Peritoneal Dialysis  ™ÿ “¬ »√∑’ æ‘ ¬«√√≥ 1. ∫∑π” 2. °“√æ≤— π“°“√√°— …“¥«â ¬«∏‘ ’ automated peritoneal dialysis 3. Continuous flow peritoneal dialysis 4. °“√æ≤— π“π”È ¬“ peritoneal dialysis fluid 5. °“√æ≤— π“°“√«“ß “¬≈“â ß™Õà ß∑Õâ ß 6. °“√ªÕÑ ß°π— °“√µ¥‘ ‡™Õ◊È „πºªâŸ «É ¬ chronic peritoneal dialysis 7. °“√„™â peritoneal dialysis √°— …“ºªŸâ «É ¬ congestive heart failure 8. °“√„™â peritoneal dialysis √°— …“ºªâŸ «É ¬ acute renal failure

New Frontiers in Dialysis 244 ∏𵑠®‘√π—π∑∏å «—™  ‘√‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå  ÿ‡¡∏°≈ÿ 1. ∫∑π” °“√√°— …“¥«â ¬«∏‘ ’ peritoneal dialysis (PD) ¡°’ “√æ≤— π“‰ªÕ¬“à ß¡“°„π™«à ß 30 ª∑ï ºË’ “à π¡“ °“√ æ≤— π“¡µ’ ßÈ— ·µ„à π «à π¢Õß°“√„™‡â §√ÕË◊ ß™«à ¬„π°“√≈“â ß™Õà ß∑Õâ ß (automated PD, APD) π”È ¬“∑„Ë’ ™„â π°“√ ≈“â ß™Õà ß∑Õâ ß (peritoneal dialysis fluid, PDF) ·≈–°“√„™â PD „π°“√√°— …“¿“«– acute renal failure (ARF) ·≈– congestive heart failure (CHF) ∫∑§«“¡π®’È –°≈“à «∂ß÷ °“√æ≤— 𓇪≈¬’Ë π·ª≈ß„πÀ«— ¢Õ⠥ߗ °≈“à «¢“â ßµπâ 2. °“√æ≤— π“°“√√°— …“¥«â ¬«∏‘ ’ automated peritoneal dialysis1 °“√√°— …“¥«â ¬ automated PD ¡°’ “√æ≤— π“‰ªÕ¬“à ß¡“°„π™«à ß 10 ª∑ï ºË’ “à π¡“ ‡πÕË◊ ß®“°§«“¡ µÕâ ß°“√∑®Ë’ –‡æ¡Ë‘ dose ¢Õß PD ·≈–§≥ÿ ¿“晫’ µ‘ ¢ÕߺªâŸ «É ¬ ∑”„À¡â °’ “√æ≤— 𓇧√ÕË◊ ß automatic machines ‡æ◊ËÕ„™â„π°“√√—°…“·≈–µ‘¥µ“¡ª√–‡¡‘π°“√√—°…“ºŸâªÉ«¬ microchips ·≈– computer „π‡§√◊ËÕß APD ∑”„À·â æ∑¬·å ≈–欓∫“≈ “¡“√∂ª√∫— °“√√°— …“„À‡â À¡“– ¡°∫—  ¿“æ peritoneum ¢ÕߺªŸâ «É ¬‰¥¡â “°¢πÈ÷ ‡™πà °“√ª√∫— fill volumes, variable tidal volumes, dwell times ·≈– additional daytime dwell µ≈Õ¥®π °“√ “¡“√∂∑” teledialysis ·≈–°“√∫π— ∑°÷ ¢Õâ ¡≈Ÿ °“√√°— …“¢ÕߺªâŸ «É ¬‰¥1â ‡§√ÕË◊ ß APD „πª®í ®∫ÿ π— ¡¢’ π“¥ ‡≈°Á ·≈–π”È Àπ°— ‡∫“ ∑”„À â “¡“√∂æ°æ“‰ª„™„â π∑µË’ “à ßÊ ‰¥ â –¥«° √Õâ ¬≈– 31.9 ¢ÕߺªŸâ «É ¬ chronic PD (CPD) „π À√—∞Õ‡¡√‘°“‰¥â√—∫°“√√—°…“¥â«¬«‘∏’ APD „π¢≥–∑’ˇ°◊Õ∫√âÕ¬≈– 60 ¢Õߺ⟪ɫ¬ CPD „π‚√ß æ¬“∫“≈»√‘ √‘ “™„™«â ∏‘ ’ APD ‡πÕË◊ ß®“°ª≠í À“º¥âŸ ·Ÿ ≈ºªŸâ «É ¬ CPD ´ßË÷ ¡°— ®–‰¡¡à ‡’ «≈“„π°“√‡ª≈¬Ë’ ππ”È ¬“„À⠺⟪ɫ¬„π‡«≈“°≈“ß«—π‡æ√“–µâÕßÕÕ°‰ª∑”ß“ππÕ°∫â“π ®÷ßµâÕß„™â‡§√◊ËÕß APD ™à«¬‡ª≈’ˬππÈ”¬“„𠇫≈“°≈“ߧπ◊ ‡§√Õ◊Ë ß APD ¢Õß∫√…‘ ∑— Baxter ª√–‡∑» À√∞— Õ‡¡√°‘ “ ∂°Ÿ  √“â ߢπ÷È „πµπâ ∑»«√√…∑’Ë 1980 ®“°ππ—È ¡°’ “√æ≤— π“µÕà ¡“‡ªπì ‡§√Õ◊Ë ß Pac-xtra ´ß÷Ë ‡ªπì ‡§√Õ◊Ë ß∑¡’Ë §’ «“¡‡ß¬’ ∫°«“à ·≈–ÕÕ°·∫∫¡“‡æÕ◊Ë „À„â ™‰â ¥∑â ∫’Ë “â π  “¡“√∂µßÈ— volume ·≈– dwell time ‰¥Àâ ≈“¬√ªŸ ·∫∫ ‡ªπì µπâ ·∫∫¢Õ߇§√ÕË◊ ß APD ∑„Ë’ ™„â πª®í ®∫ÿ π— Home Choice ·≈– Home Choice Pro ‡ªπì ‡§√ÕË◊ ß APD √πàÿ ∑„Ë’ ™°â π— „πª®í ®∫ÿ π— ¢Õß Baxter ‰¥√â ∫— °“√æ≤— π“µßÈ— ·µªà ï 1994 „™ßâ “πß“à ¬·≈–¢π“¥‡≈°Á ≈ß¡“°π”È Àπ°— ‡æ¬’ ß 11 kg ¢π“¥ 18×47×40 cm „™â pressure pump „π°“√ drain πÈ”¬“ PDF ‡¢â“·≈–ÕÕ° (non-gravity-base technology) ¡’°“√«—¥ flow rate Õ¬à“ßµàÕ‡π◊ËÕß∑”„Àâ  “¡“√∂§«∫§ÿ¡ª√– ‘∑∏‘¿“æ¢Õß°“√∑” PD ‰¥âÕ¬à“߇µÁ¡∑’Ë ·≈–§«∫§ÿ¡ dwell time „À⇪ìπ‰ªµ“¡∑’Ë µÕâ ß°“√‚¥¬µ¥— idle time ÕÕ°´ß÷Ë ‡ªπì √–¬–‡«≈“„π°“√ drain πÈ”‡¢“â ·≈–ÕÕ°™Õà ß∑Õâ ß·µ¡à º’ ≈µÕà °“√ dialysis πÕâ ¬ Home Choice Prof ‡ªπì ‡§√ÕË◊ ß∑æË’ ≤— π“‚¥¬°“√µ¥‘ µßÈ— PD Adequest software ∫√√®≈ÿ ß„π 2-MB data card ·≈–¡’ modem ™à«¬„π°“√µ‘¥µàÕ·∫∫ teledialysis ‰¥â¥â«¬  “¡“√∂∫—π∑÷°°“√∑”ß“π¢Õ߇§√◊ËÕß ∑”„À∑â √“∫∂ß÷ compliance ¢ÕߺªâŸ «É ¬ ·≈– √“â ß database ¢Õß°“√√°— …“·≈–º≈∑‡’Ë °¥‘ °∫— ºªŸâ «É ¬‰¥â ‡™πà total PDF volume, fill volume, drain time ·≈– cycle time ∑ºË’ ªâŸ «É ¬‰¥√â ∫— √«¡∑ßÈ— ultrafiltration ∑ßÈ— À¡¥∑‡Ë’ °¥‘ ¢÷Èπ¢Õߺ⟪ɫ¬ ¢âÕ¡Ÿ≈‡À≈à“π’È “¡“√∂‡°‘∫‰¥âπ“π∂÷ß 60 «—π √–∫∫π’È∑”„ÀâºâŸªÉ«¬‰¡àµâÕßµ—È߇§√◊ËÕßÀ√◊Õ ∫π— ∑°÷ ¢Õâ ¡≈Ÿ ‡Õß ºªâŸ «É ¬‡æ¬’ ßπ” data card ¡“æ∫·æ∑¬‡å æÕË◊ ª√∫— ‡ª≈¬Ë’ π·≈–µ√«® Õ∫°“√√°— …“‚¥¬‰¡à

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√∑’ ‘欫√√≥ 245 µâÕß𔇧√◊ËÕß APD ¡“¥â«¬ ∑”„Àâ –¥«°·≈–∑√“∫∂÷ߢâÕ¡Ÿ≈°“√‡ª≈’ˬπ·ª≈ß°“√√—°…“, compliance ·≈–ª≠í À“∑‡Ë’ °¥‘ °∫— ºªŸâ «É ¬√–À«“à ß°“√√°— …“∑∫Ë’ “â π √«¡∑ßÈ—  “¡“√∂≈¥√–¬–°“√ ÕπºªâŸ «É ¬„π°“√∑” CPD „À â πÈ— ≈߉¥¥â «â ¬ „π°√≥∑’ ¡Ë’ ’ modem ®–™«à ¬„À·â æ∑¬·å ≈–∑¡’ º√Ÿâ °— …“ “¡“√∂∑√“∫¢Õâ ¡≈Ÿ °“√√°— …“¢Õß ºªâŸ «É ¬‰¥µâ ≈Õ¥‡«≈“∑µ’Ë Õâ ß°“√ ‡§√ÕË◊ ß APD ¢Õß∫√…‘ ∑— Gambro ª√–‡∑» «‡’ ¥π√πàÿ ·√° §Õ◊ PD 100T „™â gravity-base technology µÕà ¡“‰¥ªâ √∫— ‡ª≈¬Ë’ π‡ªπì √πàÿ PD101 ´ßË÷ „™â pressure pump „π°“√ drain PDF ‡¢“â ÕÕ°‰¥ â ߟ  ¥ÿ ∂ß÷ 50 L ·≈– “¡“√∂ª√∫— °“√„ πà ”È ¬“ PDF ∂ßÿ  ¥ÿ ∑“â ¬„À§â “â ߉«„â π™Õà ß∑Õâ ߇ªπì day dwell „πª√¡‘ “µ√∑µË’ Õâ ß°“√‰¥â ‡§√ÕË◊ ß “¡“√∂µßÈ— ‚ª√·°√¡ª√∫— volume, cycle, number of cycles, total inflow & dwell time ·≈– outflow time ·≈–‡°∫Á ¢Õâ ¡≈Ÿ ‰¥â 15 treatments ‡§√ÕË◊ ß√πàÿ ≈“à  ¥ÿ §Õ◊ Serena machine „™â pressure pump ‡™πà °π— ‡ªπì ‡§√Õ◊Ë ß∑¡’Ë À’ π“â ®Õ∑™’Ë ¥— ‡®π·≈–„™ßâ “πß“à ¬ ¡’ high-resolution touch screen ·≈– data card ∑∫’Ë √√®ÿ software ∑’Ë “¡“√∂ª√—∫‡ª≈’ˬπ°“√√—°…“„Àâ°—∫ºâŸªÉ«¬‰¥â‡™àπ‡¥’¬«°—∫ Home Choice Pro ‡§√◊ËÕß∑”ß“π§àÕπ¢â“ß ‡ß¬’ ∫‰¡√à ∫°«π°“√πÕπ¢ÕߺªâŸ «É ¬ ¡’ flow-control chamber ´ßË÷ ∫√√®ÿ heater bag ·≈– drain bag Õ¬¥Ÿà “â π„π ∑”„À‡â §√ÕË◊ ß “¡“√∂ª√∫— stroke volume ‰¥‡â ∑“à °∫— exchange volume ∑ßÈ— À¡¥·≈–ª√∫— flow rate  ßŸ ‰¥∂â ß÷ 400 mL/min ∑”„À â “¡“√∂≈¥ drain ·≈– fill time ·µà dwell time ‡æ¡Ë‘ ¢πÈ÷ °“√‡æ¡Ë‘ ¢πÈ÷ ¢Õß flow rate ®– ‡æ¡Ë‘ ¢πÈ÷ ™“â Ê Õ¬“à ßµÕà ‡πÕË◊ ߉¡‡à ªπì ≈°— …≥– pulsatile peaks ∑”„À≈â ¥ friction ·≈– tearing ∑Ë’ peritoneal catheter ºŸâªÉ«¬®÷ß√Ÿâ ÷° ∫“¬°«à“°“√„™â‡§√◊ËÕß™π‘¥Õ◊Ëπ ‚¥¬‡©æ“–„π™à«ß ÿ¥∑⓬¢Õß°“√ª≈àÕ¬πÈ”¬“ ÕÕ°®“°™Õà ß∑Õâ ß ‡§√Õ◊Ë ß Serena ®–¡°’ “√µ√«®«¥— πÈ”Àπ°— ¢Õß PDF µ≈Õ¥‡«≈“∑”„À â “¡“√∂«¥— ultrafiltration (UF) ‰¥Õâ ¬“à ß∂°Ÿ µÕâ ß ·≈– “¡“√∂µßÈ— µ«— ·ª√µ“à ßÊ µ“¡µÕâ ß°“√‰¥‚â ¥¬Õ“»¬— software ™ÕË◊ Synergy ´ßË÷  “¡“√∂ª√∫— °“√√°— …“„À‡â À¡“–°∫— capacity ¢Õß peritoneum ¢ÕߺªâŸ «É ¬‚¥¬„™¢â Õâ ¡≈Ÿ personal dialysis capacity test ∑”„À â “¡“√∂§”π«≥ optimal dialytic dose „À°â ∫— ºªâŸ «É ¬·≈– ßË— °“√∑”ß“π‰ª¬ß— ‡§√ÕË◊ ß APD ºà“π∑“ß data card °“√√—°…“∑’˺ŸâªÉ«¬·µà≈–§π‰¥â√—∫®÷ߢ÷Èπ°—∫§ÿ≥ ¡∫—µ‘¢Õß peritoneum ¢Õߺ⟪ɫ¬ πÕ°®“°π°’È “√∑’Ë Serena ¡°’ “√«¥— flow rate µ≈Õ¥‡«≈“ ∑”„Àâ Selena ‡ªπì ‡§√Õ◊Ë ß APD ‡§√Õ◊Ë ß·√°∑ ’Ë “¡“√∂ detect ®¥ÿ breakpoint „π·µ≈à –√Õ∫°“√√°— …“¢ÕߺªâŸ «É ¬‰¥â Breakpoint ‡ªπì ®¥ÿ ∑Ë’ outflow rate ¢Õß°“√ drain PDF ¡°’ “√‡ª≈¬Ë’ π·ª≈ß≈¥≈ßÕ¬“à ß©∫— æ≈π— ®“° 200-300 mL/min ‡À≈Õ◊ 30-60 mL/min ´ßË÷ ‡ªπì ®¥ÿ ∑‡Ë’ §√ÕË◊ ß Serena ‡√¡Ë‘ ª≈Õà ¬π”È ¬“ PDF ‡¢“â  ™àŸ Õà ß∑Õâ ß„π√Õ∫µÕà ‰ª ®ß÷ ‰¡‡à  ¬’ ‡«≈“‰ª„π°“√ª≈Õà ¬π”È ¬“ PDF ÕÕ° Õ¬à“ß™â“Ê ‚¥¬¡’°“√·≈°‡ª≈’ˬπ¢Õ߇ ’¬À√◊Õ dialysis „π™à«ßπ—ÈππâÕ¬ ∑”„Àâª√– ‘∑∏‘¿“æ°“√√—°…“ºâŸ ª«É ¬¥¢’ π÷È ·≈–≈¥°“√√∫°«π°“√πÕπ¢ÕߺªâŸ «É ¬‡πÕ◊Ë ß®“°≈¥°“√√Õâ ߇µÕ◊ π®“°‡§√Õ◊Ë ß‡«≈“∑’Ëflowrate¡ª’ ≠í À“ Serena ®÷߇ªìπ‡§√◊ËÕß APD ∑’Ë “¡“√∂ª√—∫°“√√—°…“„Àâ‡À¡“–°—∫ºŸâªÉ«¬·µà≈–√“¬‰¥â§àÕπ¢â“ߥ’·≈–¬—ß  “¡“√∂ª√∫— „À„â ™ßâ “π‰¥°â ∫— πÈ”¬“ PDF √πÿà „À¡Êà ´ß÷Ë ¡’ biocompatibility ∑¥’Ë ‰’ ¥¥â «â ¬ ‡™πà low glucose degradation products (GDPs) PDF ´ß÷Ë ¡§’ «“¡ ”§≠— ‡πÕ◊Ë ß®“°ºªŸâ «É ¬∑‰’Ë ¥√â ∫— °“√√°— …“¥«â ¬‡§√Õ◊Ë ß APD ®–¡‚’ Õ°“  expose µÕà π”È ¬“ PDF ®”π«π¡“°°«“à ºªŸâ «É ¬ CAPD PD night ·≈– Sleep Safe ¢Õß∫√…‘ ∑— Fresenius Medical Care ª√–‡∑»‡¬Õ√¡π— π’ PD night ‡ªπì ‡§√ÕË◊ ß∑„Ë’ ™â gravity „π°“√§«∫§¡ÿ flow  “¡“√∂„™πâ ”È ¬“ PDF ‰¥¡â “°°«“à 25 L/session ·≈–ª√∫— π”È ¬“ PDF √Õ∫ ÿ¥∑⓬„Àâ§â“ß„π™àÕß∑âÕ߇ªìπ day dwell ‰¥â ¡’‚§√ß √â“ß·≈–Àπâ“®Õ∑’Ë„™â‰¥âßà“¬ ∑”„Àâ

New Frontiers in Dialysis 246 ∏𵑠®√‘ π—π∑å∏«™—  √‘ ‘¿“ ™â“ß»‘√°‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ‡ÿ ¡∏°ÿ≈  “¡“√∂ª√∫— ‡ª≈¬’Ë π°“√√°— …“‰¥ â –¥«°·≈–¡’codeªÕÑ ß°π— °“√ª√∫— ‡ª≈¬’Ë π°“√√°— …“‚¥¬‰¡‰à ¥√â ∫— Õπ≠ÿ “µ ¢âÕ¡Ÿ≈°“√√—°…“§√—Èß ÿ¥∑⓬®–∂Ÿ°‡°Á∫‰«â·≈–¡’Õÿª°√≥几√‘¡ ”À√—∫ teledialysis √–∫∫®–„™â “¬„π°“√ ‡™ÕË◊ ¡µÕà ‡™πà ‡¥¬’ «°∫— Andy-plus ·≈– drainage bag  “¡“√∂π”°≈∫— ¡“„™„â À¡‰à ¥â µÕà ¡“‰¥¡â °’ “√æ≤— π“ ‡§√ÕË◊ ߉ª‡ªπì √πàÿ Sleep Safe ´ßË÷ §«∫§¡ÿ flow ‰¥ â ߟ  ¥ÿ ∂ß÷ 400 mL/min ¥«â ¬ pressure ‡§√ÕË◊ ß®–∑”ß“πº“à π software ™ÕË◊ Patient on Line (POL) ´ßË÷ ‡ªπì graphic ∑„’Ë ™ßâ “à ¬ °“√ ßË— °“√√°— …“„π·µ≈à –√Õ∫ ‰¥·â °à volume, dwell time À√◊Õ tidal ®–· ¥ß‡ªìπ√Ÿª∑’ˇÀÁπ‰¥â™—¥  “¡“√∂ª√—∫°“√√—°…“„Àâ‡À¡“–°—∫ºâŸªÉ«¬„π·µà≈– √“¬‰¥‡â ™πà °π— º“à π∑“ß touch screen ‡§√ÕË◊ ß “¡“√∂§”π«≥ clearance µ“¡°“√√°— …“‰¥∂â “â „ ¢à Õâ ¡≈Ÿ ¢Õß urea kinetic model ¢ÕߺŸâªÉ«¬≈߉ª¥â«¬ °“√ —Ëß°“√√—°…“ºŸâªÉ«¬¬—ß “¡“√∂ —Ëߺà“π∑“ß data card ´÷Ëß  “¡“√∂ª√∫— ‚ª√·°√¡°“√√°— …“‰¥Àâ ≈“¬√ªŸ ·∫∫∑‡Ë’ À¡“– ¡°∫— ºªŸâ «É ¬ ‡§√ÕË◊ ß sleep safe ¬ß—  “¡“√∂Õ“à π bar code ¢Õß∂ßÿ π”È ¬“ PDF ‰¥¥â «â ¬‡ªπì °“√µ√«® Õ∫«“à „™™â 𥑠¢Õßπ”È ¬“∂°Ÿ µÕâ ßµ“¡‚ª√·°√¡∑·Ë’ æ∑¬å  ßË— À√Õ◊ ‰¡à °“√µÕà  “¬°∫— ∂ßÿ π”È ¬“ PDF ®–∑”‚¥¬Õµ— ‚π¡µ— º‘ “à π tray ¢Õ߇§√ÕË◊ ß‚¥¬‰¡µà Õâ ß„™â cones À√Õ◊ clamps ∑”„Àâ≈¥°“√ contamination ‰¥â °“√∑”„ÀâπÈ”¬“ PDF Õÿàπ®–∑”„π™à«ß infusion phase ´÷Ëß≈¥ √–¬–‡«≈“„π°“√∑’Ë®–µâÕß∑”„ÀâπÈ”¬“Õÿàπ∑—ÈßÀ¡¥°àÕπ„ à‡¢â“ Ÿà™àÕß∑âÕß ·µà≈–√Õ∫¢Õß°“√—°…“ “¡“√∂ ª√∫— ‡ª≈¬Ë’ π‰¥µâ “¡§«“¡‡À¡“– ¡¢Õß intraabdominal pressure ·≈–≈°— …≥–¢Õß peritoneum ¢ÕߺªâŸ «É ¬ ‰¥·â °à dwell time, volume ·≈– glucose concentration Bags ∑”¥«â ¬ “√ polyolefin ∑‰’Ë ¡¡à ’ polyvinyl chlorides ·≈–∑”„Àªâ ≈Õ¥‡™ÕÈ◊ ¥«â ¬«∏‘ ’ steam-sterilized POL ¬ß— ¡√’ ªŸ ¢Õß exit sites ™π¥‘ µ“à ßÊ 8 groups ·µ≈à – group ·∫ßà §«“¡√πÿ ·√ßµ“¡ Twardowski system ‡ªπì 6 degrees ∑”„À â “¡“√∂‡ª√¬’ ∫‡∑¬’ ∫≈°— …≥– exit site ¢Õߺ⟪ɫ¬„π·µà≈–§√—Èß∑’Ë¡“µ√«®‰¥â µ—«·ª√∑—ÈßÀ¡¥·≈–°“√√âÕ߇µ◊Õπ®–∂Ÿ°∫—π∑÷°„π data card ·≈– ‡°Á∫‰¥âπ“π 3 ‡¥◊Õπ ‡¡◊ËÕπ”¡“«‘‡§√“–Àå®– “¡“√∂· ¥ß¢âÕ¡Ÿ≈‡ªìπ graphic ‡ª√’¬∫‡∑’¬∫°“√√—°…“∑’Ë ·æ∑¬ å ßË— °∫— °“√√°— …“∑ºË’ ªŸâ «É ¬‰¥√â ∫— ®√ß‘ ∑”„À∑â √“∫∂ß÷ compliance ¢ÕߺªŸâ «É ¬ ¡’ option ¢Õß teledialysis ∑”„À∑â √“∫∂ß÷ °“√√°— …“∑º’Ë ªâŸ «É ¬‰¥√â ∫— µ≈Õ¥‡«≈“·≈– “¡“√∂download¢Õâ ¡≈Ÿ °“√√°— …“∑ß—È À¡¥„πsession ππÈ— Ê ‰¥â Bellco Lybera ¢Õߪ√–‡∑»Õµ‘ “≈’ §«∫§¡ÿ flow ‚¥¬„™â pressure pump ∑”ß“π§Õà π¢“â ߇߬’ ∫ · ¥ßÀπâ“®Õ‡ªìπ graphic ‡™àπ°—π ∑”„Àâßà“¬µàÕ°“√µ—Èß‚ª√·°√¡·≈–ª√—∫‡§√◊ËÕß √Ÿª·∫∫·≈–√–∫∫„°≈â ‡§¬’ ß°∫— ‡§√ÕË◊ ß Serena ¢Õß Gambro §Õ◊ ¡’ heater bag & drain bag Õ¬„àŸ π flow-control chamber ∑”„Àâ  “¡“√∂§«∫§¡ÿ inflow rate „À‡â æ¡Ë‘ ¢πÈ÷ ™“â Ê Õ¬“à ßµÕà ‡πÕË◊ ß‚¥¬‰¡¡à ’ pulsatile peak ®ß÷ ‰¡√à ∫°«πºªâŸ «É ¬ ¡’ °“√«¥— πÈ”Àπ°— ¢Õß PDF Õ¬“à ßµÕà ‡πÕ◊Ë ß∑”„À â “¡“√∂«¥— UF ‰¥Õâ ¬“à ß∂°Ÿ µÕâ ß ·≈–¬ß—  “¡“√∂°”Àπ¥ dialysis schedule ‰¥â·°à daytime dwell, tidal PD À√◊Õ intermittent PD ‰¥â ‡§√◊ËÕß “¡“√∂√—∫ data card ´÷Ëß  “¡“√∂√∫— ‚ª√·°√¡°“√√°— …“‰¥·â ≈–ª√∫— °“√√°— …“„À‡â À¡“– ¡°∫— ºªâŸ «É ¬„π·µ≈à –√“¬‡æÕË◊ „À‰â ¥â optimal dialytic dose µ«— ‡§√ÕË◊ ß “¡“√∂·¬°®“°‡ “ (trolley) ·≈–𔇠“‰ª„™„â π°“√·¢«π infusion À√Õ◊ drainage bags ‰¥â

Frontiers in Peritoneal Dialysis  ™ÿ “¬ »√’∑æ‘ ¬«√√≥ 247 3. Continuous flow peritoneal dialysis (CFPD) „πºªâŸ «É ¬∑¡Ë’ √’ ªŸ √“à ß„À≠Àà √Õ◊ ‰¡¡à ª’  í  “«–·≈«â °“√√°— …“¥«â ¬ CAPD À√Õ◊ APD Õ“®‰¡‡à 欒 ßæÕ ·µ®à “°°“√∑Ë’ peritoneal solute clearance ‰¡‰à ¥∂â °Ÿ ®”°¥— ¥«â ¬ peritoneal surface membrane ·≈– blood flow °“√ª√∫— ‡∑§π§‘ °“√∑” PD Õ“®™«à ¬‡æ¡Ë‘ ª√– ∑‘ ∏¿‘ “æ¢Õß°“√√°— …“‰¥â ¢Õâ ¡≈Ÿ °“√»°÷ …“ºªŸâ «É ¬ CPD ∑‚Ë’ √ß欓∫“≈»√‘ √‘ “™æ∫«“à small solute clearance ∑“ß peritoneal membrane ®–¬ß— §ß‡æ¡Ë‘ ¢πÈ÷ ·¡«â “à dwell time ®–º“à π‰ª∂ß÷ 7 ™«Ë— ‚¡ß ·µÕà µ— √“°“√‡æ¡Ë‘ ¢πÈ÷ ππÈ— ®–™“â ¡“°‡πÕË◊ ß®“° diffusion gradient ∑≈Ë’ ¥≈ß °“√ maintain diffusion gradient „À§â ßÕ¬ÕàŸ “®∑”‰¥‚â ¥¬‡æ¡Ë‘ √Õ∫¢Õß°“√∑” PD ¥«â ¬°“√„ πà ”È ¬“ PDF „À¡à ‡¢â“‰ª„À¡à ·µ¢à Õâ ®”°—¥§◊Õ∂Ⓡæ‘Ë¡®”π«π√Õ∫¡“°‡«≈“∑„Ë’ ™„â π°“√ dialysis ®–‡√‘Ë¡≈¥≈ß ‡πË◊Õß®“°‡«≈“  «à π„À≠®à –∂°Ÿ „™„â π°“√ª≈Õà ¬π”È ¬“ PDF ‡¢“â ÕÕ°™Õà ß∑Õâ ß (drain-fill time) ∑”„Àâ solute clearance ‡æ¡Ë‘ ‰¥â‰¡à‡µÁ¡∑’Ë ®÷ß¡’°“√æ—≤π“‡∑§π‘§ CFPD ¢÷Èπ¡“ ´÷ËßÕ“®‡ªìπ∑“߇≈◊Õ°„ÀâºâŸªÉ«¬‡À≈à“π’È°àÕπ∑’Ë®–‡ª≈’Ë¬π ‰ª√°— …“¥«â ¬«∏‘ ’ chronic hemodialysis CFPD ‡ªπì °“√√°— …“¥«â ¬ high-dose PD ®”‡ªπì µÕâ ß¡’ double lumen peritoneal catheter ‡πÕË◊ ß®“°µÕâ ß„ πà ”È ¬“ PDF ‡¢“â ™Õà ß∑Õâ ߢÕߺªŸâ «É ¬Õ¬“à ßµÕà ‡πÕË◊ ß„π¢≥–∑¡Ë’ °’ “√ drain πÈ”¬“ PDF ÕÕ°®“°™Õà ß∑Õâ ßµ≈Õ¥‡«≈“‡™πà °π— ∑”„Àâ transperitoneal solute gradient ·≈– solute transport  ßŸ Õ¬µŸà ≈Õ¥‡«≈“®“°°“√∑Ë’ intraperitoneal solute ¡√’ –¥∫— µ”Ë Õ¬µàŸ ≈Õ¥‡«≈“ Sterile PDF ®”π«π¡“°®– ∂°Ÿ „ ‡à ¢“â  ™àŸ Õà ß∑Õâ ߢÕߺªŸâ «É ¬Õ¬“à ßµÕà ‡πÕË◊ ß„π√ªŸ ·∫∫¢Õß single-pass CFPD À√Õ◊ recirculating system ‚¥¬Õ“»¬— conventional hemodialysis system À√Õ◊ sorbent-based circuit ¡°’ “√„™â CFPD √°— …“ºªŸâ «É ¬ µßÈ— ·µªà ï §.».19652 ‚¥¬„™â peritoneal catheter 2  “¬ „ πà ”È ¬“ sterile PDF ‡¢“â ™Õà ß∑Õâ ߺªŸâ «É ¬ 3 L ·≈– regenerated º“à π coil dialyzer ‚¥¬„™πâ ”È ¬“ PDF ∑ßÈ— À¡¥ 100 L Dialysate flow ª√–¡“≥ 120-300 mL/min ´ßË÷ ®–‰¥â urea clearance ª√–¡“≥ 46-125 mL/min Total body urea clearance ®–¢πÈ÷ °∫— mass transfer coefficient ¢Õß urea (MTCurea), PDF flow (Qp) ·≈– dialysate in external circuit (D) ´ßË÷ ¢πÈ÷ °∫— external dialysate flow ·≈– membrane surface area MTCurea ®–‡ªπì rate limiting ·≈– total urea clearance ®–¡§’ “à „°≈‡â §¬’ ß°∫— §“à MTCurea ®“°°“√§”π«≥‚¥¬„™¢â Õâ ¡≈Ÿ ªï §.».1965(2) æ∫«“à MTCurea ¡§’ “à 60-70 Concentration gradient ®–¢πÈ÷ °∫— ª√– ∑‘ ∏¿‘ “æ¢Õß external circuit ·≈– MTCurea ®–·ª√ºπ— ‚¥¬µ√ß°∫— Qp ·µ®à –‡√¡Ë‘ plateau ∑Ë’ Qp > 200 mL/min3 ª≠í À“¢Õß°“√√°— …“¥«â ¬«∏‘ ’ CFPD §Õ◊ ultrafiltration rate ‡πÕË◊ ß®“°µÕâ ß°”Àπ¥ internal rate (inflow rate + UF rate) „À‡â À¡“–°∫— external rate (drain rate) ∂“â internal rate > external rate ®–∑”„Àπâ ”È ¬“ PDF §“â ß„π™Õà ß∑Õâ ß¡“°¢πÈ÷ ‡√ÕË◊ ¬Ê ·µ∂à “â external rate > internal rate πÈ”¬“ PDF ®–§â“ß„π™àÕß∑âÕßπâÕ¬≈߇√◊ËÕ¬Ê ®π‰¡à “¡“√∂∑” CFPD µàÕ‰¥â ®“°°“√ §”π«≥æ∫«“à ∂“â „™πâ ”È ¬“ PDF ∑¡Ë’ ’ glucose 1-1.5% ®–¡’ UF rate 0.2-0.45 L/hr3 À√Õ◊ 6-7 mL/min4 ´ßË÷ „°≈â ‡§¬’ ß°∫— in vivo study ∑„Ë’ ™πâ ”È ¬“ 1.36% glucose PDF æ∫«“à ‰¥â UF 587 mL/4 hr5 ¡§’ «“¡æ¬“¬“¡∑®Ë’ –„™â «∏‘ °’ “√µ“à ßÊ „π°“√«¥— intraperitoneal volume ‡æÕË◊ „À∑â √“∫∂ß÷ UF rate „π¢≥–ππÈ— ‰¥·â °à bioimpedance, abdominal girth strain sensors À√Õ◊ intraperitoneal pressure ·µ¬à ß— Õ¬„àŸ π¢πÈ— µÕπ°“√»°÷ …“ πÕ°®“°πÈ’ glucose absorption Õ“®‡ªπì ª≠í À“„πºªŸâ «É ¬‡∫“À«“π ®ß÷ ¡°’ “√π” osmotic agent ™π¥‘ Õπ◊Ë ¡“„™·â ∑π glucose ‰¥·â °à albumin ·µ‰à ¡‡à ªπì ∑·Ë’ æ√Àà ≈“¬‡πÕË◊ ß®“°¡√’ “§“·æß¡“°

New Frontiers in Dialysis 248 ∏π‘µ ®‘√π—π∑å∏«—™  √‘ ¿‘ “ ™“â ß»‘√°‘ ≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°ÿ≈ Peritoneal catheter ∑„Ë’ ™„â π°“√∑” CFPD ¡§’ «“¡ ”§≠— ¡“° ‡πÕË◊ ß®“°π”È ¬“ PDF ∑„Ë’  ‡à ¢“â ™Õà ß ∑Õâ ߺªŸâ «É ¬®–µÕâ ߺ ¡Õ¬“à ß ¡Ë”‡ ¡Õ°∫— πÈ”¬“ PDF ∑§’Ë “â ßÕ¬„àŸ π™Õà ß∑Õâ ߇æÕ◊Ë ªÕÑ ß°π— °“√‡°¥‘ recirculation ·µà°“√„ à “¬ peritoneal catheter 2 ‡ âπ‰¡à‡ªìπ∑’Ëπ‘¬¡·¡â«à“®– “¡“√∂∑”„À≥â urea clearance ∑’Ë Ÿß ·µ®à –¡·’ º≈∑ÀË’ π“â ∑Õâ ß 2 µ”·Àπßà ·≈–Õ“®∑”„Àºâ ªŸâ «É ¬‰¡ à –¥«°‡πÕË◊ ß®“°¡ ’ “¬ÕÕ°®“°™Õà ß∑Õâ ß 2  “¬ ®ß÷ ¡§’ «“¡æ¬“¬“¡∑®Ë’ –ª√–¥…‘ ∞ å “¬ peritoneal catheter ∑‡Ë’ ªπì double lumen ‡æÕË◊ „™∑â ” CFPD Catheter ‡À≈“à πÈ’ (√ªŸ ∑Ë’ 1) °”≈ß— Õ¬„Ÿà π¢πÈ— µÕπ°“√»°÷ …“ ·µ™à 𥑠∑πË’ “à  π„® §Õ◊ Dual lumen catheter with diffuser æ—≤π“‚¥¬ª√–‡∑»Õ‘µ“≈’ ≈—°…≥–¢Õß “¬®–‡ªìπ double lumen ∑”¥â«¬ silicone  “¬¥â“π inflow ®–‰ª π‘È  ¥ÿ ‡ªπì °√–‡ª“–™Õ◊Ë diffuser ∑’Ë parietal peritoneum °√–‡ª“–π¡’È √’ „Ÿ Àπâ È”¬“ PDF ‰À≈ÕÕ°‰¥‚â ¥¬√Õ∫ 360°  «à 𠓬¥“â π outflow ®–‡ªπì  “¬¬“«ª≈“¬¢¥‡ªπì «ß°≈¡‰ª πÈ‘  ¥ÿ ∑Ë’ pelvic cavity ‡æÕË◊ drain π”È ¬“ PDF ÕÕ°  “¬™π¥‘ π¡È’ ª’ √– ∑‘ ∏¿‘ “æ¡“° ‡πÕË◊ ß®“°„Àâ flow rate ∑ Ë’ ߟ , ‰¡‡à æ¡Ë‘ intraabdominal pressure ¡“°·≈–¡’ recirculation πÕâ ¬  “¡“√∂„ ‰à ¥‡â ™πà ‡¥¬’ «°∫—  “¬ peritoneal catheter ∑«Ë— Ê ‰ª∑„Ë’ ™„â πª®í ®∫ÿ π— ·≈–¬—ß„™â„π°“√∑” CAPD À√◊Õ APD ‰¥â¥â«¬‡¡◊Ëժ≈“¬ “¬ inflow ¢Õß diffuser CFPD ¡’§«“¡ ‡À¡“– ¡°«“à hemodialysis „π°√≥∑’ ®Ë’ –„™‡â ªπì home dialysis ‡πÕË◊ ß®“°‰¡¡à §’ «“¡‡ ¬Ë’ ß„π‡√ÕË◊ ߢÕß air √ªŸ ∑Ë’ 1 Peritoneal catheter ™π¥‘ µ“à ßÊ ∑„Ë’ ™„â π°“√∑” CFPD

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√∑’ æ‘ ¬«√√≥ 249 embolism, bleeding ®“° accidental disconnection ·≈– sepsis ‚¥¬‡©≈¬Ë’ °“√∑” CFPD „πºªâŸ «É ¬π”È Àπ°— 70 kg π“π 8 ™«Ë— ‚¡ß/«π— ·≈–„™â Qp 250 mL/min ®–‰¥â urea clearance 40 mL/min ·≈–§“à Kt/Vurea 0.5-0.6/«π— À√Õ◊ 2.5/5 «π— / ª— ¥“Àå ¡“°°«“à §“à 1.7 ∑‡Ë’ ªπì §“à adequacy recommendation ¢Õß guidelines µ“à ßÊ „π ª®í ®∫ÿ π— ·≈–∂“â ∑”∑°ÿ «π— ®–‰¥§â “à Kt/Vurea ∂ß÷ 4.2/ ª— ¥“Àå ´ß÷Ë ¡§’ “à „°≈‡â §¬’ ß°∫— °“√∑” chronic hemodialysis ∑°ÿ «π— «π— ≈– 9 ™«Ë— ‚¡ß 5-6 «π— µÕà  ª— ¥“À6å ¢Õâ ¥Õ’ πË◊ Ê ¢Õß CFPD ‰¥·â °à  “¡“√∂„™â bicarbonate buffer, low GDPs or AGEs PDF, ¡°’ “√ ≠Ÿ ‡ ¬’ protein πÕâ ¬ ·≈–¡’ dry abdomen „πµÕπ°≈“ß«π— ‰¥â ∑”„Àâ peritoneum ‰¡µà Õâ ß expose µÕà glucose µ≈Õ¥‡«≈“ ·µ¢à Õâ ®”°¥— §Õ◊ ¬ß— µÕâ ß¡°’ “√æ≤— 𓇧√ÕË◊ ß CFPD ·≈–Õªÿ °√≥å ∑„Ë’ ™„â π°“√‡µ√¬’ ¡π”È ¬“ PDF „Àºâ ªâŸ «É ¬∑∫Ë’ “â π √«¡∑ßÈ— °“√®¥— °“√°∫— ª≠í À“‡√ÕË◊ ߢÕß UF ¥ß— °≈“à «¢“â ßµπâ 4. °“√æ≤— π“πÈ”¬“ peritoneal dialysis fluid (PDF)7 π”È ¬“ PDF ∑¥Ë’ §’ «√¡ ’ «à πª√–°Õ∫„°≈‡â §¬’ ß°∫— ‡≈Õ◊ ¥·≈–¡æ’ …‘ µÕà √“à ß°“¬À√Õ◊ peritoneum πÕâ ¬ ∑ Ë’ ¥ÿ π”È ¬“ PDF ∑„Ë’ ™°â π— ‚¥¬∑«Ë— ‰ª¡’ glucose ‡ªπì osmotic agent ·≈–¡’ lactate ‡ªπì buffer ∑”„Àâ PDF ¡’ pH ∑’˵˔ 5.5 ®π “¡“√∂∑”„Àâª≈Õ¥‡™◊ÈÕ‰¥â¥â«¬§«“¡√âÕπ‚¥¬‰¡à‡°‘¥ caramalization8 ·µà‡°‘¥ glucose degradation products (GDPs) ´ß÷Ë ¡º’ ≈‡ ¬’ µÕà ‚§√ß √“â ß·≈–°“√∑”ß“π¢Õß peritoneum (diabeticform change)9 GDPs ∑‡’Ë °¥‘ ¢π÷È ¬ß— ∂°Ÿ ¥¥Ÿ ´¡÷ ‡¢“â  °Ÿà √–· ‡≈Õ◊ ¥·≈– “¡“√∂°√–µπÿâ °“√ √“â ß advanced glycation end products (AGEs) ∑ßÈ— „π «à π local ·≈– systemic ‰¥â ‚¥¬°“√‡°¥‘ reaction ¢Õß aldehyde form ¢Õß glucose °∫— amines À√Õ◊ proteins ∑”„À‡â °¥‘ Amadori glycosylation products ´ßË÷ ¡º’ ≈‡ ¬’ µÕà peritoneum10 πÕ°®“°πÈ’ pH ∑’˵˔¢Õß PDF ¬—ßÕ“®∑”„À⇰‘¥§«“¡‡®Á∫ª«¥√–À«à“ß∑’˪≈àÕ¬πÈ”¬“‡¢â“™àÕß∑âÕߺŸâªÉ«¬·≈–¡’º≈ ‚¥¬µ√ßµÕà °“√‡°¥‘ neoangiogenesis ·≈– mesothelial cell damage ·µÕà ¬“à ߉√°µÁ “¡ direct toxicity ¢ÕßπÈ”¬“ PDF µÕà peritoneum  «à π„À≠‡à °¥‘ ®“° “√ GDPs ·≈– AGEs ¡“°°«“à pH, lactate, osmolality À√Õ◊ glucose7 ‚¥¬°√–µÿâπ„À⇰‘¥ angiogenesis ·≈– diabetiform change „πªí®®ÿ∫—π®÷ß¡’°“√æ—≤π“πÈ”¬“ PDF „Àâ¡’ biocompatibility ¡“°¢πÈ÷ ‚¥¬°“√∑”„Àπâ ”È ¬“ PDF ¡’ pH ∑„Ë’ °≈‡â §¬’ ß°∫— physiological intraperitoneal pH ¡“°¢πÈ÷ ·≈–≈¥°“√‡°¥‘ GDPs ®“°§«“¡√Õâ π„π¢πÈ— µÕπ°“√º≈µ‘ π”È ¬“‚¥¬ 1) „™ â “√ glucose alternatives ÕπË◊ Ê ‡™πà icodextrin À√Õ◊ amino acids ‡ªπì osmotic agents ´ßË÷ ®–™«à ¬≈¥°“√‡°¥‘ glucose toxicity ·≈– ‡ √¡‘  “√Õ“À“√„Àºâ ªŸâ «É ¬‰¥¥â «â ¬µ“¡≈”¥∫— À√Õ◊ 2) ·¬° “√≈–≈“¬ buffers ÕÕ°®“° “√≈–≈“¬ glucose ·≈– electrolytes „π¢πÈ— µÕπ°“√º≈µ‘ ·≈«â ®ß÷ √«¡°π— °Õà π„ ‡à ¢“â  ™Ÿà Õà ß∑Õâ ߺªâŸ «É ¬ (multibag systems) «∏‘ ’ π È’ “¡“√∂ª√∫— „À â “√≈–≈“¬ high concentrated glucose ¡’ pH ∑µË’ ”Ë ≈ß®π∂ß÷ 2.8-3 ‰¥â ´ßË÷ ®–≈¥°“√‡°¥‘ GDPs „π√–À«“à ß autoclaving À√Õ◊ ‡¡Õ◊Ë ‡°∫Á πÈ”¬“‰«‡â ªπì ‡«≈“π“π8 πÕ°®“°π¬’È ß— ªÕÑ ß°π— °“√µ°µ–°Õπ¢Õß calcium ·≈– magnesium °∫— bicarbonate buffer Õ°’ ¥«â ¬ ∫√…‘ ∑— Baxter ·≈– Fresinius „™â two bag systems ‚¥¬ Physioneal ¢Õß Baxter „™â lactate/bicarbonate mixed buffer (25 mmol/L bicarbonate with 15 mmol/ L lactate, pH 7-7.4) ¥°’ «“à °“√„™â bicarbonate buffer ‡æ¬’ ßÕ¬“à ߇¥¬’ «‡πÕ◊Ë ß®“°∑”„À‡â °¥‘ infusion pain πÕâ ¬°«“à „π¢≥–∑Ë’ Fresinius Stay Safe Balance system ®–·¬° glucose ·≈– electrolytes ®“° lactate buffer bicaVera system „™â pure bicarbonate buffer §«“¡‡¢¡â ¢πâ 34 mmol/L  «à π Gambrosol Trio ¢Õß∫√…‘ ∑—

New Frontiers in Dialysis 250 ∏𵑠®‘√π—π∑å∏«™—  √‘ ‘¿“ ™â“ß»√‘ ‘°≈ÿ ™¬— ∏π—𥓠µ√–°“√«π™‘ « —πµå  ‡ÿ ¡∏°≈ÿ Gambro ®–·¬° «à πª√–°Õ∫‡ªπì 3  «à π (three bag system) ´ßË÷ „™â lactate ‡ªπì buffer 1 ∂ßÿ Õ°’ 2 ∂ßÿ ‡ªπì hi-concentrated glucose ∑¡Ë’ §’ «“¡‡¢¡â ¢πâ µ“à ß°π— ∑”„À â “¡“√∂ª√∫— §«“¡‡¢¡â ¢πâ ¢Õß glucose „Àºâ ªŸâ «É ¬‰¥â ‚¥¬‡≈Õ◊ °„™â glucose ‡æ¬’ ß∂ßÿ „¥∂ßÿ ÀπßË÷ À√Õ◊ ∑ßÈ—  Õß∂ßÿ °“√·¬° buffer ÕÕ°®“° “√≈–≈“¬ glucose ·≈– electrolytes π’È·¡â«à“®–„™â lactate ‡À¡◊Õπ‡¥‘¡°Áµ“¡ ®– “¡“√∂∑”„Àâ pH  Ÿß¢÷Èπ‰¥â®“° 5.5 ‡ªìπ 6.5 ‡¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— π”È ¬“ PDF ‡¥¡‘ 7 ¬ß— ‰¡¡à ¢’ Õâ ¡≈Ÿ „πª®í ®∫ÿ π— ∑‡Ë’ ª√¬’ ∫‡∑¬’ ∫°“√„™â low GDP-containing glucose-based PDF ·µ≈à –™π¥‘ ∑“ߧ≈π‘ °‘ 7  “√™π¥‘ Õπ◊Ë ∑‡’Ë ªπì osmotic agents ·≈–„™·â ∑π glucose ‰¥â ‰¥·â °à 7.5%icodextrin (Extraneal) ‡ªπì glucose polymer, molecular weight 17,000 dalton ·≈–¡’ lactate ‡ªπì buffer (pH 5-6) ¢Õß∫√…‘ ∑— Baxter Icodextrin ¡’ GDPs µ”Ë °«“à glucose-based PDF ‡¥¡‘ ·≈–®–∂°Ÿ ¥¥Ÿ ´¡÷ „π√ªŸ ¢Õß maltose ´ßË÷ ‡°¥‘ ®“° intraperitoneal hydrolysis Ultrafiltration capacity ¢Õß 7.5% icodextrin ‡∑¬’ ∫‡∑“à °∫— 2.25% glucose-based PDF ·µ∑à ”„À‡â °¥‘ UF ‰¥¬â “«π“π°«“à ‚¥¬Õ“»¬— oncotic pressure ‡πÕ◊Ë ß®“°∂°Ÿ ¥¥Ÿ ´¡÷ ‡¢“â  °àŸ √–· ‡≈Õ◊ ¥‰¥πâ Õâ ¬·≈–™“â °«“à glucose∑”„À§â «“¡·µ°µ“à ß√–À«“à ßosmolarity¢Õß PDF ·≈–‡≈Õ◊ ¥§ßÕ¬‰àŸ ¥πâ “π11 ™«à ¬ improved fluid status12 Õ“®æ∫ hypersensitivity ®“°°“√„™â icodextrin ‰¥·â ≈–‰¡§à «√„™¡â “°°«“à «π— ≈– 1 ∂ßÿ ‡πÕ◊Ë ß®“°∑”„À√â –¥∫— maltose „π‡≈Õ◊ ¥ ßŸ ®π‡ªπì Õπ— µ√“¬‰¥7â πÕ°®“° icodextrin ·≈«â ¬ß— ¡°’ “√π” amino acids ¡“„™‡â ªπì osmotic agent ‰¥·â °à Nutrineal (1.1%amino acid) ¢Õß ∫√…‘ ∑— Baxter ´ßË÷ ¡’ ultrafiltration capacity ‡∑¬’ ∫‡∑“à °∫— 1.36% glucose-based PDF ·µ‰à ¡¡à ’ GDPs ·≈–  “¡“√∂∑”„À¿â “«–°“√¢“¥ “√Õ“À“√¢ÕߺªŸâ «É ¬¥¢’ π÷È ‰¥1â 3 ¢Õâ ®”°¥— §Õ◊  “¡“√∂„™‰â ¥‡â 欒 ß«π— ≈– 1 ∂ßÿ ‡∑“à ππÈ— ‡πÕË◊ ß®“°Õ“®∑”„À‡â °¥‘ ¿“«– uremia ·≈– metabolic acidosis ‰¥1â 4 °“√„™â low GDP PDF ®–™«à ¬ improved viability ·≈– proliferation ¢Õß mesothelial cells ´ßË÷ µ√«®æ∫‰¥®â “°°“√∑¡Ë’ √’ –¥∫— CA-125 ·≈– fibronectin ∑ Ë’ ߟ ¢πÈ÷ 15 √«¡∑ßÈ— improved mesothelial-based healing16, ≈¥ intraperitoneal inflammation ·≈– maintain macrophage function ¬ß— ‰¡¡à ¢’ Õâ ¡≈Ÿ ·π™à ¥— «“à º≈¥ß— °≈“à «‡ªπì º≈®“°°“√≈¥ peritonitis rate À√Õ◊ ‰¡à ·µ®à “°¢Õâ ¡≈Ÿ °“√„™â Physioneal æ∫«“à ºªâŸ «É ¬°≈¡àÿ π´È’ ßË÷ ‰¥√â ∫— °“√√°— …“¥«â ¬ automated PD ¡’ peritonitis rate & infusion pain πÕâ ¬°«“à ·≈–πÕπÀ≈∫— ‰¥¥â 7’ °“√„™â glucose-based PDF ¬ß— ¡º’ ≈µÕà metabolic effects ‰¥·â °à hyperglycemia, abnormal lipid metabolism, hyperinsulinemia ·≈– insulin resistance °“√„™â icodextrin ·∑π glucose-based PDF Õ“®™«à ¬≈¥¿“«–§«“¡º¥‘ ª°µ‡‘ À≈“à π1È’ 7 ·≈–≈¥°“√‡æ¡Ë‘ drained body weight ·≈– fat mass12 ‚¥¬ √ªÿ º≈¥¢’ Õß°“√„™πâ ”È ¬“ low GDPs PDF §Õ◊ ¡’ pH ∑„Ë’ °≈‡â §¬’ ß°∫— physiological pH, improved peritoneal membrane biocompatibility, preserve membrane defence, ≈¥ infusion pain ·≈– ·°‰â ¢¿“«– metabolic acidosis ‰¥¥â ¢’ πÈ÷ „π°√≥∑’ „Ë’ ™â pure bicarbonate buffered7 ·µπà ”È ¬“‡À≈“à π¬È’ ß— ¡√’ “§“ ·æß·≈–º≈µÕà long term outcomes ¬ß— §ßµÕâ ß√Õ°“√»°÷ …“∑¥Ë’ °’ Õà π 5. °“√æ≤— π“°“√«“ß “¬≈“â ß™Õà ß∑Õâ ß (peritoneal catheter insertion)18 §«“¡ ”‡√®Á ¢Õß°“√√°— …“¥«â ¬«∏‘ ’ CPD  «à πÀπßË÷ ¢πÈ÷ °∫— peritoneal catheter ºªŸâ «É ¬∑«Ë’ “ß·ºπ«“à ®–∑” CPD ·µà‰¡à‰¥â√—∫°“√‡µ√’¬¡æ√âÕ¡‡√◊ËÕß peritoneal catheter ‡¡◊ËÕ¡’¿“«–©ÿ°‡©‘π∑’˵âÕß∑” dialysis Õ“®µÕâ ߉ª∑” chronic hemodialysis °Õà π‚¥¬„™â vascular access ·≈– «à πÀπßË÷ ®–‰¡°à ≈∫— ¡“∑” peritoneal

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√’∑‘欫√√≥ 251 dialysis °“√„ „à ®µÕà °“√„  à “¬ peritoneal catheter ·≈– psychosocial support „π™«à ߇√¡‘Ë µπâ ¡§’ «“¡ ”§≠— µÕà technique survival ¢Õß CPD19 ª≠í À“¢Õß°“√‰À≈‡¢“â ÕÕ°¢Õßπ”È ¬“ PDF Õ“®∑”„Àºâ ªâŸ «É ¬°ß— «≈·≈–‡∫ÕË◊ Àπ“à ¬°∫— °“√√°— …“¥«â ¬«∏‘ ’ CPD °“√‡≈Õ◊ ° catheter ∑‰Ë’ ¡‡à À¡“– ¡°∫— √“à ß°“¬ºªâŸ «É ¬ Õ“®∑”„Àªâ ≈“¬ “¬ catheter Õ¬„Ÿà πµ”·Àπßà ∑‰Ë’ ¡‡à À¡“– ¡ ¡°’ “√¥ß÷ √ßÈ— ¢Õß “¬ catheter À√Õ◊ ∑”„Àâ exit site Õ¬„Ÿà πµ”·Àπßà ∑’ˉ¡à¥’ °“√‡µ√’¬¡°“√·≈–«“ß·ºπ‡°’ˬ«°—∫ peritoneal access ‰«â≈à«ßÀπâ“„Àâ‡À¡“–°—∫≈—°…≥–¢Õߺ⟠ªÉ«¬·µà≈–√“¬®÷ß¡’§«“¡ ”§—≠‡æ◊ËÕ≈¥ªí≠À“∑’ËÕ“®‡°‘¥¢÷Èπ„π√–À«à“ß∑’ˇ√‘Ë¡∑” CPD ªí®®ÿ∫—π¡’°“√ æ≤— π“°“√«“ß “¬ peritoneal catheter ‚¥¬°“√Ωßí  «à π∑µË’ Õâ ßÕ¬¥Ÿà “â ππÕ°‰«„â µºâ «‘ Àπß— °Õà π ‡¡ÕË◊ ºªŸâ «É ¬¡’ §«“¡®”‡ªπì µÕâ ߉¥√â ∫— °“√∑” dialysis ®ß÷ §Õà ¬π” “¬∑ΩË’ ßí Õ¬ÕàŸ Õ°¡“„™â (exteriorization) ‡√¬’ ° proactive implantation «∏‘ °’ “√π‡È’ √¡Ë‘ √“¬ß“π§√ßÈ— ·√°„πªï 1993 ‚¥¬ Moncrief20 √–¬–‡«≈“°Õà π∑®Ë’ –π” “¬ÕÕ°¡“ „™§â «√√Õª√–¡“≥ 3-5  ª— ¥“ÀÀå √Õ◊ ‡¡ÕË◊ ¡¢’ Õâ ∫ßà ™¢È’ Õß°“√∑” dialysis ‡æÕË◊ „À·â º≈„µºâ «‘ Àπß— À“¬ π∑‘ ¥°’ Õà π ‚¥¬‰¡àµâÕ߇ ’ˬߵàÕ°“√µ‘¥‡™◊ÈÕ∑’Ë exit site ·µà¬—߉¡à¡’À≈—°∞“π∑’Ë∫àß™’È«à“«‘∏’°“√π’È®–™à«¬≈¥Õ—µ√“°“√‡°‘¥ peritonitis „πÕ𓧵‰¥â ¢Õâ ¥Õ’ πË◊ Ê ‰¥·â °à ºªâŸ «É ¬ “¡“√∂Õ“∫π”È ‰¥¿â “¬À≈ß— °“√«“ß “¬ 48 ™«Ë— ‚¡ß·≈– ‰¡àµâÕß°—ß«≈‡√◊ËÕß°“√¥Ÿ·≈·º≈ exit site √«¡∂÷ß§à“„™â®à“¬„π°“√¥Ÿ·≈·º≈·≈– irrigate  “¬ catheter ¢Õß∫§ÿ §≈“°√∑“ß°“√·æ∑¬®å π “¡“√∂‡√¡Ë‘ °“√∑” PD ‰¥â  “¡“√∂„™â catheter ‰¥∑â π— ∑∑’ µË’ Õâ ß°“√‡¡ÕË◊ ·º≈À“¬¥·’ ≈–polyestercuffs¬¥÷ µ¥‘ °∫— ‡πÕ◊È ‡¬Õ◊Ë √Õ∫¢“â ߇√¬’ ∫√Õâ ¬·≈«â ∑”„À‚â Õ°“ ∑®’Ë –µÕâ ß∑”hemodialysis ™«Ë— §√“«À√Õ◊ ¡°’ “√√«Ë— ¢Õßπ”È ¬“ PDF √Õ∫Ê ·º≈ exit site πÕâ ¬≈ß ·≈–‡πÕË◊ ß®“°‡ªπì °“√«“ß “¬°Õà π∑Ë’ ®–¡’ indication „π°“√ dialysis °“√ºà“µ—¥®÷߉¡àµâÕß√’∫√âÕπ·≈–¬—ß “¡“√∂·°â‰¢ abdominal hernia „π √–À«à“ß°“√Ωíß “¬ catheter ‰¥â¥â«¬ √–¬–‡«≈“∑’ˇÀ¡“– ¡¢÷ÈπÕ¬Ÿà°—∫Õ—µ√“°“√‡ ◊ËÕ¡¢Õ߉µ ‚¥¬∑—Ë«‰ª ¡°— ®–Ωßí  “¬°Õà πª√–¡“≥ 3-5  ª— ¥“Àå À√Õ◊ 殑 “√≥“®“° glomerular filtration rate (GFR) ¢ÕߺªŸâ «É ¬ ºªŸâ «É ¬‡∫“À«“π§«√‡√¡Ë‘ Ωßí  “¬‡¡ÕË◊ GFR 15-20 mL/min (serum creatinine, Cr 4-5 mg%) „πºªŸâ «É ¬∑‰Ë’ ¡à ‡ªπì ‡∫“À«“πÀ√Õ◊ ‚√§ÕπË◊ √«à ¡§«√‡√¡Ë‘ Ωßí  “¬‡¡ÕË◊ GFR 10-15 mL/min (serum Cr 7-8 mg%) °“√«“ß “¬ peritoneal catheter ¥â«¬«‘∏’µà“ßÊ  “¡“√∂„™â°“√Ωíß “¬√à«¡¥â«¬‰¥â Catheter ®–∂Ÿ°„ à‡¢â“ àŸ™àÕß∑âÕߺŸâ ª«É ¬µ“¡«∏‘ °’ “√¢Õß·µ≈à –«∏‘ ’ ®π catheter ‰¥√â ∫— °“√∑¥ Õ∫«“à π”È ¬“ PDF ‰À≈‡¢“â ÕÕ°¥·’ ≈– flush heparin (100 units/mL) §√ßÈ—  ¥ÿ ∑“â ¬®“°ππÈ— Õ¥ÿ ª≈“¬ “¬ catheter ‰«â °“√Ωßí  “¬ external limb Õ“®∑”‰¥‚â ¥¬‡≈“– subcutaneous pocket À√Õ◊ „™â tunneling stylet ™«à ¬„π°“√∑” tract ´ß÷Ë ®– trauma πÕâ ¬°«“à ·≈–¡º’ ≈·∑√°´Õâ π §Õ◊ hematoma ·≈– seroma πÕâ ¬°«“à Tunneling stylet ∑ Ë’ «¡‡¢“â °∫— ª≈“¬ catheter ®–∂°Ÿ ¥ß÷ ÕÕ°∑“ß skin incision ¢π“¥ 1 cm ∑®’Ë –‡ªπì exit site „πÕ𓧵‚¥¬„Àâ superficial catheter cuff Õ¬„àŸ πµ”·Àπßà ∑‡’Ë À¡“– ¡ (≈°÷ ®“°º«‘ Àπß— ª√–¡“≥ 2 cm)21 ®“°ππÈ— «“ߪ≈“¬ “¬ catheter ∑¬Ë’ ß— ¡’ tunneling stylet Õ¬√àŸ “∫°∫— ºπß— Àπ“â ∑Õâ ß≈ߥ“â π≈“à ß ∑” skin incision 0.5 cm ∑µ’Ë ”·Àπßà µË”°«“à ª≈“¬ “¬ catheter 1 cm ¥ß÷ ª≈“¬ catheter ·≈– stylet ¬Õâ π°≈∫— §π◊ ‰ª∑™Ë’ πÈ— subcutaneous tissue Õ°’ §√ßÈ— ∑µË’ ”·Àπßà ¢Õß·º≈ exit site „πÕ𓧵 „™â tunneling stylet ∑” tract „µºâ «‘ Àπß— „À â “¬ catheter º“à πµ”·Àπßà ∑®Ë’ –‡ªπì exit site „πÕ𓧵 (≈°÷ ®“° º«‘ Àπß— ª√–¡“≥ 0.5 cm ‡æÕË◊  –¥«°„π°“√ exteriorization „πÕ𓧵) ‚¥¬„Àªâ ≈“¬ tunneling stylet ‰ª∑–≈Õÿ Õ°∑Ë’ skin incision Õπ— ≈“à ß·µªà ≈“¬ “¬ catheter  «à π external limb ¬ß— §ßÕ¬„Ÿà µºâ «‘ Àπß— ®“° ππÈ— À°— ª≈“¬ tunneling stylet „À â «à πª≈“¬¬ß— §ßÕ¥ÿ „πª≈“¬ “¬ catheter ·≈«â ‡¬∫Á ª¥î ·º≈ skin incision

New Frontiers in Dialysis 252 ∏𵑠®‘√ππ— ∑å∏«—™  ‘√¿‘ “ ™â“ß»√‘ °‘ ≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°ÿ≈ ∑ß—È À¡¥ ‡¡Õ◊Ë ∂ß÷ °”Àπ¥∑®’Ë –µÕâ ß∑” CPD „À∑â ” exteriorization ¢Õߪ≈“¬ “¬ catheter ¥«â ¬ sterile technique °“√©¥’ ¬“™“µÕâ ß√–«ß— ‰¡„à À‡â ¢¡Á ·∑ß∂°Ÿ catheter ∑” skin incision ¢π“¥ 0.5 cm ∑·Ë’ º≈‡ªπì ∫√‡‘ «≥∑®Ë’ – ‡ªπì exit site Dissect ≈߉ª®π∂ß÷ catheter ·≈–¥ß÷ ª≈“¬ “¬ catheter ÕÕ°¡“ µ¥— ª≈“¬ “¬ «à π∑¡Ë’ ª’ ≈“¬ tunneling stylet Õ¥ÿ Õ¬ÕàŸ Õ° ®“°ππÈ— µÕà ‡¢“â °∫— adapter ·≈– transfer set ∑¥ Õ∫°“√‰À≈‡¢“â ÕÕ°¢Õß πÈ”¬“ PDF ‰¡®à ”‡ªπì µÕâ ߇¬∫Á ·º≈ exit site ·µµà Õâ ߬¥÷  “¬ catheter ‰¡„à À‡â ≈Õ◊Ë π‡¢“â ÕÕ°¥«â ¬ sterile adhesive strips À≈ß— ®“°ππÈ— „À°â “√¥·Ÿ ≈ exit site µ“¡À≈°— °“√∑«Ë— ‰ª ‡∑§π‘§°“√«“ß “¬ peritoneal catheter ¡’À≈“¬«‘∏’ «‘∏’ laparoscopic implantation ‡ªìπ«‘∏’∑’Ë π¬‘ ¡„™·â ≈–¡ª’ √– ∑‘ ∏¿‘ “æ ‚¥¬‡©æ“–∂“â ∑” proactive °Õà π∑‡Ë’ √¡Ë‘ PD ‡πÕË◊ ß®“° “¡“√∂∑” rectus sheath tunneling (™à«¬ªÑÕß°—π catheter tip migration), selective prophylactic omentopexy (ªÑÕß°—π omental entrapment), selective resection of epiploic appendices ¢Õß colon (ªÕÑ ß°π— catheter obstruction), adhesiolysis (ªÑÕß°—π compartmentalization) ·≈– “¡“√∂‡¬Á∫´àÕ¡·°â‰¢ abdominal hernia ∑’ˉ¡à∑√“∫¡“°àÕπ‰¥â ‡∑§π§‘ ·≈–«∏‘ °’ “√µ“à ßÊ ‡À≈“à πÀÈ’ “Õ“à π‰¥„â π reference ∑„Ë’ À‰â «1â 8  “¬ peritoneal catheter ™π‘¥µà“ßÊ ‰¥â∂Ÿ°æ—≤π“¢÷Èπ‡æ◊ËÕÀ«—߇æ‘Ë¡ª√– ‘∑∏‘¿“æ·≈–≈¥º≈ ·∑√°´Õâ 𠉥·â °à catheter tip migration, tissue attachment, pericatheter leak ·≈– pericatheter bacterial entry Õ¬“à ߉√°µÁ “¡¬ß— ‰¡¡à ¢’ Õâ ¡≈Ÿ «“à catheter ∑æ’Ë ≤— π“¢π÷È „À¡®à –¥°’ «“à standard 2-cuff, coiled tip Tenckhoff catheter ‡∑§π§‘ °“√«“ß “¬ catheter ∑¥’Ë ¡’ §’ «“¡ ”§≠— ¡“°°«“à ™π¥‘ ¢Õß “¬ catheter Peritoneal Catheter ∑¥Ë’ §’ «√®–¡§’ ≥ÿ  ¡∫µ— ∑‘  Ë’ “¡“√∂∂°Ÿ «“ß≈ßµ”·Àπßà ∑≈Ë’ °÷ ∑ Ë’ ¥ÿ ¢Õß pelvis ‰¥â ´ßË÷ ®–∑”„Àπâ ”È ¬“ PDF ‰À≈ ‡¢“â ÕÕ°‰¥¥â ·’ ≈– omentum ≈߉ª§≈¡ÿ ‰¡∂à ß÷ , ¡’ exit site ∑‡Ë’ ÀπÁ ‰¥ßâ “à ¬, ‰¡Õà ¬„àŸ πµ”·Àπßà ¢Õß belt line, skin creases À√Õ◊ folds ·≈– “¡“√∂„ ºà “à π abdominal wall ‚¥¬‡°¥‘ tubing stress πÕâ ¬∑ Ë’ ¥ÿ  “¬ chronic Tenckhoff catheter ‰¥∂â °Ÿ ª√∫— „À‡â À¡“– ¡°∫— ºªŸâ «É ¬ ¡’ 3 √ªŸ ·∫∫ ®”·π°µ“¡µ”·Àπßà ¢Õß exit site ∑µ’Ë Õâ ß°“√ (√ªŸ ∑’Ë 2) ‰¥·â °à 1) preformed bend  ”À√∫— exit site ∑ÕË’ ¬Ÿà lower abdomen, 2) straight intercuff segment  ”À√∫— exit site ∑’Ë mid abdomen ·≈– 3) 2-piece extended system  ”À√∫— exit site ∑Ë’ upper abdomen À√Õ◊ upper chest ·¡«â “à ®– ¡’§”·π–π”∂÷ß∑‘»∑“ߢÕß tunnel tract ·≈– exit site «à“§«√¡’≈—°…≥–∑—Èß downward ·≈– lateral ·µà®“° ¢âÕ¡Ÿ≈∑’Ë»÷°…“ tunnel tract ·≈– exit site ∑’Ë¡’≈—°…≥– downward ‡ª√¬’ ∫‡∑¬’ ∫°∫— lateral æ∫«“à ‰¡¡à §’ «“¡·µ° µ“à ß√–À«“à ß exit site, tunnel infection, peritonitis ·≈– √ªŸ ∑’Ë 2 mechanical complications22 ºªâŸ «É ¬∑¡Ë’ ’ belt line Õ¬‡àŸ ÀπÕ◊ Modified 2-cuff, coiled tip Tenckhoff  –¥Õ◊ §«√„™â preformed bend ‡æÕË◊ „Àâ exit site Õ¬àŸ lower catheter ·∫ßà µ“¡µ”·Àπßà ¢Õß exit site abdomen „π¢≥–∑ºË’ ªŸâ «É ¬∑¡Ë’ ’ belt line Õ¬„àŸ µ â –¥Õ◊ §«√„™â straight intercuff segment ‡æÕË◊ „Àâ exit site Õ¬∑àŸ Ë’ lateral

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√’∑‘欫√√≥ 253 ‡ÀπÕ◊ beltline «à πºªâŸ «É ¬∑Õ’Ë «â π¡º’ πß— Àπ“â ∑Õâ ßÀ¬Õà π°≈π—È ª í  “«–Õ®ÿ ®“√–‰¡‰à ¥Àâ √Õ◊ µÕâ ßÕ“∫πÈ”„πÕ“à ßπÈ” §«√„™â extended system ‡æÕË◊ „Àâ exit site Õ¬∑àŸ Ë’ upper abdomen À√Õ◊ upper chest °“√°”Àπ¥µ”·Àπßà ¢Õß catheter insertion site ·≈– exit site ∑”‰¥‚â ¥¬„Àºâ ªâŸ «É ¬πÕπÀß“¬ (√ªŸ ∑Ë’ 3a) «“ßµ”·Àπßà „Àâ catheter tip Õ¬∑àŸ Ë’ pubic symphysis  «à π insertion site ®–Õ¬∑àŸ µË’ ”·Àπßà ¢Õß deep cuff „π·π« paramedian plane 3 cm lateral of midline µ”·Àπßà ¢Õß exit site ππÈ— ∂“â „™â preformed bend ≈°— …≥–¢Õß tunnel tract §«√‡ªπì ‰ªµ“¡§«“¡‚§ßâ ¢Õß intercuff bend ·≈– exit site ®–Õ¬‡àŸ ≈¬µ”·Àπßà ¢Õß superficial cuff ‰ª 2-3 cm „π°√≥∑’ „Ë’ ™â straight intercuff segment °“√°”Àπ¥ tunnel tract ·≈– exit site Õ“®∑”‰¥¥â ß— √ªŸ 3b °“√®–‡≈Õ◊ °„™â catheter ™π¥‘ „¥¢πÈ÷ Õ¬°àŸ ∫— belt line ¢ÕߺªŸâ «É ¬ §«√°”Àπ¥„π¢≥–∑Ë’ ºªŸâ «É ¬πßË— ·≈–·µßà µ«— µ“¡ª°µ‡‘ æÕË◊ „À∑â √“∫ belt line ∑·Ë’ ∑®â √ß‘ ‚¥¬‡≈Õ◊ ° catheter ∑¡Ë’ ’ exit site ‰¡Õà ¬„àŸ π belt line, skin fold À√Õ◊ skin crease ∂“â „™‰â ¥∑â ßÈ— 2 ™π¥‘ „À‡â ≈Õ◊ °™π¥‘ ∑∑Ë’ ”„Àâ exit site Õ¬ÀàŸ “à ß®“° belt line ¡“°∑ ’Ë ¥ÿ ·≈–‡ÀπÁ ‰¥™â ¥— ∑ ’Ë ¥ÿ ∂“â catheter ∑ß—È 2 ™π¥‘ ‰¡‡à À¡“– ¡®ß÷ §Õà ¬‰ª‡≈Õ◊ °„™â 2-piece extended system ´ßË÷ ª√–°Õ∫¥«â ¬ catheter 2  «à 𠉥·â °à  «à π 1-cuff coiled tip abdominal catheter ®–¡ ’ «à π∑ÕË’ ¬„Ÿà π™Õà ß∑Õâ ß ·≈– «à π 2-cuff extension tube ‡ªπì  «à π∑ÕË’ ¬„àŸ π™πÈ— „µºâ «‘ Àπß— ®–¡’ preformed bend Õ¬√àŸ –À«“à ß 2 cuffs ∑ßÈ—  Õß «à π‡™ÕË◊ ¡°π— ¥«â ¬ titanium connector  «à π external limb ¢Õß abdominal catheter ·≈– ascending limb ¢Õß extension tube  “¡“√∂µ¥— ·≈–ª√∫— „À‡â À¡“– ¡°∫— µ”·Àπßà ¢Õß exit site ‰¥â ‡™πà ∑Ë’ upper abdomen À√Õ◊ upper chest Exit site ∑∫Ë’ √‡‘ «≥ upper chest §«√À“à ß®“° midline Õ¬“à ßπÕâ ¬ 3 cm ≈°÷ ®“°º«‘ Àπß— ª√–¡“≥ 2-3 cm ·≈–‰¡¢à “â ¡ midline ‡πÕË◊ ß®“°ºªŸâ «É ¬Õ“®®”‡ªπì µÕâ ߉¥√â ∫— °“√º“à µ¥— À«— „® „πÕ𓧵 ·≈–§«√®–À≈∫Õ¬àŸ„µâ§Õ‡ ◊ÈÕ ‰¡àÕ¬Ÿà„πµ”·ÀπàߢÕß “¬‡ ◊ÈÕ™—Èπ„πºâŸÀ≠‘ßÀ√◊Õ„π‡π◊ÈÕ‡µâ“π¡  «à π·π«¢Õß external limb ¢Õß extension tube §«√¡∑’ »‘ ∑“߇¢“â  Ÿà medial ‰ª¬ß—  «à π flat part ¢Õß chest ‡æÕË◊ ≈¥°“√‡§≈ÕË◊ π‡¢“â ÕÕ°¢Õß catheter ‡«≈“∑¡Ë’ °’ “√‡§≈ÕË◊ π‰À«¢Õß·¢πºªâŸ «É ¬ „π°√≥∑’ ºË’ ªŸâ «É ¬µÕâ ß°“√„Àâ exit site Õ¬∑àŸ Ë’ upper abdomen °“√∑” tunnel tract °‰Á ¡§à «√¢“â ¡ midline ‡™πà °π— ‡πÕË◊ ß®“°ºªŸâ «É ¬Õ“® √ªŸ ∑Ë’ 3 3a) °“√°”Àπ¥µ”·Àπßà ¢Õß insertion site 3b) °“√°”Àπ¥µ”·Àπßà ¢Õß exit site ∑’Ë lateral mid abdomen

New Frontiers in Dialysis 254 ∏π‘µ ®√‘ ππ— ∑å∏«—™  √‘ ‘¿“ ™“â ß»‘√°‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ ®”‡ªπì µÕâ ߉¥√â ∫— °“√º“à µ¥— ™Õà ß∑Õâ ß„πÕ𓧵·≈–§«√¡∑’ »‘ ∑“߉ª∑“ß lateral ‚¥¬‰¡µà ¥‘ °∫— costal margin ®π‡°π‘ ‰ª´ßË÷ ®–∑”„À â “¬ catheter §¥ßÕ‰¥â °“√æ≤— π“¢Õß peritoneal catheter ∑”„À â “¡“√∂‡≈Õ◊ °„™â catheter ∑’ˇÀ¡“– ¡°—∫ºâŸªÉ«¬·≈–¡’ catheter survival ∑’ˬ“«π“π¢÷Èπ  àߺ≈µàÕ§«“¡ ”‡√Á®¢Õß°“√ √°— …“¥«â ¬«∏‘ ’ CPD 6. °“√ªÕÑ ß°π— °“√µ¥‘ ‡™ÕÈ◊ „πºªâŸ «É ¬ chronic peritoneal dialysis23 Infection ‡ªπì  “‡Àµ°ÿ “√µ“¬∑ Ë’ ”§≠— ¢ÕߺªŸâ «É ¬ CPD √Õß®“° cardiovascular disease (CVD)24 Peritonitis ¬ß— §ß‡ªπì  “‡Àµ∑ÿ  Ë’ ”§≠— ¢Õß technique failure ·≈– hospitalization(24) °“√∑®Ë’ –∑”„Àâ outcome ¢ÕߺªŸâ «É ¬ CPD ¥¢’ πÈ÷ ®ß÷ ®”‡ªπì ∑®Ë’ –µÕâ ߪÕÑ ß°π— °“√‡°¥‘ peritonitis ºªŸâ «É ¬∫“ß√“¬‡°¥‘ peritonitis À≈“¬ §√ßÈ— „π¢≥–∑ºË’ ªâŸ «É ¬∫“ß√“¬‰¡‡à §¬‡°¥‘ peritonitis ‡≈¬ ª®í ®¬— ‡ ¬Ë’ ߢÕß°“√‡°¥‘ peritonitis ‰¥·â °à °“√¡’ ¿“«– hypoalbuminemia ‡¡ÕË◊ ‡√¡Ë‘ dialysis ·µ°à “√¡’ peritonitis ´”È À≈“¬Ê §√ßÈ— °∑Á ”„À¡â ’ hypoalbuminemia ‰¥‡â ™πà °π— Guidelines ¢Õß International Society of Peritoneal Dialysis (ISPD) ≈“à  ¥ÿ ®–‡ππâ ∂ß÷ °“√«π‘ ®‘ ©¬— °“√√°— …“ √«¡∂ß÷ °“√ªÕÑ ß°π— ´ßË÷ ¡§’ «“¡ ”§≠— ‡™πà °π— 25 °“√ªÕÑ ß°π— °“√µ¥‘ ‡™ÕÈ◊ √–À«“à ß·≈–À≈ß— °“√«“ß “¬ chronic Tenckhoff „π√–¬–‡√¡Ë‘ ·√°¡§’ «“¡  ”§≠— ¡“° ‡∑§π§‘ °“√«“ß “¬∑¥’Ë ¡’ §’ «“¡ ”§≠— °«“à ™π¥‘ ¢Õß “¬catheter¥ß— °≈“à «¢“â ßµπâ §«“¡°«“â ߢÕß exit site §«√®–æÕ¥°’ ∫—  “¬ catheter ‡æÕË◊ ‰¡„à À â “¬‡≈ÕË◊ π‡¢“â ÕÕ°‰¥ßâ “à ¬·≈–‰¡§à «√‡¬∫Á ∑∫Ë’ √‡‘ «≥ exit site ‡πÕ◊Ë ß®“°‰¡®à ”‡ªπì ·≈–Õ“®‡ªπì ·À≈ßà ¢Õß°“√µ¥‘ ‡™Õ◊È ¡À’ ≈°— ∞“π«“à tunnel tract ·≈– exit site ∑™’Ë ≈’È ß¥“â π≈“à ß (downward) ·≈–°“√„Àâ antibiotic ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”°Õà π°“√„  à “¬ catheter ™«à ¬≈¥°“√µ¥‘ ‡™ÕÈ◊ ‰¥â ¬“ vancomycin ‰¥ºâ ≈¥°’ «“à ¬“°≈¡ÿà cephalosporins ·≈–°“√„À¬â “ gentamicin °Õà π°“√«“ß “¬¥°’ «“à °“√‰¡„à Àâ antibiotic ‡≈¬ °“√∑”·º≈À≈ß— °“√«“ß “¬ peritoneal catheter „À„â ™â sterile solution dressing §«√∑”‚¥¬ PD nurse ·π–π”„À â «¡∂ßÿ ¡Õ◊ ·≈– mask ·≈–ª“Ñ ¬¬“ antibiotic cream À√Õ◊ ointment ∑Ë’ exit site √«à ¡¥«â ¬ §«√∑”·º≈∑°ÿ 1  ª— ¥“À¬å °‡«πâ ·µ·à º≈‚¥ππÈ” ¡‡’ ≈Õ◊ ¥´¡÷ ¡“°À√Õ◊ ¡’ discharge „À‡â ª¥î ∑”∑π— ∑’ ·≈–‡æÕ◊Ë „Àâ epithelial growth ‡°‘¥¢÷Èπ‡√Á«∑’Ë exit site §«√¬÷¥ “¬„ÀâÕ¬Ÿà„πµ”·Àπàß∑’ˉ¡à¥÷ß√—ÈßÀ√◊Õ‡§≈◊ËÕπ‡¢â“ÕÕ° ‰¡à §«√‚¥ππ”È °Õà π∑·Ë’ º≈ exit site ®–À“¬ π∑‘ ¥’ °“√ª“Ñ ¬®¡°Ÿ ºªŸâ «É ¬¥«â ¬ mupirocin 2 §√ßÈ— µÕà «π— ‡ªπì ‡«≈“ 5 «π— Õ“®®–≈¥°“√µ¥‘ ‡™ÕÈ◊ Staphylococcus aureus „π™«à ß·√°À≈ß— °“√«“ß “¬ catheter ‰¥â ·µ¬à ß— ‰¡¡à °’ “√ »°÷ …“∑¬’Ë π◊ ¬π— ™¥— ‡®π °“√¥·Ÿ ≈ exit site À≈ß— ®“°∑·Ë’ º≈À“¬¥·’ ≈«â (chronic exit site care) ·º≈ exit site ∑ÀË’ “¬ ¥·’ ≈«â §«√®–¡ ’ ¢’ Õߺ«‘ Àπß— ‚¥¬√Õ∫ª°µ‘ ‰¡¡à ™’ Õà ß√–À«“à ߺ«‘ Àπß— ·≈– catheter ‰¡¡à ’ erythema, discharge, crust ·≈–‰¡‡à ®∫Á ‡πÕË◊ ß®“°·º≈ exit site ∑ÀË’ “¬·≈«â Õ“®¡’ colonization ¢Õß bacteria ‰¥â ´ßË÷ ∂“â ¡“°°«“à 100,000 colony-forming-unit ®–‡æ‘Ë¡§«“¡‡ ’ˬߵàÕ°“√µ‘¥‡™È◊Õ ¥—ßπ—Èπ®÷ß¡’∫“ß√“¬ß“π欓¬“¡∑’Ë®–„™â «‘∏’Ωíß “¬∑—ÈßÀ¡¥‰«â„µâº‘«Àπ—ߥ—ß°≈à“«¡“·≈â«¢â“ßµâπ°àÕπ‡√‘Ë¡°“√∑” PD ·µà¬—߉¡à¡’À≈—°∞“π«à“«‘∏’π’È  “¡“√∂ªÕÑ ß°π— °“√µ¥‘ ‡™ÕÈ◊ ‰¥â °“√∑”·º≈∑¥Ë’ ®’ –™«à ¬≈¥ bacterial colony count ‰¥â °“√∑”·º≈ exit site ®–‡√¡‘Ë µπâ ¥«â ¬º∑⟠”·º≈®–µÕâ ß≈“â ß¡Õ◊ ¥«â ¬ antibacterial soap „À â –Õ“¥À√Õ◊ „™â alcohol-based cleaning agent

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√∑’ ‘欫√√≥ 255 ´÷ËßµâÕß¡’ isopropanol À√◊Õ ethanol Õ¬à“ßπâÕ¬√âÕ¬≈– 60 À≈—ß®“°≈â“ß¡◊Õ·≈⫵âÕß√Õ„Àâ¡◊Õ·Àâß π‘∑ °Õà πª√–¡“≥ 15 π“∑’ ∂“â ¡Õ◊ ·Àßâ °Õà π 15 π“∑·’  ¥ß«“à „™â alcohol-based agent „πª√¡‘ “≥∑πË’ Õâ ¬‡°π‘ ‰ª ¢Õâ §«√√–«ß— §Õ◊ alcohol-based agent ®–‰¡¡à ƒ’ ∑∏¢‘Ï Õß sporicidal ·≈–‰¡ à “¡“√∂°”®¥— ‡™Õ◊È Clostridium difficile ®ß÷ ‰¡ à “¡“√∑¥·∑π°“√≈“â ß¡Õ◊ ∑ Ë’ –Õ“¥‰¥â CPD nurse §«√®¥— ∑” hand washing instruction „Àºâ ªâŸ «É ¬ À√Õ◊ º∑Ÿâ ®Ë’ –∑” PD ‡æÕË◊ ≈¥°“√ contamination §«√∑”§«“¡ –Õ“¥·º≈ exit site ∑ÀË’ “¬¥·’ ≈«â ∑°ÿ «π— ¥«â ¬ antibacterial soap À√Õ◊ non-irritating cleansing agents ¬¥÷  “¬ catheter „ÀÕâ ¬°Ÿà ∫— ∑ÕË’ ¬“à „À¥â ß÷ √ßÈ— ®π‡°π‘ ‰ª‡πÕË◊ ß®“°Õ“®∑”„À‡â ≈Õ◊ ¥ÕÕ°·≈–µ¥‘ ‡™ÕÈ◊ µ“¡¡“‰¥â ¬ß— ‰¡¡à ¢’ Õâ ¡≈Ÿ ∑»Ë’ °÷ …“∂ß÷ ™π¥‘ ¢Õß antiseptics °∫— °“√µ¥‘ ‡™ÕÈ◊ ∑Ë’ exit site Õ¬“à ß™¥— ‡®π ºªŸâ «É ¬∑¡Ë’ ·’ º≈ exit site ∑¥Ë’  ’ “¡“√∂≈ß«“à ¬π”È „π∑–‡≈À√Õ◊  √–«“à ¬ πÈ”∑’Ë¡’§≈Õ√’π‰¥âµ“¡§”·π–π”¢Õß PD nurse ·µà‰¡à§«√·™à„πÕà“ßÕ“∫πÈ”À√◊Õ«à“¬πÈ”„π·¡àπÈ” ·≈–®– µÕâ ß∑”„À·â º≈·Àßâ  π∑‘ ‡ ¡ÕÀ≈ß— °“√«“à ¬πÈ” ¡°’ “√»°÷ …“∂ß÷ °“√„Àâ antibiotics ‡æÕ◊Ë ªÕÑ ß°π— °“√µ¥‘ ‡™Õ◊È „πºªâŸ «É ¬ CPD °“√„™â intranasal mupirocin ∑°ÿ ‡¥Õ◊ π„πºªŸâ «É ¬∑‡Ë’ ªπì Staphylococcus aureus carrier ®–≈¥ Staphylococcus aureus exit site infection ·≈– tunnel infection ·µ‰à ¡≈à ¥°“√‡°¥‘ peritonitis26 °“√„™â mupirocin ª“Ñ ¬∑·Ë’ º≈ exit site  “¡“√∂≈¥ Staphylococcus aureus exit site infection and peritonitis ‰¥2â 3 °“√„™â gentamicin cream ª“Ñ ¬∑·Ë’ º≈ exit site  “¡“√∂≈¥°“√µ¥‘ ‡™Õ◊È Staphylococcus aureus ·≈– Pseudomonas aeruginosa ∑’Ë exit site ·≈– peritonitis ‰¥2â 7 ¢Õâ §«√√–«ß— ¢Õß°“√„™â topical antibiotics ‡ªπì ‡«≈“π“πÊ §Õ◊ °“√¥Õ◊È ¬“·≈–Õ“®¡°’ “√µ¥‘ ‡™Õ◊È Candida ∑’Ë exit site ‰¥â∫àÕ¬¢÷Èπ„π°≈ÿà¡∑’Ë„™â¬“ gentamicin cream ·µà “¡“√∂√—°…“‰¥âßà“¬¥â«¬¬“ fluconazole ·≈–¡°— ‰¡‡à °¥‘ fungal peritonitis ·≈–§«√‡ª≈¬’Ë π‰ª„™â mupirocin cream ·∑π23 Õ¬“à ߉√°µÁ “¡°“√„™â topical antibiotics „π°“√ªÕÑ ß°π— °“√µ¥‘ ‡™ÕÈ◊ ∑·Ë’ º≈ exit site ®–™«à ¬≈¥°“√‡°¥‘ peritonitis ∑”„Àºâ ªŸâ «É ¬‰¡µà Õâ ߉¥√â ∫— systemic antibiotics ‡ªìπ‡«≈“π“πÊ ·µà∫ÿ§≈“°√∑“ß°“√·æ∑¬å®–µâÕß√–«—ß°“√·æ√à¢Õ߇™◊ÈÕ∑’Ë¥◊ÈÕ¬“π’È ‰ª¬ß— ºªŸâ «É ¬√“¬ÕπË◊ ¥«â ¬ „π°√≥∑’ ¡Ë’ °’ “√√«Ë— ¢Õßπ”È ¬“ PDF √Õ∫Ê ·º≈ exit site (∑¥ Õ∫¥«â ¬ strip ®–¡’ glucose  ßŸ ) §«√„Àâ antibiotic prophylaxis ®π°«“à ®– “¡“√∂·°‰â ¢°“√√«Ë— ´¡÷ ‰¥â „π°√≥∑’ ¡Ë’ °’ “√µ¥‘ ‡™ÕÈ◊ ∑Ë’ ·º≈ exit site ·≈«â («π‘ ®‘ ©¬— µ“¡ exit site scoring system ¢Õß ISPD ªï 200525, µ“√“ß∑Ë’ 1) §Õ◊ ¡§’ –·ππ ≥ 4 ®–µÕâ ß„À°â “√√°— …“∑π— ∑‡’ πÕË◊ ß®“°¡‚’ Õ°“ ∑®Ë’ –‡°¥‘ peritonitis µ“¡¡“‰¥â ´ßË÷ ‡™ÕÈ‘ ∑·Ë’ º≈ exit site °∫— peritonitis ¡°— ®–‡ªπì ‡™ÕÈ◊ ‡¥¬’ «°π— ‚¥¬‡©æ“–‡™ÕÈ◊ Staphylococcus aureus ·≈– Pseudomonas aeruginosa µ“√“ß∑’Ë 1 Exit site scoring system 0 points 1 point 2 points Exit only; <0.5 cm >0.5 and/or tunnel Swelling No <0.5 cm >0.5 cm Crust No <0.5 cm >0.5 cm Slight Severe Redness No Serous Purulent Pain No Drainage No

New Frontiers in Dialysis 256 ∏π‘µ ®√‘ ππ— ∑å∏«—™  ‘√¿‘ “ ™â“ß»√‘ °‘ ÿ≈™—¬ ∏π—𥓠µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ ¡°— ‡°¬Ë’ «¢Õâ ß°∫— °“√µ¥‘ ‡™ÕÈ◊ ∑Ë’ peritoneal catheter √–¬–‡«≈“¢Õß°“√√°— …“°“√µ¥‘ ‡™ÕÈ◊ ∑·Ë’ º≈ exit site ππÈ— ®–µÕâ ß√°— …“®π°«“à ·º≈®–ª°µ‘„π°√≥∑’ √’Ë °— …“·≈«â ‰¡¥à ¢’ π÷È Õ“®®”‡ªπì µÕâ ß„À°â “√√°— …“‡æ¡‘Ë ‡µ¡‘ ‰¥·â °àtunnel revision, cuff resection À√Õ◊ ¬“â ¬µ”·Àπßà ¢Õß exit site ®π∂ß÷ °“√‡ª≈¬Ë’ 𠓬 peritoneal catheter °“√ ®–„™â«‘∏’„¥π—Èπ¢÷Èπ°—∫ªí≠À“¢Õß·º≈ exit site ¢Õߺ⟪ɫ¬ ‰¡à¡’¢âÕ¡Ÿ≈«à“«‘∏’„¥‰¥âº≈¥’°«à“·≈–‰¡à¡’¢âÕ¡Ÿ≈ ¢Õß√–¬–‡«≈“∑‡’Ë À¡“– ¡∑§’Ë «√®–‡ª≈¬’Ë π “¬ catheter §«“¡ ”§≠— ¢Õß°“√√°— …“ §Õ◊ °“√ªÕÑ ß°π— °“√‡°¥‘ peritonitis ¥ß— ππÈ— ∂“â ‰¡¥à ¢’ πÈ÷ ¥«â ¬«∏‘ °’ “√µ“à ßÊ ¥ß— °≈“à «¢“â ßµπâ §«√殑 “√≥“‡ª≈¬Ë’ πÀ√Õ◊ ‡Õ“ “¬ catheter ÕÕ°∑π— ∑’ ‚¥¬ √ªÿ °“√≈¥Õµ— √“°“√µ¥‘ ‡™ÕÈ◊ ∑·Ë’ º≈ exit site ·≈– peritonitis ®–µÕâ ߇√¡Ë‘ µßÈ— ·µ°à “√«“ß “¬ peritoneal catheter Õ¬“à ß√–¡¥— √–«ß— °“√¥·Ÿ ≈·º≈ exit site µß—È ·µ‡à √¡‘Ë ·√°·≈–‡¡Õ◊Ë ·º≈À“¬¥·’ ≈«â ·≈–°“√„™â prophylactic topical antibiotic cream ∑“∑·Ë’ º≈ exit site ¬“∑„Ë’ ™‰â ¥·â °à mupirocin À√Õ◊ gentamicin cream ‡¡ÕË◊ ‡°¥‘ exit site infection „À√â ∫’ √°— …“∑π— ∑·’ ≈–‡ª≈¬Ë’ 𠓬 catheter ∑π— ∑∂’ “â ‰¡¥à ¢’ πÈ÷ °“√Ω°ñ Õ∫√¡ºªŸâ «É ¬ CPD ‚¥¬æ¬“∫“≈º‡âŸ ™¬Ë’ «™“≠¥“â π PD „À â “¡“√∂∑” CPD ‰¥Õâ ¬“à ß∂°Ÿ µâÕß¡’§«“¡ ”§—≠µàÕ°“√ªÑÕß°—π°“√ contamination ·≈–≈¥§«“¡‡ ’ˬߢÕß°“√‡°‘¥ peritonitis ‰¥â 欓∫“≈°≈¡àÿ πÈ’ §«√¡§’ «“¡√‡Ÿâ √ÕË◊ ß home dialysis ´ßË÷ Õ“®®–√«¡∑ßÈ— hemodialysis ·≈– PD ·≈–§«√‡ªπì 欓∫“≈∑’Ë∑”ß“π‡µÁ¡‡«≈“„Àâ°—∫ß“π CPD ‚¥¬¡’ continuous quality improvement (CQI) µ‘¥µ“¡º≈ °“√ Õπ¢Õß欓∫“≈‡À≈“à πÈ’ °“√Ω°ñ Õ∫√¡æ¬“∫“≈º‡Ÿâ ™¬Ë’ «™“≠°≈¡àÿ πÈ’ §«√„™‡â «≈“ª√–¡“≥ 6-8  ª— ¥“Àå ‡æÕË◊ „À√⠮⟠°— °∫— PD ·≈–¡æ’ ¬“∫“≈º‡Ÿâ ™¬Ë’ «™“≠∑¡Ë’ ª’ √– ∫°“√≥§å Õ¬¥·Ÿ ≈„π√–À«“à ß°“√ ÕπºªâŸ «É ¬ CPD Õ¬“à ßπÕâ ¬ 1 √“¬°Õà π∑®Ë’ – Õπ‰¥‡â Õß‚¥¬‰¡¡à º’ ·Ÿâ π–π”28 ·≈–§«√¡°’ “√µ√«® Õ∫‡ªπì √–¬–¥«â ¬«∏‘ ’ trainer learning objectives ¡°’ “√æ≤— π“Õ¬“à ßµÕà ‡πÕË◊ ß (continuing education) 欓∫“≈ 1 §π§«√ ÕπºªŸâ «É ¬ CPD 1 §π °“√ ÕπºªâŸ «É ¬‚¥¬¡°’ “√«“ß·ºπ Õπ„π ßË‘ ∑ºË’ ªŸâ «É ¬®”‡ªπì µÕâ ß√µâŸ “¡¢πÈ— µÕπ (adult learning theory- based curriculum)  “¡“√∂≈¥ exit site infection ·≈– admission rate ‰¥2â 9 ‡πÕ◊Ë ß®“°ºªâŸ «É ¬∫“ß√“¬Õ“® ‡√‘Ë¡¡’ uremia À√◊Õ´÷¡‡»√â“®“°‚√§‰µ«“¬´÷ËßÕ“®¡’Õÿª √√§µàÕ°“√‡√’¬π«‘∏’°“√∑” CPD ¥—ßπ—ÈπºŸâªÉ«¬∑’Ë ‡≈Õ◊ °°“√√°— …“¥«â ¬«∏‘ ’ CPD §«√‡√¡Ë‘ °“√∑” dialysis ‡√«Á °«“à ºªŸâ «É ¬ chronic hemodialysis  ∂“π∑„Ë’ ™ â Õπ Õ“®‡ªìπ∑’Ë‚√ß欓∫“≈À√◊Õ∫â“π¢ÕߺŸâªÉ«¬ æ∫«à“°“√ Õπ∑’Ë∫â“π¢Õߺ⟪ɫ¬®–¡’Õ—µ√“°“√‡°‘¥ peritonitis µË”°«“à °“√ Õπ∑‚’Ë √ß欓∫“≈30 √–¬–‡«≈“∑‡’Ë À¡“– ¡„π°“√ Õπ¢π÷È °∫— ≈°— …≥–¢ÕߺªŸâ «É ¬ºªâŸ «É ¬∫“ß√“¬ Õ“®‡√¬’ π√‰Ÿâ ¥‡â √«Á „™‡â «≈“ª√–¡“≥ 3 «π— ∫“ß√“¬Õ“®µÕâ ß„™‡â «≈“‡ªπì  ª— ¥“À®å πº Ÿâ Õπ¡πË— „®«“à º∑⟠” CPD  “¡“√∂∑”µ“¡¢πÈ— µÕπ∑ Ë’ ”§≠— ∑°ÿ ¢πÈ— ‰¥Õâ ¬“à ߪ≈Õ¥¿¬— ·≈–∑√“∫∂ß÷ °“√ contamination À√Õ◊ °“√µ¥‘ ‡™ÕÈ◊ µ≈Õ¥®π∂÷ߢ÷ÈπµÕπ„π°“√ªØ‘∫—µ‘·≈–·®âߧ«“¡º‘¥ª°µ‘∑’ËÕ“®‡°‘¥¢÷Èπ·°à∑’¡·æ∑¬å·≈–欓∫“≈∑’Ë„Àâ°“√ √°— …“ºªâŸ «É ¬ ‡¡Õ◊Ë ¡°’ “√ contamination ‡°¥‘ ¢π÷È ºªâŸ «É ¬®–µÕâ ßÀ¬¥ÿ °“√∑” dialysis ∑π— ∑·’ ≈–ª¥î clamp ∑’Ë transfer set ‰¡„à À¡â °’ “√‰À≈‡¢“â ÕÕ°¢Õßπ”È ¬“ PDF ®“°ππÈ— „Àµâ ¥‘ µÕà °∫— 欓∫“≈ PD ∑π— ∑‡’ æÕË◊ ‡ª≈¬Ë’ π transfer set ·≈–‡°∫Á PDF  ßà µ√«® cell count ·≈– culture ∂“â °“√ contamination ‡°¥‘ ¢πÈ÷ „π¢≥–∑Ë’ clamp ‡ª¥î Õ¬§Ÿà «√„Àâ antibiotics ∑§Ë’ √Õ∫§≈¡ÿ ‡™ÕÈ◊ ∑ßÈ— gram positive ·≈– gram negative bacteria ·µ∂à “â ¬ß— ‡ªπì closed system „À‡â ª≈¬Ë’ π transfer ‚¥¬‰¡µà Õâ ß„Àâ antibiotics „π°√≥∑’ ºË’ ªŸâ «É ¬‰¡·à π„à ®«“à ¡°’ “√ contamination À√Õ◊ ‰¡à „Àâ ∂◊ժؑ∫—µ‘«à“¡’ contamination ‡ ¡Õ „π°√≥’∑’˺⟪ɫ¬‡°‘¥°“√µ‘¥‡™◊ÈÕ∑’Ë catheter, peritonitis, Õ¬Ÿà‚√ß

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√’∑‘欫√√≥ 257 欓∫“≈π“πÀ√Õ◊ µÕâ ßÀ¬¥ÿ °“√∑” CPD ¥«â ¬µπ‡Õ߇ªπì ‡«≈“π“𠧫√¡°’ “√µ√«® Õ∫¢π—È µÕπ°“√∑” CPD ¢ÕߺŸâ∑” CPD ‡æ◊ËÕ„Àâ·πà„®«à“ºâŸ∑”¬—ß¡’§«“¡ “¡“√∂„π°“√∑”CPD ‰¥âÕ¬à“ß∂Ÿ°µâÕßÀ√◊Õ‰¡à ·≈–¬—ß Õ“®∑”„Àâ∑√“∫∂÷ß “‡Àµÿ¢Õß°“√µ‘¥‡™◊ÈÕ‰¥â¥â«¬ ·¡â«à“¬—߉¡à¡’¢âÕ¡Ÿ≈„πªí®®ÿ∫—π∑’Ë∫àß™’È«à“°“√µ√«® Õ∫ ¢πÈ— µÕπ°“√∑” CPD ¢ÕߺªâŸ «É ¬Õ¬“à ß ¡”Ë ‡ ¡Õ‡ªπì √–¬–®–‰¥ªâ √–‚¬™πå ISPD Nurse Liaison Committee ·π–π”„Àâ¡’°“√µ√«®‡¬’ˬ¡∫â“π¢Õߺ⟪ɫ¬¥â«¬ ‡æ◊ËÕ„Àâ∑√“∫∂÷ß≈—°…≥–§«“¡‡ªìπÕ¬Ÿà·≈– ‘Ëß·«¥≈âÕ¡ ¢ÕߺŸâªÉ«¬  —µ«å‡≈’Ȭ߷≈–¢—ÈπµÕπ°“√∑” CPD ∑’Ë∫â“π¢Õߺ⟪ɫ¬ ‡™àπ ¡’°“√ªî¥æ—¥≈¡√–À«à“ß°“√ ‡ª≈¬Ë’ π∂ßÿ π”È ¬“ PDF À√Õ◊ ‰¡à §«“¡ –Õ“¥¢Õß∫“â π·≈–∫√‡‘ «≥∑„Ë’ ™„â π°“√‡ª≈¬Ë’ π∂ßÿ π”È ¬“ √«¡∂ß÷ π”È ∑Ë’ „™≈â “â ß¡Õ◊ ‡ªπì µπâ πÕ°®“°πÈ’ ·æ∑¬·å ≈–º∫Ÿâ √À‘ “√®–µÕâ ß„À°â “√ π∫—  ππÿ 欓∫“≈ PD „À¡â °’ “√æ≤— π“ §«“¡√¥âŸ “â π∑ƒ…Æ·’ ≈– skill √«¡∑ß—È À≈°’ ‡≈¬Ë’ ß°“√π”欓∫“≈°≈¡ÿà π‰’È ª∑”ß“π„π «à πÕπ◊Ë ∑‰’Ë ¡‡à °¬’Ë «¢Õâ ß°∫— ß“π PD ·≈–„À¡â ®’ ”π«π¢Õß PD nurse µÕà ®”π«πºªâŸ «É ¬¡“°æÕ ºªâŸ «É ¬∑¡Ë’ ’ relapsing peritonitis (µ¥‘ ‡™ÕÈ◊ µ«— ‡¥¡‘ À≈ß— ®“°À¬¥ÿ antibiotics ¿“¬„π 2-4  ª— ¥“À)å ´ß÷Ë Õ“®‡°¥‘ ®“°°“√∑¡’Ë ·’ À≈ßà µ¥‘ ‡™Õ◊È Õ¬„Ÿà π√“à ß°“¬ ‚¥¬‡©æ“–„π™Õà ß∑Õâ ß ¡’ biofilm ∑’Ë catheter À√Õ◊ °“√∑¬’Ë ß— ¡’ tunnel infection À≈߇À≈◊ÕÕ¬Ÿà ºâŸªÉ«¬‡À≈à“π’ȧ«√®–‰¥â√—∫°“√µ√«®À“·À≈àß°“√µ‘¥‡™◊ÈÕ„π™àÕß∑âÕßÀ√◊Õ ‡ª≈¬’Ë π “¬ peritoneal catheter µ“¡≈”¥∫— °“√ªÕÑ ß°π— fungal infection ´ß÷Ë ¡°— ‡°¥‘ µ“¡À≈ß— °“√‰¥â antibiotics ‡ªπì ‡«≈“π“π∑”‰¥‚â ¥¬°“√„À¬â “ antifungal ‡™πà nystatin „πºªâŸ «É ¬°≈¡ÿà π’È ´ß÷Ë Õ“®™«à ¬ªÕÑ ß°π— fungal infection ‰¥â °“√µ¥‘ ‡™Õ◊È „π√–∫∫∑“߇¥π‘ Õ“À“√Õ“®∑”„À‡â °¥‘ peritonitis ‰¥‡â ™πà °π— ‰¥·â °à infectious diarrhea, ischemic bowel disease À√Õ◊ cholecystitis √«¡∂ß÷ constipation §«√ªÕÑ ß°π— ºªŸâ «É ¬ CPD ‰¡„à À∑â Õâ ߺ°Ÿ πÕ°®“°π’È peritonitis Õ“®‡°¥‘ µ“¡À≈ß— °“√∑”Àµ— ∂°“√µ“à ßÊ ∑∑’Ë ”„À‡â °¥‘ transient bacteremia ‰¥â ‡™πà dental procedure, uterine biopsy, ·≈– colonoscopy ‚¥¬‡©æ“–∂“â ¡°’ “√∑” polypectomy √«à ¡¥«â ¬ °Õà π°“√ ∑”Àµ— ∂°“√µ“à ßÊ ‡À≈“à πº’È ªâŸ «É ¬§«√®–‰¥√â ∫— prophylactic antibiotics ºªâŸ «É ¬∑∂Ë’ °Ÿ √∫— ‰«„â π‚√ß欓∫“≈∑‰Ë’ ¡¡à ’ PD nurse ¥·Ÿ ≈√«à ¡¥«â ¬ ®–¡§’ «“¡‡ ¬Ë’ ßµÕà °“√µ¥‘ ‡™ÕÈ◊  ßŸ ‡™πà °π— ‡πÕË◊ ß®“°∫§ÿ ≈“°√∑“ß°“√·æ∑¬¢å “¥ §«“¡√§Ÿâ «“¡™”π“≠„π°“√¥·Ÿ ≈ºªâŸ «É ¬ CPD ‡¡ÕË◊ ¡°’ “√µ¥‘ ‡™ÕÈ◊ peritonitis ‡°¥‘ ¢πÈ÷ ºªâŸ «É ¬§«√®–‰¥√â ∫— °“√´°— ∂“¡‡°¬Ë’ «°∫— ¢πÈ— µÕπ°“√∑” CPD «“à ∂°Ÿ µÕâ ßÀ√Õ◊ ‰¡à ¡°’ “√‡ª≈¬’Ë π·ª≈ߢπ—È µÕπÀ√Õ◊ º∑Ÿâ ”À√Õ◊ ‰¡à À√Õ◊ ‰¥√â ∫— °“√∑”Àµ— ∂°“√¥ß— °≈“à «¢“â ßµπâ À√Õ◊ ‰¡à √«¡∂ß÷ °“√µ√«® exit site ™π¥‘ ¢Õ߇™ÕÈ◊ °Õà ‡ÀµÕÿ “®∫Õ°∂ß÷  “‡Àµ¢ÿ Õß°“√‡°¥‘ peritonitis ‰¥â ‡™πà ‡™ÕÈ◊ coagulase-negative staphylococcus ¡—°¡“®“°°“√ contamination ‡™◊ÈÕ Staphylococcus aureus ·≈– Pseudomonas aeruginosa ¡°— ‡°¬Ë’ «¢Õâ ß°∫— °“√µ¥‘ ‡™ÕÈ◊ ∑Ë’ peritoneal catheter ·µ≈à – ∂“∫π— §«√¡’ CQI ‡æÕË◊ ∑®Ë’ –æ≤— π“°“√ Õπ·≈–°“√√°— …“¢Õßµπ‡Õß ‚¥¬®–µÕâ ß¡µ’ «— ™«È’ ¥— „π°“√µ¥‘ µ“¡ ´ßË÷ ‰¥·â °à Õµ— √“°“√‡°¥‘ peritonitis ·≈– exit site infection ‡ªπì µπâ Õµ— √“°“√µ¥‘ ‡™ÕÈ◊ Õ“®· ¥ß‡ªπì Õµ— √“°“√‡°¥‘ µÕà ªï (rate/year = number of peritonitis/patient-year) À√Õ◊ §”π«≥‡ªπì √–¬–‡«≈“‡ªπì ‡¥Õ◊ π√–À«“à ß°“√‡°¥‘ peritonitis (monthly interval between episodes = 12/annual rate) §«√¡°’ “√®¥— ª√–™¡ÿ ∫§ÿ ≈“°√∑‡Ë’ °¬Ë’ «¢Õâ ß°∫— ß“π CPD ∑°ÿ ‡¥Õ◊ π‡æÕË◊ À“ “‡Àµ¢ÿ Õß°“√‡°¥‘ infection ·≈–ªÕÑ ß°π— ‰¡„à À‡â °¥‘ ¢πÈ÷ Õ°’ „πÕ𓧵 ¡°’ “√«‡‘ §√“–À∂å ß÷ ·π« ‚πâ¡¢ÕßÕ—µ√“°“√µ‘¥‡™◊ÈÕ ª√–‡¡‘𧫓¡‡ ’ˬ߄πºâŸªÉ«¬·µà≈–√“¬·≈–æ—≤π“°“√ªÑÕß°—π·≈–°“√√—°…“

New Frontiers in Dialysis 258 ∏𵑠®‘√π—π∑å∏«™—  ‘√¿‘ “ ™“â ß»√‘ °‘ ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå  ‡ÿ ¡∏°≈ÿ ‡ªÑ“À¡“¬¢Õß°“√ªÑÕß°—π°“√µ‘¥‡™◊ÈÕ‰¡à§«√®–‡ªìπµ—«‡≈¢¢ÕßÕ—µ√“∑’ˬա√—∫‰¥â ·µà§«√®–¡’‡ªÑ“À¡“¬ ‰¡„à À‡â °¥‘ ¢πÈ÷ ‡≈¬ ‡æÕË◊ ®–≈¥Õµ— √“°“√µ¥‘ ‡™ÕÈ◊ „Àπâ Õâ ¬∑ Ë’ ¥ÿ ‡∑“à ∑®Ë’ –∑”‰¥â 7. °“√„™â peritoneal dialysis √°— …“ºªâŸ «É ¬ congestive heart failure31 °“√√°— …“¥«â ¬«∏‘ ’ peritoneal dialysis πÕ°®“°®–„™„â πºªŸâ «É ¬‰µ«“¬√–¬– ¥ÿ ∑“â ¬·≈«â ¬ß— ¡°’ “√ „™â PD „π°“√√°— …“ºªŸâ «É ¬ congestive heart failure (CHF), acute pancreatitis, psoriasis, hypothermia ·≈– intraperitoneal chemotherapy ‡ªπì µπâ ºªŸâ «É ¬∑¡’Ë ’ CHF ¡°— ®–¡’ renal dysfunction √«à ¡¥«â ¬ ‡√¬’ °«“à cardiorenal syndrome ´ß÷Ë Õ“®‡°¥‘ ®“° 1) ºªŸâ «É ¬ heart failure ¡°— ®–¡‚’ √§´ß÷Ë ∑”„ÀÀâ «— „®·≈–‰µ‡ Õ◊Ë ¡‰¥‡â ™πà ‡¥¬’ «°π— ‰¥·â °à ‚√§‡∫“À«“𠧫“¡¥π— ‚≈Àµ‘  ßŸ ·≈– atherosclerosis 2) Neurohumoral response „πºªâŸ «É ¬ CHF ¡º’ ≈ ‡ ¬’ µÕà ∑ßÈ— À«— „®·≈–‰µ ‡™πà °“√°√–µπâÿ renin-angiotensin-aldosterone system (RAAS) ·≈– sympathetic nervous system ®–∑”„À‡â °¥‘ myocardial apoptosis, fibrosis, left ventricular hypertrophy ·≈– heart failure ∑·Ë’ ¬≈à ß „π¢≥–‡¥¬’ «°π— ∑‰Ë’ µ®–‡°¥‘ glomerulosclerosis ·≈– interstitial fibrosis 3) ¿“«– CHF ∑Ë’ cardiac index < 1.5 L/m2 ®–≈¥ renal perfusion πÕ°®“°πÈ’ ¬“∑„Ë’ ™√â °— …“ CHF Õ“®¡º’ ≈µÕà °“√∑”ß“π¢Õ߉µ‰¥â ‡™πà diuretics À√Õ◊ ¬“∑¬Ë’ ∫— ¬ßÈ— RAAS ºªŸâ «É ¬∑¡Ë’ ’ resistant CHF ¡°— ®–µÕ∫ πÕßµÕà diuretic ‰¡¥à ·’ ¡«â “à ®– „À¬â “„π¢π“¥ ßŸ °µÁ “¡ ®ß÷ ¡°’ “√π” PD ¡“„™„â πºªŸâ «É ¬ CHF ‡æÕË◊ ¢∫— π”È ·≈–‡°≈Õ◊ ÕÕ°∑“ß ultrafiltration (UF) πÕ°®“°π’È πÈ”¬“ PDF ¬ß— ‰¡¡à ’ potassium ·≈–¡’ magnesium µË” ∑”„À â “¡“√∂„™¬â “„π°≈¡ÿà angiotensin converting enzyme inhibitors À√Õ◊ angiotensin receptor blockers ‰¥‡â µ¡Á ∑‚Ë’ ¥¬‰¡‡à °¥‘ hyperkalemia ·µà §«√√–«ß— °“√‡°¥‘ hypokalemia ·≈– hypomagnesemia ´ßË÷ Õ“®∑”„À‡â °¥‘ arrhythmias ‰¥â ºªŸâ «É ¬ resistant CHF ∑¡Ë’ ’ acute volume overload §«√‰¥√â ∫— °“√√°— …“¥«â ¬ dextrose-based, short, frequent exchanges PD ´ßË÷ ®–‰¥â UF rate ª√–¡“≥ 67-568 mL/min πÕ°®“°πÈ’ ¬ß— ™«à ¬·°‰â ¢¿“«– hyponatremia ‰¥¥â «â ¬‡πÕË◊ ß®“° short exchange PD ®–∑”„Àâ UF  «à π„À≠„à π™«à ßµπâ ‡ªπì free water ®“° sodium sieving ∑‡Ë’ °¥‘ ¢πÈ÷ ®“° hypertonic solution ¬ß— ‰¡¡à °’ “√»°÷ …“∑‡Ë’ ªπì clinical trials ¢Õß°“√„™â PD „π°“√√°— …“ºªâŸ «É ¬ resistant CHF ·µà PD π“à ®–¡ª’ √–‚¬™πµå Õà ºªâŸ «É ¬‡À≈“à π’È ‚¥¬‡©æ“–ºªâŸ «É ¬∑µ’Ë Õâ ߇¢“â πÕπ‚√ß欓∫“≈∫Õà ¬Ê ¥«â ¬‡√Õ◊Ë ß¢Õß CHF ´ßË÷ ∫“ߧ√ßÈ— °“√∑” hemofiltration Õ“®∑”„À‡â °¥‘ hypotension ‰¥ßâ “à ¬ º≈¥Õ’ πË◊ Ê ¢Õß°“√∑” PD πÕ°‡ÀπÕ◊ ®“°°“√ remove π”È ·≈– sodium  «à π‡°π‘ ÕÕ°‚¥¬µ√ß·≈«â PD ¬ß— ™«à ¬„À‰â µµÕ∫ πÕßµÕà ¬“¢∫— ª í  “«–¥¢’ πÈ÷ ‡ªπì bridge therapy „Àºâ ªŸâ «É ¬°Õà π∑®Ë’ –‰¥√â ∫— definite therapy ‡™πà valve repair or replacement À√◊Õ cardiac transplantation „π°√≥’∑’ˉ¡à “¡“√∂√—°…“‚√§À—«„®‰¥â Õ“®„™â PD „π°“√ √°— …“·∫∫ª√–§∫— ª√–§√Õß ´ßË÷ ®–∑”„ÀÕâ “°“√, functional class ·≈– exercise tolerance ¥¢’ πÈ÷ , preserve residual renal function, ≈¥Õ—µ√“°“√πÕπ‚√ß欓∫“≈·≈–∑”„Àâ§ÿ≥¿“æ™’«‘µ¥’¢÷Èπ ‚¥¬∑’Ë¡’º≈ ·∑√°´Õâ π®“°°“√√°— …“πÕâ ¬¡“° ‡™πà peritonitis À√Õ◊ hernia ‰¡·à µ°µ“à ß®“°°≈¡àÿ ºªŸâ «É ¬ ESRD ·µà PD ‰¡à‡ª≈’ˬπ natural history ¢Õß‚√§À—«„®·≈–‰¡à≈¥Õ—µ√“°“√µ“¬¢ÕߺŸâªÉ«¬ resistant CHF °“√„™â PD √°— …“ºªâŸ «É ¬‡À≈“à π¡È’ ‡’ ∑§π§‘ À≈“¬«∏‘ ’ ºªâŸ «É ¬∑µË’ Õâ ß°“√°”®¥— ¢Õ߇ ¬’ ÕÕ°¥«â ¬ §«√‡≈Õ◊ °„™«â ∏‘ ’ CAPD À√Õ◊ APD „π¢≥–∑ºË’ ªâŸ «É ¬∑µË’ Õâ ß°“√°”®¥— π”È ·≈– sodium  «à π‡°π‘ ÕÕ°‡∑“à ππÈ— Õ“®„™«â ∏‘ ’ nocturnal APD À√Õ◊

Frontiers in Peritoneal Dialysis  ™ÿ “¬ »√∑’ ‘欫√√≥ 259 icodextrin „πµÕπ°≈“ߧπ◊ ‡∑“à ππÈ— 8. °“√„™â peritoneal dialysis √°— …“ºªŸâ «É ¬ acute renal failure32 „π™«à ßªï §.».1970 ¡°’ “√„™â intermittent PD (IPD) „π°“√√°— …“ºªâŸ «É ¬ acute renal faiure ‡ªπì §√ßÈ— ·√°°Õà π°“√„™â hemodialysis ¢Õâ ¥¢’ Õß IPD §Õ◊ ∑”‰¥ßâ “à ¬ √«¥‡√«Á ‚¥¬„™â semi-rigid À√Õ◊ single cuff Tenckhoff catheter ‰¡µà Õâ ß„™â anticoagulant ·≈–¡º’ ≈µÕà hemodynamic πÕâ ¬ ª®í ®∫ÿ π— ¡°’ “√π” automatic machine ¡“„™„â πºªâŸ «É ¬ ARF ∑”„Àßâ “à ¬µÕà °“√∑” IPD ·≈–≈¥°“√‡°¥‘ peritonitis ≈߉¥¡â “° °“√„™â PD „π°“√√°— …“ºªâŸ «É ¬ ARF Õ“®∑”‰¥‚â ¥¬ 1) classical IPD „™â automatic machine, PDF 1-2 L, flow 2-6 L/hr, 16-20 hr, 40-60 L/session, 2-3 §√ßÈ— / ª— ¥“À,å ´ßË÷ ®–‰¥√â ∫— °“√∑” PD 80-180 L/ ª— ¥“Àå 2) continuous equilibration PD (CEPD) ‡À¡Õ◊ π°“√∑” CAPD ·µ∑à ”¡“°°«“à §Õ◊ ∑°ÿ 2-6 hr, Õ“®„™‡â §√ÕË◊ ßÀ√Õ◊ manual °‰Á ¥â Dwell time ®–π“π°«“à IPD, ∑”„Àâ PDF flow πÕâ ¬°«“à IPD ®ß÷ ¡’ small solute clearances µ”Ë °«“à IPD 3) Tidal PD (TPD) ‡ªπì «∏‘ °’ “√‡æ¡Ë‘ solute clearances ‚¥¬°“√§“â ßπ”È ¬“ PDF ª√–¡“≥ 0.5-1 L ‰«„â π™Õà ß ∑Õâ ßµ≈Õ¥°“√∑” PD ‚¥¬¡’ initial filling 2 L °“√∑” TPD „πºªâŸ «É ¬ ARF ®–„™â rapid exchange §Õ◊ dwell time 4-6 min, total exchange time 20 min ∑”π“π 8-10 hr ®–‰¥â total volume 26-30 L ¢Õâ ∫ßà ™¢È’ Õß °“√√°— …“ºªâŸ «É ¬ ARF ¥«â ¬«∏‘ ’ PD §Õ◊ ºªâŸ «É ¬∑¡Ë’ ’ unstable hemodynamic ·≈– oliguria, ¡’ bleeding disorders, ‰¡à “¡“√∂À“ vascular access ‰¥â·≈–„πºŸâª«¬∑’Ë¡’ uremic syndrome ‡™àπ uremic pericarditis À√◊Õ encephalopathy πÕ°®“°π¬’È ß— ¡°’ “√„™â PD „πºªŸâ «É ¬∑¡’Ë ª’ ≠í À“Õπ◊Ë ∑‰’Ë ¡„à ™à ARF ‰¥·â °à refractory CHF, volume overload, hyperkalemia, ·≈– severe metabolic acidosis ‚¥¬∑«Ë— ‰ª PD ®–¡’ small solute clearances µ”Ë °«“à hemodialysis Small solute concentration „π PDF ®– ßŸ ¢πÈ÷ ®π∂ß÷ √–¥∫— √Õâ ¬≈– 30-50 ¢Õß serum À≈ß— °“√∑” PD 1 hr ·≈–√Õâ ¬≈– 50-80 À≈ß— °“√∑” 4 hr ·µà PD ®–¡’ clearance ¢Õß “√∑¡Ë’ ’ molecular weight  ßŸ °«“à „π conventional hemodialysis ∑‰Ë’ ¡‰à ¥„â ™â high flux dialyzer Ultrafiltration rate ¢Õß PD ®– ßŸ  ¥ÿ „π™«à ß·√°Ê ∑¡’Ë §’ «“¡‡¢¡â ¢πâ ¢Õß glucose „π PDF  ßŸ  ¥ÿ À≈ß— ®“°ππ—È ®–≈¥≈߇√Õ◊Ë ¬Ê Intraperitoneal volume ®– ßŸ  ¥ÿ ∑Ë’ dwell time ª√–¡“≥ 120-180 min „π°√≥∑’ „Ë’ ™â 3.86% glucose PDF ∑” PD „π∑“à πÕπ√“∫ ®–‰¥â transcapillary ultrafiltration  ßŸ ∂ß÷ 15 mL/min Peritoneal dialysis Õ“®‰¡‡à À¡“– ¡°∫— ºªâŸ «¬ critically ill ∑¡Ë’ ’ hypercatabolic state ‡πÕË◊ ß®“°ºªŸâ «É ¬°≈¡àÿ πµÈ’ Õâ ß°“√°“√§«∫§¡ÿ volume status, acid-base ·≈– electrolytes Õ¬“à ß„°≈™â ¥‘ √«¡∑ß—È µÕâ ß°“√ hyperalimentation À√Õ◊ UF ∑‡Ë’ À¡“– ¡πÕ°‡ÀπÕ◊ ®“° remove ¢Õ߇ ¬’ ‡∑“à ππÈ— ´ßË÷ „πª®í ®∫ÿ π— ¡°’ “√æ≤— π“ technology ¢Õß°“√√°— …“¥«â ¬«∏‘ ’ hemodialysis ‰ª Õ¬“à ß¡“° ®π “¡“√∂∑”‰¥µâ Õà ‡πÕ◊Ë ßµ≈Õ¥ 24 hr (continuous renal replacement therapy) ‚¥¬¡’ hemodynamic ∑Ë’ stable ·≈– “¡“√∂ª√∫— °“√„™â anticoagulant ‰¥Õâ ¬“à ߇À¡“– ¡À√Õ◊ „™‡â ©æ“–∑„Ë’ π«ß®√πÕ°√“à ß°“¬‰¥â ¡°’ “√»°÷ …“°“√„™â acute PD „π°“√√°— …“ºªŸâ «É ¬∑¡Ë’ ’ ARF ®“°°“√µ¥‘ ‡™ÕÈ◊ falciparum malaria À√Õ◊ sepsis ‡ª√¬’ ∫‡∑¬’ ∫°∫— °“√√°…— “¥«â ¬«∏‘ ’ hemofiltration „πª√–‡∑»‡«¬’ ¥π“¡ æ∫«“à ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“¥«â ¬ hemofiltration  “¡“√∂·°â‰¢¿“«– metabolic acidosis, °“√≈¥√–¥—∫ serum Cr, ·≈–¡’Õ—µ√“°“√√Õ¥ ™«’ µ‘ ∑¥’Ë °’ «“à ºªŸâ «É ¬°≈¡ÿà PD Õ¬“à ߉√°¥Á ’ °“√»°÷ …“π’È „™°â “√√°— …“ PD ·∫∫¥ß—È ‡¥¡‘ §Õ◊ rigid peritoneal catheter,

New Frontiers in Dialysis 260 ∏π‘µ ®√‘ ππ— ∑∏å «—™  ‘√‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™¬— ∏π—𥓠µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ manual exchange, local prepared high glucose PDF with acetate buffer ·µ¡à °’ “√»°÷ …“°“√„™â IPD √°— …“ºªŸâ «É ¬ ARF „π™«à ߇√¡‘Ë µπâ æ∫«“à ®–™«à ¬≈¥ morbidity ·≈– mortality ¢ÕߺªâŸ «É ¬‰¥â ‚¥¬‡©æ“–„π∑´’Ë ß÷Ë ‰¡¡à ’nephrologist ‡πÕË◊ ß®“° IPD  “¡“√∂∑”‰¥ßâ “à ¬·≈–√«¥‡√«Á πÕ°®“°πÈ’ ¬ß— ¡°’ “√„™â PD „π°“√√°— …“ºªâŸ «É ¬∑¡Ë’ ’ mild to moderate hypercatabolic ARF33 ´ßË÷ æ∫«“à TPD ¡’ solute clearances ∑¥Ë’ ’ (normalized Cr clearance 68.5 L/ wk, weekly Kt/Vurea 2.43) ·≈–¡’ potassium ·≈– phosphate clearances  ßŸ °«“à ·µà glucose absorption ·≈–§“à „™®â “à ¬µË”°«“à „π¢≥–∑’Ë protein loss  ßŸ °«“à °“√√°— …“¥«â ¬«∏‘ ’ CEPD ¡°’ “√»°÷ …“°“√„™â high volume PD, 36-44 L/session, „πºªŸâ «É ¬ ARF ´ßË÷  «à π„À≠Õà ¬„àŸ π intensive care unit æ∫«“à ¡’ high solute removal, adequate dialysis dose (Kt/Vurea 0.65/session) & fluid removal ·≈– “¡“√∂§«∫§¡ÿ metabolic & pH ‰¥â ¥3’ 4 „πÕ𓧵‡¡ÕË◊ ¡°’ “√æ≤— π“ CFPD (´ßË÷ ¡’ small solute clearance  ßŸ ¡“°) „À â “¡“√∂„™‰â ¥ â –¥«°¡“° ¢πÈ÷ °“√√°— …“ºªâŸ «É ¬ ARF ∑¡Ë’ ’ hypercatabolic state Õ“®‰¡¡à §’ «“¡·µ°µ“à ß√–À«“à ß PD À√Õ◊ hemodialysis ‰¡¡à ¢’ Õâ ¡≈Ÿ ¬π◊ ¬π— ∂ß÷ ª√–‚¬™π¢å Õß°“√„™â PD „π°“√√°— …“ºªâŸ «É ¬ acute pancreatitis ¡°’ “√„™â PD „π°“√ ‡æ‘Ë¡À√◊Õ≈¥Õÿ≥À¿Ÿ¡‘¢Õß√à“ß°“¬„π¿“«– hypothermia À√◊Õ hyperthermia µ“¡≈”¥—∫ ·µà prognosis ®–¢πÈ÷ °∫—  “‡Àµ°ÿ “√‡°¥‘ §«“¡º¥‘ ª°µ¢‘ ÕßÕ≥ÿ À¿¡Ÿ √‘ “à ß°“¬ Peritoneal dialysis Õ“®‰¥ªâ √–‚¬™π„å πºªâŸ «¬ fulminant hepatic failure35 ‡πÕË◊ ß®“°°“√∑”‰¡µà Õâ ß„™â anticoagulant,  “¡“√∂·°‰â ¢§«“¡º¥‘ ª°µ¢‘ Õß fluid & electrolytes, ≈¥§«“¡‡ ¬Ë’ ß°“√‡°¥‘ ¿“«– hypoglycemia & hypothermia ·≈–™«à ¬ remove ¢Õ߇ ¬’ ‡™πà ammonia, methyl mercaptan, biliribin & fatty acids ÕÕ°®“°√“à ß°“¬‰¥â πÕ°®“°π¬È’ ß— Õ“®„À¬â “·≈–  “√Õ“À“√∑“ß peritoneum ‰¥¥â «â ¬ Relative contraindications ¢Õß°“√√°— …“¥«â ¬«∏‘ ’ acute PD · ¥ß „πµ“√“ß∑Ë’ 2  “¡“√∂∑” PD ‰¥Àâ ≈ß— °“√∑”º“à µ¥— aortic graft 4-6 ‡¥Õ◊ π ´ßË÷ ‡ªπì ™«à ß∑·Ë’ º≈º“à µ¥— À“¬ ¥·’ ≈«â Prescription ¢Õß acute PD ¢÷Èπ°—∫Õ“°“√¢Õߺ⟪ɫ¬·µà≈–√“¬ §«√¡’·∫∫øÕ√å¡°“√√—°…“ ·≈–°“√ —Ëß°“√√—°…“§«√‡ªìπ·∫∫«—πµàÕ«—π ‡π◊ËÕß®“°ºŸâª«¬¡—°¡’Õ“°“√‡ª≈’ˬπ·ª≈߉¥âµ≈Õ¥‡«≈“ ´÷Ëß µ“√“ß∑Ë’ 2 Relative contraindications ¢Õß°“√∑” acute peritoneal dialysis Recent abdominal or cardiothoracic surgery Diaphragmatic peritoneopleural connections Fecal or fungal peritonitis Severe respiratory failure Abdominal wall cellulitis Severe gastroesophageal reflux disease Low peritoneal clearances Life-threatening hyperkalemia Severe acute pulmonary edema Extremely high catabolysis

Frontiers in Peritoneal Dialysis  ÿ™“¬ »√∑’ æ‘ ¬«√√≥ 261 °“√ ß—Ë °“√√°— …“§«√ª√–°Õ∫¥«â ¬ ë Infusion volume: 0.5-2 L (20-50 mL/kg „π‡¥°Á ) µ“¡¢π“¥¢ÕߺªâŸ «É ¬·≈–§«“¡√πÿ ·√ߢÕß uremia §«√‡√¡Ë‘ ¥«â ¬ª√¡‘ “µ√πÕâ ¬Ê °Õà π ë Exchange time: 1 hr ·∫ßà ‡ªπì inflow 10 min, dwell 30 min ·≈– outflow 20 min ®–‰¥â total exchange volume 48 L/day °“√≈¥ dwell time ‡À≈Õ◊ 15 min ®–∑”„Àâ diasate flow ‡æ¡Ë‘ ∂ß÷ 4 L/hr (66 mL/ min) Õ“®‡æ¡Ë‘ solute clearance ‰¥ â ߟ ¢πÈ÷ ´ßË÷ Õ“®π”¡“„™„â π¿“«– hypercatabolic À√Õ◊ hyperkalemia ‰¥â ·µ°à “√≈¥ dwell time ®–∑”„À‡â «≈“„π°“√ diffusion ≈¥≈ß∑”„Àâ clearance ≈¥≈߉¥‡â ™πà °π— ë Glucose: °“√„™â 1.5% glucose PDF 2 L ®–‰¥â UF rate ª√–¡“≥ 50-150 mL/hr À√Õ◊ 1,200- 3,600 mL/day °“√„™â 2.5%-4.25% glucose PDF ®–‰¥â UF rate  ßŸ ∂ß÷ 200-400 mL/hr „πºªŸâ «É ¬∑¡Ë’ ’ pulmonary edema °“√„™â 4.25% glucose PDF 2-3 exchanges µ¥‘ µÕà °π— Õ“®‰¥â UF  ßŸ ∂ß÷ 1 L/hr ë Total time per session: ¢πÈ÷ °∫— dose ¢Õß PD ∑µË’ Õâ ß°“√„À°â ∫— ºªâŸ «É ¬ ºªŸâ «É ¬ ARF ∑¡Ë’ ’ §«“¡®”‡ªπì µÕâ ß remove ‡Õ“¢Õ߇ ¬’ π”È ·≈–‡°≈Õ◊  «à π‡°π‘ ÕÕ°µ≈Õ¥‡«≈“ ‡™πà ºªŸâ «É ¬∑¡Ë’ ’ hypercatabolic state ·≈–µÕâ ß°“√ nutritional support §«√®–∑” PD 2 L/exchange µÕà ‡πÕË◊ ßµ≈Õ¥ 24-72 hr ‚¥¬ª√∫— PD dose „À⺟âªÉ«¬ “¡“√∂√—∫Õ“À“√„À≥âæ≈—ßß“π·≈– protein µ“¡§«“¡®”‡ªìπ∑’˵âÕß°“√·≈–¡’ fluid & electrolytes ∑ªË’ °µ‘ ë Total volume per day: ‚¥¬∑«Ë— ‰ª §Õ◊ 48 L/day (PDF 2 L ∑°ÿ 1 ™«Ë— ‚¡ß) ºªâŸ «É ¬∑µË’ Õâ ß°“√‡æ¡Ë‘ solute clearance §«√ª√∫— ‡æ¡‘Ë infusion volume ¡“°°«“à ª√∫— ≈¥ dwell time ¬°‡«πâ „π√“¬∑‡’Ë ªπì high solute transport „πºªŸâ «É ¬∑¡Ë’ ¢’ π“¥√“à ß°“¬µ“¡ª°µ‘ °“√‡æ¡Ë‘ infusion volume ‡ªπì 2.5 L ¡°— ®– “¡“√∂‡æ¡Ë‘ small solute clearance ‰¥∂â ß÷ ‡ª“Ñ À¡“¬µ“¡∑µË’ Õâ ß°“√ ºªŸâ «É ¬∑¡Ë’ ’ body surface area > 2 m2 Õ“®µÕâ ߇æ¡Ë‘ infusion volume ‡ªπì 3 L ë Heparin: ‚¥¬∑«Ë— ‰ª„™â 1,000 U/2 L ë Insulin: „πºªâŸ «É ¬∑‡’Ë ªπì ‡∫“À«“π Õ“®‡µ¡‘ insulin „π PDF ‚¥¬„™â insulin 3-4 U/1.5% glucose 1 L, 5-6 U/2.5% glucose 1 L, ·≈– 7-10 U/4.25% glucose 1 L ‡ª“Ñ À¡“¬¢Õß°“√∑” acute PD §«√®–‰¥â dialysate urea clearance ª√–¡“≥ 10-30 mL/min (14.4-43.2 L/day) ¢÷Èπ°—∫¢π“¥√Ÿª√à“ߢÕߺŸâªÉ«¬ ®“°¢âÕ¡Ÿ≈¢Õß hemodialysis ·π–π”„Àâ¡’√–¥—∫ pre- hemodialysis BUN < 80 mg/dL36 Complication ¢Õß°“√∑” acute PD æ∫‰¥‡â ™πà ‡¥¬’ «°∫— °“√∑” CPD ‰¥·â °à ë Peritonitis ≈¥‰¥‚â ¥¬°“√„™â automatic machine ë Inflow pain ®“° low pH, low temperature ·≈– jet flow ·°‰â ¢‰¥‚â ¥¬°“√‡æ¡Ë‘ pH ¥«â ¬ sodium bicarbonate 5-25 mEq/L, ∑”π”È ¬“ PDF „ÀÕâ πàÿ °Õà π„ ‡à ¢“â  ™àŸ Õà ß∑Õâ ߺªâŸ «É ¬ ·≈–„™â infusion rate ™“â Ê ë Out flow pain Õ“®‡°‘¥®“°°“√∑’Ë “¬ peritoneal catheter ‰ª —¡º— °—∫ omentum À√◊Õ Õ«¬— «–ÕπË◊ ·°‰â ¢‚¥¬°“√≈¥ outflow rate ë Visceral perforation ‰¥·â °à bowel, bladder À√Õ◊ aorta „ÀÀâ ¬¥ÿ ∑” PD ·≈–‡ª≈¬Ë’ π‰ª∑” hemodialysis

New Frontiers in Dialysis 262 ∏π‘µ ®‘√ππ— ∑∏å «™—  √‘ ¿‘ “ ™â“ß»√‘ ‘°ÿ≈™¬— ∏π—𥓠µ√–°“√«π™‘ « π— µå  ‡ÿ ¡∏°ÿ≈ ë Bloody dialysate Õ“®‡ªπì ‡≈Õ◊ ¥∑ÕË’ Õ°∫√‡‘ «≥ºπß— Àπ“â ∑Õâ ß™πÈ— °≈“â ¡‡πÕÈ◊ √–À«“à ß°“√„  à “¬ catheter ´÷Ëß¡—°®–®“ß≈߉¥â „π°√≥’∑’ˉ¡à®“ß≈ß„Àâ ß —¬«à“Õ“®¡’ vessel À√◊Õ visceral organ injury µÕâ ߪ√°÷ …“»≈— ¬·æ∑¬√å «à ¡ª√–‡¡π‘ ºªâŸ «É ¬¥«â ¬ ë Dialysate leakage ¡°— æ∫„πºªŸâ «É ¬ ßŸ Õ“¬ÿ > 60 ªï ºªŸâ «É ¬∑ÕË’ «â 𠇪πì ‡∫“À«“π „™¬â “ steroids ¡°’ “√µßÈ— §√√¿Àå ≈“¬§√ßÈ— ·≈–‡§¬º“à µ¥— Àπ“â ∑Õâ ß¡“°Õà π ·°‰â ¢‚¥¬°“√„™â infusion volume πÕâ ¬Ê °Õà π ºªŸâ «É ¬∫“ß√“¬Õ“®¡°’ “√√«Ë— ¢Õß PDF ‡¢“â ‰ª„π‡πÕÈ◊ ‡¬ÕË◊ √Õ∫¢“â ß ∑”„À¡â Õ’ “°“√∫«¡¢Õߺπß— Àπ“â ∑Õâ ßÀ√Õ◊ Õ«¬— «–‡æ» §«√‰¥√â ∫— °“√ª√∫— µ”·Àπßà À√Õ◊ „  à “¬ peritoneal catheter „À¡à ë Abdominaldistension´ß÷Ë Õ“®∑”„À°â “√À“¬„®¢ÕߺªŸâ «É ¬¡ª’ ≠í À“‰¥âÕ“®‡°¥‘ ®“°°“√§“â ߢÕß PDF „π™Õà ß∑Õâ ß ·°‰â ¢‚¥¬°“√欓¬“¡ª≈Õà ¬πÈ”¬“ PDF ÕÕ°®“°™Õà ß∑Õâ ߺªŸâ «É ¬„ÀÀâ ¡¥„π·µ≈à – exchange ë Hydrothorax ‡ªπì complication ∑‡Ë’ °¥‘ ‰¡∫à Õà ¬ Õ“°“√Õ“®‰¡¡à “°À√Õ◊ ¡“°®π‡°¥‘ respiratory failure ‰¥â «π‘ ®‘ ©¬— ®“° chest X-ray ·≈–°“√µ√«®√–¥∫— glucose „π pleural effusion ¡°— µÕâ ßÀ¬¥ÿ ∑” PD ·µÕà “®≈Õß≈¥ infusion volume ·≈– ß— ‡°µÕ“°“√ ∂“â ‰¡¥à ¢’ πÈ÷ µÕâ ßÀ¬¥ÿ °“√∑” PD ë Medical complication ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√√°— …“¥«â ¬ acute PD §«√‰¥√â ∫— °“√µ√«®√“à ß°“¬ ª√–‡¡π‘ volume status ·≈–µ√«®‡≈Õ◊ ¥Õ¬“à ßπÕâ ¬«π— ≈–§√ß—È ‡æÕ◊Ë ª√–‡¡π‘ §«“¡º¥‘ ª°µ¢‘ Õß electrolytes ·≈– acid-base status Hypernatremia Õ“®‡°¥‘ ¢πÈ÷ ‰¥„â πºªŸâ «É ¬∑„Ë’ ™â hypertonic solution ·°‰â ¢‚¥¬°“√„Àâ free water ‡æ¡Ë‘ ¢πÈ÷ Õ“®‚¥¬°“√√∫— ª√–∑“πÀ√Õ◊ ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”„π√ªŸ ¢Õß 5%dextroxe in water ºªâŸ «É ¬ ∑¡Ë’ ‚’ √§µ∫— ®–¡ª’ ≠í À“„π°“√‡ª≈¬Ë’ π lactate ‡ªπì bicarbonate ∑µË’ ∫— ‰¥™â “â ∑”„À¡â §’ “à serum lactate  ßŸ ‰¥â ·°‰â ¢‚¥¬„™â buffer „π√ªŸ ¢Õß bicarbonate „π√“¬∑¡Ë’ ’ metabolic acidosis ·≈–‰¥â intravenous sodium bicarbonate infusion √«à ¡¥«â ¬ ºªŸâ «É ¬®–¬ß— §ß¡’ acidosis „π cerebrospinal fluid, ‡°¥‘ hyperventilation ·≈– alkalosis µ“¡¡“‰¥â °“√∑” acute PD À≈“¬ exchange µÕà «π— Õ“®∑”„À¡â °’ “√ ≠Ÿ ‡ ¬’ albumin 10-20 g/day ‰¥·â ≈–Õ“®¡“°‡ªπì 2 ‡∑“à ∂“â ¡’ peritonitis √«à ¡¥«â ¬ Ultrafiltration failure Õ“®æ∫‰¥„â πºªŸâ «É ¬∑‡Ë’ ªπì high transport (dialysate to plasma creatinine > 0.8) ·≈–®–‡ªπì ¡“°¢πÈ÷ „π™«à ß∑¡Ë’ ’ peritonitis ‡Õ° “√Õ“â ßÕß‘ 1. DellûAquila R, Rodighiero MP, Spano E, Di Loreto P, Kohn CO, Cruz D, et al. Advances in the technology of automated, tidal, and continuous flow peritoneal dialysis. Perit Dial Int. 2007;27 Suppl 2:S130-7. 2. Shinaberger JH, Shear L, Barry KG. Peritoneal-Extracorporeal Recirculation Dialysis a Technique for Improving Efficiency of Peritoneal Dialysis. Investigative urology. 1965;2:555-66. 3. Gotch FA. Kinetic modeling of continuous flow peritoneal dialysis. Seminars in dialysis. 2001;14:378-83. 4. Diaz-Buxo JA. Solution formulation for continuous flow peritoneal dialysis. Contrib Nephrol. 2003(140):309- 17. 5. Amerling R, Glezerman I, Savransky E, Dubrow A, Ronco C. Continuous flow peritoneal dialysis: principles and applications. Seminars in dialysis. 2003 Jul-Aug;16:335-40. 6. Diaz-Buxo JA, Cruz C, Gotch FA. Advances in end-stage renal diseases 2000. Continuous-flow peritoneal dialysis. preliminary results. Blood purification. 2000;18:361-5.

Frontiers in Peritoneal Dialysis  ™ÿ “¬ »√’∑‘欫√√≥ 263 7. McIntyre CW. Update on peritoneal dialysis solutions. Kidney Int. 2007;71:486-90. 8. Wieslander A, Linden T. Glucose degradation and cytotoxicity in PD fluids. Perit Dial Int. 1996;16 Suppl 1:S114-8. 9. Di Paolo N, Sacchi G. Peritoneal vascular changes in continuous ambulatory peritoneal dialysis (CAPD): an in vivo model for the study of diabetic microangiopathy. Perit Dial Int. 1989;9:41-5. 10. Krediet RT, Zweers MM, van der Wal AC, Struijk DG. Neoangiogenesis in the peritoneal membrane. Perit Dial Int. 2000;20 Suppl 2:S19-25. 11. Ho-dac-Pannekeet MM, Schouten N, Langendijk MJ, Hiralall JK, de Waart DR, Struijk DG, et al. Peritoneal transport characteristics with glucose polymer based dialysate. Kidney Int. 1996;50:979-86. 12. Davies SJ, Woodrow G, Donovan K, Plum J, Williams P, Johansson AC, et al. Icodextrin improves the fluid status of peritoneal dialysis patients: results of a double-blind randomized controlled trial. J Am Soc Nephrol. 2003;14:2338-44. 13. Taylor GS, Patel V, Spencer S, Fluck RJ, McIntyre CW. Long-term use of 1.1% amino acid dialysis solution in hypoalbuminemic continuous ambulatory peritoneal dialysis patients. Clin Nephrol. 2002;58:445-50. 14. Chen CJ, Moberly JB, Martis L. New developments in peritoneal dialysis solutions. Adv Perit Dial. 1998;14:116- 9. 15. Witowski J, Korybalska K, Ksiazek K, Wisniewska-Elnur J, Jorres A, Lage C, et al. Peritoneal dialysis with solutions low in glucose degradation products is associated with improved biocompatibility profile towards peritoneal mesothelial cells. Nephrol Dial Transplant. 2004;19:917-24. 16. Morgan LW, Wieslander A, Davies M, Horiuchi T, Ohta Y, Beavis MJ, et al. Glucose degradation products (GDP) retard remesothelialization independently of D-glucose concentration. Kidney Int. 2003 ;64:1854-66. 17. Bredie SJ, Bosch FH, Demacker PN, Stalenhoef AF, van Leusen R. Effects of peritoneal dialysis with an overnight icodextrin dwell on parameters of glucose and lipid metabolism. Perit Dial Int. 2001;21:275-81. 18. Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Int Suppl. 2006 Nov(103):S27-37. 19. Heaf J. Underutilization of peritoneal dialysis. Jama. 2004;291:740-2. 20. Moncrief JW, Popovich RP, Broadrick LJ, He ZZ, Simmons EE, Tate RA. The Moncrief-Popovich catheter. A new peritoneal access technique for patients on peritoneal dialysis. Asaio J. 1993;39:62-5. 21. Ash SR. Chronic peritoneal dialysis catheters: overview of design, placement, and removal procedures. Seminars in dialysis. 2003;16:323-34. 22. Crabtree JH, Burchette RJ. Prospective comparison of downward and lateral peritoneal dialysis catheter tunnel-tract and exit-site directions. Perit Dial Int. 2006;26:677-83. 23. Bender FH, Bernardini J, Piraino B. Prevention of infectious complications in peritoneal dialysis: best demonstrated practices. Kidney Int Suppl. 2006 Nov(103):S44-54. 24. Chung SH, Heimburger O, Lindholm B, Lee HB. Peritoneal dialysis patient survival: a comparison between a Swedish and a Korean centre. Nephrol Dial Transplant. 2005;20:1207-13.

New Frontiers in Dialysis 264 ∏𵑠®√‘ π—π∑∏å «—™  √‘ ¿‘ “ ™“â ß»‘√‘°≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°≈ÿ 25. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int. 2005;25:107-31. 26. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. Am J Kidney Dis. 2004;44:591-603. 27. Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, et al. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol. 2005;16:539-45. 28. Recommendations of the International Society for Peritoneal Dialysis for training requirements of nephrology trainees and nurses. Perit Dial Int. 1994;14:117-20. 29. Hall G, Bogan A, Dreis S, Duffy A, Greene S, Kelley K, et al. New directions in peritoneal dialysis patient training. Nephrol Nurs J. 2004;31:149-54, 59-63. 30. Castro MJ, Celadilla O, Munoz I, Martinez V, Minguez M, Auxiliadora Bajo M, et al. Home training experience in peritoneal dialysis patients. EDTNA/ERCA journal (English ed. 2002 Jan-Mar;28(1):36-9. 31. Mehrotra R, Kathuria P. Place of peritoneal dialysis in the management of treatment-resistant congestive heart failure. Kidney Int Suppl. 2006 Nov(103):S67-71. 32. Passadakis PS, Oreopoulos DG. Peritoneal dialysis in patients with acute renal failure. Advances in peritoneal dialysis. 2007;23:7-16. 33. Chitalia VC, Almeida AF, Rai H, Bapat M, Chitalia KV, Acharya VN, et al. Is peritoneal dialysis adequate for hypercatabolic acute renal failure in developing countries? Kidney international. 2002;61:747-57. 34. Gabriel DP, Nascimento GV, Caramori JT, Martim LC, Barretti P, Balbi AL. High volume peritoneal dialysis for acute renal failure. Perit Dial Int. 2007;27:277-82. 35. Mactier R. Non-renal indications for peritoneal dialysis. Adv Perit Dial. 1992;8:141-4. 36. DuBose TD, Jr., Warnock DG, Mehta RL, Bonventre JV, Hammerman MR, Molitoris BA, et al. Acute renal failure in the 21st century: recommendations for management and outcomes assessment. Am J Kidney Dis. 1997 ;29:793-9.

14 Hemodialysis in Renal Failure Children °“≠®π“ µß—È π√“√™— ™°®‘ 1. ∫∑π” 2. §«“¡·µ°µ“à ß∑“ß √√’ –«∑‘ ¬“¢Õ߇¥°Á ·≈–ºŸâ„À≠à 3.  “‡Àµ¢ÿ Õß‚√§‰µ«“¬„πºªâŸ «É ¬‡¥°Á 4. Hemodialysis 5. ·π«∑“ß°“√∑” hemodialysis „π‡¥°Á 6.  √ªÿ

New Frontiers in Dialysis 266 ∏𵑠®‘√π—π∑∏å «™—  ‘√‘¿“ ™â“ß»‘√‘°≈ÿ ™¬— ∏π—𥓠µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°ÿ≈ 1. ∫∑π” Hemodialysis ‡ªπì °“√√°— …“∑¥·∑π‰µ™π¥‘ ÀπßË÷ ‚¥¬Õ“»¬— ‡§√ÕË◊ ߉µ‡∑¬’ ¡ ´ßË÷ ‡ªπì «∏‘ ∑’ „Ë’ ™°â π— ¡“° ∑’Ë ÿ¥„πºâŸ„À≠à∑’Ë¡’¿“«–‰µ«“¬∑—Èß™π‘¥‡©’¬∫æ≈—π·≈–‡√◊ÈÕ√—ß Õÿª°√≥åµà“ßÊ ∑’Ë„™â„π°“√øÕ°‡≈◊Õ¥√«¡∂÷ß ‡§√Õ◊Ë ß‰µ‡∑¬’ ¡‰¥√â ∫— °“√æ≤— π“„À¥â ¢’ π÷È µ“¡≈”¥∫— „πª√–‡∑»‰∑¬°“√∑” hemodialysis „π‡¥Á° ®–§≈⓬§≈÷ß°—∫¢Õß∑«’ª¬ÿ‚√ª„π∫“ߪ√–‡∑» ‡π◊ËÕß®“° hemodialysis ®”‡ªìπµâÕß¡’ vascular access ∑’Ë„À≠àæÕ ®÷ß¡—°∂Ÿ°‡≈◊Õ°„À⇪ìπ°“√√—°…“ ∑¥·∑π‰µ„π‡¥°Á ∑§Ë’ Õà π¢“â ß‚µ §Õ◊ Õ“¬¡ÿ “°°«“à 5 ªï ‡ªπì  «à π„À≠à ‡¥°Á ‡≈°Á ‚¥¬‡©æ“–Õ“¬πÿ Õâ ¬°«“à 2 ¢«∫ π‘¬¡„™â peritoneal dialysis °“√∑” hemodialysis „π‡¥Á°‡≈Á°®÷ß¡—°∑”‡©æ“–„π√“¬∑’Ë¡’¢âÕÀâ“¡ ”§—≠ ¢Õß°“√∑” peritoneal dialysis ‰¥·â °à abdominal wall defect, diaphragmatic hernia, post-abdominal surgery À√Õ◊ extensive abdominal adhesion ºªŸâ «É ¬·º≈§«“¡√Õâ π≈«°∫√‡‘ «≥Àπ“â ∑Õâ ß ´ßË÷ Õ“®¡º’ ≈„À‡â °¥‘ °“√ Õ—°‡ ∫µ‘¥‡™◊ÈÕ‰¥âßà“¬ À√◊ÕºŸâªÉ«¬∑’Ë∑” peritoneal dialysis ·≈â«¡’¿“«–·∑√°´âÕ𠇙àπ πÈ”¬“√—Ë«∫√‘‡«≥ ·º≈∑’Ë„ à “¬ peritoneal catheter À√◊Õ “¬Õÿ¥µ—π ·°â‰¢·≈⫉¡à¥’¢÷Èπ ·≈–ºâŸªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ∑’˺π—ß Àπ“â ∑Õâ ß·≈–¿“¬„π™Õà ß∑Õâ ß∫Õà ¬Ê °“√µ—¥ ‘π„®∑” hemodialysis ¬—ߢ÷Èπ°—∫§«“¡æ√âÕ¡¢Õß∑’¡∫ÿ§≈“°√∑“ß°“√·æ∑¬å·≈– Õÿª°√≥å∑’Ë„™â∑” hemodialysis „π‡¥Á° §«“¡‡ÀÁπ™Õ∫®“°ºâŸªÉ«¬‡¥Á° ·≈–/À√◊Õ®“°ºŸâª°§√Õß Õ¬à“߉√ °Áµ“¡ªí®®—¬∑’˵âÕߧ”π÷ß∂÷ß√à«¡¥â«¬§◊Õ √–¬–∑“ß√–À«à“ß∑’ËÕ¬àŸ·≈– ∂“π欓∫“≈/‚√ß欓∫“≈∑’Ë¡’»Ÿπ¬å ‰µ‡∑’¬¡ ªí®®ÿ∫—π‰¥â¡’»Ÿπ¬å‰µ‡∑’¬¡ ”À√—∫ºŸâ„À≠à®”π«π¡“°¢÷Èπ∑—Èß„π°√ÿ߇∑æ·≈–µà“ß®—ßÀ«—¥ ∑”„Àâ„𠇥°Á Õ“®∑”‰¥ â –¥«°¬ß‘Ë ¢π÷È æß÷ √–≈°÷ ‡ ¡Õ«“à °“√∑” dialysis ‡ªπì ‡æ¬’ ß «à πÀπßË÷ ¢Õß√ªŸ ·∫∫°“√¥·Ÿ ≈ºªâŸ «É ¬·∫∫∫√Ÿ ≥“°“√ (integrated care model) ¥ß— ππÈ— ·æ∑¬ºå ¥âŸ ·Ÿ ≈ºªŸâ «É ¬‡¥°Á ‰µ«“¬‡√ÕÈ◊ √ß— √–¬– ¥ÿ ∑“â ¬§«√«“ß·ºπ„À°â “√¥·Ÿ ≈ ·∫∫∫√Ÿ ≥“°“√ ‚¥¬¡‡’ ª“Ñ À¡“¬§Õ◊ ‚§√ß°“√√«à ¡¢Õß dialysis-kidney transplantation „π°¡ÿ “√‡«™»“ µ√‚å √§‰µ hemodialysis ‰¥√â ∫— °“√æ≤— π“¡“‚¥¬µ≈Õ¥ ‚¥¬‡©æ“–™«à ß 20 ªï ∑’˺à“π¡“ ‡π◊ËÕß®“°¡’°“√ª√—∫ª√ÿß·≈–æ—≤π“∑—Èß„π¥â“πÕÿª°√≥åµà“ßÊ „Àâ‡À¡“–°—∫‡¥Á° ·≈–°“√ —Ëß°“√ √°— …“‚¥¬«∏‘ ’ hemodialysis „π‡¥°Á ¢Õß°¡ÿ “√·æ∑¬‚å √§‰µ‡ª≈¬Ë’ π‡ª“Ñ À¡“¬®“° minimum À√Õ◊ adequate ‡ªπì optimum À√Õ◊ maximum dialysis prescription ·∑π ‡æÕË◊ „À‡â ¥°Á ∑®Ë’ ”‡ªπì µÕâ ß„™â long term dialysis ¢≥–√Õ°“√ª≈°Ÿ ∂“à ¬‰µ¡°’ “√‡®√≠‘ ‡µ∫‘ ‚µ∑¥Ë’ ·’ ≈–¡ª’ ≠í À“∑“ßÀ«— „®·≈–À≈Õ¥‡≈Õ◊ ¥πÕâ ¬∑ Ë’ ¥ÿ ≈“à  ¥ÿ The European Pediatric Dialysis Working Group1 ‰¥®â ¥— ∑” çHemodialyis in Children: General Practice Guidelineé ¢πÈ÷ „πªï æ.». 2548 ´ßË÷ ®–¢Õ𔇠πÕ„π∫∑§«“¡πÈ’ 2. §«“¡·µ°µ“à ß∑“ß √√’ –«∑‘ ¬“¢Õ߇¥°Á ·≈–ºâŸ„À≠à «¬— ‡¥°Á ¡°’ “√‡ª≈¬Ë’ π·ª≈ß∑“ß√“à ß°“¬Õ¬“à ß√«¥‡√«Á ‡¥°Á ¡°’ “√‡®√≠‘ ‡µ∫‘ ‚µ‡√«Á ¡“°„π™«à ߢ«∫ªï ·√° ‚¥¬¡π’ ”È Àπ°— µ«— ‡æ¡Ë‘ ¢πÈ÷ ∂ß÷ 3 ‡∑“à ¢Õßπ”È Àπ°— ·√°‡°¥‘ §Õ◊ ª√–¡“≥ 9-10 °‚‘ ≈°√¡— ·≈–§«“¡¬“«

Hemodialysis in Renal Failure Children °“≠®π“ µÈß— π√“√—™™°‘® 267 ‡æ¡Ë‘ ¢πÈ÷ ®“° 50 ‡´πµ‡‘ ¡µ√‡¡ÕË◊ ·√°‡°¥‘ ‡ªπì 75 ‡´πµ‡‘ ¡µ√‡¡ÕË◊ Õ“¬ÿ 1 ªï ‡¡ÕË◊ Õ“¬ÿ 4 ªï ‡¥°Á ®– ßŸ 100 ‡´πµ‡‘ ¡µ√ ·≈–¡π’ ”È Àπ°— ª√–¡“≥ 16-18 °‚‘ ≈°√¡— ®“°ππÈ— ®–¡π’ ”È Àπ°— ‡æ¡Ë‘ ¢πÈ÷ ª≈ï – 2 °‚‘ ≈°√¡— §«“¡  ßŸ ‡æ¡Ë‘ ª≈ï – 4-6 ‡´πµ‡‘ ¡µ√ π”È Àπ°— ·≈– «à π ßŸ ®–‡æ¡Ë‘ ¢πÈ÷ Õ¬“à ß√«¥‡√«Á Õ°’ §√ßÈ— ‡¡ÕË◊ ‡¢“â  «àŸ ¬— √πàÿ πÕ°®“°°“√‡ª≈’ˬπ·ª≈ß∑“ߥâ“π√à“ß°“¬·≈â« ‡¥Á°¬—ß¡’ ¡¥ÿ≈¢ÕßπÈ”·≈–‡°≈◊Õ·√à∑’˵à“ß®“° ºâŸ„À≠à ‡¥Á°·√°‡°‘¥¡’πÈ”‡ªìπ à«πª√–°Õ∫∂÷ß√âÕ¬≈– 80 ‚¥¬‡ªìπ à«πª√–°Õ∫¢ÕßπÈ”„π‡´≈≈å ·≈–πÈ” πÕ°‡´≈≈åÕ¬à“ß√âÕ¬≈– 50 ‚¥¬æ∫«à“√âÕ¬≈– 25 ¢ÕßπÈ”πÕ°‡´≈≈åÀ√◊Õ extracellular fluid ‡ªìπ à«π∑’Ë¡’ °“√‰À≈‡«’¬π‡¢â“ÕÕ°®“°√à“ß°“¬„π·µà≈–«—π ´÷Ëß¡“°°«à“„πºâŸ„À≠à∑’Ë„™âπÈ”‰À≈‡«’¬π‡æ’¬ß√âÕ¬≈– 16 ≈—°…≥–¥—ß°≈à“«∑”„À⇥Á°ª√—∫µ—«µàÕ°“√‡ª≈’ˬπ·ª≈ߢÕß “√πÈ”·≈–‡°≈◊Õ·√à‰¥â‰¡à¥’‡∑à“ºâŸ„À≠à ‚¥¬ ‡©æ“–„π‡¥°Á ‡≈°Á Ê Õ“®æ∫¿“«–·∑√°´Õâ π¢Õß hemodynamic ‰¥∫â Õà ¬·≈–√πÿ ·√ß°«“à 2 3.  “‡Àµ¢ÿ Õß‚√§‰µ«“¬„πºªŸâ «É ¬‡¥°Á ‰µ«“¬‡©¬’ ∫æ≈π—  “‡Àµ¢ÿ Õ߉µ«“¬‡©¬’ ∫æ≈π— (acute renal failure) ∑æË’ ∫∫Õà ¬¢πÈ÷ °∫— ™«à ßÕ“¬ÿ ¢Õ߇¥°Á ‡¥°Á ∑“√°·√°‡°¥‘ ¡°— ‡ªπì acute tubular necrosis ¡ ’ “‡Àµ¡ÿ “®“° birth asphyxia °“√‡ ¬’ ‡≈Õ◊ ¥ √–À«“à ß°“√‡°¥‘ ‡™πà ¿“«– placenta previa, fetal-maternal transfusion À√Õ◊ twin-twin transfusion ·≈– °“√‰¥√â ∫— ¬“∑¡Ë’ º’ ≈µÕà ‰µ ‡™πà ∑“√°‡°¥‘ °Õà π°”À𥉥â endomethacin ‡æÕË◊ ª¥î patent ductus arteriosus À√Õ◊ ‰¥√â ∫— aminoglycoside √°— …“°“√µ¥‘ ‡™ÕÈ◊ ºªâŸ «É ¬™«à ß 2 ¢«∫ª·ï √°¡°— ¡¿’ “«–‰µ«“¬‡©¬’ ∫æ≈π— ‡πÕË◊ ß®“° diarrheal dehydration „π‡¥°Á ‚µ¡°— æ∫«“à ‡°¥‘ ®“° prolong shock ®“°¿“«– sepsis, post-cardiac surgery, ‰¢â‡≈◊Õ¥ÕÕ° ´÷Ëß¿“«– acute tubular necrosis æ∫‰¥â‡ªìπ à«πÀπ÷ËߢÕß multiple organ system failure πÕ°®“°πÕÈ’ “®æ∫ “‡Àµ¡ÿ “®“°¿“«–‰µÕ°— ‡ ∫√πÿ ·√ß®“°‚√§ systemic lupus erythematosus, hemolytic uremic syndrome, acute poststreptococcal glomerulonephritis ·≈– rapidly progressive glomerulonephritis ‰¥·â ¡«â “à ®–æ∫πÕâ ¬≈ß°«“à √–¬– 20 ª°ï Õà π3 °“√√°— …“¿“«– acute tubular necrosis æ∫«“à ∂“â ·°‰â ¢¿“«– impaired renal perfusion ‰¥√â «¥‡√«Á ·≈–‡æ¬’ ßæÕ °“√∑”ß“π¢Õ߉µ¡°— øπôó ¢πÈ÷ Õ¬“à ß√«¥‡√«Á ∫“ß√“¬Õ“®¡’ oliguria  πÈ— ‡æ¬’ ߉¡°à ™Ë’ «Ë— ‚¡ß®π∂ß÷ 2- 3 «—π ·≈⫇¢â“ √Ÿà –¬–ª í  “«–¡“°À√◊Õ diuretic phase °“√√°— …“·∫∫ª√–§—∫ª√–§Õß√«¡∂÷ß°“√√—°…“  ¡¥ÿ≈¢Õß “√πÈ”·≈–‡°≈◊Õ·√à ‚¥¬µ‘¥µ“¡°“√‡ª≈’ˬπ·ª≈ߢÕßπÈ”Àπ—°·≈–‡°≈◊Õ·√à∑ÿ°«—π À≈’°‡≈’Ë¬ß ¬“∑’ˇªìπæ‘…°—∫‰µ·≈–ª√—∫¢π“¥¢Õ߬“„Àâ‡À¡“– ¡°—∫°“√∑”ß“π¢Õ߉µ ‡æ◊ËÕÀ≈’°‡≈’ˬߺ≈°√–∑∫µàÕ ‰µ°¡Á °— ®–‡æ¬’ ßæÕ ®π°√–∑ßË— ‰µøπôó µ«— °≈∫— ¡“∑”Àπ“â ∑‰Ë’ ¥‡â Õß °√≥∑’ ¡’Ë ‰’ µ«“¬‡©¬’ ∫æ≈π— √πÿ ·√ß√«à ¡°∫— multi-organ system failure À√Õ◊ ‰µÕ°— ‡ ∫√πÿ ·√ß (severe glomerular disease) °“√√—°…“ª√–§—∫ª√–§ÕßÕ“®‰¡à‡æ’¬ßæÕ®”‡ªìπµâÕ߉¥â√—∫°“√√—°…“∑¥·∑π‰µ ‚¥¬¡¢’ Õâ ∫ßà ™È’ §Õ◊ ¡¿’ “«–π”È ‡°π‘ ¿“«–‚æ·∑ ‡´¬’ ¡„π‡≈Õ◊ ¥ ßŸ ‡≈Õ◊ ¥‡ªπì °√¥√πÿ ·√ß ¡Õ’ “°“√¢Õß uremia ´ß÷Ë °“√√°— …“‚¥¬°“√„™¬â “‰¡ à “¡“√∂·°‰â ¢‰¥â ‰µ«“¬‡√È◊Õ√—ß ¿“«–‰µ«“¬‡√◊ÈÕ√—ß„π‡¥Á°æ∫‰¥â‰¡à∫àÕ¬ ·µà‡¡◊ËÕ‡°‘¥¢÷Èπ·≈â«®–‡ªìπ¿“√–µàÕ §√Õ∫§√«— ·≈–√–∫∫ “∏“√≥ ¢ÿ ¢Õߪ√–‡∑»Õ¬“à ß¡“° ¬ßË‘ ‡¡ÕË◊ ‚√§¥”‡ππ‘ ‡¢“â  ¿àŸ “«–‰µ«“¬√–¬– ¥ÿ ∑“â ¬

New Frontiers in Dialysis 268 ∏𵑠®√‘ ππ— ∑å∏«™—  √‘ ‘¿“ ™“â ß»‘√°‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå  ÿ‡¡∏°ÿ≈ (end stage renal disease, ESRD) ‡¥Á°®”‡ªìπµâÕ߉¥â√—∫°“√√—°…“∑¥·∑π‰µ√à«¡°—∫°“√µ‘¥µ“¡°“√ √°— …“Õ¬“à ß„°≈™â ¥‘ ∑”„À¡â §’ “à „™®â “à ¬ ßŸ ¡“° ¬ßË‘ ¡º’ ≈°√–∑∫¡“°¢πÈ÷ ª√–‡∑»‰∑¬‰¡¡à √’ “¬ß“πÕ∫ÿ µ— °‘ “√≥·å ≈–§«“¡™°ÿ ¢Õß ESRD „π‡¥°Á ™¥— ‡®π √“¬ß“π¢Õß United Stage Renal Data System (USRDS) ª√–‡∑» À√∞— Õ‡¡√°‘ “ „πª§ï .». 25504 æ∫«“à Õ∫ÿ µ— °‘ “√≥·å ≈–§«“¡™°ÿ ¢Õß ESRD ∑µË’ Õâ ߉¥√â ∫— °“√∫”∫¥— ∑¥·∑π‰µ„π‡¥°Á Õ“¬πÿ Õâ ¬°«“à 19 ªï ¡®’ ”π«π 14.2 ·≈– 84.9 √“¬µÕà ª√–™“°√ 1 ≈â“π§πµ“¡≈”¥—∫ æ∫«à“Õÿ∫—µ‘°“√≥å®– Ÿß„π‡¥Á°‡≈Á°·≈–«—¬√ÿàπ ‚¥¬æ∫«à“§«“¡™ÿ° Ÿß¢÷Èπ Õ¬à“ßµàÕ‡π◊ËÕß„π√–¬–‡«≈“∑’˺à“π¡“ πÕ°®“°π’Ȭ—ßæ∫«à“ºâŸªÉ«¬‡¥Á°¡’·π«‚πâ¡®–µâÕß√Õ°“√ª≈Ÿ°∂à“¬‰µ π“π¢π÷È ¥«â ¬  “‡Àµ¢ÿ Õ߉µ«“¬‡√Õ◊È √ß— „π‡¥°Á ¢Õߪ√–‡∑»‰∑¬ Õ®— ©√“  ¡— ∫≥ÿ ≥“ππ∑å ·≈–§≥–5 ‰¥√â «∫√«¡ ®”π«πºªŸâ «É ¬‡¥°Á Õ“¬πÿ Õâ ¬°«“à 15 ªï ∑‰Ë’ ¥√â ∫— °“√«π‘ ®‘ ©¬— ‰µ«“¬‡√ÕÈ◊ √ß— „π√–À«“à ߪæï .». 2539 ∂ß÷ æ.». 2541 ®“°‚√ß欓∫“≈√«¡ 78 ·Àßà ∑«—Ë ª√–‡∑» æ∫«“à ºªŸâ «É ¬‡¥°Á ‰µ«“¬‡√Õ◊È √ß— 238 √“¬ (ª√–¡“≥ 4 √“¬µÕà ª√–™“°√ 1 ≈“â π§π)  “‡Àµ ÿ «à π„À≠‡à °¥‘ ®“° structural ·≈– anatomical defect ‰¥·â °à obstructive uropathy ·≈– hypoplastic/dysplastic kidney √Õß≈ß¡“‰¥·â °à °≈¡àÿ glomerulonephritis ¥ß— · ¥ß„πµ“√“ß∑Ë’ 1 ´ßË÷ º≈§≈“â ¬ §≈÷ß°—∫∞“π¢âÕ¡Ÿ≈¢Õß NAPRTCS ªïæ.». 25506 ·≈–®“° Ital kid project7 ∑’Ë√«∫√«¡®“°ºâŸªÉ«¬‡¥Á° ‰µ«“¬‡√ÕÈ◊ √ß— √–¬–‡«≈“ 10 ªï µßÈ— ·µæà .». 2530-2543 ‚¥¬æ∫«“à ‡¥°Á Õ“¬πÿ Õâ ¬°«“à 2 ªï ‡°Õ◊ ∫∑ßÈ— À¡¥®–‡ªπì structural ·≈– anatomical defect ∑’ˇªìπ¡“·µà°”‡π‘¥  à«π‚√§„π°≈ÿà¡ glomerulonephritis æ∫‡ªìπ  “‡Àµ¢ÿ Õ߉µ«“¬‡√Õ◊È √ß— ‰¥¡â “°¢π÷È „π‡¥°Á ‚µ·≈–«¬— √πÿà 4. Hemodialysis  «à πª√–°Õ∫À≈°— ¢Õß hemodialysis „π‡¥°Á ‡À¡Õ◊ π°∫— „πº„⟠À≠à ‰¥·â °à √–∫∫√∫— - ßà ‡≈Õ◊ ¥ (vascular access ·≈– blood line) √–∫∫√∫— - ßà π”È ¬“ dialysate (dialysate delivery) µ«— °√Õ߇≈Õ◊ ¥ (dialyzer) ·≈– µ«— ‡§√ÕË◊ ß hemodialysis µ“√“ß∑Ë’ 1 √Õâ ¬≈–  “‡Àµ¢ÿ Õ߉µ«“¬‡√ÕÈ◊ √ß— „π‡¥°Á ‰∑¬ (N 238, 100%) 20.6 8.4  “‡Àµÿ 5.0 Obstructive uropathy 1.8 Chronic glomerulonephritis 1.7 Hypoplastic/dysplastic kidney 0.8 SLE nephrotic Familial nephritis Polycystic kidney disease

Hemodialysis in Renal Failure Children °“≠®π“ µß—È π√“√—™™°®‘ 269  à«πª√–°Õ∫µà“ßÊ ¡—°‡πâπÕÿª°√≥å∑’ˇÀ¡“– ¡°—∫¢π“¥¢Õßµ—«‡¥Á° ´÷Ëß¡’§«“¡·µ°µà“ß°—π §Õà π¢“â ß¡“° ‚¥¬¡À’ ≈°—  ”§≠— ∑«Ë— ‰ª ¥ß— πÈ’ 4.1 Dialyzer Pediatric dialyzer ∑¥Ë’ §’ «√¡’ internal blood volume µ”Ë ·≈–¡’ biocompatibility ‡¡ÕË◊ π”¡“„™°â ∫— √°— …“ºªâŸ «É ¬‡¥°Á ·≈«â ¡º’ ≈µÕà hemodynamic ¢Õ߇¥°Á πÕâ ¬ ·≈–‰¡°à √–µπâÿ ªØ°‘ √‘ ¬‘ “∑“ß immune8, 9 Dialyzer  ”À√—∫‡¥Á°„πª√–‡∑»‰∑¬‡ªìπ™π‘¥ low-flux dialyzer (KUF πâÕ¬°«à“ 10 ¡≈./™¡./ ¡¡.ª√Õ∑) ¢π“¥µßÈ— ·µà 0.4-1.3 µ“√“߇¡µ√ ¥ß— · ¥ß„πµ“√“ß∑Ë’ 2 „π‡¥°Á ‚µ∑¡Ë’ æ’ πÈ◊ ∑ºË’ «‘ °“¬¡“°°«“à 1.3 µ“√“߇¡µ√ Õ“®„™™â 𥑠high performance dialyzer (KUF µßÈ— ·µà 10-20 ¡≈./™¡./¡¡.ª√Õ∑) ‰¥â §«√‡≈Õ◊ °„™â dialyzer membrane ∑¡Ë’ ’ biocompatibility ‰¥·â °à polysulfone À√Õ◊ polyamine ´ßË÷ ‡ªπì  “√ ß— ‡§√“–Àå À√Õ◊ hemophan ´ßË÷ ‡ªπì cellulosynthetic °“√‡≈Õ◊ ° pediatric dialyzer §«√‡≈Õ◊ °„™â dialyzer ∑¡Ë’ ’ surface area „°≈‡â §¬’ ß°∫— æπÈ◊ ∑ºË’ «‘ °“¬ (body surface area ¢Õ߇¥°Á ) ‚¥¬§”π«≥®“° µŸ √ Body surface area (m2) = Ht × Wt / 3600 Ht = height (cm) Wt = body weight (kg) 4.2 Blood delivery system  «à πª√–°Õ∫∑πË’ ”‡≈Õ◊ ¥ÕÕ°¡“ àŸ dialyzer ‰¥·â °à vascular access ·≈– blood line §«√‡≈Õ◊ °„™â µ“¡¢π“¥µ«— ‡¥°Á 8-10 ¢π“¥¢Õß acute hemodialsis catheter ∑¡’Ë ®’ ”Àπ“à ¬„πª√–‡∑»‰∑¬¡¢’ π“¥µß—È ·µà single lumen 5 Fr ∑„Ë’ ™ â ”À√∫— ‡¥°Á ∑“√° ·µµà Õâ ß„ à 2 µ”·Àπßà ·≈–¢π“¥„À≠¢à πÈ÷ ‡ªπì double lumen µßÈ— ·µà 7-12 Fr µ«— Õ¬“à ß·≈–¢Õâ ·π–π”„π°“√‡≈Õ◊ °„™·â  ¥ß„πµ“√“ß∑Ë’ 3 ·≈– 4 µ“√“ß∑’Ë 2 · ¥ßµ«— Õ¬“à ß pediatric dialyzer ∑¡Ë’ „’ ™„â πª√–‡∑»‰∑¬ Dialyzer Membrane Surface Priming Kuf Urea Clearance at type area (m2) volume (ml) (ml/hr/mHg) BFR 200 ml/min F3 Polysulfone 0.4 28 1.7 125 F4 é 0.7 42 2.8 155 F5 é 1.0 63 4.0 170 F6 é 1.3 82 5.5 180 Surflux 110E Celluosynthetic 1.1 65 15 184 Surflux 130E é 1.3 75 17.8 188 Surflux 150E é 1.5 90 20.5 191

New Frontiers in Dialysis 270 ∏π‘µ ®√‘ ππ— ∑å∏«—™  √‘ ‘¿“ ™“â ß»‘√‘°ÿ≈™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ µ“√“ß∑Ë’ 3 ¢Õâ ·π–π”„π°“√‡≈Õ◊ °„™â acute hemodialysis catheter Patient size Access size Site of insertion Neonate 5 Fr (single lumen) Femoral vein 3 › 6 kg 6.5 or 7 Fr Internal jugular, subclavian or femoral vein 6 › 15 kg 7 Fr Internal jugular, subclavian or femoral vein 10 › 20 kg 8 Fr Internal jugular, subclavian or femoral vein 20 › 30 kg 9 Fr Internal jugular, subclavian or femoral vein More than 30 kg 10 Fr Internal jugular, subclavian or femoral vein 11.5 or 12 Fr Internal jugular, subclavian or femoral vein µ“√“ß∑Ë’ 4 · ¥ß¢Õâ ¥¢’ Õâ ‡ ¬’ ¢Õß°“√„  à “¬ «π„πµ”·Àπßà ‡ πâ ‡≈Õ◊ ¥„À≠µà “à ßÊ Location Advantage Disadvantage Internal jugular vein Long duration More difficult to access Easy for mobility Complication: pneumothorax Less complication with infection and venous stenosis Subclavian vein Long duration More difficult to access Easy for mobility Complication: pneumothorax High incidence of venous stenosis Femoral vein Easy to access for emergency High incidence of infection placement Difficult for mobility Chronic vascular access  ”À√∫— ‡¥°Á „πª®í ®∫ÿ π— ¡∑’ ßÈ— AV fistula, AV graft ·≈– cuffed central venous catheter „πª√–‡∑»‰∑¬‰¡¡à ’ catheter  ”À√∫— ‡¥°Á ‡≈°Á ®”Àπ“à ¬ ‡¥°Á ‡≈°Á ®ß÷ §«√‡≈Õ◊ °∑” chronic peritoneal dialysis ∂Ⓡ¥Á°¡’πÈ”Àπ—°¡“°°«à“ 25-30 °‘‚≈°√—¡ °Áæ‘®“√≥“∑” AV fistula °àÕπÕ¬à“ßÕ◊Ëπ °√≥∑’ ‰Ë’ ¡ à “¡“√∂„™â AVF ‰¥â Õ“®‡ª≈¬’Ë π∑“߇≈Õ◊ °‡ªπì AV graft ·µ‚à Õ°“ ‡°¥‘ °“√Õ¥ÿ µπ— ®–¡ ’ ߟ °«“à AVF Prediatric blood line §«√¡’ internal volume µ”Ë µ«— Õ¬“à ß¢π“¥¢Õß blood line ¢Õß Kawasumi ∑¡Ë’ „’ ™·â  ¥ß„πµ“√“ß∑Ë’ 5 °“√‡≈Õ◊ ° dialyzer ·≈– blood line §«√¡’ priming volume √«¡°π— ‰¡‡à °π‘ √Õâ ¬≈– 10 ¢Õß blood volume ¢Õ߇¥°Á (‡¥°Á ¡’ blood volume ‡∑“à °∫— 80 ¡≈./°°.)

µ“√“ß∑’Ë 5 Hemodialysis in Renal Failure Children · ¥ßµ«— Õ¬“à ß blood line ∑¡Ë’ „’ ™„â πª√–‡∑»‰∑¬ (Kawasumi) °“≠®π“ µÈ—ßπ√“√™— ™°®‘ 271 Type of blood line Priming volume Body weight of patient < 20 °°. Pediatric 48 ¡≈. > 20 °°. Adult 88 ¡≈. 4.3 Hemodialysis machine 1,10 ‡§√Õ◊Ë ß‰µ‡∑¬’ ¡ ”À√∫— ‡¥°Á ππ—È §«√‡ªπì ‡§√Õ◊Ë ß∑¡’Ë §’ ≥ÿ  ¡∫µ— ¥‘ ß— π’ȧÕ◊ ‡ªπì √–∫∫bicarbonate “¡“√∂ §«∫§¡ÿ §“à ultrafiltration (UF) ‰¥Õâ ¬“à ß·¡πà ¬”‚¥¬√–∫∫ volumetric control ¡√’ –∫∫§«“¡ª≈Õ¥¿¬— ∑ ’Ë ”§≠— ‰¥·â °à monitor · ¥ß venous pressure, transmembrane pressure ·≈–√–∫∫§«∫§¡ÿ Õ≥ÿ À¿¡Ÿ ¢‘ Õßπ”È ¬“ dialysate ¡’ blood pump ∑ªË’ √∫— „™°â ∫— blood line ‰¥∑â ßÈ— ¢Õߺ„⟠À≠·à ≈–‡¥°Á  “¡“√∂ª√∫— blood flow rate µ”Ë Ê ‰¥â ª®í ®∫ÿ π— ‡§√ÕË◊ ß√πàÿ „À¡®à –¡’ monitor  ”À√∫— blood volume ·≈– “¡“√∂‡≈Õ◊ °„™‚â ª√·°√¡ sodium modeling ‰¥¥â «â ¬ 4.4 Dialysate π”È ¬“ dialysate §«√‡ªπì ™π¥‘ ∑¡Ë’ ’ bicarbonate ‡ªπì  “√∫ø— ‡øÕ√å ·≈– “¡“√∂ª√∫— §«“¡‡¢¡â ¢πâ ¢Õß solute ‰¥µâ “¡µÕâ ß°“√ Õµ— √“°“√‰À≈¢Õß dialysate ‰¡§à «√πÕâ ¬°«“à 1.5-2 ‡∑“à ¢Õß blood flow rate ‚¥¬ «à π„À≠¡à °— ª√∫— ‰«∑â ’Ë 500 ¡≈./π“∑’ „π‡¥°Á ‡≈°Á πÈ”Àπ°— πÕâ ¬°«“à 10-15 °‚‘ ≈°√¡— ¡°— ¡¿’ “«– hypothermia ‰¥∫â Õà ¬ ®ß÷ §«√µßÈ— Õ≥ÿ À¿¡Ÿ ¢‘ Õßπ”È ¬“ dialysate ‰« â ߟ ∂ß÷ 38-39°C11 ·≈–∫“ß√“¬Õ“®µÕâ ß„™â radiant warmer √«à ¡¥«â ¬ °“√µßÈ— π”È ¬“ dialysate ‚¥¬„™â sodium modeling §Õ◊ °“√µßÈ— √–¥∫— ‚´‡¥¬’ ¡‰« â ߟ (hyperosmolar dialysate sodium concentration) „π™—Ë«‚¡ß·√° ·≈â«≈¥≈ß„π™—Ë«‚¡ßÀ≈—ß ¡’¢âÕ¡Ÿ≈„πºâŸªÉ«¬«—¬√ÿàπ·≈– º„Ÿâ À≠æà ∫«“à ™«à ¬¥ß÷ ultrafiltration ÕÕ°‰¥¥â ’ ‚¥¬ºªŸâ «É ¬¡ ’ ≠— ≠“≥™æ’ §ß∑·Ë’ ≈–Õ“°“√·∑√°´Õâ π√–À«“à ß∑” hemodialysis ≈¥≈ß12 4.5 Anticoagulant „π°“√∑” hemodialysis µÕâ ßÕ“»¬— anticoagulant ‡æÕË◊ ªÕÑ ß°π— °“√·¢ßÁ µ«— ¢Õ߇≈Õ◊ ¥„π blood line ·≈–„π dialyzer ‚¥¬‡©æ“–ºªâŸ «É ¬‡¥°Á ‡≈°Á ∑¡Ë’ °— „™â blood flow rate µ”Ë Ê ´ß÷Ë ®–¡§’ «“¡‡ ¬Ë’ ßµÕà °“√·¢ßÁ µ«— ¢Õ߇≈Õ◊ ¥‰¥ßâ “à ¬ Anticoagulant ∑„Ë’ ™∫â Õà ¬„π‡¥°Á §Õ◊ heparin „π¢π“¥ loading dose 10-30 ¬πŸ µ‘ /°°. ·≈–À¬¥ µÕà „π¢π“¥ 10-20 ¬πŸ µ‘ /°°./™¡. ‡æÕ◊Ë „À§â “à activated clotting time (ACT) π“π 150-200 «π‘ “∑’ À√Õ◊ activated partial thromboplastic time (aPTT) π“π 1.5-3 ‡∑“à ¢Õߧ“à control À√Õ◊ Õ“®‡≈Õ◊ °„™â low molecular weight heparin ‡™πà enoxaparin 0.5-1 ¡°./°°. §√ß—È ‡¥¬’ «‡¡ÕË◊ ‡√¡Ë‘ ∑” hemodialysis9, 13

New Frontiers in Dialysis 272 ∏π‘µ ®√‘ ππ— ∑∏å «—™  √‘ ¿‘ “ ™“â ß»√‘ ‘°≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°ÿ≈ „π√“¬∑®’Ë ”‡ªπì µÕâ ß„À°â “√√°— …“·∫∫ anticoagulant-free dialysis ¡°— ‡°¥‘ ≈¡‘Ë ‡≈Õ◊ ¥Õ¥ÿ µπ— „π dialyzer ·≈– blood line ‰¥∫â Õà ¬ ´ßË÷ ªÕÑ ß°π— ‰¥¥â «â ¬°“√ prime blood line ¥«â ¬ heparin-saline solution §«“¡‡¢¡â ¢πâ 5,000-10,000 ¬πŸ µ‘ /≈µ‘ √ ·≈«â µßÈ— ∑ßÈ‘ ‰«â 1-2 ™«Ë— ‚¡ß °Õà π flush ¥«â ¬ NSS ∑ßÈ‘ √«à ¡°∫— °“√„Àâ NSS flush 100- 200 ¡≈. „π√–À«“à ß°“√∑” hemodialysis ∑°ÿ 15-30 π“∑2’ 4.6 Hemodialysis prescription ‡≈Õ◊ ° dialyzer µ“¡¢π“¥ body surface area ¢Õ߇¥°Á ·≈– blood line ‰¥·â ≈«â §«√§”π«≥ priming volume ∑®Ë’ –µÕâ ß„™„â π blood line ·≈– dialyzer √«¡°π— ·≈«â ‰¡§à «√‡°π‘ √Õâ ¬≈– 10 ¢Õß total blood volume ¢Õ߇¥°Á (80 ¡≈./°°.) ‡æÕË◊ ªÕÑ ß°π— ¿“«– hypovolemia, hypotension ·≈– anemia °√≥∑’ Ë’ priming volume ¡“°°«“à √Õâ ¬≈– 10 À√Õ◊ ‡¥°Á π”È Àπ°— πÕâ ¬°«“à 10 °‚‘ ≈°√¡— „À„â ™â pack red cells º ¡°∫— NSS „πÕµ— √“ «à π 1:1 À√Õ◊ „™â 5% albumin À≈Õà „π dialyzer ·≈– blood line ·∑π NSS °Õà π∑”°“√øÕ°‡≈Õ◊ ¥10,13 µ«— Õ¬“à ß°“√§”π«≥ ‡¥°Á Õ“¬ÿ 2 ªï πÈ”Àπ°— 9 °‚‘ ≈°√¡—  ßŸ 80 ‡´πµ‡‘ ¡µ√ Total blood volume (TBV) = 80 ¡≈./°°. x 9 °°. = 720 ¡≈. 10% ¢Õß TBV = 72 ¡≈. Body surface area (m2) = 80 × 9 / 3600 = 0.45 m2 ‡≈Õ◊ ° dialyzer F3 (0.4 m2) ·≈– pediatric blood line §”π«≥ extracorporeal blood volume ¢Õß dialyzer ·≈– blood line √«¡ (28 + 48) ‡∑“à °∫— 76 ¡≈. (®“°µ“√“ß∑Ë’ 3 ·≈– 5) æ∫«“à extracorporeal blood volume ¡“°°«“à √Õâ ¬≈– 10 ¢Õß TBV °√≥π’ §È’ «√À≈Õà dialyzer ·≈– blood line ¥«â ¬ packed red blood cells º ¡°∫— NSS 1:1 À√Õ◊ Õ“®„™â 5% albumin ·∑π ·≈«â „Àâ packed red blood cells „π™«Ë— ‚¡ß·√°¢Õß°“√ √°— …“¥«â ¬ hemodialysis ¢Õâ ‡ ¬’ ¢Õß°“√„™â packed red blood cells ¡“À≈Õà blood line ·≈– dialyzer §Õ◊ ‡≈Õ◊ ¥„π blood line ¡§’ «“¡Àπ¥◊ (Hct Õ“®¡“°°«“à 40%) ∑”„Àµâ Õâ ß°“√¢π“¥ heparin  ßŸ °«“à ª°µ‘ ·≈–∑ Ë’ ”§≠— ‡≈Õ◊ ¥ ¡°— ®–¡‚’ æ·∑ ‡´¬’ ¡ ßŸ ·≈–¡’ pH ‡ªπì °√¥®“° lactate  ßŸ ∑”„À¡â ’ metabolic derangement „π√–¬–∑Ë’ ‡√¡‘Ë ∑” hemodialysis ‰¥â ·π–π”„Àªâ ÕÑ ß°π— ‚¥¬∑” dialysis „À‡â ≈Õ◊ ¥¥ß— °≈“à «‚¥¬µÕà blood line 2 ¢“â ߇¢“â ¥«â ¬°π— ·≈«â recirculate ‡≈Õ◊ ¥¥ß— °≈“à « æ√Õâ ¡„Àâ anticoagulant ·≈–‡ª¥î π”È ¬“ dialysate º“à π‡¢“â dialyzer π“π 30 π“∑’ °àÕπ‡√‘Ë¡°“√√—°…“ æ∫«à“∑”„Àâ‡≈◊Õ¥¡’√–¥—∫‚æ·∑ ‡´’¬¡·≈– lactate ≈¥≈ß ·≈–¬—ߙ૬ªÑÕß°—π ª≠í À“°“√ clot ‰¥¥â «â ¬14 ‡¡ÕË◊ ‡√¡Ë‘ √°— …“§√ßÈ— ·√°§«√µßÈ— blood flow rate µ”Ë Ê ‡æÕË◊ „À‰â ¥â urea clearance ª√–¡“≥ 3 ¡≈./ °°./π“∑’ ·≈–„™‡â «≈“ πÈ— ‰¡‡à °π‘ 2 ™«Ë— ‚¡ß °√≥∑’ √Ë’ –¥∫— BUN °Õà π∑” hemodialysis ¡“°°«“à 100 ¡°./¥≈. §«√„Àâ 20% mannitol 0.5 °√¡— ./°°. À¬¥„Àµâ Õà ‡πÕ◊Ë ß„π√–À«“à ß°“√√°— …“ æ∫«“à ™«à ¬ªÕÑ ß°π—  ¡Õß∫«¡®“° disequilibrium syndrome

Hemodialysis in Renal Failure Children °“≠®π“ µßÈ— π√“√™— ™°®‘ 273 „π°“√√°— …“§√ßÈ— µÕà Ê ‰ª §Õà ¬Ê ‡æ¡Ë‘ ®π‰¥â urine clearance 5 ¡≈./°°./π“∑’ ·≈–‡æ¡Ë‘ ‡«≈“‡ªπì 4 ™«—Ë ‚¡ß °“√§”π«≥ blood flow rate (BFR) Urea clearance 3 ¡≈./°°./π“∑’ = 3 ¡≈./°°./π“∑’ x 9 °°. = 27 ¡≈./π“∑’ ®“°µ“√“ß∑Ë’ 2 F3 dialyzer „™â BFR 200 ¡≈./π“∑’ ®–‰¥â urea clearance 125 ¡≈./π“∑’ 200 QB X QB 125 urea cl. = 27 X = 200 × 27 125 = 43 ¡≈./π“∑’ ‡æÕË◊ „À‰â ¥â urea clearance 3 ¡≈./°°./π“∑’ µÕâ ßµßÈ— BFR ª√–¡“≥ 50 ¡≈./π“∑’ ‚¥¬°“√§”π«≥ ¢“â ßµπâ æ∫«“à °“√µßÈ— BFR ª√–¡“≥ 75 ¡≈./π“∑’ ®–‰¥â urea clearance 5 ¡≈./°°./π“∑’ 4.7 ‡ª“Ñ À¡“¬°“√øÕ°‡≈Õ◊ ¥∑‡Ë’ À¡“– ¡ ª®í ®∫ÿ π— ¬ß— ‰¡¡à °’ “√»°÷ …“ √ªÿ ‡ª“Ñ À¡“¬¢Õß chronic hemodialysis „π‡¥°Á Õ¬“à ߉√°µÁ “¡¡¢’ Õâ ·π–π”«“à ‡ª“Ñ À¡“¬°“√øÕ°‡≈Õ◊ ¥„π‡¥°Á §«√ ßŸ °«“à ‡ª“Ñ À¡“¬∑°Ë’ ”Àπ¥„πº„⟠À≠à ´ßË÷ °“√øÕ°‡≈Õ◊ ¥ 3 §√ßÈ— /  ª— ¥“Àå §“à Kt/V §«√¡“°°«“à 1.2-1.4 ‡πÕË◊ ß®“°°“√√°— …“¥«â ¬°“√øÕ°‡≈Õ◊ ¥Õ¬“à ߇欒 ßæÕ®–™«à ¬„Àâ ‡¥Á°¡’°“√‡®√‘≠‡µ‘∫‚µ∑’ˇÀ¡“– ¡·≈–¡’‚¿™π“°“√∑’Ë¥’ ‚¥¬°“√»÷°…“„πºŸâªÉ«¬‡¥Á°æ∫«à“‡¡◊Ëպ⟪ɫ¬‰¥â √∫— °“√øÕ°‡≈Õ◊ ¥∑¡’Ë √’ –¬–‡«≈“‡æ¡‘Ë ¢π÷È ®–™«à ¬≈¥ left ventricular hypertrophy ‰¥1â ·≈–ºªŸâ «É ¬‡¥°Á ∑‰’Ë ¥√â ∫— °“√ øÕ°‡≈Õ◊ ¥∑°ÿ «π— æ∫«“à ¡Õ’ µ— √“°“√‡®√≠‘ ‡µ∫‘ ‚µ‡æ¡‘Ë ¢π÷È Õ¬“à ß™¥— ‡®π15 ‚¥¬∑«—Ë ‰ª°“√øÕ°‡≈Õ◊ ¥ 3 §√ß—È / ª— ¥“Àå ‡«≈“π“π 4-6 ™«Ë— ‚¡ßµÕà §√ßÈ— °‡Á 欒 ßæÕ ”À√∫— ‡¥°Á 1,13 „π°√≥‡’ ≈°Á π”È Àπ°— πÕâ ¬°«“à 10 °°. Õ“®®”‡ªπì µÕâ ßøÕ°‡≈Õ◊ ¥ 4-5 §√ßÈ— / ª— ¥“À1å 1 5. ·π«∑“ß°“√∑” hemodialysis „π‡¥°Á ·π«∑“ßπ ’È ”À√∫— °¡ÿ “√·æ∑¬‚å √§‰µ/·æ∑¬‚å √§‰µ∑®’Ë ¥— ∑”¢π÷È ‚¥¬TheEuropeanPediatricsDialysis Working Groups1 „πªæï .».2548 ¡ßàÿ ¡πË— æ≤— π“°“√∑” hemodialysis „π‡¥°Á „À¡â ‡’ ª“Ñ À¡“¬‡æÕË◊ °“√ ßË— °“√ √—°…“∑’ˇÀ¡“– ¡·≈–„À⥒∑’Ë ÿ¥ ‡æ◊ËÕ„ÀâºâŸªÉ«¬‡¥Á°¡’§ÿ≥¿“æ™’«‘µ °“√‡®√‘≠‡µ‘∫‚µ  Ÿß ÿ¥µ“¡»—°¬¿“æ √à«¡°—∫°“√≈¥¿“«–·∑√°´âÕπ¢Õß√–∫∫À≈Õ¥‡≈◊Õ¥·≈–À—«„®∑’Ë¡—°æ∫∫àÕ¬„πºŸâªÉ«¬∑’˵âÕß∑” dialysis π“π√–À«“à ß√Õ°“√ª≈°Ÿ ∂“à ¬‰µ°“√dialysis‡Õ߉¡ à “¡“√∂·°‰â ¢·≈–∑¥·∑π°“√∑”ß“π¢Õ߉µ‰¥∑â °ÿ ª√–°“√ °“√„À§â ”·π–𔥓â π‚¿™π“°“√·≈–¬“µ“à ßÊ ∂Õ◊ ‡ªπì  ßË‘ ®”‡ªπì  ”À√∫— ‡¥°Á ∑∑Ë’ ” hemodialysis Õ¬Ÿà Guideline 1 The dialysis unit - Hemodialysis §«√∑”„πÀπ«à ¬‰µ‡∑¬’ ¡¢Õ߇¥°Á ∑¡Ë’ §’ «“¡æ√Õâ ¡¢Õß∑¡’ ß“π∑¡Ë’ “ “¡“√∂„Àâ °“√¥·Ÿ ≈ºªŸâ «É ¬∑ßÈ— ‡©æ“–∫§ÿ §≈ ·≈–„À°â “√√°— …“„π√ªŸ ·∫∫¢Õß∫√Ÿ ≥“°“√

New Frontiers in Dialysis 274 ∏𵑠®√‘ ππ— ∑å∏«™—  √‘ ¿‘ “ ™â“ß»‘√‘°≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°≈ÿ - °“√¥·Ÿ ≈„π¥“â π‚¿™π“°“√ °“√‡®√≠‘ ‡µ∫‘ ‚µ ·≈–°“√„À§â «“¡√Ÿâ ∂Õ◊ ‡ªπì  ßË‘  ”§≠— Õ¬“à ߬ßË‘ - ‡π◊ËÕß®“°§«“¡µâÕß°“√¢Õߺ⟪ɫ¬‡¥Á°¡’§«“¡·µ°µà“ß®“°ºâŸ„À≠à °“√¥Ÿ·≈ºâŸªÉ«¬‡¥Á°‰µ «“¬‡√ÕÈ◊ √ß— ®ß÷ §«√‡ªπì ∑¡’ ∑‡Ë’ ªπì multidisciplinary team ª√–°Õ∫¥«â ¬ ·æ∑¬å 欓∫“≈ π°— °”Àπ¥Õ“À“√ π—°®‘µ«‘∑¬“ §√Ÿ π—°∫”∫—¥ (play therapist) ·≈–π—° —ߧ¡ ß‡§√“–Àå ´÷Ë߇ª√’¬∫‡ ¡◊Õπ second family À√◊Õ∑’¡ π—∫ πÿπ·°àºâŸªÉ«¬‡√◊ÈÕ√—ß ‡æ◊ËÕ°√–µÿâπ„ÀâºâŸªÉ«¬‡¥Á°¡’™’«‘µ§√Õ∫§√—«∑’˪°µ‘ ‰¥â√—∫°“√ π—∫ πÿπ °“√»°÷ …“®“°‚√߇√¬’ π √«¡∂ß÷ °“√ π∫—  ππÿ „Àºâ ªŸâ «É ¬ “¡“√∂ª√∫— µ«— °∫—  ß— §¡‰¥¥â ¢’ πÈ÷ - ‚¥¬∑—Ë«‰ª°“√∑” hemodialysis ¡—°∑” 3 §√—Èß/ —ª¥“Àå §«“¡∂’ËÕ“®‡æ‘Ë¡¡“°°«à“π’È¢÷Èπ°—∫ §«“¡µÕâ ß°“√®”‡æ“–¢ÕߺªâŸ «É ¬·µ≈à –§π Guideline 2 Water quality -  «à πª√–°Õ∫¢Õßπ”È dialysate §«√¡Õ’ ߧªå √–°Õ∫∑“ß™«’ ‡§¡µ’ “à ßÊ ‡À¡“– ¡‡æ¬’ ßæÕ - ‰¡¡à °’ “√ªπ‡ªÕóô π¢Õ߇™Õ◊È ‚√§ - §≥ÿ ¿“æ¢ÕßπÈ”∑π’Ë ”¡“∑”πÈ”¬“ dialysis §«√‰¥√â ∫— °“√µ√«® Õ∫Õ¬“à ß ¡Ë”‡ ¡Õ Õ¬“à ßπÕâ ¬ ª≈ï – 1 §√ßÈ— π”È ¬“ dialysis  ¥ÿ ∑“â ¬°Õà π„™°â ∫— ºªŸâ «É ¬ §«√‰¥√â ∫— °“√µ√«® Õ∫¥“â π·∫§∑‡’ √¬’ ·≈– endotoxin „À‰â ¥µâ “¡¡“µ√∞“π∑°Ë’ ”À𥵓¡µ“√“ß∑Ë’ 6 Guideline 3 The dialysis machine - Hemodialysis machine ∑‡Ë’ À¡“– ¡°∫— ‡¥°Á µÕâ ߇ªπì volumetric ultrafiltration control ·≈–¡’ blood pump ∑ Ë’ “¡“√∂‡≈Õ◊ °„™‰â ¥∑â ßÈ— single needle dialysis ·≈– double needle dialysis - ª®í ®∫ÿ π— π«µ°√√¡„À¡Êà ¢Õ߇§√ÕË◊ ß∑”„À‡â §√ÕË◊ ß√πàÿ „À¡ à “¡“√∂‡≈Õ◊ °∑”‰¥∑â ßÈ— hemodialysis, hemofiltraiton À√Õ◊ hemodiafiltration ∑”„Àªâ √– ∑‘ ∏¿‘ “æ¢Õß°“√ dialysis  ßŸ ¡“°°«“à ¡“µ√∞“π∑°’Ë ”À𥉫‰â ¥â √«¡∂ß÷ ∫“߇§√ÕË◊ ß®–¡‚’ ª√·°√¡ sodium modeling monitoring ¢Õß blood volume ®“°°“√«¥— §“à Œ¡’ “‚∑ §√µ‘ ·≈–§”π«≥ urea kinetic ‚¥¬µ√ß„À¥â «â ¬ Õ¬“à ߉√°µÁ “¡°“√π” π«—µ°√√¡„À¡àÊ ‡À≈à“π’È¡“„™â°—∫ºŸâªÉ«¬‡¥Á°§«√§”π÷ß∂÷ߪ√–‚¬™πå∑’˧“¥«à“®–‰¥â√—∫ ·≈–§à“ „™®â “à ¬∑ ’Ë ßŸ ¢π÷È ¥«â ¬ Guideline 4 Blood lines - µÕâ ß¡¢’ π“¥∑‡’Ë À¡“– ¡°∫— ‡¥°Á ‚¥¬‡©æ“–¢π“¥‡¥°Á ‡≈°Á Ê ·≈–∑”®“°« — ¥∑ÿ ¡’Ë ’ compatibility µ“√“ß∑’Ë 6 §”®”°¥— ¢Õߧ≥ÿ ¿“æπ”È ·≈–π”È ¬“ dialysate (§“à „πµ“√“߇ªπì §“à  ßŸ  ¥ÿ ∑¬Ë’ Õ¡√∫— ‰¥)â Bacterial growth (cfu mL-1) Endotoxin (EU mL-1) Cytokine-induction AAMI, water 200 5+ European pharmacopoeia Regular water 100 0.25 + Ultra-pure 0.01 0.03 - Sterile 10-6 0.03 -

Hemodialysis in Renal Failure Children °“≠®π“ µ—Èßπ√“√—™™°‘® 275 πÕ°®“°π§È’ «“¡§”πß÷ ∂ß÷ ™π¥‘ ¢Õß “√∑∑Ë’ ”°“√ª≈Õ¥‡™ÕÈ◊ §«√‡≈Õ◊ °™π¥‘ ethylene oxide-free Guideline 5 Principle of blood purification - ‡ππâ „À§â “à °“√¢®¥— small solute ∑¡Ë’ “°¢πÈ÷ ‚¥¬¢∫«π°“√ diffusion ´ßË÷ ‡ππâ °“√¢®¥—  “√¬‡Ÿ √¬’ ·≈–‚¥¬¢∫«π°“√ convection mass transport ‡æÕË◊ °”®¥— uremic toxic °≈¡àÿ middle molecule - Hemodiafiltration ∂Õ◊ ‡ªπì ∑“߇≈Õ◊ °‡æÕ◊Ë „À‰â ¥ªâ √– ∑‘ ∏¿‘ “æ¢Õß°“√ dialysis  ßŸ  ¥ÿ (maximum) Guideline 6 Extracorporeal blood access and circulation - AV fistula ∂◊Õ‡ªìπ vascular access ∑’ˇÀ¡“– ¡ ”À√—∫ chronic hemodialysis „π‡¥Á° π”È Àπ°— πÕâ ¬°«“à 15 °°. Õ“®µÕâ ß„™‡â «≈“À≈“¬‡¥Õ◊ π°Õà π∑Ë’ AF fistula ®–„™‰â ¥â - «∏‘ ¡’ “µ√∞“π∑„’Ë ™§â Õ◊ double-needle technique ·µ«à ∏‘ ’ single needle ‚¥¬„™√â –∫∫ blood pump 2 µ«— Õ“®‡ªπì ∑“߇≈Õ◊ °‰¥„â π‡¥°Á ‡≈°Á Ê ‡πÕË◊ ß®“°‡ªπì «∏‘ ∑’ ¡Ë’ ª’ √¡‘ “µ√„π extracorporeal system µ”Ë - Extracorporeal blood volume §«√πÕâ ¬°«“à √Õâ ¬≈– 10 ¢Õß total blood volume ¢ÕߺªâŸ «É ¬ ‡¥°Á - Anticoagulant  “¡“√∂„™‰â ¥¥â ∑’ ßÈ— heparin ·≈– low molecular weight heparin - Blood flow rate 150-200 ¡≈./π“∑/’ æπÈ◊ ∑ºË’ «‘ °“¬ µ√.¡. À√Õ◊ 5-7 ¡≈./π“∑/’ °°.  «à π„À≠à ®–‡æ¬’ ßæÕ∑®Ë’ –‰¥‡â ª“Ñ À¡“¬µ“¡µÕâ ß°“√ „π‡¥°Á ‡≈°Á  “¡“√∂§”π«≥ blood flow rate ‰¥®â “°π”È Àπ°— µ«— ‚¥¬„™ â µŸ √ QB (mL/min) = [BW (kg) + 10] × 2.5 Guideline 7 Which dialyzer membrane to choose - ‡≈Õ◊ °„™â dialyzer ™π¥‘ synthetic membrane ·≈–™π¥‘ low flux „π°“√∑” hemodialysis °√≥’ „™â high flux membrane „π°“√∑” HF, HDF ®”‡ªπì µÕâ ß„™â ultrapure dialysate - °“√‡≈Õ◊ ° dialysis membrane §«√殑 “√≥“ª®í ®¬— µ“à ßÊ ¥ß— · ¥ß„πµ“√“ß∑Ë’ 7 Guideline 8 The dialysate - „À„â ™â bicarbonate ‡ªπì ∫ø— ‡øÕ√å ·≈–√–¥∫— ·§≈‡´¬’ ¡µË” 1.25 ¡≈‘ ≈‚‘ ¡≈/≈µ‘ √ ∂Õ◊ ‡ªπì dialysate µ“√“ß∑Ë’ 7 Dialyzer membranes: practical parameters of choice ë Type of membrane: biocompatibility toward complement system ë Initial blood volume needed, i.c. area-related, quality of restitution ë Molecular permeability: maximum clearance for urea and the other uremic toxins, e.g. phosphate, related to potential patient osmotic risk ë Hydraulic permeability: possibility of use for HF or HDF procedure, but related to back filtration risk, high flux membranes need ultrapure dialysate ë Adsorption capacity on to the membrane (a characteristic of synthetic membranes) ë Cost

New Frontiers in Dialysis 276 ∏𵑠®‘√ππ— ∑∏å «—™  √‘ ‘¿“ ™â“ß»‘√°‘ ÿ≈™¬— ∏π—𥓠µ√–°“√«π‘™ « π— µå  ‡ÿ ¡∏°≈ÿ ¡“µ√∞“𠧫“¡‡¢¡â ¢πâ ¢Õß°≈‚Ÿ § §«√Õ¬„àŸ π physiologic level ·≈–°“√§«∫§¡ÿ §≥ÿ ¿“æ¢Õßπ”È ¬“‚¥¬ ‡©æ“–‡√ÕË◊ ߢÕß°“√ªπ‡ªÕôó π‡™ÕÈ◊ ‚√§ ·≈– endotoxin ‡ªπì  ßË‘ ®”‡ªπì Guideline 9 Post-dialytic dry weight assessment and adjustment - °“√ª√–‡¡π‘ post-dialytic dry weight §Õà π¢“â ߬“°„π‡¥°Á ∑°Ë’ ”≈ß— ‡®√≠‘ ‡µ∫‘ ‚µ ®”‡ªπì µÕâ ß Õ“»—¬·æ∑¬å∑’Ë¡’§«“¡™”π“≠‚¥¬√à«¡¡◊Õ°—∫π—°‚¿™π“°“√ °“√ª√–‡¡‘π§«√∑”Õ¬à“ß ¡Ë”‡ ¡Õ ‚¥¬ ‡©æ“–„π‡¥°Á ∑“√°·≈–«¬— √πÿà ´ß÷Ë ‡®√≠‘ ‡µ∫‘ ‚µ‡√«Á Õ“®®”‡ªπì µÕâ ߪ√–‡¡π‘ post-dialytic dry weight ∑°ÿ 1 ‡¥Õ◊ π Guideline 10 Urea dialytic kinetic - §“à Kt/V §”π«≥‰¥®â “° single pool urea model µ“¡ µŸ √ Kt / V = log n  Cpre − 0.008td − UF     Ceq BW  Cpre = predialysis urea concentration Ceq = equilibrated postdialysis urea concentration UF = ultrafiltration volume (L) BW = body weight (kg) td = dialysis time (h) - °“√§”π«≥ volume of distribution (V) ¢Õß urea µ“¡§«“¡ ßŸ π”È Àπ°— ‡æ»·≈–Õ“¬ÿ µ“¡  µŸ √ ‡¥°Á ™“¬ : Ht <132.7 cm V = 1.927+0.465/BW (kg) + 0.0045/ht (cm) Ht >132.7 cm V = 21.1933+0.406/BW (kg) + 0.209/ht (cm) ‡¥°Á À≠ß‘ : Ht <110.8 cm V = 0.076+0.507/BW (kg) + 0.013/ht (cm) Ht >110.8 cm V = 10.313 + 0.252/BW (kg) + 0.154/ht (cm) Guideline 11 Dialysis dose and outcome - Kt/V ¢Õß urea ∑‡Ë’ 欒 ßæÕµÕâ ߉¡µà ”Ë °«“à 1.2-1.4 °“√ª√–‡¡π‘ Kt/V §«√∑”∑°ÿ ‡¥Õ◊ π ‡æÕË◊ „Àâ ‰¥°â “√¢®¥— ¢Õ߇ ¬’ ∑‡Ë’ 欒 ßæÕ (adequate dialysis) - °“√ —Ëß°“√√—°…“‚¥¬ hemodialysis §«√®–‰¥â°“√¢®—¥¢Õ߬Ÿ‡√’¬∑’ˇ撬ßæÕ°àÕπ‡√‘Ë¡„Àâ°“√ √°— …“Õ¬“à ߇µ¡Á ∑Ë’ (optimum) ‚¥¬°“√¢®¥— uremic toxic ÕπË◊ Ê √«à ¡¥«â ¬ - °“√ª√–‡¡π‘ Kt/V ‡ªπì ¥™— π¢’ Õß°“√¢®¥— ¢Õ߇ ¬’ ∑‡Ë’ 欒 ßæÕππÈ— §«√«‡‘ §√“–À√å «à ¡°∫— Õ“À“√ ‚ª√µπ’ ·≈–æ≈ß— ß“π∑‰Ë’ ¥√â ∫— µ“¡√ªŸ ∑Ë’ 1 - ¡°’ “√»°÷ …“ π∫—  ππÿ „π‡¥°Á æ∫«“à °“√‡æ¡Ë‘ √–¬–‡«≈“ hemodialysis ™«à ¬∑”„À‡â ¥°Á ‡®√≠‘ ‡µ∫‘ ‚µ‰¥¥â ¢’ πÈ÷ πÕ°®“°π°È’ “√∑” dialysis ∑°ÿ «π— æ∫«“à ¡º’ ≈¥∑’ “ߧ≈π‘ °‘ ∑ßÈ— „πºªŸâ «É ¬º„⟠À≠·à ≈–«¬— √πàÿ Guideline 12 The dialysis session, prescription and monitoring - °“√ —Ëß°“√√—°…“µâÕß®”‡æ“– ”À√—∫‡¥Á°·µà≈–§π §«√∑”°“√ª√–‡¡‘π·≈–ª√—∫°“√√—°…“ Õ¬à“ß ¡Ë”‡ ¡Õ„π‡¥Á°‡≈Á°·≈–‡¥Á°∑’Ë‚µ‡√Á« °“√„Àâ°“√ª√–§—∫ª√–§Õߥâ“𮑵„®¡’§«“¡®”‡ªìπµàÕ‡¥Á°

Dialysis dose Hemodialysis in Renal Failure Children Blood flow °“≠®π“ µß—È π√“√™— ™°®‘ 277 Duration Membrane Nutrition Kt Protein and caloric intake Catabolism, anabolism (growth) Volume of distribution V Kt/V nPCR Urea Guideline 12 The dialysis session, prescription and monitoring √ªŸ ∑’Ë 1 Dialysis prescription balance ·≈–§√Õ∫§√«— °“√„À°â “√ªÕÑ ß°π— §«“¡‡®∫Á ª«¥‡ªπì  ßË‘ ®”‡ªπì  ”À√∫— ‡¥°Á - °“√‡µ√’¬¡ºâŸªÉ«¬·≈–„À⬓™“‡©æ“–∑’Ë (xylocain ointment) 1 ™—Ë«‚¡ß°àÕπ °àÕπ·∑߇¢Á¡ ‡ªìπ ‘Ëß®”‡ªìπ‚¥¬‡©æ“–°“√∑” hemodialysis §√—Èß·√° §«√‡πâπ‡√◊ËÕߪÑÕß°—π°“√µ‘¥‡™◊ÈÕ‡ ¡Õ §«√ ªÕÑ ß°π— °“√‡°¥‘ §«“¡‡ ¬’ À“¬µÕà ‡¬ÕË◊ ∫Àÿ ≈Õ¥‡≈Õ◊ ¥‚¥¬ monitor arterial aspiration pressure ‰¡„à Àµâ ”Ë °«“à -150 ¡¡.ª√Õ∑ ·≈– venous return pressure ‰¡¡à “°°«“à +200 ¡¡.ª√Õ∑ °“√‡√¡Ë‘ ∑” hemodialysis „π§√ßÈ— ·√°„Àµâ ßÈ— blood flow rate µ”Ë Ê ª√–¡“≥ 3 ¡≈./π”È Àπ°— µ«— 1 °‚‘ ≈°√¡— (À√Õ◊ 90 ¡≈./µ√.¡.) ®–‰¥â urea clearance µ”Ë °«“à 3 ¡≈./π“∑/’ °°. ‚¥¬‡¥°Á ¡°— ®– tolerate ‰¥â ‰¡à§àÕ¬‡°‘¥ dysequilibrium syndrome √–¬–‡«≈“§√—Èß·√°§«√®– —Èπ‰¡à‡°‘π 2-3 ™—Ë«‚¡ß À√◊Õª√—∫µ“¡ ultrafiltration ∑’˵âÕß°“√ „π°“√∑”§√—ÈßµàÕÊ ‰ª §àÕ¬Ê ‡æ‘Ë¡ blood flow rate √–¬–‡«≈“µàÕ§√—Èß ·≈– ®”π«π§√ßÈ— µÕà  ª— ¥“Àå ®π‰¥â blood flow rate 150-200 ¡≈./π“∑/’ µ√.¡. √–¬–‡«≈“ 3-4 ™«Ë— ‚¡ßµÕà °“√∑” ·µ≈à –§√ß—È ·≈–‰¥â 3 §√ß—È µÕà  ª— ¥“Àå ®– “¡“√∂‰¥â Kt/V 1.2-1.4 µ“¡∑µ’Ë Õâ ß°“√ „π‡¥°Á ‡≈°Á Õ“®®”‡ªπì µÕâ ß∑” 4-5§√ß—È µÕà  ª— ¥“Àå‡πÕ◊Ë ß®“°¥¡◊Ë π¡∑”„À®â ”π«ππÈ”∑¥’Ë ¡◊Ë ·µ≈à –«π— ¡“°°“√‡Õ“ultrafiltrationÕÕ°§√ß—È ≈–¡“°Ê

New Frontiers in Dialysis 278 ∏𵑠®√‘ ππ— ∑∏å «—™  ‘√¿‘ “ ™â“ß»√‘ ‘°ÿ≈™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°ÿ≈ Õ“®¡¿’ “«–·∑√°´Õâ π‰¥â ®ß÷ Õ“®µÕâ ߪ√∫— ‡æ¡Ë‘ ®”π«π§√ßÈ— ∑∑Ë’ ”µÕà  ª— ¥“Àå °àÕπ°“√øÕ°‡≈◊Õ¥„Àâª√–‡¡‘π ¿“«–πÈ”„π√à“ß°“¬ µ√«®«—¥§«“¡¥—π‚≈À‘µ µ√«®∑“ßÀâÕß ªØ∫‘ µ— °‘ “√∑®Ë’ ”‡ªπì ‡™πà BUN, creatinine, electrolytes, calcium, phosphate, parathyroid hormone ·≈–ÕπË◊ Ê µ“¡§«“¡®”‡ªπì ™ßË— π”È Àπ°— µ«— °Õà π·≈–À≈ß— °“√øÕ°‡≈Õ◊ ¥ ‡¥°Á ∑πË’ ”È Àπ°— ‡æ¡Ë‘ ¢πÈ÷ ¡“°°«“à √Õâ ¬≈– 10 ¢Õß dry weight „π°“√øÕ°‡≈Õ◊ ¥§√ßÈ— µÕà ‰ª · ¥ß«“à ‰¡‰à ¥§â ¡ÿ Õ“À“√À√Õ◊ ªØ∫‘ µ— µ‘ “¡·π«∑“ß°“√√°— …“ √–À«à“ß°“√øÕ°‡≈◊Õ¥§«√«—¥§«“¡¥—π‚≈À‘µ∑ÿ° 15-30 π“∑’  —߇°µÕ“°“√∑—Ë«‰ª ‡ΩÑ“√–«—ß ¿“«–·∑√°´Õâ πµ“à ßÊ 6.  √ªÿ °“√∑”hemodialysis„π‡¥°Á ¡·’ π«‚π¡â ∑®’Ë –æ≤— π“∑ß—È Õªÿ °√≥·å ≈–°“√ ß—Ë °“√√°— …“‡æÕ◊Ë „À‰â ¥°â “√ ¢®¥— ¢Õ߇ ¬’ ∑‡Ë’ 欒 ßæÕ ·≈–æ≤— π“µÕà ‰ª °àŸ “√¢®¥— ¢Õ߇ ¬’ „À‰â ¥Õâ ¬“à ߇µ¡Á ∑Ë’ (opimum/maximum dialysis) ‡æ◊ËÕ¡ÿàßÀ«—ß„À⇥Á°¡’°“√‡®√‘≠‡µ‘∫‚µ∑’Ë¥’¢÷Èπ ¡’¿“«–·∑√°´âÕπµà“ßÊ πâÕ¬∑’Ë ÿ¥ ºŸâªÉ«¬‡¥Á°‰µ«“¬√–¬–  ÿ¥∑⓬§«√‰¥â√—∫°“√√—°…“·∫∫∫Ÿ√≥“°“√ (integrated care model) ·≈–¡’‡ªÑ“À¡“¬§◊Õ°“√‰¥â√—∫°“√ ‡µ√¬’ ¡æ√Õâ ¡‡æÕË◊ °“√ª≈°Ÿ ∂“à ¬‰µ (kidney transplantation)16 ´ßË÷ ‡ªπì °“√√°— …“∑¥·∑π‰µ∑¥Ë’ ∑’  Ë’ ¥ÿ „πª®í ®∫ÿ π— ‡Õ° “√Õ“â ßÕß‘ 1. Fischbach M, Edefonti A, Schroder C, Watson A. The European Pediatric Dilaysis Working Group. Hemodialysis in children: general practical guidelines. Pediatr Nephrol 2005;20:1054-66. 2. æ√™¬— °ßË‘ «≤— π°≈ÿ . Fundamental basis of pediatric dialysis. „π:  ¡™“¬ ‡Õ¬Ë’ ¡ÕÕà ß, ‡°ÕÈ◊ ‡°¬’ √µ‘ ª√–¥…‘ ∞æå √ »‘≈ªá, ∏π—𥓠µ√–°“√«π‘™, ‡∂≈‘ß»—°¥‘Ï °“≠®π∫ÿ»¬å. (∫√√≥“∏‘°“√) Improving quality of dialysis. °√ßÿ ‡∑æ¡À“π§√: ‡∑°ä ´å ·Õπ¥å ‡®Õ√πå ≈— ; 2006 Àπ“â 53-64. 3. Quan A, Quigley R. Renal replacement therapy and acute renal failure. Curr Opinion in Pediatr 2005;17:205- 9. 4. US Renal Data System. USRDS 2007 Annual Data Report. Atlas of End-stage Renal Disease in the United States. Bethesda: MD; 2007. 5. Somboonanonda A, Thirakupt P, Kingwatanakul P, Vongjirad A. Chronic renal failure in Thai children: etiology, cost and outcome. J Med Assoc Thai 2000;83:894-901. 6. North American Pediatric Trial and Collaborative Studies (NAPRTCS). NAPRTCS 2007 Annual Report. The EMMES Corporation 2007. 7. Ardissino G, Daccò V, Testa S, Bonaudo R, Claris-Appiani A, Taioli E, et al; ItalKid Project. Epidemiology of chronic renal failure in children: data from the ItalKid project.Pediatrics. 2003;111:382-7. 8. Mian AN, Mendley SR. Acute dialysis in children. In: Henrich WL, editor. Principles and practice of dialysis. 3rd ed. Philadelphia: Williams & Wilkins; 2004. p. 617-28. 9. Warady BA, Jabs KL, Goldstein SL. Chronic dialysis in children. In: Henrich WL, editor. Principle and practice

Hemodialysis in Renal Failure Children °“≠®π“ µ—Èßπ√“√—™™°‘® 279 of dialysis. 3rd ed. Philadelphia: Williams & Wilkins; 2004. p. 592-616. 10. Donckerwolcke RA, Bunchman TE. Hemodialysis in infant and small children. Pediatr Nephrol 1994;8:103- 6. 11. Cochat P, Lioux C. Maintenance dialysis during infancy. In: Warady BA, Schaefer FS, Fine RN, Alexander SR, editors. Pediatric dialysis. Dordrechit: Kluwer Academic Publishers; 2006. p. 91-112. 12. Sadowski RH, Allred EN, Jabs K. Sodium modeling ameliorates intradialytic and interdialytic symptoms in young hemodialysis patients. J Am Soc Nephrol 1993;4:1192-8. 13. Goldstein SL. Prescribing and monitoring hemodialysis. In: Warady BA, Schaefer FS, Fine RN, Alexander SR, editors. Pediatric Dialysis. Dordrecht; Kluwer Academic Publishers; 2004. p. 135-410. 14. Hackbarth RM, Eding D, Gianoli Smith C, Koch A, Sanfilippo DJ, Bunchman TE. Zero balance ultrafiltration (Z-BUF) in blood-primed CRRT circuits achieves electrolyte and acid-base homeostasis prior to patient connection. Pediatr Nephrol. 2005 ;20:1328-33. 15. Fischbach M, Terzic J, Menouer S, Dheu C, Soskin S, Helmstetter A, et al. Intensified and daily hemodialysis might improve statural growth. Pediatr Nephrol 2006;21:1746-52. 16. Goldstein SL. Advances in renal replacement therapy as a bridge to renal transplantation. Pediatr Transplantation 2007;11:463-70.



15 Chronic Hemodialysis in Children Õ¥ ‘ √≥å ≈”‡æ“æß»å 1. ∫∑π” 2. Dialysis technique 3. ¿“«–∑“ß‚¿™π“°“√ 4. ·§≈‡´¬’ ¡ øÕ øÕ√ — ·≈–°√¥-¥“à ß„π√“à ß°“¬ 5. ¿“«–´¥’ 6. √–∫∫°“√∑”ß“π¢ÕßÀ«— „®

New Frontiers in Dialysis 282 ∏π‘µ ®‘√π—π∑∏å «™—  √‘ ‘¿“ ™“â ß»√‘ ‘°ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « —πµå  ÿ‡¡∏°ÿ≈ 1. ∫∑π” ‡ªπì ∑∑Ë’ √“∫¥«’ “à °“√‡ª≈¬Ë’ π‰µ (Kidney transplantation) ‡ªπì °“√√°— …“∑‡Ë’ À¡“– ¡„πºªâŸ «É ¬‡¥°Á ‰µ«“¬‡√◊ÈÕ√—ß Õ¬à“߉√°Áµ“¡æ∫«à“ºâŸªÉ«¬‡¥Á°∫“ß√“¬¬—߉¡àæ√âÕ¡∑’Ë®–√—∫°“√‡ª≈’Ë¬π‰µ‡¡◊ËÕ‡√‘Ë¡«‘π‘®©—¬‚√§ ‰µ«“¬‡√Õ◊È √ß— (preemptive kidney transplantation) ¥ß— ππ—È °“√„À°â “√√°— …“¥«â ¬°“√∑” peritoneal dialysis À√Õ◊ hemodialysis ®ß÷ ‡ªπì «∏‘ °’ “√√°— …“ª√–§∫— ª√–§Õß∑‡’Ë À¡“– ¡°Õà π‡ª≈¬’Ë π‰µ ®“°¢Õâ ¡≈Ÿ ¢Õß US Renal Data System (USRDS) æ∫«à“ºâŸªÉ«¬‡¥Á°‰µ«“¬‡√◊ÈÕ√—ß¡’·π«‚πâ¡∑” chronic dialysis ‡¡◊ËÕ°“√∑”ß“π¢Õ߉µ¬—ß ‰¡µà ”Ë ¡“°°≈“à «§Õ◊ 9.8 cc/min/1.73m2 „π√–À«“à ßªï §.». 1995-1999 ‡ªπì 11.0 cc/min/1.73m2 √–À«“à ßªï §.». 2000-20041 °“√≈“â ß∑“ß™Õà ß∑Õâ ߇ªπì «∏‘ ∑’ πË’ ¬‘ ¡„π‡¥°Á ‡πÕË◊ ß®“° “¡“√∂§«∫§¡ÿ π”È Àπ°— ª√¡‘ “≥π”È „π√“à ß°“¬‰¥ßâ “à ¬°«“à Õ¬“à ߉√°µÁ “¡°“√∑” hemodialysis °‰Á ¥√â ∫— §«“¡π¬‘ ¡¡“°¢πÈ÷ ¢Õâ ¡≈Ÿ ®“° USRDS æ∫«“à ºªŸâ «É ¬‡¥°Á  «à π„À≠à ‰¥√â ∫— °“√√°— …“¥«â ¬«∏‘ ’ hemodialysis ¡“°°«“à peritoneal dialysis1 Õ¬“à ߉√°µÁ “¡ °“√µ—¥ ‘π„®‡≈◊Õ°«‘∏’°“√∑” dialysis ¢÷Èπ°—∫ªí®®—¬À≈“¬Õ¬à“ß ‡™àπ ºŸâªÉ«¬ ºâŸª°§√Õß §«“¡æ√âÕ¡¢Õß Àπ«à ¬√°— …“ √–∫∫ª√–°π—  ¢ÿ ¿“æ Õ“¬·ÿ ≈–π”È Àπ°— ¢ÕߺªâŸ «É ¬ ‚¥¬ºªŸâ «É ¬Õ“¬πÿ Õâ ¬°«“à 5 ªï À√Õ◊ ºªŸâ «É ¬ πÈ”Àπ—°πâÕ¬°«à“ 10 °‘‚≈°√—¡ π‘¬¡√—°…“¥â«¬«‘∏’≈â“ß∑“ß™àÕß∑âÕß¡“°°«à“2 „πÀπ૬‰µ‡¥Á° √æ. æ√–¡ß°ÿƇ°≈â“ ºâŸªÉ«¬ à«π„À≠à‰¥â√—∫°“√√—°…“¥â«¬«‘∏’ chronic hemodialysis „π∫∑π’È®–°≈à“«∂÷ß°“√ ¥·Ÿ ≈ºªâŸ «É ¬‡¥°Á ‰µ«“¬‡√ÕÈ◊ √ß— ¥«â ¬«∏‘ °’ “√ hemodialysis 2. Dialysis technique À≈°— °“√‚¥¬∑«Ë— ‰ªππÈ— ‰¡·à µ°µ“à ß®“°º„⟠À≠¡à “°π°— ·µ‡à πÕË◊ ß®“°ºªŸâ «É ¬‡¥°Á ¡π’ ”È Àπ°— ·µ°µ“à ß ®“°º„⟠À≠à °“√§”π«≥ blood flow, ultrafiltration rate, dialyzer surface area √«¡∂ß÷ extracorporeal blood volume ®ß÷ µÕâ ßπ”¡“§”πß÷ ¥«â ¬‡ ¡Õ Blood Flow  “¡“√∂§”π«≥ blood flow „π chronic hemodialysis ‰¥®â “° µŸ √ blood flow (Qb) = 150-200 cc/min/m2 À√Õ◊ 5-7 cc/kg/min „π‡¥°Á ‡≈°Á §”π«≥®“° µŸ √ Qb = (weight (kg) + 10) × 2.5 ·≈–§«√„Àâ arterial aspiration pressure Õ¬√àŸ –À«“à ß 150-200 mmHg ‡æÕË◊ ªÕÑ ß°π— endothelial trauma2 Dialsate flow „™Õâ µ— √“°“√‰À≈¢ÕßπÈ”¬“ dialysate ‰¥µâ ß—È ·µà 300-800 cc/min ‚¥¬∑«—Ë ‰ªºªâŸ «É ¬‡¥°Á ®–„™â dialysate flow ‡∑“à °∫— 500 cc/min ¬°‡«πâ „π‡¥°Á ‡≈°Á  “¡“√∂„™â dialysate flow 300 cc/min °‡Á 欒 ßæÕ‰¥â

Chronic Hemodialysis in Children Õ¥‘ √≥å ≈”‡æ“æß»å 283 Dialysate solution §«“¡‡¢πâ ¢πâ ¢Õß sodium „ππ”È ¬“ dialysate ∑„’Ë ™‡â ∑“à °∫— 138-144 mEq/L  “¡“√∂„™â sodium profile ‡æÕË◊ ªÕÑ ß°π— º≈¢“â ߇§¬’ ß„π√–À«“à ßøÕ°‡≈Õ◊ ¥‰¥‡â ™πà ‡¥¬’ «°∫— º„⟠À≠3à  ”À√∫— ·§≈‡´¬’ ¡ππÈ— 𬑠¡„™â πÈ”¬“ low calcium ‡æ◊ËÕªÑÕß°—π‰¡à„Àâ·§≈‡´’¬¡‡¢â“‰ª„π‡≈◊Õ¥¡“°‡°‘π‰ª ∑”„Àâº≈√«¡¢Õß·§≈‡´’¬¡ øÕ øÕ√ — ¡§’ “à  ßŸ ´ßË÷ ‡ªπì ª®í ®¬—  ”§≠— µÕà °“√‡°¥‘ coronary calcification4 Dialyzer ‚¥¬∑«—Ë ‰ªºªŸâ «É ¬‡¥°Á ¡°— ®–øÕ°‡≈Õ◊ ¥‚¥¬«∏‘ ’ conventional hemodialysis ·≈–„™â dialyzer ™π¥‘ low flux (CUF < 10 cc/min/hr) ´ßË÷ ‡æ¬’ ßæÕ„π°“√¢∫—  “√ª√–‡¿∑ small molecule  ”À√∫— °“√¢∫— ¢Õ߇ ¬’  “√ ª√–‡¿∑ middle ·≈– large molecule ‚¥¬„™â high flux synthetic membrane „π°“√øÕ°‡≈Õ◊ ¥«∏‘ ’ on-line hemodiafiltration ππ—È ¬ß— ‰¡‡à ªπì ∑π’Ë ¬‘ ¡5 ‡πÕ◊Ë ß®“°ºªâŸ «É ¬‡¥°Á  «à π„À≠®à –√Õ°“√‡ª≈¬’Ë π‰µ (waiting time) ‰¡à π“π  ”À√∫— dialyzer surface area §«√„™â dialyzer ∑¡’Ë ’ surface area „°≈‡â §¬’ ß°∫— body surface area ¢ÕߺªâŸ «É ¬ Dry weight assessment °“√ª√–‡¡‘ππÈ”Àπ—°µ—«¢ÕߺŸâªÉ«¬‡ªìπ√–¬–Ê ¡’§«“¡®”‡ªìπ„π‡¥Á° ‡π◊ËÕß®“°ºŸâªÉ«¬®–¡’°“√ ‡ª≈¬’Ë π·ª≈ߢÕß√“à ß°“¬µ≈Õ¥‡«≈“µ“¡°“√‡®√≠‘ ‡µ∫‘ ‚µ‚¥¬ª√–‡¡π‘ ‰¥Àâ ≈“¬«∏‘ ’‡™πà bioelectricimpedance analysis, √–¥∫— atrial natriuretic peptide, cyclic guanosine monophosphate ª√–‡¡π‘ ‡ πâ º“à »πŸ ¬°å ≈“ߢÕß inferior vena cava (IVCD) ‚¥¬„™‡â §√ÕË◊ ß ultrasound ‚¥¬§“à ∑‡Ë’ À¡“– ¡ §Õ◊ IVCD √–À«“à ß 8.0-11.5 mm/m2 ·≈– collapse index √–À«“à ß 40-75%6 πÕ°®“°ππ—È °“√„™«â ∏‘ ’ noninvasive monitoring (NIVM) ¢Õߧ“à hematocrit ‡æÕË◊ ‡ªπì ·π«∑“ß„π°“√ª√∫— ª√¡‘ “≥ ultrafiltrate  “¡“√∂≈¥¿“«– volume overload §«“¡¥π— ‚≈Àµ‘  ßŸ ·≈–Õµ— √“°“√πÕπ‚√ß欓∫“≈‰¥7â ,8,9 Ultrafiltration Ultrafiltration rate ‰¡§à «√‡°π‘ 1.5-2.0% ¢Õßπ”È Àπ°— µ«— /™«Ë— ‚¡ß À√Õ◊ ‰¡‡à °π‘ 5% ¢Õßπ”È Àπ°— µ«— µÕà dialysis session2 „πºªŸâ «É ¬∑¡Ë’ π’ ”È Àπ°— ‡°π‘ ¡“° (interdialytic weight gain) Õ“®æ®‘ “√≥“∑” sequential ultrafiltration À√Õ◊ ‡æ¡Ë‘ §«“¡∂„Ë’ π°“√øÕ°‡≈Õ◊ ¥ ‡æÕË◊ À≈°’ ‡≈¬Ë’ ߺ≈¢“â ߇§¬’ ß√–À«“à ß·≈–¿“¬À≈ß— øÕ°‡≈Õ◊ ¥ Dialysis session √–¬–‡«≈“„π°“√øÕ°‡≈Õ◊ ¥§«√‡∑“à °∫— 3-4 ™«Ë— ‚¡ßµÕà °“√øÕ°‡≈Õ◊ ¥·µ≈à –§√ßÈ— ·≈–∑”°“√øÕ° ‡≈Õ◊ ¥ 3 §√ßÈ— µÕà  ª— ¥“À2å Anticoagulant „™‡â æÕË◊ ªÕÑ ß°π— ‡≈Õ◊ ¥·¢ßÁ µ«— √–À«“à ß∑”°“√øÕ°‡≈Õ◊ ¥‚¥¬„™â heparin bolus 10-30 U/kg ‡¡ÕË◊ ‡√¡Ë‘ øÕ°‡≈Õ◊ ¥·≈–µÕà ¥«â ¬ continuous infusion „πª√¡‘ “≥ 10-20 U/kg/hr À√Õ◊ „™â low molecular weight heparin

New Frontiers in Dialysis 284 ∏π‘µ ®√‘ π—π∑å∏«™—  √‘ ‘¿“ ™â“ß»‘√°‘ ≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°≈ÿ ‡™πà enoxaparin „πª√¡‘ “≥ 1 mg/kg ‡¡ÕË◊ ‡√¡Ë‘ øÕ°‡≈Õ◊ ¥ Vascular access K/DOQI guideline ‰¥·â π–π”„À„â ™â arteriovenous fistula (AVF) À√Õ◊ graft (AVG) „πºªâŸ «É ¬‡¥°Á ∑Ë’ ∑” chronic hemodialysis  ”À√∫— °“√„  à “¬ permanent central venous catheter §«√殑 “≥“„πºªŸâ «É ¬ ∑¡Ë’ ¢’ Õâ ∫ßà ™‡È’ ™πà π”È Àπ°— πÕâ ¬°«“à 20 °‚‘ ≈°√¡— ‡πÕË◊ ß®“°‡ πâ ‡≈Õ◊ ¥¬ß— ¡¢’ 𓥇≈°Á ‚¥¬·π–π”„À„â  ∫à √‡‘ «≥ internal jugular vein ¢Õâ ¡≈Ÿ ®“° North American Pediatric Renal Cooperative Study (NAPRTCS) æ∫«“à ºªâŸ «É ¬‡¥°Á  «à π„À≠„à ™â vascular access ™π¥‘ central venous catheter10 ¡“°°«“à „™â AVF À√Õ◊ AVG Õ¬“à ߉√ °µÁ “¡ºªŸâ «É ¬‡¥°Á „π À√∞— Õ‡¡√°‘ “¡°— ®–≈ß∑–‡∫¬’ π√Õ√∫— ‰µ·≈–„™‡â «≈“√Õ‰µ‰¡πà “π ®ß÷ „™â central venous catheter ‚¥¬∑«Ë— ‰ª¢π“¥¢Õß “¬ central venous catheter ∑‡Ë’ 欒 ßæÕ„π°“√øÕ°‡≈Õ◊ ¥§«√¡¢’ π“¥ 8 Fr ¢πÈ÷ ‰ª ‚¥¬ “¡“√∂„Àâ blood flow Õ¬“à ßπÕâ ¬ 3-5 cc/kg/min ·≈–µ”·Àπßà ¢Õߪ≈“¬ “¬Õ¬∫àŸ √‡‘ «≥ right atrium11  ”À√∫— ºªâŸ «É ¬∑‰’Ë ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥‚¥¬„™â AVF À√Õ◊ AVG §«√殑 “√≥“„™¬â “™“∑“‡©æ“–∑’Ë (EMLA) ‡æÕË◊ ≈¥Õ“°“√‡®∫Á ª«¥·≈–§«“¡°≈«— ·≈–„™‡â ¢¡Á ·∑ß¢π“¥ 17 G2 ºªŸâ «É ¬‡¥°Á ‰µ«“¬‡√ÕÈ◊ √ß— ∑‰Ë’ ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥ 1-3 §√ßÈ— „π§√ßÈ— ·√°§«√„À°â “√√°— …“·∫∫ acute hemodialysis °≈“à «§Õ◊ „™â blood flow µË”Ê 3 cc/kg À√Õ◊ 90 cc/m2 ·≈–„Àâ mannitol 0.5-1 g/kg √–À«“à ß øÕ°‡≈◊Õ¥ ‚¥¬°“√øÕ°‡≈◊Õ¥·µà≈–§√—È߉¡à§«√‡°‘π 2-3 ™—Ë«‚¡ß „π√–À«à“ßøÕ°‡≈◊Õ¥ §«√ª√–‡¡‘π Õ“°“√ºªâŸ «É ¬  ≠— ≠“≥™æ’ ‡ªπì √–¬–Ê ∑°ÿ 15-30 π“∑’ ∫π— ∑°÷ ª√¡‘ “≥ ultrafiltrate ·≈–µ√«® Õ∫ arterial ·≈– venous pressure ‰¡„à À‡â °π‘ -150 ·≈– +200 mmHg µ“¡≈”¥∫— Hemodialysis adequacy °“√ª√–‡¡π‘ §«“¡‡æ¬’ ßæÕ„π°“√øÕ°‡≈Õ◊ ¥ππÈ—  “¡“√∂§”π«≥‚¥¬„™§â “à spKt/V ‡™πà ‡¥¬’ «°∫— º„⟠À≠à ‚¥¬§”π«≥®“° µŸ √ formal urea kinetic modeling À√Õ◊  µŸ √¢Õß Daugirdas ·≈–§«√¡§’ “à Õ¬“à ß πÕâ ¬‡∑“à °∫— 1.212 „πºªŸâ «É ¬∑∑Ë’ ”°“√øÕ°‡≈Õ◊ ¥ 3 §√ßÈ— ·¡«â “à ®–¬ß— ‰¡¡à §’ “à spKt/V ‡À¡“– ¡ ”À√∫— ºªâŸ «É ¬ ‡¥°Á æ∫«“à §“à spKt/V √–À«“à ß 1.2-1.4 π“à ®–‡æ¬’ ßæÕ ”À√∫— °“√øÕ°‡≈Õ◊ ¥ ‚¥¬§«√ª√–‡¡π‘ ∑°ÿ ‡¥Õ◊ π2 Tom ·≈–§≥– æ∫«à“ºâŸªÉ«¬‡¥Á°∑’Ë¡’§à“ spKt/V ¡“°°«à“ 2.0 ·≈–‰¥â√—∫ “√Õ“À“√æÕ‡æ’¬ß (150% ¢Õß æ≈ß— ß“π∑‰Ë’ ¥®â “° RDA) ®–∑”„Àºâ ªâŸ «É ¬¡Õ’ µ— √“°“√‡®√≠‘ ‡µ∫‘ ‚µ·≈–‡æ¡Ë‘ ¢πÈ÷ ¢Õß «à π ßŸ 13 Goldstein ·≈– §≥– æ∫«“à pro-inflammatory cytokines „π‡≈Õ◊ ¥®–≈¥≈ߺ°ºπ— °∫— °“√‡æ¡‘Ë ¢π÷È ¢Õß spKt/V14 Õ¬“à ߉√°µÁ “¡ ®“°°“√»°÷ …“‚¥¬√«¡æ∫«“à §“à spKt/V ‰¡¡à §’ «“¡ ¡— æπ— ∏°å ∫— °“√‡®√≠‘ ‡µ∫‘ ‚µ ¿“«–´¥’ √–¥∫— albumin „π‡≈Õ◊ ¥ ·≈–Õµ— √“°“√πÕπ‚√ß欓∫“≈15 ´ßË÷ Õ“®‡°¥‘ ®“°°“√°”®¥— small molecule uremic toxins Õ“® ‡æ¬’ ßæÕ„πºªâŸ «É ¬‡À≈“à π’È 3. ¿“«–∑“ß‚¿™π“°“√ æ∫§«“¡ ¡— æπ— ∏√å –À«“à ß‚¿™π“°“√·≈–º≈∑“ߧ≈π‘ °‘ „πºªâŸ «É ¬‡¥°Á ‰µ«“¬‡√Õ◊È √ß— K/DOQIguideline

Chronic Hemodialysis in Children Õ¥‘ √≥å ≈”‡æ“æß»å 285 ·π–π”„Àªâ √–‡¡π‘ ¿“«–∑“ß‚¿™π“°“√‰¥·â °à π”È Àπ°—  «à π ßŸ mid-arm circumference, skin fold thickness ‡ πâ √Õ∫»√’ …– √–¥∫— albumin ·≈– height Z score ∑°ÿ Ê 1-3 ‡¥Õ◊ π16  ”À√∫— °“√ª√–‡¡π‘ ºªâŸ «É ¬‡¥°Á ‰∑¬ππÈ— ‰¡§à «√„™§â “à ª°µ¢‘ Õß mid-arm circumference, skin fold thickness ·≈– height Z score ∑·Ë’ π–π”„π K/DOQI guideline ¡“„™â ‡πÕË◊ ß®“°¡‰’ ¢¡π— πÕâ ¬°«“à ®ß÷ §«√„™§â “à ª°µ¢‘ Õ߇¥°Á ‰∑¬µ“¡°“√»°÷ …“¢Õß°√¡Õπ“¡¬— °√–∑√«ß “∏“√≥ ÿ¢ °“√§”π«≥ nPCR ¡’§«“¡®”‡ªìπ„π°“√¥Ÿ·≈ºâŸªÉ«¬‡™àπ°—π ‚¥¬æ∫«à“¡’§«“¡  ¡— æπ— ∏°å ∫— dietary protein intake „π∑“ߪØ∫‘ µ— À‘ π«à ¬‰µ‡¥°Á ‰¥√â «à ¡°∫— ·ºπ°‚¿™π“°“√ √æ.æ√–¡ß°Æÿ ‡°≈“â ª√–‡¡π‘ Õ“À“√∑ºË’ ªŸâ «É ¬√∫— ª√–∑“π„π·µ≈à –«π— ‚¥¬„™‚â ª√·°√¡ Inmucal ·≈–‚ª√·°√¡ Nutrisurvey ‡æÕË◊ π”¡“·π–π”ª√—∫ª√ÿß√“¬°“√Õ“À“√∑’ˇÀ¡“– ¡ ”À√—∫ºâŸªÉ«¬·µà≈–√“¬ ‚¥¬∑—Ë«‰ªºâŸªÉ«¬‡¥Á°∑’Ë∑”°“√ øÕ°‡≈◊Õ¥§«√‰¥â√—∫æ≈—ßß“πÕ¬à“ßπâÕ¬‡∑à“°—∫æ≈—ßß“π∑’ˇ¥Á°ª°µ‘§«√‰¥â„π·µà≈–«—π ·≈–‰¥â‚ª√µ’π¡“° °«“à ª°µ‘ 0.4 °√¡— /°‚‘ ≈°√¡— /«π— 16 (µ“√“ß∑1Ë’ ,2) 4. ·§≈‡´¬’ ¡ øÕ øÕ√ — ·≈–°√¥-¥“à ß„π√“à ß°“¬ ‡π◊ËÕß®“°„π‡¥Á°®”‡ªìπµâÕß„™âøÕ øÕ√— „π°“√‡®√‘≠‡µ‘∫‚µ·≈– √â“߇´≈≈å ¥—ßπ—Èπ§à“ øÕ øÕ√ — §«√Õ¬√Ÿà –À«“à ß 4-6 mg/dL „πºªâŸ «É ¬‡¥°Á Õ“¬ÿ 1-12 ªï ·≈–‡∑“à °∫— 3.5-5.5 mg/dL „πºªŸâ «É ¬ ‡¥°Á Õ“¬¡ÿ “°°«“à 12 ªï ·≈–„À§â “à º≈§≥Ÿ ¢Õß·§≈‡´¬’ ¡·≈–øÕ øÕ√ — ‰¡‡à °π‘ 65 mg2/dL2 „π‡¥°Á Õ“¬ÿ 1-12 ªï ·≈–‰¡‡à °π‘ 55 mg2/dL2 „π‡¥°Á Õ“¬¡ÿ “°°«“à 12 ªï √°— …“√–¥∫— parathyroid hormone „π‡≈Õ◊ ¥√–À«“à ß 200-300 pg/mL ·≈–„Àâ√–¥—∫‰∫§“√å∫Õ‡πµ„π‡≈◊Õ¥‰¡àµË”°«à“ 22 mEq/L ‚¥¬ª√–‡¡‘π√–¥—∫·§≈‡´’¬¡ øÕ øÕ√ — ·≈–‰∫§“√∫å Õ‡πµ„π‡≈Õ◊ ¥∑°ÿ ‡¥Õ◊ π ·≈–ª√–‡¡π‘ iPTH ∑°ÿ Ê 3 ‡¥Õ◊ π16 µ“√“ß∑Ë’ 1 Õ“¬ÿ (ª)ï Kcal/kg/day æ≈ß— ß“π∑§’Ë «√®–‰¥√â ∫— „π·µ≈à –«π— 0-0.5 108 Infant 0.5-1 98 Children 1-3 102 4-6 90 Male 7-10 70 11-14 55 Female 15-18 45 18-21 40 11-14 47 15-18 40 18-21 38

New Frontiers in Dialysis 286 ∏𵑠®√‘ π—π∑å∏«™—  ‘√‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™¬— ∏π—𥓠µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°ÿ≈ µ“√“ß∑Ë’ 2 RDA Protein intake for ª√¡‘ “≥‚ª√µπ’ ∑§’Ë «√®–‰¥√â ∫— „π·µ≈à –«π— (g/kg/day) hemodialysis (g/kg/day) Õ“¬ÿ (ª)ï 2.2 2.6 1.6 2.0 Infants 0-0.5 1.2 1.6 Children 0.5-1 1.2 1.6 Male 1-3 1.0 1.4 Female 4-6 1.0 1.4 7-10 0.9 1.3 5. ¿“«–´¥’ 11-14 0.8 1.2 15-18 1.0 1.4 18-21 0.8 1.2 11-14 0.8 1.2 15-18 18-21 §«√√°— …“√–¥∫— hemoglobin „π‡≈Õ◊ ¥„ÀÕâ ¬√àŸ –À«“à ß 11-12 g/dL ·≈–‰¡§à «√ ßŸ °«“à 13 g/dL17 ·≈–„À√â –¥∫— ferritin „π‡≈Õ◊ ¥¡“°°«“à 100 ng/mL ·≈– TSAT ¡“°°«“à 20% ‚¥¬ª√–‡¡π‘ ∑°ÿ ‡¥Õ◊ π‡¡ÕË◊ ‡√¡Ë‘ „À¬â “ erythropoietin ·≈–∑°ÿ Ê 3 ‡¥Õ◊ π‡¡ÕË◊ Õ“°“√ºªâŸ «É ¬§ß∑Ë’ ®“°¢Õâ ¡≈Ÿ ¢Õß NAPRTCS æ∫«“à ºªâŸ «É ¬ ‡¥°Á ‰µ«“¬‡√ÕÈ◊ √ß— ∑‰Ë’ ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥ «à π„À≠à 90% ‰¥√â ∫— erythopoietin ª√¡‘ “≥∑„Ë’ ™‚â ¥¬‡©≈¬Ë’ „π‡¥°Á Õ“¬πÿ Õâ ¬°«“à 1 ªï ‡∑“à °∫— 350 U/kg/wk „πºªŸâ «É ¬Õ“¬ÿ 2-5 ªï ‡∑“à °∫— 275 U/kg/wk „πºªâŸ «É ¬Õ“¬ÿ 6-12 ªï ‡∑“à °∫— 250 U/kg/wk ·≈–„πºªŸâ «É ¬Õ“¬¡ÿ “°°«“à 12 ªï ‡∑“à °∫— 200 U/kg/wk18 ºªŸâ «É ¬‡¥°Á ∑∑Ë’ ” chronic hemodialysis §«√‰¥√â ∫— erythropoietin ∑“ß intravenous ‡æÕË◊ ≈¥§«“¡«µ‘ °°ß— «≈„π°“√∂°Ÿ ©¥’ ¬“  ”À√∫— ¬“„π°≈¡àÿ darbepoietin alfa (NESP) „π‡¥°Á ππÈ— æ∫«“à ¬ß— ‰¡¡à °’ “√„™·â æ√Àà ≈“¬19 6. √–∫∫°“√∑”ß“π¢ÕßÀ«— „® æ∫«“à cardiovascular disease ‡ªπì  “‡Àµ°ÿ “√‡ ¬’ ™«’ µ‘ Õπ— ¥∫— ·√°„πºªâŸ «É ¬°≈¡àÿ πÈ’ (21%) 10 æ∫ ¿“«– left ventricular hypertrophy ‰¥â∂÷ß 57% ´÷Ë߇°’ˬ«¢âÕß°—∫¿“«–§«“¡¥—π‚≈À‘µ Ÿß ´’¥ ·≈– hyperparathyroidism20 πÕ°®“°ππÈ— ºªŸâ «É ¬‡À≈“à πæÈ’ ∫ coronary calcification ‰¥∫â Õà ¬ ‚¥¬ ¡— æπ— ∏°å ∫— ª√¡‘ “≥ ·§≈‡´¬’ ¡∑√Ë’ ∫— ª√–∑“π √«¡∑ßÈ— º≈§≥Ÿ ¢Õß·§≈‡´¬’ ¡·≈–øÕ øÕ√ — „π‡≈Õ◊ ¥4, 21

Chronic Hemodialysis in Children Õ¥ ‘ √≥å ≈”‡æ“æß»å 287 ·¡â«à“°“√∑” chronic hemodialysis ‡ªìπ‡æ’¬ß°“√√—°…“ºŸâªÉ«¬‡¥Á°‰µ«“¬‡√◊ÈÕ√—ß„π√–À«à“ß√Õ °“√‡ª≈’Ë¬π‰µ°Áµ“¡ °“√¥Ÿ·≈ºŸâªÉ«¬„π√–¬–π’È¡’§«“¡ ”§—≠¡“° ∂⓺ŸâªÉ«¬ ÿ¢¿“扡෢Áß·√ß Õ“®¡’º≈ °√–∑∫À√◊Õº≈¢â“߇§’¬ß¿“¬À≈—߇ª≈’Ë¬π‰µ ¢âÕ¡≈Ÿ °“√»÷°…“‡°’ˬ«°—∫ chronic hemodialysis „π‡¥Á°¡’‰¡à ¡“°π—°‡¡◊ËÕ‡∑’¬∫°—∫ºŸâ„À≠à ªí®®ÿ∫—π·π«∑“ß°“√¥Ÿ·≈¡—°®–„™â·π«∑“ßµ“¡°“√»÷°…“„πºâŸ„À≠à ¥—ß∑’Ë °≈“à «¡“§“à spKt/V „π‡¥°Á ππÈ— ‰¡¡à §’ «“¡ ¡— æπ— ∏°å ∫— °“√‡®√≠‘ ‡µ∫‘ ‚µ ¿“«–´¥’ √–¥∫— albumin „π‡≈Õ◊ ¥ ·≈–Õ—µ√“°“√πÕπ‚√ß欓∫“≈ ·æ∑¬åºŸâ¥·Ÿ ≈®÷߉¡à§«√„™â§à“ spKt/V ‡æ’¬ßÕ¬à“߇¥’¬«„π°“√√—°…“ºâŸªÉ«¬ §«√ª√–‡¡π‘ °“√‡®√≠‘ ‡µ∫‘ ‚µ ¿“«–∑“ß‚¿™π“°“√ √–∫∫‰À≈‡«¬’ π‚≈Àµ‘ √«à ¡¥«â ¬ ·≈– „À°â “√¥·Ÿ ≈·∫∫ Õߧ√å «¡‚¥¬„Àºâ ªŸâ «É ¬ ºªŸâ °§√Õß ·æ∑¬å 欓∫“≈ ‚¿™π“°√ ·≈–π°—  ß— §¡ ß‡§√“–Àå ¡ ’ «à π√«à ¡„π°“√ «“ß·ºπ°“√√°— …“¥«â ¬ ‡Õ° “√Õ“â ßÕß‘ 1. US Renal Data System. Excerpts from the USRDS Annual Report. Am J Kidney Dis 2006; 47: S1-S286. 2. Fischbach M, Edefonti A, Schroder C, Watson A; The European Pediatric Dialysis Working Group.Hemodialysis in children: general practical guidelines. Pediatr Nephrol. 2005; 20:1054-66. 3. Sadowski RH, Allred EN, Jabs K. Sodium modeling ameliorates intradialytic and interdialytic symptoms in young hemodialysis patients. J Am Soc Nephrol. 1993; 4:1192-8. 4. Goodman WG, Goldin J, Kuizon BD, Yoon C, Gales B, Sider D, Wang Y, Chung J, Emerick A, Greaser L, Elashoff RM, Salusky IB. Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis. N Engl J Med. 2000 May 18; 342:1478-83. 5. Fischbach M, Terzic J, Laugel V, Dheu C, Menouer S, Helms P, Livolsi A. Daily on-line haemodiafiltration: a pilot trial in children. Nephrol Dial Transplant. 2004; 19:2360-7. 6. Dietel T, Filler G, Grenda R, Wolfish N. Bioimpedance and inferior vena cava diameter for assessment of dialysis dry weight. Pediatr Nephrol. 2000; 14:903-7. 7. Goldstein SL, Smith CM, Currier H: Noninvasive interventions to decrease hospitalization and associated costs for pediatric patients receiving hemodialysis. J Am Soc Nephrol. 2003; 14:2127-31. 8. Jain SR, Smith L, Brewer ED, Goldstein SL: Non-invasive intravascular monitoring in the pediatric hemodialysis population. Pediatr Nephrol 2001; 16:15-8. 9. Michael M, Brewer ED, Goldstein SL: Blood volume monitoring to achieve target weight in pediatric hemodialysis patients. Pediatr Nephrol 2004; 19:432-7. 10. https://web.emmes.com/study/ped/annlrept/annlrept2007.pdf 11. Clinical practice recommendation 8: vascular access in pediatric patients. Am J Kidney Dis. 2006 ;48 Suppl 1:S274-6. 12. Hemodialysis Adequacy 2006 Work Group.Clinical practice guidelines for hemodialysis adequacy, update 2006.Am J Kidney Dis. 2006; 48 Suppl 1:S2-90. 13. Tom A, McCauley L, Bell L, et al: Growth during maintenance hemodialysis: Impact of enhanced nutrition and clearance. J Pediatr 1999; 134:464-71.