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Том 25 №2 2023 год - Нефрология и диализ

Рекомендации международного общества перитонеального диализа по оценке дисфункции перитонеальной мембраны у взрослых: классификация, методы оценки, интерпретация и обоснования для вмешательства

Морель Иоганн Стаховска-Пьетка Джоанна Эберг Карл Гадола Лилиана Ла Милиа Винченцо Ю Занже Лэмби Марк Мехротра Раджниш де Артеага Хавьер Дэвис Саймон

DOI: 10.28996/2618-9801-2023-2-232-266

Аннотация: При перитонеальном диализе (ПД) в качестве диализирующей мембраны используется брюшина. Брюшина - это тонкий слой ткани, выстилающий брюшную полость. Эта оболочка используется в качестве фильтра, помогающего удалять лишнюю жидкость и токсичные продукты обмена из крови. Каждый человек уникален. То, что является нормальным для мембраны одного человека, может сильно отличаться у другого. Диализная команда стремится подобрать каждому пациенту наилучший для него режим диализа, и для этого необходимо оценивать состояние брюшины. Иногда само лечение диализом может привести к изменению мембраны через несколько лет. И это означает, что потребуются дополнительные обследования, чтобы определить, изменилась ли брюшина. Изменения мембраны могут потребовать изменений режима диализа. Это необходимо для достижения наилучших результатов. Ключевым инструментом для этих оценок является тест перитонеального равновесия - ПЭТ (peritoneal equilibration test - PET1). Это простой, стандартизированный и воспроизводимый инструмент. Он используется для измерения функции брюшины вскоре после начала диализа. Цель состоит в том, чтобы понять, насколько хорошо работает перитонеальная мембрана в начале диализа. На более поздних этапах лечения ПЭТ помогает отслеживать изменения в функции брюшины. Если в период между оценками возникают проблемы, вызванные изменениями функции брюшины, данные ПЭТ могут объяснить причину дисфункции. Эти данные можно использовать для изменения режима диализа в целях достижения наилучших результатов. Наиболее распространенная проблема с перитонеальной мембраной возникает, когда жидкость удаляется не так хорошо, как следовало бы. Это происходит, когда растворенные вещества из крови проникают через мембрану быстрее, чем должно. Это состояние обозначается как высокая скорость перитонеального переноса растворенных веществ (СППВ) {fast peritoneal solute transfer rate - высокая СППВ}. Поскольку более эффективное удаление жидкости связано с лучшими результатами лечения, назначение персонального режима ПД, основанного на СППВ пациента, является критически важным. Менее распространенная проблема возникает, когда мембрана не работает должным образом (состояние также обозначается как дисфункция мембраны), из-за того, что она менее эффективна в удалении растворенных веществ либо на старте лечения, либо по прошествии нескольких лет. Если дисфункция мембраны со временем усиливается, это связано с прогрессирующим повреждением, фиброзом и утолщением мембраны. Эту проблему можно выявить по изменению еще одного показателя ПЭТ. Он обозначается как «степень снижения концентрации натрия в диализате» в (dipNa).2 Мембранная дисфункция этого типа труднее поддается лечению и имеет значимые последствия для пациента. Если повреждения мембраны серьезны, пациенту, возможно, потребуется прекратить ПД. Потребуется начало лечения гемодиализом. Это очень важное и эмоционально значимое решение для пациентов с почечной недостаточностью. Любое решение, которое включает прекращение ПД или переход на терапию гемодиализом, следует принимать совместно клинической командой, пациентом на диализе и при необходимости лицом, помогающим проводить лечение ПД. Хотя нет убедительных данных о том, как часто следует проводить тесты для определения функции брюшины, представляется разумным повторять их всякий раз, когда возникают трудности с удалением такого количества жидкости, которое необходимо для поддержания хорошего состояния и самочувствия пациента. Не изучалось, связана ли регулярная оценка функции мембраны с лучшими результатами лечения. Необходимы дальнейшие исследования, чтобы ответить на этот важный вопрос, поскольку национальная политика во многих частях мира и COVID-19 сместили акценты и дополнительно стимулировали более широкое внедрение методов лечения диализом на дому, особенно - ПД. Перевод краткого изложения на китайский и испанский языки см. в Приложении 1.

Для цитирования: Рекомендации международного общества перитонеального диализа по оценке дисфункции пери­то­неальной мембраны у взрослых: классификация, методы оценки, интерпретация и обоснования для вмеша­тельства. Перевод на русский язык: А.М. Андрусев, Р.П. Герасимчук, А.Ю. Земченков, К.А. Салихова под общей редакцией А.М. Андрусева. ­Нефрология и диализ. 2023. 25(2):-266. doi: 10.28996/2618-9801-2023-232-266

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