透析
透析とは
透析とは尿として余分な水分や老廃物を排出する役割を果たしている腎臓が機能しなくなった際に人工的に腎臓の働きを補う治療法である。
透析の種類
透析には維持血液透析と緊急血液透析と腹膜透析がある。
維持血液透析と腹膜透析は慢性腎不全の治療として行われるものである。
緊急血液透析は主に急性腎不全の治療として行われるものである。
透析液の組成
透析の原理は半透膜を介して血液側と透析液側との間で物質を拡散させ合うことで血液を正常な状態に戻すという仕組みである。
このため、透析液は透析患者に不足している物質を多めに含み、余分な物質を少なめに含んでいる。
腎不全の患者は高P血症となるので透析液にPは含まれない。また、腎不全の患者は高K血症となるので透析液にKは少なめに含まれる。
腎不全の患者は低Ca血症となるので透析液にCaは多めに含まれている。また、腎不全の患者は代謝性アシドーシスによってHCO3が消耗性に低下しているので透析液にHCO3は多めに含まれている。
維持血液透析と腹膜透析
維持血液透析と腹膜透析は慢性腎不全に対して長期に渡って行われる透析である。
維持血液透析
維持血液透析とは機械を使って病室で行われる一般的ないわゆる「透析」である。
維持血液透析は機械が血液側に圧力を掛けて物質を限外濾過させることで透析を行う。
機械で圧力を掛ける限外濾過によって除水するので除水効率が良いがアミノ酸を喪失しやすい。しかし、蛋白質は維持血液透析の半透膜を通過できないので蛋白質を喪失することはない。
維持血液透析のポイントは非連続的である点である。病院に週に3回程度通院して4~5時間程度透析を行うので2日程度おきに身体に溜まった老廃物や水分を取り出すことになる。
このため血圧変動が大きくなる。非連続的であるので透析間にできるだけ体重を増加させないことが重要となり、飲水・食事制限が厳しい。
腹膜透析
腹膜透析は透析液を腹腔内に入れて取り替えることを繰り返すことによって行う透析である。機械を使って行う一般的な透析である維持血液透析と違ってマイナーであり、イメージしにくいかもしれない。
腹膜透析では高濃度ブドウ糖液で透析液を組成することによって浸透圧差を生じさせて除水する仕組みとなっているが、機械で圧力を掛ける限外濾過によって除水する維持血液透析と比べると除水効率は劣る。
腹膜透析の半透膜は蛋白質を通すので腹膜透析では蛋白質を喪失しやすい。
腹膜透析ではブドウ糖を体内に取り込むことになるため多くのカロリーを摂取してしまうことに加えて、蛋白質を喪失しやすいのでリポ蛋白合成が亢進して高脂血症になりやすい。
また、腹膜透析液は高濃度のブドウ糖で組成されているので、長期間腹膜透析を行うと糖尿病による血管障害のような変化が腹膜に生じて劣化してしまう。腹膜が劣化すると除水能力が落ちたり、形態学的な変化が起こると腹膜と腸管が癒着して腸閉塞を生じさせてしまうことがある。これらのデメリットを避けるために腹膜透析から血液透析へと段々移行させる。
腹膜透析は自宅で1日に数回、30分程度自分で透析を行うので毎日連続して体内の老廃物や水分を取り出し続けることができる。病院には月に1回程度通院するだけでよいので社会復帰しやすい。
連続して取り出し続けることができるため血圧変動は少ない。このため、飲水制限・食事制限は維持血液透析と比べて緩い。
患者によってはメリットの大きい透析方法となる腹膜透析であるが、日本において腹膜透析を選択する患者は全透析患者のうち約3%にしか過ぎない。これは諸外国と比べて著しく低い割合となっている。
緊急血液透析
緊急血液透析とは主に急性腎不全に対して行われる短期間の緊急的な透析である。緊急血液透析には導入基準があり、これに当てはまる場合に行われる。
緊急血液透析はAIUEOで覚える方法が一般的である。検査値のみで緊急血液透析の可否を判断するという暗記要素が強い医師国家試験問題も過去に出題されており、検査値と症状を結び付けて導入基準を覚えると良いかもしれない。
[緊急血液透析の適応]
透析合併症
透析中：血圧低下
透析患者は尿によって体外に余分な水分と老廃物を排出することができない。
このため、透析によって余分な水分と老廃物を排出するのだが、透析間でどうしても体重増加は生じてしまう。
透析では適切なドライウェイト(DW)を決めて、適切な水分バランス時の体重まで減らすことになる。
このとき、透析間の体重増加が大きいとその分だけ多量の除水が必要となるので血圧低下が起こりやすくなる。
そのため、透析間では水分・塩分制限をしっかりとして体重増加を少なくすることが重要になる。
透析初期：不均衡症候群
透析では血液から速やかに老廃物を取り除くことができるが、細胞内液の老廃物は速やかに取り除くことができない。
老廃物は浸透圧を生じさせるので、透析後は血管内と細胞内の間で浸透圧差が生じて細胞内に水が移動することになる。
これが脳細胞で起こると脳浮腫となり、頭蓋内圧が亢進して頭痛・吐き気などの症状が出る不均衡症候群となる。
不均衡症候群は身体がまだ透析に慣れていない透析導入初期によくみられる。身体が透析に慣れてくると不均衡症候群は起こりにくくなる。
透析長期：透析アミロイドーシス→手根管症候群
アミロイドーシスとはアミロイド前駆蛋白が凝集して生じるアミロイド蛋白と呼ばれる異常蛋白質が全身の様々な臓器に沈着してしまうことで機能障害を引き起こす疾患の総称である。アミロイド前駆蛋白とアミロイド蛋白の種類によってアミロイドーシスは分類される。
透析アミロイドーシスはβ2-ミクログロブリンがアミロイド前駆蛋白となり、凝集してAβ2Mと呼ばれるアミロイド蛋白を生じさせることによって引き起こされる。
β2-ミクログロブリンとは主にリンパ球系の細胞表面に存在する蛋白質であり、細胞が崩壊すると一定量が血中に放出される。
β2-ミクログロブリンは分子量約1.2万の低分子量蛋白であるので、糸球体を容易に通過して近位尿細管で大部分が再吸収される。近位尿細管が障害されると尿中への排泄が増加することから近位尿細管障害の指標として使われる。
正常であれば近位尿細管で再吸収された後に分解されるのだが腎機能が低下すると分解ができなくなるため、慢性腎不全の患者ではβ2-ミクログロブリンが段々と体内に蓄積していく。
透析では分子量1.2万のβ2-ミクログロブリンは除去しきれないので、長期透析患者の体内に蓄積したβ2-ミクログロブリンは凝集してAβ2Mと呼ばれるアミロイドを形成してアミロイドーシスを引き起こす。
長期透析患者において認めるアミロイドーシスなので、透析アミロイドーシスと呼ばれている。
手根管とは手根骨と横手根靭帯に囲まれた空間を指し、指を曲げる腱と正中神経が通過する。この腱にアミロイドが沈着して正中神経が圧迫されると手指にしびれ感が出る手根管症候群が引き起こされる。
透析の原疾患と死因
医療技術の進歩によって慢性腎不全のコントロールが良好となり、透析導入に至るまでの腎保存期間が長くなった結果として透析導入時の平均年齢は上昇している。
透析の原疾患と死因の推移グラフは新規透析導入患者と慢性透析導入患者(1年以上)で分けられており、医師国家試験問題を解くときやグラフを見る際にどっちであるかというように混乱しないようにすることが重要である。しかし、そもそもここまで細かく覚える必要があるかどうかというのは微妙である。
医師国家試験問題を解くためだけならば、[①透析導入時の平均年齢上昇②原疾患として糖尿病性腎症が増加傾向であり１位③糖尿病性腎症増加傾向により透析導入患者の死亡原因として感染症の増加④原疾患として慢性糸球体腎炎が減少傾向]ということのみを覚えればほぼ全ての関係する医師国家試験問題は解くことができると考えられる。逆にこれ以外の情報が求められる医師国家試験問題を解ける受験生は少ないと思われるので差があまりつかないと考えられる。
慢性糸球体腎炎の予後は発見時点での腎機能がどれだけ保たれているのかということに影響される。慢性糸球体腎炎は検尿による早期発見システムの確立によって透析導入まで悪化することが少なくなってきたので、慢性糸球体腎炎は透析導入の原疾患としては減少し続けている。
高血圧が原因となる腎硬化症も増加し続けている。これは生活習慣病の増加が関係している。
透析患者の高齢化や原因疾患として糖尿病性腎症が増加したことによって、全体としてみると透析患者の免疫力が低下しているので死亡原因として感染症が増加し続けている。
透析患者では尿が出ないので余分な水分が体内に貯留してしまうことで、心臓に過大な負担が掛かった結果として心不全に至り死亡することが多い。
血液浄化療法の種類
医師国家試験において血液浄化療法に関して問われるときは透析がほとんどであるが、透析以外の血液浄化療法が出題されることもあるので最低限知っておくべき血液浄化療法の情報を載せておく。
慢性血液浄化療法
維持血液透析を行う際のブラッドアクセス(内シャント)は恒久的なものになるので、橈側皮静脈と橈骨動脈を吻合することによって十分な血液流量を確保できるように血管を発達させて設置する。内シャントが発達するまでは2週間程度を要するので維持血液透析導入に先立って内シャント作製手術を行う必要がある。
慢性血液浄化療法は透析である。維持血液透析と腹膜透析については上記の情報を参考にして頂きたい。
腹膜透析は血液浄化療法の中で唯一体外に血液を脱血しないので、唯一抗凝固剤を必要としない血液浄化療法であることは重要である。
急性血液浄化療法
急性血液浄化療法を行う際のブラッドアクセス(血液を人体から脱血・返血するための人体側の出入り口)は一時的なものになるので、大腿静脈か内頸静脈にカテーテルを留置して設置する。
血液濾過(持続血液濾過)
血液濾過とは透析液を用いないで、濾過器(高性能膜)によって老廃物とともに多量の体液自体を取り除いて、それに見合った量の新しい補充液を血液側に入れるという治療法である。
血液濾過透析(持続血液濾過透析)
血液濾過透析とは血液透析と血液濾過を組み合わせた治療法である。血液濾過透析では血液濾過よりも補充液が少なくて済む。
血漿交換
血漿交換とは血液を血漿分離器で血漿成分と血球成分に分離して病因物質を含む血漿を除去した後に、除去した分の血漿を血液製剤で補ってから体内に戻すという治療法である。
血液吸着
エンドトキシン血症患者の血液を体外へ脱血してエンドトキシン吸着剤に血液を通すことで吸着除去した後に体内へ返血するという血液浄化療法の一つである。エンドトキシンを除去できる唯一の血液浄化療法である。
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