| 特集名 | 腎不全患者の血液浄化療法の選択 | |
|---|---|---|
| 題名 | 日常遭遇する病態と血液浄化療法の選択 (4) 中枢神経疾患 | |
| 発刊年月 | 2000年 01月 | |
| 著者 | 平方 秀樹 | 九州大学医学部附属病院腎疾患治療部 |
| 著者 | 石田 伊都子 | 九州大学大学院医学系研究科病態機能内科学 |
| 【 要旨 】 | 脳血管障害を代表とする中枢神経疾患を合併した患者では，脳浮腫の増悪を極力防止する対策がもっとも重要である．血液浄化療法を適用する場合には，施行中の頭蓋内圧の変動がもっとも問題で，頭蓋内圧を経時的に測定した研究によって，血液透析では，施行中に頭蓋内圧が急激に上昇することが明らかにされた．そのため，血液透析を選択した場合には，施行中にグリセオールを持続点滴し，高ナトリウム透析などを併用して低効率，短時間，頻回に行うことが推奨されている．一方，腹膜透析法では，頭蓋内圧の変動が小さく，脳灌流圧を維持することが可能で，全身的な血行動態の変動も小さく，抗凝固薬が不要なことから，脳血管障害例での血液浄化療法の第一選択とされてきた．しかし，腹膜透析法では体液量管理や十分な効率を維持することが困難になる例が多い．半減期が短い抗凝固薬が開発されて以後は，血漿浸透圧の低下が緩除で，全身的な血行動態値や脳灌流圧が安定して保たれる持続血液透析濾過法など持続的血液浄化療法を適用して安全に施行できることが報告されている．中枢神経疾患を合併した場合には，原疾患の管理とともに，症例ごとに病態を評価し，全身的血行動態値と頭蓋内圧を安定維持できる血液浄化療法を選択することが重要である． | |
| Theme | The Choice of Blood Purification for the Patients with Renal Failure | |
|---|---|---|
| Title | Strategies for blood purification therapy in patients with brain injuries | |
| Author | Hideki Hirakata | Kidney Care Unit, Kyushu University Hospital |
| Author | Itsuko Ishida | Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyusyu University |
| [ Summary ] | In patients with brain injuries, requiring blood purification therapy (BPT), it is very important to prevent further neurological deterioration due to intracranial hypertension. Control of changes in the intracranial pressure (ICP) is, therefore, required. It is known that ICP rises steeply during conventional hemodialysis, whereas it remains stable during peritoneal dialysis (PD). Since there is no need for anticoaglulants with PD, it is also advantageous to use it for treatment of those with hemorrhagic brain injuries. However, poor control of hypervolemia and underdialysis, due to low efficiency are serious problems with PD therapy. Recently, many modifications in continuous renal replacement therapy (CRRT) have been developed and are quite useful for treatment of patients with brain injuries, where we use anticoagulants with short-half lives. One of these is continuous arteriovenous hemofiltration (CAVHF), which has been reported to achieve management of both ICP and perfusion to the brain. In patients with epilepsy or dementia, data concerning pharmacodynamics, such as protein binding capacity, metabolic pathways and the dialysability of anticonvulsant and psychotropic agents, should be reminded along with close monitoring the relationship between blood levels and resultant effects. It is important to select the safest method for BPT in those patients with brain injuries, in association with systemic blood pressure control, in order to maintain the perfusion pressure to the brain along with stable ICP. |
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