不同超滤功能的持续不卧床腹膜透析患者腹膜液体转运功能评估

目的 容量控制对于腹膜透析至关重要.腹膜平衡实验(peritoneal equilibration test,PET)可以评估腹膜小分子溶质转动功能,对优化腹膜透析存腹时间提供依据,但是不能预测腹膜液体转运功能.所以,本研究使用计算机拟合对不同超滤功能腹膜透析患者的腹膜液体转运功能进行评估.方法 纳入研究患者包括每天使用3～4袋2.5％葡萄糖透析液者(为腹膜超滤功能差组)和使用3～4袋1.5％葡萄糖透析液者(为腹膜功能好组),两组患者在上述透析处方下都能达到足够的液体清除.所有入组的患者都要求详细记录自己每天的腹膜透析换液情况,以评估腹膜液体转运功能.结果 本研究包括了17名持续不卧床腹膜透析患者(continuous ambulatory peritoneal dialysis,CAPD),其中9名为超滤功能差组,8名为超滤功能好组.与超滤功能好组相比,超滤功能差组的患者每天更多的处于高葡萄糖(P＜0.01)环境中,透析液/血浆肌酐比值(D/Pcre)更高(P＜0.05),有更高的腹膜液体吸收率(Ke)(P＜0.01). 结论 与超滤功能好的患者相比超滤功能差的患者的腹膜小分子溶质转运率更高,更为重要的是,超滤能力差的患者腹膜液体吸收率更高.     

腹膜透析患者腹膜平衡试验及其操作

对52例腹膜透析患者进行腹膜平衡试验（PET），判断腹膜对小分子物质的转运能力。其中，高转运者6例（11．5％），高于平均转运者35例（67．4％），低于平均转运者9例（17．3％），低转运者2例（3．8％）。分析腹膜转运功能与透析充分性的关系，在标准剂量透析状态时高转运和低转运类型的患者平均尿素KT／V及Ccr明显低于其它转运类型，在低于平均转运的患者中有残余肾功能者KT／V及Ccr明显高于无尿或少尿者。根据PET的结果，对11例患者调整了透析方案，透析效能明显改善，说明PET有助于腹透选择或调整适合CAPD患者的透析方式。同时对PET的操作过程中应注意的一些问题进行了总结和讨论。     

腹膜透析患者左心室肥厚与腹膜转运特性的关系

目的 探讨腹膜透析患者左心室肥厚与腹膜转运特性的关系.方法 69例持续性不卧床腹膜透析（CAPD）患者,超声心动图检查测算左心室心肌质量指数（LVMI）,应用改良腹膜平衡试验（PET）,按患者腹膜转运类型分高转运组、高平均转运组、低平均转运组及低转运组,同时检测血红蛋白、血白蛋白、尿素氮、肌酐等,以及测定尿素清除指数（Kt/V）和肌酐清除率（Ccr）,记录透析龄、收缩压、舒张压.结果 腹膜高转运和高平均转运例数比低转运和低平均转运多（41/28）;高转运组、高平均转运组、低平均转运组、低转运组透析龄分别为（39.2±21.8）、（26.6±15.6）、（28.6±14.4）、（45.7±35.0）岁,4组间差异有统计学意义（F=4.128,P＜0.05）,高转运组透析龄比高平均转运组、低平均转运组长（P均＜0.05）,低转运组透析龄比高平均转运组、低平均转运组长（P均＜0.05）;LVMI与4h透析液肌酐与血肌酐比值（D/Pcr）、收缩压、舒张压呈正相关（r值分别为0.339、0.351、0.316,P均＜0.01）,与白蛋白呈负相关（r=-0.292,P＜0.05）;69例CAPD患者发生左心室肥厚44例,发生率63.8％,高转运组高于低平均转运组及低转运组（x2值分别为5.455、5.091,P均＜0.05）.结论 维持性腹膜透析患者高转运特性占大多数,有较高左心室肥厚发生率,高转运者更为明显.D/Pcr、收缩压、舒张压升高和低白蛋白与左心室肥厚密切相关.     

71例腹透患者的腹膜平衡试验分析

了解腹透患者的溶质转运类型的分布，并重点了解腹膜炎后的腹膜功能变化。方法：７１例腹膜透析患者的８４次腹膜平衡试验。结论：在腹膜炎后腹膜转运持续呈高溶质转运类型，且伴有残余肾功能低和低白蛋白血症的腹膜透析患者是腹透的高危人群。     

不同血清成纤维细胞生长因子23水平对腹膜透析患者磷代谢的影响及相关因素分析

目的观察分析不同血清成纤维细胞生长因子（FGF）23水平对腹膜透析患者磷代谢的影响,探讨腹膜透析患者血清FGF23的影响因素。 方法选取重庆医科大学附属成都第二临床学院稳定腹膜透析治疗3个月以上的92例患者,根据患者血清FGF23中位数821 pg/ml,将患者分为低水平组（FGF23<821 pg/ml）和高水平组（FGF23≥821 pg/ml）,比较2组患者饮食蛋白质及磷摄入量、血磷水平、腹膜磷清除率、残肾磷清除率、总磷清除率、血清甲状旁腺素（iPTH）水平、残余肾功能（RRF）;根据透析液肌酐浓度/血浆肌酐浓度值,其中32例患者分为A组（高平均转运＋高转运组）和B组（低平均转运＋低转运组）,比较A、B组患者腹膜转运功能与FGF23的清除。采用多元逐步回归法分析PD患者血FGF23水平的独立影响因素。 结果FGF23高水平组蛋白质和饮食磷摄入量高于低水平组,差异具有统计学意义（P<0.05）;高水平组血磷、iPTH水平高于低水平组,差异具有统计学意义（P<0.05）;高水平组腹膜磷清除、残肾磷清除率、总磷清除率、尿素清除指数、周肌酐清除率较低水平组更低,差异具有统计学意义（P<0.05）。亚组分析显示A组患者FGF23清除率较B组更低,差异具有统计学意义（P=0.044）。多元逐步回归分析显示血磷水平、总磷清除率、Log（iPTH水平）、残肾功能、透析龄是本研究中血清FGF23升高的独立影响因素。 结论血清FGF23更高水平的腹膜透析患者存在总磷清除率更低,饮食磷摄入和血磷水平更高的临床特征;残肾清除磷与腹膜清除磷均影响腹膜透析患者血清FGF23水平,腹膜转运功能高的腹膜透析患者具更低的腹膜FGF23清除率;血磷水平、总磷清除率、Log（iPTH水平）及残肾功能和透析龄是腹膜透析患者血清FGF23水平的独立影响因素。     

腹膜透析患者透析充分性的影响因素分析

目的 探讨腹膜透析充分性的影响因素,为制订合理的个体化透析方案提供依据.方法 回顾性分析了连续性非卧床腹膜透析患者42例的临床资料,透析时间1～36个月,透析剂量平均8.5 L/d.通过尿素清除指数(KT/V)和肌酐清除率(Ccr)来评价患者的腹膜透析充分性,并观察透析时间、残余肾功能(RRF)、体表面积、单位透析剂量(PV/S)对腹膜透析充分性的影响.结果 尿素KT/V和Ccr,高于平均转运组或低于平均转运组的患者明显高于高转运组、低转运组患者.RRF和PV/S,透析不充分组明显低于透析充分组,而透析时间和BSA透析不充分组明显高于透析充分组.结论 影响透析充分性的重要因素为腹膜转运功能、残余肾功能、透析时间、透析量,应根据病情变化制订合理的个体化透析的方案.     

持续腹膜透析患者的生存率及多变量预后分析

目的分析腹膜透析患者的生存率及其独立的预后因素,观察腹膜转运特性及相关临床特点对患者生存的影响。方法选择北京协和医院肾内科随诊腹膜透析患者232例,采用Cox模型回归分析透析开始时各临床指标对生存时间的影响。结果CAPD患者1年、2年、3年及4年总体生存率分别为91.1%、77.7%、68.7%及55.8%;单因素COX模型回归分析表明：糖尿病患者、腹膜高转运状态、年龄增加、血浆白蛋白低于3.0的患者预期生存率均降低（P〈0.05）。232例患者中180（78%）位患者在开始透析的前6个月完成腹膜平衡实验（PET）,其中高转运状态与死亡显著相关（与低于平均转运患者相比,RR2.70;95% CI 1.03 to 7.05;P=0.043）。经多因素COX模型回归分析,糖尿病和年龄是尿毒症腹膜透析患者死亡的独立危险因素。糖尿病患者死亡的相对危险度为非糖尿病患者的2.96倍（95% CI 1.62 to 5.38;P〈0.0001）;年龄每增加10岁,相对危险度增加0.31（P=0.039）。结论根据透析前年龄、原发病、血清白蛋白和腹膜的转运状态可以对腹膜透析患者的预后进行初步判断。     

持续性非卧床腹膜透析患者局部内皮素与腹膜转运功能异常的相关性分析

目的探讨持续性非卧床腹膜透析患者腹腔局部内皮素（ET-1）与腹膜转运功能异常的相关性。方法60例持续性非卧床腹膜透析患者,根据腹膜转运功能分为转运功能正常组和转运功能异常组,分别测定和计算透析充分性指标（Kt／V）、肌酐清除率（Ccr）和腹透液ET-1。结果与腹膜转运功能正常组比较,转运功能异常组患者Kt／V和Ccr明显降低（P〈0．05）,超滤量明显增加（P〈0．05）;腹腔局部ET-1水平明显升高,且与腹膜转运功能呈负相关（r=-0．752,P〈0．05）。结论腹膜透析患者腹腔局部内皮素水平与腹膜功能受损密切相关。     

渐进性腹膜透析的临床应用CSCD

渐进性腹膜透析(peritoneal dialysis,PD)是对于残余肾功能较好的患者,起始采用低于传统“全量”腹膜透析的剂量,结合适量的蛋白饮食及水盐限制,使残余肾功能和腹膜对溶质和液体达到总清除目标。随着残余肾功能的变化,逐渐递增或递减透析剂量及超滤量,以保证总溶质清除及液体清除不变的个体化治疗模式。与传统PD比较,更有利于延缓残余肾功能减退,减少并发症,节省费用,提高生活质量。但更优的临床结局现有的证据尚不足。目前对于这种治疗模式仍存在适合人群,透析处方调整时机及方法以及依从性和安全性等多种问题值得探讨。     

腹膜透析充分性的评估的新认识

长期以来小分子溶质清除率作为肾脏替代治疗充分性的一个重要指标,应用于持续性不卧床腹膜透析(CAPD)是在20世纪80年代后期。小分子物质的清除的指标尿素清除指数Kt/V和肌酐清除率CrCl是建立在尿素动力学模型基础上,并认为腹膜和残余。肾溶质清除相等,两者可以相加,并影响着透析患者的预后。     

High peritoneal permeability is not associated with higher mortality or technique failure in patients on automated peritoneal dialysis.

BACKGROUND: Patients on continuous ambulatory peritoneal dialysis (CAPD) who have high small-molecule peritoneal transport have increased mortality. OBJECTIVE: To investigate the impact of baseline peritoneal transport characteristics on patient and technique survival in incident peritoneal dialysis (PD) patients, most of whom are on automated PD (APD), with the use of icodextrin. DESIGN: Retrospective observational cohort study. SETTING: A single PD unit. Patients and METHODS: 193 new patients that began PD between January 2000 and September 2004, and had an initial peritoneal equilibration test within 6 months of commencement of PD. Patients were divided into low (L), low average (LA), high average (HA), and high (H) peritoneal transport groups. Death-censored technique failure and patient survival were examined. RESULTS: Of the 193 patients, 151 (78.1%) were on APD or on APD with icodextrin or on CAPD with icodextrin. At the end of 1, 3, and 5 years, patient survival was 91%, 82%, and 67% in LA group; 95%, 77%, and 69% in HA group; and 96%, 71%, and 71% in H group. Technique survival was 100%, 90%, and 77% in LA group; 96%, 84%, and 72% in HA group; and 92%, 87%, and 77% in H group. High peritoneal permeability did not predict worse patient survival or technique failure, while age, diabetes, a lower glomerular filtration rate, and high body mass index (> or =30 kg/m(2)) were independent predictors of death. CONCLUSION: This study suggests that higher peritoneal transport is not a significant independent risk factor for either mortality or death-censored technique failure. The favorable outcome for high transporters in this study may be due to improved management of volume status by the increased use of APD and the use of icodextrin-based dialysis fluid.     

腹膜透析治疗糖尿病肾病尿毒症患者的临床分析

目的　探讨影响糖尿病终末期肾病 (ESRD)患者腹膜透析生存率的因素。方法　对糖尿病ESRD患者 2年存活组与死亡组开始透析时的肾功能、营养状态及合并症情况进行对比分析。结果　糖尿病ES RD患者 2年死亡组开始透析时的尿素氮 (BUN)、血肌酐 (Scr)高于存活组 ,内生肌酐清除率低于存活组 ;与存活组相比 ,2年死亡组开始透析时的血红蛋白 (Hb)、血浆白蛋白 (Alb)明显较低 ;2年死亡组开始透析时的合并症数目多于存活组。结论　糖尿病ESRD患者的腹膜透析生存率与开始透析时的肾功能、营养状态及合并症情况密切相关 ,应根据患者透析前肾功能、营养状态及合并症情况综合考虑 ,选择适当的透析时机。     

日间非卧床腹膜透析与持续非卧床腹膜透析长期临床疗效观察

目的 比较采用日间非卧床腹膜透析(daytime ambulatory peritoneal dialysis,DAPD)患者与经典持续非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)患者之间的长期临床疗效,探讨适合中国人的长期腹膜透析(peritoneal dialysis PD)模式.方法 选自海军总医院肾内科行腹膜透析患者32例,随机分成A、B2组,每组16例,A组采用经典的CAPD模式,每天的透析剂量为8L、4次交换、夜间留腹;B组采用DAPD模式,即日间采用8L的透析剂量,每袋透析液交换时间为3～4h,夜间干腹.随后长期监测并比较2组患者的透析充分性,包括尿素清除指数(K t/V(周)、肌酐清除率(Ccr),营养状况包括营养不良发生率(SGA)、血清白蛋白(sALB),并发症控制情况包括血红蛋白(Hb)、二氧化碳结合力(CO2CP)、血钾(K +)、血钙(Ca2+)、血磷(P3- )、游离甲状旁腺激素(iPTH)及血压控制水平(平均动脉压)、腹腔感染率、每组维持透析人数、每组患者维持透析的有效时限(月数)、就业率,采用Barthel指数(BI)进行日常生活能力的评价和汉密尔顿抑郁量表(HAMD)进行抑郁程度的评分,记录患者每天的尿量和超滤量.实验数据以x±s表示,组间均数比较采用方差分析,2组间比较采用t检验或X2检验,P ＜0.05表示差异有统计学意义.结果 A、B2组患者在残余尿量、超滤量、透析充分性[Kt /V(周)、Ccr]、并发症控制中的CO2CP、K +、Ca2+等方面比较差异无统计学意义( P＞ 0.05);B组在营养状况、慢性肾衰竭并发症控制中的Hb、P 3-、iPTH、平均动脉压、腹腔感染率、维持透析人数、透析维持时间、就业率、BI、HAMD等方面均优于A组,差异有统计学意义( P＜0.05).结论 在使用相同透析剂量的情况下,长期行DAPD治疗的患者比经典的CAPD患者在维持透析时间、透析的充分性、营养状况的维护 、并发症的控制、血压的调节、降低腹腔感染率、保持较高的日常生活能力和缓解抑郁程度等方面均有更满意的临床疗效.     

Contribution of lymphatic absorption to loss of ultrafiltration and solute clearances in continuous ambulatory peritoneal dialysis.

The contribution of peritoneal cavity lymphatic absorption to ultrafiltration kinetics and solute clearances in continuous ambulatory peritoneal dialysis was evaluated in patients with normal (group 1) and high (group 2) peritoneal permeability X area during 4-h exchanges using 2 liters 2.5% dextrose dialysis solution with 30 g added albumin. Cumulative lymphatic drainage in all continuous ambulatory peritoneal dialysis (CAPD) patients averaged 358 +/- 47 ml per 4-h exchange and reduced cumulative net transcapillary ultrafiltration at the end of the exchange by 58 +/- 7.2%. The peak ultrafiltration volume was observed before osmotic equilibrium between serum and dialysate was reached and occurred when the net transcapillary ultrafiltration rate had decreased to equal the lymphatic absorption rate. Thereafter the lymphatic absorption rate exceeded the net transcapillary ultrafiltration rate, and intraperitoneal volume decreased. Extrapolated to 4 X 2 liters, 2.5% dextrose, 6-h exchanges per d, lymphatic drainage reduced potential daily net ultrafiltration by 83.2 +/- 10.2%, daily urea clearance by 16.9 +/- 1.9%, and daily creatinine clearance by 16.5 +/- 1.9%. Although lymphatic absorption did not differ between the two groups, lymphatic drainage caused a proportionately greater reduction in net ultrafiltration in group 2 (P less than 0.025), because these patients had more rapid dialysate glucose absorption (P less than 0.05) and less cumulative transcapillary ultrafiltration (P less than 0.01). These findings indicate that cumulative lymphatic drainage significantly reduces net ultrafiltration and solute clearances in CAPD and that ultrafiltration failure in CAPD occurs when daily lymphatic absorption equals or exceeds daily transcapillary ultrafiltration. Reduction of lymphatic absorption may provide a means for future improvement in the efficiency of CAPD.     

透析前腹膜微血管密度与腹膜基线溶质转运关系的研究

目的借助免疫组化技术,分析透析前腹膜微血管密度(腹膜透析置管术时)与腹膜基线溶质转运间的关系,以探究基线转运的可能形态学基础。方法入选首都医科大学附属北京友谊医院腹膜透析中心的新入非糖尿病持续不卧床腹膜透析患者。腹膜透析置管术时留取壁层腹膜标本,以CD34为血管内皮标志行免疫组化染色,显微镜下计数微血管密度(microvessel density,MVD)。开始透析4～6周后行标准腹膜平衡试验(peritoneal equilibration test.PET),计算存腹4h的肌酐腹腔引流液/血浆比值(D/Pcr),;前1日收集24h腹膜透析液,测定蛋白质总量(peritoneal protein excretion,PPE)。结果共纳入32例患者,以D/Pcr=0.65为界,分为高/高平均转运组(19例)和低/低平均转运组(13例)。研究期内无急性腹膜炎发作。在对体表面积、残余肾功能、平均动脉压、降压药使用情况、2.5%葡萄糖透析液使用频率、PET当天的血红蛋白、血浆C反应蛋白、白蛋白水平校正之后,前者腹膜MVD值显著高于后者(F=10.470,P=0.004);腹膜MVD值与D/Pcr呈显著正相关(r=0.432,P=0.035),但与PPE无显著相关性(r=0.079,P=0.683)。结论非糖尿病腹膜透析患者透析前腹膜MVD与其小分子溶质基线转运率正相关,与24h腹腔蛋白丢失量无关,可能蛋白质的漏出更多受制于微血管的内在通透性。     

Continuous ambulatory peritoneal dialysis in patients with diabetes mellitus

AIM: To analyse the results of continuous ambulatory peritoneal dialysis (CAPD) in diabetes mellitus (DM) patients, to specify complications, to evaluate transport characteristics of peritoneal membrane. MATERIAL AND METHODS: The ability of peritoneal membrane to eliminate low-molecular substances (creatinine, urea), electrolytes and to evaluate treatment efficacy by residual renal function (peritoneal equilibration, total urine and creatinine clearance). RESULTS: DM patients on CAPD developed vascular complications typical for DM:gangrene (n = 2), diabetic foot (n = 4), acute disorder of cerebral circulation (n = 3), acute myocardial infarction (n = 3). Diabetics' residual renal function deteriorated faster than in patients with non-diabetic uremia, though transport characteristics of the peritoneum in diabetics and non-diabetics were the same. Peritonitis in diabetics was observed much less frequently than in non-diabetics. CONCLUSION: CAPD is an adequate replacement therapy in patients with uremia of different origin including diabetes. In the course of the treatment DM patients develop complications typical for basic disease but their frequency is unrelated to CAPD.     

腹膜血管形成对腹膜透析失超滤的影响

目的　探讨腹膜透析失超滤的患病率及有关因素。方法　比较失超滤患者和非失超滤患者在透析龄、腹膜透析平衡试验 (PET)结果、腹膜炎、外周血白蛋白 (Alb)、高糖累积量及腹膜血管变化的差异。结果　失超滤患者的透析龄、腹膜通透性、高糖累积量及腹膜毛细血管的生成均高于非失超滤患者 ,但Alb相对较低 ;腹膜炎的患病率两组之间差异无显著性。结论　尿毒症环境、葡萄糖累积量的增多可能导致腹膜毛细血管的生成、腹膜的高转运 ,与腹膜透析的失超滤有关。     

Risk factors influencing the decline of residual renal function in continuous ambulatory peritoneal dialysis patients.

OBJECTIVE: To assess the nature of the decline in residual renal function (RRF) after the initiation of peritoneal dialysis, and to identify risk factors influencing the preservation of RRF. DESIGN: A retrospective single-center study. SETTING: Tertiary medical center. PATIENTS: Eighty patients who were clinically stable and had been on continuous ambulatory peritoneal dialysis (CAPD) for a minimum of 6 months. MAIN OUTCOME MEASURES: All subjects had at least three measurements of RRF, which was calculated as the average of creatinine clearance (Ccr) and urea clearance from a 24-hour urine collection. All measurements of RRF were plotted on a logarithmic scale and a linear scale against the duration of CAPD. Covariables used in the correlation analyses were age, sex, the presence of diabetes mellitus, mean blood pressure, mean diastolic blood pressure, hematocrit and Ccr at the start of peritoneal dialysis, peritoneal membrane transport characteristics by peritoneal equilibration test (PET), and the rate of peritonitis. RESULTS: A significant correlation was found between CAPD duration and RRF decline represented on a logarithmic scale with a correlation coefficient (r) of 0.355 (p < 0.001). In contrast, on a linear scale, the correlation coefficient was only 0.273 (p < 0.01). By linear multiple regression analysis, the only independent risk factor for the decline of RRF was the rate of peritonitis (r = -0.446, p < 0.001). CONCLUSION: These results suggest that RRF declines exponentially rather than linearly with time, and that the rate of peritonitis is an independent risk factor for the decline of RRF in CAPD patients.