高通量血液透析对患者营养状况的影响

目的 研究高通量血液透析对患者营养状况的影响.方法 采用前瞻性、自身对照研究.30例维持性常规低通量血液透析患者,转换为高通量血液透析6个月.试验前(0个月)、试验后3、6个月分别测定白蛋白、胆固醇、铁蛋白水平,计算标准化的蛋白氮出现率相当蛋白质(nPNA),测量瘦体重、握力并进行食欲量表评分.结果 转换为高通量透析后患者白蛋白、胆固醇、铁蛋白浓度比较差异无统计学意义(P<0.05).瘦体重在试验开始0、3、6个月分别为(39.7±8.7)kg、(35.0±6.8)kg、(34.5±1.3)kg,试验前、后比较差异有统计学意义(P<0.05),而握力水平比较分别为(22±10)kg、(25±11)kg、(25±10)kg.nPNA及食欲母表分数在试验前、后比较差异无统计学意义(P>0.05).结论 高通量血液透析会对患者的营养状况产生一定影响.     

糖尿病肾病维持性血液透析状态下血糖状况分析

目的：了解维持性血液透析状态下2型糖尿病肾病患者血糖的变化特点。方法：测定34例维持性血液透析的2型糖尿病肾病患者和86例维持性血液透析的慢性肾小球病变患者血液透析前、透析2h、透析结束时、透析结束后2h血糖,对两组患者血糖进行比较。结果：糖尿病肾病维持性血液透析患者透析前血糖为（8．3±4．4）mmol／L,慢性肾小球病变维持性血液透析患者透析前血糖为（7．8±2．3）mmol／L,两者无统计学差异（P〉0．05）。透析2h糖尿痛肾病维持性血液透析患者血糖为（3．0±2．1）mol／L,慢性肾小球病变维持性透析患者血糖为（4．7±1．3）mmol／L,两者存在统计学差异（P〈0．05）。透析结束时糖尿病肾病维持性血液透析患者血糖为（1．9±2．4）mmol／L,慢性肾小球病变维持性透析患者血糖为（4．4±2．2）mmol／L,两者存在统计学差异（P〈0．05）。透析结束后2h糖尿病肾病维持性血液透析患者血糖为（2．1±1．4）mmol／L,慢性肾小球病变维持性透析患者血糖为（5．6±2．1）mmol／L,两者存在统计学差异（P〈0．05）。结论：维持性糖尿病血液透析患者透析期间血糖下降快,透析结束后血糖恢复慢,透析期间和透析后更容易发生低血糖。     

血液透析对慢性肾功能衰竭患者血浆髓过氧化物酶水平的影响

目的 探讨慢性肾功能衰竭维持性血液透析患者透析前、后血浆髓过氧化物酶水平的变化,分析其可能的原因及意义.方法 收集40例维持性血液透析患者透析前、后血标本各4 ml,其中2 ml置于乙二胺四乙酸抗凝管,2 ml置于普通试管,低温离心后分别收集血浆和血清.采用酶联免疫吸附法分别检测血浆髓过氧化物酶及血清中性粒细胞弹性蛋白酶的水平并比较透析前、后的变化.结果 透析前、后血浆髓过氧化物酶水平分别为(161±33)μg/L和(426±188)μg/L,治疗前、后比较差异有统计学意义(P＜0.01);透析前、后血清中性粒细胞弹性蛋白酶水平分别为(191±33)μg/L和(193±34)μg/L,治疗前、后比较差异无统计学意义(P＞0.05).结论 在维持性血液透析患者中应用肝素作为抗凝剂透析后,血浆髓过氧化物酶水平的升高并非由中性粒细胞释放所致,很可能是由肝素刺激血管壁固化髓过氧化物酶释放所致.     

维持性血液透析患者氧化应激状态的影响因素及黄芪注射液对其的作用研究

目的:探讨维持性血液透析患者氧化应激状态的相关影响因素,以及血液透析过程中滴注黄芪注射液对氧化应激的影响。方法:入选本院血液净化中心54例维持性血液透析患者。检测指标包括人体学测量、血生化指标、透析充分性指标(eKt/V)、氧化应激指标(AOPP、MDA)等。同时,观察血透过程中予以黄芪注射液滴注维持后血清氧化应激指标的变化。结果:(1)AOPP与干体重、肱三头肌皮褶厚度、三酰甘油呈正相关,与高密度脂蛋白、eKt/V呈负相关(P0.05);MDA与干体重、体重指数呈正相关(P0.05);多元回归分析显示三酰甘油是影响AOPP的独立危险因素;BMI是影响MDA的独立危险因素;(2)透后AOPP较透前明显升高(P0.05),透后MDA较透前也有升高,但差异无统计学意义;(3)应用黄芪注射液后透析前后AOPP差值较未用药时明显减少(P0.05)。结论:(1)维持性血透患者氧化应激状态与营养不良、脂代谢紊乱、透析充分性相关,其中三酰甘油、BMI是影响氧化应激的独立危险因素;(2)透析过程能加重氧化应激状态;(3)滴注黄芪注射液能部分改善透析过程中的氧化应激状态。     

传统维持性血液透析患者钠水平衡与高血压

目的 探讨传统维持性血液透析模式下透析患者钠水清除和高血压之间的关系.方法 血液透析组:3次/周,透析3个月及以上的维持性血液透析患者98例,收集人选病例最近1个月透析前的血压、血钠水平、脱水量占透析前体重的比例以及是否达到干体重等数据;未透析组:同期未进行过任何肾脏替代治疗的CKD4期、CKD5期所有住院患者118例,收集其入院当天的血压、血钠水平等.对组内和组间的数据以及与高血压之间的关系进行分析.结果 与未透析组相比维持性血液透析更好的控制了患者的血压(X2=10.767,P=0.001).两组组内高血压和血钠水平无相关关系,两组患者高血压和血钠之间存在等级相关关系(rs=0.151,p=0.027).透析组内达到干体重患者高血压的比例显著低于未达到干体重的患者(X2=16.450,P<0.01).结论 在低盐饮食的基础上,以超滤对流为主,配合以合适的透析液钠浓度弥散的方式为辅进一步完成对钠水的清除从而达到人体钠水平衡才是控制维持性血液患者高血压最重要的方案.     

血液透析超滤脱水对细胞内外液的影响

目的了解血液透析对细胞内液(intracellular water,ICW)和细胞外液(extracellular water,ECW)的影响。方法选择2012年3月1日至2014年12月31日解放军空军总医院血液净化中心行维持性血液透析(maintenance hemodialysis,MHD)治疗的患者68例,应用整体多频生物电阻抗仪测定透析前和透析后1min内的ICW和ECW,比较血液透析后ICW和ECW的减少量(△ICW和△ECW),观察透析超滤脱水对ICW和ECW变化率(ⅤICW/ICW和△ECW/ECW)的影响。结果血液透析患者68例中,男性37例(占54.41%),平均身高(1.62±0.09)m,体质量指数(bodymnas8 index,BMI)为(23.43±3.13),透析前体质量为(64.72±10.65)kg,干体质量为(61.37±10.74)kg,超滤量为(2.78士0.97)L,透析后ICW/ECW值为(1.99:1)。MHD患者透析前后,ICW从(23.34±4.53)kg下降到(21.64±4.18)kg,差异有统计学意义(t=9.518,P0.01),ICW变化量△ICW=(1.70±1.47)kg;ECW从(12.02±2.41)kg下降到(10.91±2.20)kg,差异有统计学意义(t=10.726,P0.01),ECW变化量△ECW=(1.11±0.85)kg,两种体液变化率分别为△ICW/ICW(7.07%±5。16%)和@ECW/ECW(9.02%±5.80%)。该研究中透析后ICW/ECW=1.99:1,与应用同位素标记的金标准测得的结果 2.0:1高度一致,优于其他多数研究中的1.11:1。结论血液透析超滤脱水同时来源于ICW和ECW变化,并非主要来源于ECW;本方法可能是最为接近金标准的方法。     

多频生物电阻抗法评估血液透析患者干体重

目的 应用多频生物电阻抗评估血液透析患者干体重.方法 选择81例维持性血液透析(Maintenance Hemodialysis,MHD)患者,采用人体成分分析仪,分别于透析前、后测定患者全身液体量(TBW,Total Body Water)、细胞外液(ECW,Extracellular Water)、细胞内液(ICW,Intracellular Water)、ECW与ICW之比E/I、容量超负荷(OH,Overhydration),并分别计算占体重的百分比(TBW％、ECW％和ICW％).结果 患者仅ICW透析前后无明显变化,透析后OH、TBW、TBW％、ECW、ECW％均较透析前明显下降,ICW％较透析前升高;透前TBW、ECW、ICW、TBW％、ECW％、ICW％和OH男性均高于女性,男性ECW/ICW比值低于女性.结论 MHD患者存在体液分布异常,主要表现为ECW％显著增加;血液透析脱水主要是除去多余的ECW,而对ICW无明显影响;多频生物电阻抗法可以对透析患者的容量状况提供客观依据.     

运用N-末端脑钠肽评估维持性血液透析患者干体质量

目的观察N-末端脑钠肽(N-terminal brain natriuretie peptide,NT-proBNP)运用于维持性血液透析患者干体质量的评估并分析临床意义。方法 48例行维持血液透析患者分为干体质量组(Ⅰ组,24例),容量超负荷组(Ⅱ组,24例)。治疗前比较两组年龄、平均动脉压、心胸比例、左室射血分数、左室容积、NT-proBNP、血肌酐、尿素氮、估算肾小球滤过率。两组常规透析前后检测NTproBNP、血肌酐、尿素氮,计算尿素清除指数(the urea clearance index,Kt/V)值,并于下次透析前检测NT-proBNP、血肌酐、尿素氮。结果Ⅰ、Ⅱ两组患者间性别、年龄、左室射血分数、左室容积、透析之前血肌酐、尿素氮及估算肾小球滤过率比较,差异均无统计学意义(均P0.05);平均动脉压[(88.10±10.16)mm Hg、(93.92±8.03)mm Hg]、心胸比例[(48.80±6.11)%、(53.25 4-2.72)%]及NT-proBNP[(3 827.67±712.12)ng/L、(5 793.58±945.20)ng/L],Ⅰ组小于Ⅱ组,差异有统计学意义(P0.05或P0.01);透析后两组间NT-proBNP[(1847.77 4-802.54)ng/L、(3 023.58±876.56)ng/L]、血肌酐[(287.26±62.86)μmol/L、(298.86±74.57)μmol/L]比较,差异有统计学意义(P0.01)。下次透析前测NT-proBNP、血肌酐值,与上次透析前比较,差异均无统计学意义(均P0.05)。Ⅰ、Ⅱ两组NT-proBNP值远高于正常值范围。结论在非显性水肿的维持性血液透析的患者中,NT-proBNP增高提示容量超负荷普遍存在。NT-proBNP可用来评估非显性水肿的维持性血液透析的容量负荷,但具有局限性,可辅助调节干体质量。维持性血液透析干体质量的确定需要查体及多项检测综合判断。     

个性化干预对MHD患者透析充分性的影响

目的：探讨个性化干预措施对维持性血液透析患者透析充分性的影响。方法：选择维持性血液透析患者尿素清除数（Kt/V）小于1.2的患者53例，根据体重、内瘘条件、血液再循环、透析时间、透析器、液体状况等原因，分别进行个性化干预。结果：53例维持性血液透析患者干预后血流量（244.53±24.224）ml/min较干预前（223.40±22.87）ml/min显著增加，透析器膜面积干预后（1.71±0.13）m2较干预前（1.66±0.17）m2也显著增加。患者的Kt/V干预后（1.35±0.19）较干预前（1.07±0.10）显著改善。结论：通过采取个体化干预措施能显著改善维持性血液透析患者的透析充分性。     

血液透析患者背力测定技术规范的临床研究

目的:肌肉力量是血液透析患者全因死亡率的独立预测因子。背力作为核心力量,能反映人体的全身肌肉力量水平,具有握力、捏力等不能比较的优势。目前对于血液透析患者尚无背力研究的相关文献和报道。我们希望通过研究血液透析患者背力测定技术规范,为长期开展背力研究工作提供依据。方法:入选我院长期规律血液透析患者92名,标准化背力测量流程和方法,研究背力重测的信度,以及透析间隔对背力影响、透析前后背力变化,观察背力测量的并发症。结果:背力重测ICC=0. 961;重测散点图提示呈直线相关。透析前背力均值(81. 54±28. 00) kg,透析后(73. 08±25. 56) kg,两者比较有显著性统计学差异。每周3次透析频次血液透析患者30例,短、长透析间隔背力均值分别为(82. 57±27. 16)、(82. 47±27. 70) kg;每2周透析5次患者34例,短透析间隔和长透析间隔背力均值分别为(84. 24±32. 63)、(81. 82±31. 17) kg;每周2次透析频次患者28例,短、长透析间隔背力均值分别为(76. 04±26. 39)、(77. 61±25. 99) kg。不同透析频率的不同透析间隔背力比较均无显著性统计学差异。结论:背力重测信度高,透析不同时间间隔对背力无影响,且背力测量简单、无创,适合作为血液透析患者肌肉力量和身体状况的评估监测工具。     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.