两种不同血液净化治疗方式对尿毒症脑病疗效分析

<正> 此文报道应用两种不同血液净化方式救治72例尿毒症脑病患者的疗效分析结果。 1 对象和方法 1.1 研究对象:作者医院2004-01-01—2009-12-31收治的尿毒症患者72例,男41例、女31例,年龄19～68岁,平均(42.1 6±12.31)岁,其中慢性肾小球肾炎45例,糖尿病肾病14例,梗阻性肾病5例,高血压性肾损害6例,狼疮性肾炎2例。所有患者符合慢性肾衰竭的诊断标准,伴有中     

间歇与连续性透析对终末期肾病合并脑出血患者血流动力学影响的对照研究

目的探讨不同透析模式下(间歇性与连续性)对终末期肾病合并脑出血患者的血流动力学的影响。方法选择2010-01—2016-12至我院血液净化中心治疗的明确诊断为终末期肾病合并脑出血患者36例,随机分为间歇性透析组与连续性透析组,分别进行透析治疗,比较透析期间患者的心脏指数、每搏量等血流动力学指标,颅内压的变化及血管活性肽、氧化及炎症因子变化情况。结果透析前通过神经功能评估结果显示,2组脑损伤程度及临床表现无显著性差异;两种透析模式下患者的平均血压无显著性差异;透析期间间歇性透析与连续性透析的心脏输出增加分别为(5.2±1.8)%、(4.9±1.2)%,心脏指数分别为(3.2±1.4)%、(2.6±1.3)%。不同透析模式下未观察到每搏量与每搏量指数的显著差异,然而接受间歇性透析患者的每搏量变异显著高于连续性透析组(P=0.028);透析后3h出现平均颅内压水平显著增加,患者神经损害临床症状随之加重,间断性透析患者尤其明显;血清内皮素-1水平在连续性透析后显著升高(P=0.015),但未见于间歇性透析组患者。结论对于终末期肾病合并脑出血患者,使用间歇性及连续性血液透析对血流动力学的影响无显著性差异;连续性透析能够显著增加血管活性肽的水平,流体反应性较低,间歇性透析具备有效清除小分子毒素的优势。     

贝那普利对腹膜透析大鼠腹膜纤维化的影响

通过大鼠的长期腹膜透析,观察贝那普利在大鼠腹膜透析中对腹膜的影响。 方法：实验于2005－04/2006-04在中南大学湘雅二医院肾内科实验室完成。①实验材料：雄性SD大鼠,体质量180～240g,由中南大学湘雅二医院动物实验中心提供。②实验方法：将40只大鼠按随机数字表随机分为4组,每组10只。正常对照组不予任何干预;生理盐水组腹腔注射20 mL生理盐水;腹膜透析组腹腔注射20mL 4.25%葡萄糖透析液,腹膜透析合并用药组在腹膜透析的同时口服贝那普利片(20mg/kg.d),腹腔注射均为1次/d。4周后,向大鼠腹腔注射4.25% 葡萄糖腹膜透析液20mL,4h后于大鼠右下腹缓慢插入带有多个侧孔的10号静脉留置针,缓慢低位引流腹透液,量取引流液。③实验评估：取大鼠壁层腹膜组织,VG法染色光学显微镜观察,镜下测量腹膜胶原厚度。 结果：37只大鼠均进入结果分析,3只大鼠死亡。①单纯腹膜透析组的超滤量分别与正常对照,生理盐水对照组比较,均明显下降,口服用药组的超滤量比单纯腹透组明显提高,（P均< 0.05）。②与正常对照组相比,单纯腹膜透析组的腹膜厚度增加最明显,口服用药组的腹膜尽管比正常对照组明显增厚,但与单纯腹透组比较,己有显著减轻,（P均< 0.05）。结论：1. 在大鼠长期维持性腹膜透析中,服用贝那普利能有效的保护腹膜的超滤功能,减轻腹膜的纤维化。     

高通量透析膜对C-反应蛋白及血脂代谢的影响

背景：传统低通量透析不能改善微炎症状态和脂质代谢紊乱,新型的高通量透析则可以很好的改善这种微炎症状态和脂质代谢,有助于提高患者的生活质量和存活率,因此如何改善微炎症状态和脂质代谢成为人们研究的热点。 目的：观察高通量和低通量聚砜膜血液透析器对维持性血液透析患者血浆超敏C-反应蛋白及血脂代谢的影响。 方法：将44例维持性血液透析患者随机分为高通量透析组和低通量透析组,另选22例健康体健者作为正常对照组。高通量透析组使用高通量透析器FX60,低通量透析组使用低通量透析器F6,均每周透析3次,每次透析4 h;治疗1年后,分别比较两组患者治疗前后及与正常对照组的血超敏C-反应蛋白与总胆固醇、三酰甘油及低密度脂蛋白胆固醇等指标的变化。 结果与结论：两组治疗前血浆超敏C-反应蛋白与三酰甘油、总胆固醇及低密度脂蛋白胆固醇水平均高于正常对照组(P < 0.05);治疗后高通量透析组患者的血浆超敏C-反应蛋白与总胆固醇、三酰甘油及低密度脂蛋白胆固醇水平明显下降(P < 0.05),而低通量透析组无明显变化(P > 0.05)。结果提示采用高通量FX60聚砜膜透析器进行透析能改善维持性透析患者的微炎症状态及脂质代谢。 关键词：高通量透析;血液透析膜;血浆超敏C-反应蛋白;血脂;膜材料 doi:10.3969/j.issn.1673-8225.2010.25.032     

社会心理因素对终末期肾病行腹膜透析患者康复结局的影响*

目的：分析社会心理因素对终末期肾病行腹膜透析患者康复结局的影响。 方法：选择2005-08/2007-03北京大学第一医院肾内科腹膜透析中心确诊的终末期肾病接受腹膜透析治疗患者171例,男66例,女 105例,年龄(60±13)岁,平均透析时间22.8个月。采用问卷调查与访谈相结合方法对患者的康复结局进行评定：主要利用Karnofsky活力指数评估活动状况;采用社会功能缺陷筛选表评估社会参与状况。评估患者的心理社会因素主要采用Hamilton抑郁、焦虑等级量表、医学应对方式问卷和社会支持评定量表。 结果：共发放问卷200份,回收有效问卷171份,占85.5%。本组患者活动正常者134例,占78.4%;存在参与受限者129例,占75.4%;焦虑症状的发生率为24.5%(42例),抑郁症状的发生率为8.2%(15例)。本组患者对疾病在采取“屈服”应对方式方面的得分显著高于其他慢性病患者,而“面对”和“回避”两种应对方式的采用与其他患者无统计学差异。将反映康复结局的活动、参与指标作为因变量,社会心理因素中的抑郁焦虑水平、应对方式、社会支持等作为自变量,用多元逐步标准回归篩除法,找出影响康复结局的相关因素,最后进入回归模型的因素为患者的抑郁程度、对疾病采取面对或屈服应对方式、对社会支持的利用程度。 结论：社会因素中患者对社会支持的利用程度、心理因素中患者的抑郁状况及对疾病所采取的应对方式等因素对终末期肾病患者的康复结局有重要影响。     

维持性血液透析患者并发脑血管病的原因分析及护理对策

2008-01—2011-07我们通过针对维持性血液透析患者高血压的原因,提出相应的护理对策,以提高透析患者的透析质量和生存率,总结如下。1资料与方法1.1一般资料本组138例,男87例,女51例;年龄20～83岁,平均(56.4±18.4)岁。其中慢性肾炎61例,高血压肾病16例,糖尿病肾病42例,梗阻性肾病5例,痛风性肾病3     

行血液净化的肾病患者血管通路的护理

1资料与方法1.1临床资料2003—2006年收治当初行血液净化和后来发展为血液净化患者121例,行动—静脉内瘘成形术38例,临时插管87例,半永久置管17例;其中男79例,女42例;年龄23~78岁。原发病包括慢性肾小球肾炎30例,糖尿病肾病63例,梗阻性肾病19例,先天性多囊肾7例,先天性多囊     

终末期肾功能衰竭腹膜透析患者的生命质量调查

目的调查终末期肾功能衰竭腹膜透析患者的生命质量.方法运用健康状况调查问卷(SF-36)测定41名腹膜透析病人,并与1455名社区老年人群生命质量常模进行了对照.结果与正常组对照腹膜透析病人几乎所有生命质量亚量表分数低于正常者(包括生理机能、躯体疼痛、一般健康状况、精力、情感职能和精神健康等,P＜0.01).患者的腹膜透析时间与精神健康、躯体疼痛和社会功能(P＜0.05)呈负相关.白蛋白水平与健康变化呈负相关(P＜0.05);与躯体疼痛呈正相关(P＜0.05).结论终末期肾功能衰竭腹膜透析患者的生命质量随着腹透病程时间而下降.本研究提示应对腹膜透析患者以更多的心理关心和营养支持.     

急性脑血管病并发急性肾衰竭的腹透治疗及护理对策

目的探讨急性脑血管病并发急性肾衰竭的腹透治疗及护理对策。方法对26例急性脑血管病并发急性肾衰竭的患者进行腹膜透析治疗及临床护理观察。结果本组26例,存活22例(占84.6%)。20例肾功能恢复正常,恢复时间8～40d。2例肾功能未恢复正常者中1例有高血压史15年,另1例有糖尿病史10年,4例死亡。结论监测肾功能、早期行腹膜透析治疗,可提高急性脑血管病并发急性肾衰竭患者的生存率和康复率。     

高通量透析膜对维持性血液透析过程中溶质清除及皮肤瘙痒的作用

背景：如何有效地清除尿毒症毒素,以减少透析患者的并发症,改善维持性血液透析患者生活质量及长期预后,一直是人们研究的热点。 目的：观察高通量和低通量聚砜膜血液透析器对维持性血液透析患者溶质清除及皮肤瘙痒的作用。 方法：选择皮肤瘙痒的维持性血液透析患者38例,随机分为高通量透析组和低通量透析组,每组19例。高通量透析组使用高通量透析器FX60,低通量透析组使用低通量透析器F6,均每周透析3次,每次透析4 h,观察1年;检测血尿素氮、肌酐、磷、β2微球蛋白及甲状旁腺素;观察透析前后各种溶质含量的变化,计算溶质清除率和尿素清除指数(Kt/V值);用目测类比评分法评估瘙痒程度。 结果与结论：两组患者透析后尿素氮、肌酐下降率差异无显著性意义(P > 0.05),磷和β2微球蛋白的下降率高通量透析组均高于低通量透析组(P < 0.05),两组Kt/V相比差异无显著性意义(P > 0.05);治疗1年后高通量透析组甲状旁腺素显著低于低通量透析组(P < 0.05),皮肤瘙痒与治疗前相比两组均有减轻(P < 0.05),高通量透析组瘙痒程度评分显著低于低通量透析组(P < 0.05)。提示采用高通量FX60聚砜膜透析器进行透析,不仅充分清除小分子毒素,而且增加了对于大、中分子毒素的清除,能改善维持性透析患者顽固性皮肤瘙痒症状。     

The influence of cerebrovascular risk factors on incident dementia in patients with Parkinson's disease

OBJECTIVE: To examine if risk factors for cerebrovascular disease would increase the risk for dementia in patients with Parkinson's disease (PD). METHODS: Non-demented patients were recruited from an epidemiological study of PD in the county of Rogaland, Norway. PD and dementia were diagnosed according to strict diagnostic criteria. Established cerebrovascular risk factors were recorded at baseline, and their influence on incident dementia was assessed 4 years later using logistic regression analysis. RESULTS: A total of 171 non-demented PD patients constituted the at-risk population. Seventy-two (55%) had at least one cerebrovascular risk factor. A total of 130 subjects (96% of survivors) completed the follow-up examination. Forty-three (33%) new cases of dementia were found. Twenty-five of the 72 (35%) patients with and 18 of the 58 (31%) subjects without any risk factor developed dementia (ns). A significant association with dementia was found for a diagnosis of heart failure in the univariate analyses. However, in the logistic regression analysis none of the cerebrovascular risk factors were significantly associated with incident dementia. CONCLUSIONS: In this large and representative cohort of patients with PD cerebrovascular risk factors were not associated with incident dementia, indicating that the disease-related degenerative brain changes are the main causes of dementia in PD.     

Patients on peritoneal dialysis but not on hemodialysis have elevated concentration and activity of thrombin-activatable fibrinolysis inhibitor.

Cardiovascular disease (CVD) is a leading cause of death in patients on dialysis. Increased concentration of fibrinogen, dyslipidemia and impaired fibrinolysis are regarded as important risk factors for CVD. Thrombin-activatable fibrinolysis inhibitor (TAFI) is a recently discovered inhibitor of the fibrinolytic system. The aim of this study was to investigate whether peritoneal dialysis (PD) and hemodialysis (HD) patients differ with regard to TAFI concentration and/or its activity. We also measured albumin, cholesterol, triglycerides and fibrinogen. The study was performed on 35 chronically dialyzed patients (14 on PD and 21 on HD) and 18 healthy volunteers. TAFI antigen and its activity were measured with commercially available kits. Albumin, cholesterol, triglycerides and fibrinogen were measured using standard laboratory methods. Only PD patients had significantly elevated level of TAFI antigen and its activity compared to control subjects. Differences in TAFI concentration and its activity between PD and HD were at the level of statistical significance (P=.09 and P=.07, respectively). PD patients had significantly higher concentration of cholesterol and triglycerides than HD group. Fibrinogen was elevated significantly in PD patients compared to HD and controls. There was no difference in albumin concentration between PD and HD. Significant positive correlations were found between fibrinogen or triglycerides and TAFI activity only in PD patients. We conclude that the above phenomenon may predispose PD patients to suppression of fibrinolysis.     

Severity and specificity of cognitive impairment in Alzheimer's, Huntington's, and Parkinson's diseases and progressive supranuclear palsy

To investigate differences in severity and specificity of cognitive impairment among various neurodegenerative diseases, we tested groups of patients presenting with senile dementia of the Alzheimer type (SDAT; 44), progressive supranuclear palsy (PSP; 45), Huntington's disease (HD; 35) and Parkinson's disease (PD; 164), with an extensive neuropsychological battery. We found dementia, as defined by a global intellectual performance 2 standard deviations lower than mean control values, in 93% of SDAT, 66% of HD, 58% of PSP, and 18% of PD patients. Specific features of cognitive impairment distinguished the four groups of patients once they were matched for level of intellectual deterioration: remote memory and linguistic disorders in SDAT, frontal lobe-like abnormalities in PSP, concentration and acquisition disorders in HD. There was no specific alteration in demented PD patients. This study demonstrates the frequency of dementia in predominantly subcortical degenerative diseases and indicates that "subcortical dementia," rather than being a homogeneous entity, should be divided into specific subtypes of cognitive impairment related to different underlying specific lesions of each disease.     

Oxidative stress effects fibrinolytic system in dialysis uraemic patients

INTRODUCTION: Enhanced oxidative stress (SOX) and changes in the fibrinolytic system are common in end-stage renal failure patients undergoing maintenance dialysis. This study attempted to verify the existence of a relationship between SOX documented by Cu/Zn superoxide dismutase (Cu/Zn SOD) and fibrinolysis analyzed by tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor 1 (PAI-1) and plasmin/antiplasmin (PAP) complexes in dialysis patients. MATERIALS AND METHODS: Twenty-seven patients on maintenance haemodialysis (HD) and 16 on maintenance peritoneal dialysis (CAPD) were examined together with 18 healthy controls. Pre-dialysis blood levels of all the parameters were determined using commercially ELISA kits. RESULTS: Cu/Zn SOD, uPA and PAP levels were increased in both groups of dialyzed patients compared to the controls. PAI-1 was significantly lower in CAPD subjects compared to HD subjects and control group. PAI-1/uPA ratio and PAI-1/tPA ratio were significantly decreased in CAPD and HD compared to controls, being significantly lower in CAPD patients relative to HD patients. In the patients, increased Cu/Zn SOD levels directly correlated with those of uPA (r=0.565, p<0.0001) and PAP (r=0.335, p<0.05); the fibrinolytic markers were also positively associated with each other (r=0.377, p<0.05). CONCLUSIONS: The positive association between Cu/Zn SOD and both uPA as well as PAP levels suggests a link between SOX and the fibrinolytic activity in dialysis patients. We hypothesize that increased SOX-mediated fibrinolytic activity may be a part of the counter-system against activation of blood coagulation in these patients.     

Alteration of serum semicarbazide-sensitive amine oxidase activity in chronic renal failure

Summary Despite recent intensive investigations, physiological and pathological role of semicarbazide-sensitive amine oxidase (SSAO) is far from clear. In this study, serum SSAO activity was determined, radiochemically, in various groups of uremic patients: haemodialysed (HD), peritoneally dialysed (PD) and those receiving conservative treatment but still not dialysed (ND), as well as in controls. Reduced enzyme activity was found in HD uremic patients before and after dialysis treatment, compared to controls (5260 ± 862 and 6011 ± 958 pmol/h/ml vs. 8601 ± 283 pmol/h/ml, p < 0.01 and p < 0.05, respectively). The activity was slightly lower in PD, and normal in ND patients. In HD patients SSAO activity was also determined by an assay based on the formation of hydrogen peroxide, and was found to be elevated compared to controls (2384 ± 323 pmol/h/ml vs. 1437 ± 72 pmol/h/ml, p < 0.05). The elevated serum SSAO activity measured through the detection of the enzyme-generated hydrogen peroxide in HD patients might indicate its contribution to the accelerated atherosclerotic disease observed in uremia.     

65例青年人脑梗死的临床特点

目的分析青年人脑梗死的临床特点。方法回顾性分析65例青年脑梗死患者的临床资料,探讨其病因、危险因素和预后等临床特点。结果有明确病因者38例(58.46%),其中动脉粥样硬化25例(38.46%),心源性脑栓塞10例(15.38%),梅毒性动脉炎2例(3.08%),真性红细胞增多症1例(1.54%);病因不明者27例(41.54%)。主要危险因素有吸烟、高血压、血脂异常、脑血管疾病家族史、肥胖、酗酒、TIA病史、糖尿病、房颤等。经治疗基本痊愈22例(33.85%),显著进步16例(24.62%),进步13例(20.00%),无变化14例(21.54%)。结论青年人脑梗死的病因以动脉粥样硬化、心源性脑栓塞、梅毒性动脉炎最常见。以吸烟、高血压、血脂异常等为最常见的危险因素,大多数患者预后较好。     

Risk Factors and Outcomes of Cerebral Stroke in End-Stage Renal Disease Patients Receiving Hemodialysis

Objective: Dialysis patients have a higher incidence of stroke, and outcomes are often poor. Diabetic nephropathy (DN) is a stroke risk-factor, but the importance is unclear in dialysis patients. This study investigated the stroke features and risk factors in hemodialysis (HD) patients. Methods: All end-stage renal disease patients undergoing HD at Teraoka Memorial Hospital dialysis center were identified, with 195 recruited. Baseline clinical characteristics were collected, and the clinical outcomes and related factors of stroke in HD patients were retrospectively analyzed. The incidence rate of stroke and mortality were calculated using Kaplan-Meier survival analysis. Factors potentially related to stroke were analyzed by the log-rank test and Cox proportional hazards model for univariate and multivariate analysis. Results: In total, 21.0% (41 of 195) patients developed stroke. The incidence rates of stroke per 1000 patient-years were 53.6, 65.2, and 34.0 in all HD patients, DN patients, and non-DN patients, respectively. The cumulative incidence rates of stroke in all HD patients, DN patients, and non-DN patients per 5 years, and per 10 years were 22.6%, 43.5%; 28.8%, 59.6%; and 17.6%, 31.1%, respectively. The incidence rate of stroke in the DN patients was significantly higher than in the non-DN patients (P = .013). DN was the significant risk factor for stroke by multivariate analysis (hazard ratio 2.63, 95% confidence interval 1.08-7.85; P = .032). Conclusions: This study revealed the trends of stroke in HD patients at a single institution in Japan. DN was shown to be a significant risk factor for stroke in HD patients.     

2019冠状病毒病合并出血性脑血管病患者临床特点和治疗探讨

目的 分析2019冠状病毒病（coronavirus disease 2019，COVID-19）合并出血性脑血管病患者的临床 特点及治疗经验。 方法 回顾性分析2020年1月13日-3月13日武汉市6家医院连续收治的COVID-19且合并出血性脑血管 病患者的临床资料，描述患者临床特点和治疗经验，比较高血压脑出血患者中行微创治疗和开颅手 术治疗患者的临床特点和术后气管切开率。 结果 研究共纳入82例患者，年龄43～78岁，男性占48.78%（40/82）。轻型肺炎45.12%（37/82），重 症肺炎54.88%（45/82）；高血压脑出血占68.29%（56/82），颅内动脉瘤破裂出血30.49%（25/82）， 出血性烟雾病1.22%（1/82）；71.95%（59/82）的患者进行了针对脑出血的手术治疗，其中高血压脑 出血患者64.41%（38/59），颅内动脉瘤破裂35.59%（21/59），术后气管切开者52.54%（31/59）。高 血压脑出血患者中，开颅手术组15例（39.47%），微创手术组23例（60.53%），两组的年龄、性别分 布、肺炎严重程度和GCS评分差异均无统计学意义，但开颅手术组术后气管切开率高于微创手术组 （93.33% vs 30.43%，P＜0.001）。 结论 COVID-19合并高血压脑出血且需要手术治疗的患者，选择微创手术较开颅手术的气管切开率 更低。     

血管性帕金森综合征临床病例对照研究

目的 探讨脑血管病及其危险因素在帕金森综合征发病中的作用,分析血管性帕金森综合征（VP）与帕金森病（PD）的临床特点。方法 收集在我科住院的86例帕金森综合征及PD,根据有无高血压病、动脉硬化或脑卒中病史,分为VP组和PD组,并对两组的临床特点进行回顾性对比分析。结果 脑血管病及其危险因素在两组间的发生率有显著性差异（P＜0.001),与PD组比较,VP组病人发病年龄偏大（P＜0.01）,临床表现以少动－四肢强直为主,而静止性震颤少见（P＜0.05）,常伴发假性延髓麻痹、尿失禁（P＜0.01）、智能障碍（P＜0.001）等,头颅MRI以基底节区腔隙性脑梗死多见。且左旋多巴的治疗效果多不满意（P＜0.05）。结论 VP是病因、发病机理及临床特征不同于PD的一种帕金森综合征。     

Morphological substrates of parkinsonism with and without dementia: a retrospective clinico-pathological study

A retrospective study of a 50-year autopsy series of 900 patients with the clinical diagnosis of parkinsonism (31.2% with dementia) revealed pure Lewy body disease (LBD) in 84.9%, but only 44.7% with idiopathic Parkinson disease (PD); 16% were associated with cerebrovascular lesions, 14.8% with Alzheimer pathology; 8.9% were classified dementia with Lewy bodies (DLB), 9.4% showed other degenerative disorders, and 5.6% other/ secondary parkinsonian syndromes. The frequency of LBD during different periods was fairly stable, with increase of DLB and PD plus Alzheimer changes, but decrease of associated cerebrovascular lesions during the last decades. Using variable clinical diagnostic criteria not only by specified neurologists, the misdiagnosis rate ranged from 11.5 to 23% and was similar to that in most previous clinico-pathological studies. The majority of cases with false clinical diagnosis of PD had a final pathological diagnosis of DLB with or without Alzheimer lesions. A postmortem series of 330 elderly patients clinically diagnosed as parkinsonism with (37.6%) and without dementia showed that IPD, Braak stages 3-5 were rarely associated with cognitive impairment, which was frequently seen in IPD with associated Alzheimer pathology (35.5%), DLB (33.9%), and in Alzheimer disease (AD) or mixed dementia (17%), whereas it almost never was associated with minor cerebrovascular lesions. Clinico-pathological studies in DBL, demented and nondemented PD, and AD cases showed a negative relation between cognitive impairment and Alzheimer changes, suggesting that these either alone or in combination with cortical Lewy body pathologies are major causes of cognitive dysfunction. Further prospective clinico-pathological studies are needed to validate the currently used clinical criteria for PD, to increase the diagnostic accuracy until effective biomarkers are available, and to clarify the impact of structural and functional changes on cognitive function in parkinsonism as an ultimate goal of early disease detection and effective treatment.