腹部小手术史患者单通道输尿管镜辅助下腹膜透析管置入技术的应用

目的 探讨既往有腹腔小手术史患者单通道输尿管镜辅助下腹膜透析管置入技术临床应用的安全性及其意义.方法 选择既往有腹部小手术史的终末期肾脏病患者13例,所有患者均自愿选择腹膜透析替代治疗,使用Peer-Away鞘建立腹腔单通道,输尿管镜进入腹腔,观察腹腔内是否存在粘连,并酌情分离粘连,将腹膜透析管放置于膀胱直肠窝或子宫直肠窝,近端建立皮下隧道并经左下腹戳洞引出.结果 13例患者中12例见腹腔内粘连,通过输尿管镜简单分离粘连并直视下置管,所有腹膜透析管均放置成功,手术时间（44 ±13）分钟,术中追加麻药（15±6）ml,术中出血极少,无出血导致输血情况发生.所有患者随访时间6个月,腹膜透析顺利,未见漂管、渗漏、堵管等并发症.结论 既往有腹部小手术史患者,单通道输尿管镜辅助下腹膜透析管定位精确,安全可靠,并发症少,有助于观察腹腔内情况,并可酌情分离腹腔内粘连.     

性别差异在慢性阻塞性肺疾病中的研究进展

世界卫生组织分析慢性阻塞性肺疾病已成为全球范围内第4位致死原因,且患病人数呈逐年上升趋势,尤其是女性.男性和女性患者在流行病学、危险因素、生活质量、对治疗的反应等方面均存在性别差异.本文就二者在慢性阻塞性肺疾病发病机制、疾病管理等方面的最新研究进展作一综述.     

The impact of dialysis modality on quality of life: a systematic review

Background: This systematic review aims to generate evidence on which dialysis modality (in‐centre haemodialysis HD, or peritoneal dialysis, PD) improves the quality of life (QOL) of end stage renal disease (ESRD) patients. Methods: MEDLINE, CINAHL and EMBASE were searched from their inception to July 2010 for studies that compared QOL in both HD and PD patients. Results: Only 26 of the 574 studies identified were included in this review. These were crosssectional, longitudinal or retrospective in design. QOL tools used include SF‐36, Kidney Disease Quality of Life (KDQOL) and CHOICE Health Experience Questionnaire (CHEQ). PD patients mostly rate their QOL higher than HD patients. Yet HD patients may enjoy a relatively better QOL in the physical dimensions over time. Mental health components are comparable between both dialysis populations. Conclusion: There is no simple ‘yes’ or ‘no’ answer to the question of which dialysis modality improves QOL. However a good understanding of the evidence base will facilitate individual decision‐making.     

Renal replacement therapy in Slovenia: 2003 annual report

The total number of end-stage renal disease patients treated by renal replacement therapy increased from 1584 on 31 December 2002 to 1661 on 31 December 2003 (4.9% increase). Of these patients, 70.5% were treated by hemodialysis, 7.0% by peritoneal dialysis and 22.5% had a functioning renal graft. The patients were treated at 18 dialysis centers and one transplant center. The number of prevalent patients treated by renal replacement therapy per million of the population (p.m.p.) was 846 at the end of 2003. The number of incident (new) patients in 2003 was 131 p.m.p. The gross mortality rate of dialysis patients was stable through the years of the study and reached 11.8% in 2003. 57.6% of new patients starting hemodialysis were > or = 65 years old and 23.2% were diabetics. Epoetin therapy was prescribed to 89.8% of dialysis patients. The number of patients positive for hepatitis B or hepatitis C viruses is stable and low (3.1% of all dialysis patients).     

High density lipoprotein (HDL) particle composition in patients with end stage renal failure (ESRF) on chronic dialysis

Background: Hypertriglyceridaemia, low high density lipoprotein (HDL) cholesterol level and reduced LDL particle size are the major features of uraemic dyslipidaemia. They are also found in the Insulin Resistance Syndrome. Aim: To examine alterations in HDL composition in patients on chronic dialysis and their relationship with insulin resistance. Methods: HDL particle size was determined in 33 patients on chronic haemodialysis (HD), 27 on chronic ambulatory peritoneal dialysis (CAPD) and 32 control non-diabetic subjects (C) without renal disease by non-denaturing 3–30% polyacrylamide gradient gel electrophoresis. A weighted HDL particle size score was calculated taking into account both HDL particle size and percentage total HDL protein concentration of each HDL band of the individual. lipid and apolipoliprotein concentrations were determined in HDL2 and HDL3 particles obtained by sequential ultracentrifugation. In a subset of 24 control subjects and 22 subjects on HD, insulin sensitivity was also determined by an intravenous glucose tolerance test (IVGTT). Results: HDL particles were found to be more triglyceride enriched and apoAI depleted in subjects on HD even though plasma triglyceride level was highest in patients on CAPD. Five subpopulations of HDL particles were identified by gradient gel electrophoresis in all subjects combined. In the subgroup of subjects who underwent IVGTT, the weighted HDL particle size score correlated positively with HDL cholesterol level 0=0.6, p<0.0005), LDL particle size (r=0.47, p>0.001), and insulin sensitivity (r=0.48, p<0.001), and negatively with plasma triglyceride level (r=-0.37, p<0.01). Conclusions: We conclude that even though HDL cholesterol is reduced to a similar level in subjects on both forms of dialysis for end stage renal failure, abnormalities of HDL composition are more marked in subjects on HD. Reduction in HDL particle size is linked with insulin resistance and accompanies reduction in LDL particle size and hypertriglyceridaemia.     

Beta2-microglobulin amyloidosis in hemodialysis and peritoneal dialysis patients

Beta(2)-microglobulin (beta(2)-M) amyloidosis is an important cause of morbidity in patients on dialysis. In this cross-sectional study, we evaluated supraspinatus tendon thickness (as a measure of shoulder involvement from beta(2)-M amyloidosis) in patients who are on hemodialysis (HD) compared with those on continuous ambulatory peritoneal dialysis (CAPD). In 27 patients on HD who were treated with high-flux dialyzers, 31 patients on CAPD, and 31 healthy volunteers, we performed bilateral shoulder magnetic resonance imaging and measured the supraspinatus tendon thickness using electronic calipers. There were no statistically significant differences in age or dialysis duration between the HD and CAPD patients. Each patient was asked about the presence or absence of shoulder pain. The supraspinatus tendon thickness in HD patients (mean thickness 6.6 +/- 1.3 mm, range 3.20-8.80 mm, N = 53) and CAPD patients (6.8 +/- 0.9 mm, range 4.9-8.8 mm, N = 61) was not significantly different (P = 0.289); however, the mean thickness in either group was higher than in the healthy controls (5.5 +/- 0.6 mm, range 4.3-6.8 mm, N = 61) (HD patients vs. controls: P = 0.000; CAPD patients vs. controls: P = 0.000). Patients with shoulder pain had higher mean supraspinatus tendon thickness measurements than patients without shoulder pain (P = 0.042). The thickness of supraspinatus tendons is not significantly different between patients on CAPD and HD. An association exists between shoulder pain and mean supraspinatus tendon thickness. This hidden complication of ESRD should be further studied in larger populations of dialysis patients.     

Evaluating Factors Contributing to Dropout in a Large Peritoneal Dialysis Program

BackgroundThe low prevalence of peritoneal dialysis (PD) (9%) vs. hemodialysis (HD) (88.2%) is partly due to patient dropout from therapy.MethodsThis retrospective study identified patients who withdrew from PD between 2016 and 2018 in our program. We evaluated all other factors as controllable losses. Analysis included time on therapy at dropout (very early, early or late) and method of initiation (HD to PD conversion, unplanned PD, or planned start).ResultsEighty-three patients enrolled into our PD program. 27 dropped out; 24 were due to controllable factors, 3 due to death, with a median age at dropout of 52 years old. We determined psychosocial factors (PF) to be the largest controllable factor influencing dropout; contributing a 63% rate among all controllable factors. When considering time until dropout, 100% of very early dropout patients and 50% of late dropout patients did so due to PF. Among early dropout patients 67% dropped out due to other medical reasons. The mean time to dropout for PF, other, and infection (INF) were 13, 26, and 33 months, respectively. When considering type of initiation, we found PF to be the largest attributable factor with 50% of unplanned, 100% of planned, and 50% of conversions stopping therapy.ConclusionsOur study indicates that the primary reason for controllable loss from therapy was secondary to PF regardless of the time on therapy or the method of initiation to therapy.     

Association of Lower Serum Bilirubin With Loss of Residual Kidney Function in Peritoneal Dialysis Patients

Bilirubin is recognized as an endogenous antioxidant, and low serum bilirubin is reported to be associated with the progression of kidney disease. However, it is unclear whether serum bilirubin levels are associated with the loss of residual kidney function (RKF) in peritoneal dialysis (PD) patients. This study investigated the relationship between serum total bilirubin and loss of RKF. We prospectively followed 94 PD patients who started PD in our hospital between June 2006 and May 2016. Ten patients who had chronic liver disease or cirrhosis were excluded. Patients were divided into three groups based on serum total bilirubin concentration tertiles: tertile 1 (T1) < 0.3, T2 = 0.3, and T3 ≥ 0.4 mg/dL. We estimated the relationship between serum bilirubin and loss of RKF, defined as daily urine volume (<100 mL) within 3 years after starting PD, using a Cox proportional hazards model. During the 3‐year observation period, 22 patients lost RKF. The incidence rate of loss of RKF increased linearly with the decrease in serum total bilirubin levels (P for trend < 0.05). After adjusting for confounding factors, low serum total bilirubin level was shown to be an independent predictor of loss of RKF (hazard ratio [HR] for every 0.1 mg/dL decrease, 1.50; 95% confidence interval [CI], 1.01–2.51; HR [95%CI] for T2 and T1 [vs. T3] 2.03 [0.65–7.88] and 3.70 [1.00–15.9]). This study suggests that low serum total bilirubin levels are associated with the loss of RKF in PD patients.     

Cardiovascular calcification in patients with end-stage renal disease

Vascular calcifications are very frequent extraosseous calcifications in patients with chronic renal disease. They occur in the intima and in the media. They are associated with decreased arterial elasticity and increased mortality. The risk factors are: advanced age, duration of dialysis treatment, diabetes, increased phosphate concentration, the dose of Ca-containing phosphate binders and inflammation. It is now well established that vascular smooth muscle cells actively take up phosphate to form bioapatite. This process is associated with a phenotypic transformation of vascular smooth muscle cells during which they express osteoblast markers. Lipids and inflammatory cytokines also increase bioapatite formation. Calcification inhibitors are matrix Gla protein and fetuin-A. Decreased serum fetuin-A concentration is associated with a higher mortality rate in dialysis patients. An important preventive measure for vascular calcification is the substitution of Ca-containing by non-Ca-containing phosphate binders.     

Association Between Dialysis Modalities and Risk of Coronary Artery Disease: A Population‐Based Cohort Study in Taiwan

The hemodynamic effects of hemodialysis (HD) and peritoneal dialysis (PD) on end‐stage renal disease (ESRD) patients differ. The influence of dialysis modalities on the cardiovascular system has not been well investigated. We aimed to evaluate the association between dialysis modalities and risk of coronary artery disease (CAD) by using the claim data of Taiwan's Longitudinal Health Insurance Database. This study followed up a cohort of 1624 new onset ESRD patients (≥18 years old), who had started renal replacement therapy during 2000 to 2010; and was followed until 2012. After adjusting for potential confounders, patients who underwent HD had significantly higher risks of incidence of CAD, in comparison with patients who underwent PD (adjusted hazard ratio = 1.47; 95% confidence interval = 1.01–2.11). An increased risk of incident CAD was distinguished in patients receiving HD, compared with those on PD. Further studies are warranted to explore the underlying mechanism and improve dialysis outcomes.     

Randomized,Double‐Blind,Placebo‐Controlled Trial of Spironolactone for Hypokalemia in Continuous Ambulatory Peritoneal Dialysis Patients

The incidence of hypokalemia in continuous ambulatory peritoneal dialysis (CAPD) patients is about 15–60%, leading to significant complications. There is no standard treatment other than potassium supplement in this setting. The aim of this study was to evaluate effect of spironolactone 25 mg/day in CAPD patients who have a history of hypokalemia. This is a randomized, double‐blind, placebo‐controlled, cross‐over study in CAPD patients who had a history of hypokalemia. Study intervention is 4 weeks of oral spironolactone 25 mg/day or placebo, cross‐over after a 2‐week wash‐out period. The primary outcome was the difference of serum potassium before and after 4 weeks of spironolactone treatment. Serum potassium was measured every 2 weeks, serum magnesium, urine and peritoneal fluid potassium measured before and after each treatment period. We enrolled 24 patients, and 20 completed the cross‐over study. Ten patients were anuric. The total doses of potassium supplement were the same during the study period. Serum potassium levels before and after study intervention were not significantly different in both groups (4.23 ± 0.64 vs. 3.90 ± 0.59 mEq/L for spironolactone P = 0.077 and 3.84 ± 0.62 vs. 3.91 ± 0.52 for placebo P = 0.551). Total 24‐h potassium, magnesium, sodium excretion, urine volume and ultrafiltration volume were not affected by spironolactone or placebo. There was one episode of hyperkalemia (5.6 mEq/L) during the spironolactone treatment period. Spironolactone 25 mg/day does not have a significant effect on serum potassium or urine and peritoneal excretion rate in CAPD patients who have a history of hypokalemia.     

连续性不卧床腹膜透析治疗艾滋病并发终末期肾脏病(附一例报道)

目的：观察连续性不卧床腹膜透析（CAPD）对艾滋病（acquired immunodeficiency syndrome,AIDS）并发终末期肾脏病（ESRD）的疗效。方法：一例确诊为艾滋病的男性患者,合并慢性丙型肝炎、血友病甲（Ⅷ因子缺乏）和糖尿病,高效抗逆转录病毒治疗（HAART）1年后出现蛋白尿及肾功能不全,进展至ESRD后行CAPD治疗,观察CAPD前后残余肾功能、贫血、钙磷代谢、心功能、营养状况等变化,并进行透析充分性及并发症评估。结果：患者行CAPD治疗后高血压、贫血、氮质血症、酸中毒及心功能均明显改善,体重稳定,无水肿,Kt/V2.01/周,nPCR1.133g/（kg.d）。存在营养不良-炎症-心血管疾病综合征及代谢紊乱。结论：AIDS并发ESRD行CAPD作为肾脏替代治疗可取得满意疗效。     

性别差异对中重度慢性阻塞性肺疾病患者运动耐力的影响

目的 比较中重度慢性阻塞性肺疾病(COPD)患者运动耐力的性别差异.方法 本研究对151例中、重度COPD患者的肺功能(PFT)和功率递增心肺运动试验(CPET)结果进行了分析.将患者分为Ⅱ级COPD组和Ⅲ级COPD组.并选择43例年龄、性别、身高、体质量相匹配的正常人作为对照组.本研究测定第1秒用力呼气容积(FEV1)、用力肺活量(FVC)、峰值运动功率(Peak Load)、峰值摄氧量(Peak (V)O2)、峰值心率(Peak HR)、峰值氧脉搏(Peak(V)O2/HR)、最大分钟通气量(M(V)E)、气促指数(M(V)E/MVV)等指标.本研究分别在不同COPD分级和性别之间分析比较了上述指标的差异.结果 Ⅱ级COPD组和Ⅲ级COPD组的女性患者的Peak (V)O2实/预％和Peak (V)O2/HR实/预％较同组男性更高(P值均＜0.05).Ⅲ级COPD男性患者的运动耐力较Ⅱ级有明显降低(P＜0.0001),然而,Ⅲ级、Ⅱ级COPD女性患者之间运动耐力差异无统计学意义(P=0.246).结论 在中、重度COPD患者中,男性运动耐力下降较女性更为严重,吸烟可能是造成这一差异的重要因素.     

慢性肾衰竭117例血液透析时机的调查

目的　调查慢性肾衰竭 (CRF)患者开始血液透析的时机以及影响因素。方法　调查 2 0 0 1- 0 12 0 0 2 - 12于北京大学第一医院血液透析中心治疗的 117例非糖尿病性CRF患者开始透析时肌酐清除率 (Ccr)、血肌酐 (Scr)、尿毒症症状、并发症以及首次透析的情况 ,比较不同透析时机患者间的差别 ,分析影响透析时机的因素。结果　 (1)进入透析时Ccr为 (4 18± 3 2 6 )mL/min。 (2 ) 87 18%患者有明显尿毒症症状 ;5 5 0 0 %营养状态下降 ;71 79%出现心、脑并发症 ;2 7 35 %需急诊透析。 (3) 83 76 %患者透析时机过晚 ,原因以CRF发现过晚最多见 (76 5 2 % )。结论　 (1)近 2年开始血液透析的CRF患者多数透析时机过晚。 (2 )健康宣教、疾病筛查以及医疗保健是影响透析时机的关键因素。     

Nutritional status evaluated by multi-frequency bioimpedance is not associated with quality of life or depressive symptoms in hemodialysis patients

Hemodialysis therapy significantly impacts on patients' physical, psychological, and social performances. Such reduced quality of life depends on several factors, such as malnutrition, depression, and metabolic derangements. This study aims to evaluate the current nutritional status, quality of life and depressive symptoms, and determine the possible relationships with other risk factors for poor outcomes, in stable hemodialysis patients. This was a single-center, cross-sectional study that enrolled 59 adult patients undergoing hemodialysis. Laboratory tests that included high-sensitivity c-reactive protein (CRP), and quality of life and depressive symptom evaluation, as well as malnutrition-inflammation score, nutritional status and body composition (by direct segmental multi-frequency bioimpedance analysis) determinations were performed. Patients were classified as "underfat", "standard", "overfat", or "obese" by multi-frequency bioimpedance analysis. Seven patients were underfat, 19 standard, 19 overfat, and 14 obese. Triglyceride levels significantly differed between the underfat, standard, overfat, and obese groups (1.06 [0.98-1.98]; 1.47 [1.16-1.67]; 2.53 [1.17-3.13]; 2.12 [1.41-2.95] mmol/L, respectively; P=0.026), as did Kt/V between the underfat, overfat, and obese groups (1.49 ± 0.14; 1.23 ± 0.19; 1.19 ± 0.22; P=0.015 and P=0.006, respectively). Depressive symptoms, quality of life, and CRP and phosphate levels did not diverge among nutritional groups. Creatinine, albumin, and phosphate strongly correlated, as well as percent body fat, body mass index, and waist circumference (r=0.859 [P<0.001], and r=0.716 [P<0.001], respectively). Depressive symptoms and physical and psychological quality-of-life domains also strongly correlated (r(s) = -0.501 [P<0.001], r(s) = -0.597 [P<0.001], respectively). The majority of patients were overfat or obese and very few underfat. Inflammation was prevalent, overall. No association of nutritional status with malnutrition-inflammation, quality of life, or depressive symptoms could be established.     

Slovenian Renal Replacement Therapy Registry: Excerpts From the 2006 Annual Report

The total number of end‐stage renal disease patients treated by renal replacement therapy (RRT) in Slovenia on 31 December 2006 was 1835, that is, 913 per million population (pmp). Of these patients, 1271 (69%) were treated by hemodialysis, 102 (6%) by peritoneal dialysis, and 461 (25%) had a functioning kidney graft. Two hundred and forty‐nine incident patients, 124 pmp (at day one), started RRT: median age 66 years, 60% men, 30.5% diabetics. Of the hemodialysis patients, 77% were dialyzed in hospital and 23% in private dialysis centers. Hemodiafiltration was used in 38% of the hemodialysis patients. The vascular accesses were native arteriovenous fistulas in 84%, polytetrafluoroethylene grafts in 5%, and hemodialysis catheters in 11% of patients. The crude death rate of dialysis patients was 14.7%, of transplant recipients 1.35%, of both dialysis and transplant patients 11.4%. The number of patients positive for hepatitis B or C viruses is stable and low at 2.3% of the dialysis patients.