腹腔镜引导下腹膜透析管置放术

目的　探讨腹腔镜引导下放置腹膜透析管的方法。　方法　选择 9例慢性肾功能衰竭患者 ,在腹腔镜引导将Tenckhoff腹膜透析管置入腹腔并经皮下隧道引出。　结果　所有病例腹膜透析管均放置成功。手术时间 10min～ 2 0min。均成功的进行了腹膜透析。患者术后 2～ 7天出院。　结论　腹腔镜引导放置腹膜透析管技术具有透析管定位准确 ,手术切口小 ,术后疼痛轻。优于常规开腹技术     

Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy.

BACKGROUND: Many patients with end stage renal disease (ESRD) undergoing dialysis therapy suffer from sleep disturbances. The aim of this study was to investigate the prevalence of sleep disorders in a large population of uraemic patients recruited from 20 different dialytic centres in Triveneto. METHODS: 883 patients on maintenance dialysis were enrolled in the study. Demographic, lifestyle, renal and dialysis data were recorded. Renal parameters were compared with the database of the Veneto Dialysis Register. Using a self-administered questionnaire we assessed the presence of the following sleep disorders: insomnia, restless leg syndrome (RLS), obstructive sleep apnoea syndrome (OSAS), excessive daytime sleepiness (EDS), possible narcolepsy, sleepwalking, nightmares and possible rapid eye movement behaviour disorders (RBD). Moreover, in order to determine the prevalence of sleep disturbances and the possible effect of demographic or clinical data on sleep, we divided our population into two groups: with (SLEEP+) and without (SLEEP-) sleep disorders. RESULTS: The questionnaire revealed the presence of insomnia (69.1%), RLS (18.4%), OSAS (23.6%), EDS (11.8%), possible narcolepsy (1.4%), sleepwalking (2.1%), nightmares (13.3%) and possible RBD (2.3%). Eighty percent demonstrated SLEEP+, having at least one sleep disorder. Independent risk factors for sleep disorders were advanced age (P<0.001), excessive alcohol intake (P<0.04), cigarette smoking (P<0.006), polyneuropathy (P<0.05) and dialysis shift in the morning (P<0.001). CONCLUSIONS: The questionnaire showed a high presence of sleep disruption in dialytic populations. Awareness by Italian nephrologists regarding sleep disruption seems to be insufficient. Our data might help nephrologists to deal with uraemic patients with possible sleep disorders. Concerning the high prevalence of possible narcolepsy, further studies using polysomnographic records are necessary to confirm our results.     

Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or chronic ambulatory peritoneal dialysis

Hyperprolactinemia is common in patients with renal failure. Because radiographic contrast material given during a computed tomographic (CT) scan of the sella as part of the evaluation for prolactinoma worsens renal insufficiency, we attempted to define the point at which hyperprolactinemia becomes an expected finding in patients with renal insufficiency in this study. Of 59 patients with serum creatinine levels of 1.5 to 12 mg/dL, 16 (27.1%) were hyperprolactinemic. Of these 16, nine were not taking medications known to raise prolactin levels and their prolactin levels were less than 100 ng/mL. In the eight patients taking medications prolactin levels were much higher. In one patient the prolactin level fell from 2,210 to 100 ng/mL when methyldopa was discontinued. In patients with chronic renal failure prolactin levels were similar regardless of the method of dialysis. We conclude that in the absence of medications known to affect prolactin secretion, hyperprolactinemia occurs infrequently (18.3%) and, when it occurs, is mild (less than 100 ng/mL). Marked hyperprolactinemia may occur in patients taking such medications. These should be stopped and the prolactin level rechecked before a CT scan is performed.     

Antibiotic prophylaxis in dialysis patients undergoing invasive dental treatment

BACKGROUND AND AIMS: The role of antibiotic prophylaxis for invasive dental procedures in patients on dialysis therapy is unclear. We examined current clinical practice in Australia and New Zealand and compared our findings to a systematic review of the current literature. METHODS: Australian and New Zealand nephrology units were surveyed with regard to their use of antibiotic prophylaxis for dental procedures. A systematic review of the literature was performed by using an online web-based search engine (PubMed) using the key words: renal patients, dental and antibiotic prophylaxis. RESULTS: Forty-one per cent of respondents do not routinely give antibiotic prophylaxis to haemodialysis patients prior to dental surgery, but a majority (53%) would consider antibiotic prophylaxis if the patient had a synthetic arteriovenous fistula. CONCLUSIONS: The majority of clinicians follow the American Heart Association (AHA) guidelines with a single oral preoperative dose of 2 g amoxycillin or 600 mg clindamycin if patients are allergic to penicillin. From the literature and the data obtained by questionnaire, it would appear that renal patients receiving haemodialysis in Australia and New Zealand receive antibiotic prophylaxis prior to invasive dental procedures. The standard single dose of 2 g amoxycillin orally or 600 mg clindamycin orally 1 h preoperatively, as recommended by the AHA, is most frequently used. Peritoneal dialysis patients generally do not receive a prophylactic dose of antibiotics.     

Late diagnosis of chronic renal failure and mortality on maintenance dialysis

BACKGROUND.: Recent observations in our country have shown that late diagnosisof chronic renal failure (CRF) is an important cause of latereferral and late commencement of maintenance dialysis. We prospectivelyinvestigated the influence of late diagnosis of CRF on patientmortality during dialysis therapy. METHODS.: Among 184 consecutive patients with non-diabetic end-stage renaldisease starting chronic dialysis at the Federal UniversityHospital in the city of So Paulo, 106 had a late diagnosis ofCRF (less than 1 month before starting dialysis) and 78 hadan early diagnosis. During the first 6 months of dialysis treatment,patient survival was compared in the two groups, using the Kaplan-Meiermethod and the Cox proportional hazards model. RESULTS.: Six-month patient survival rate was lower in the late than inthe early diagnosis group (69% versus 87%, P<0.01). In thelate diagnosis group, the hazard ratio of mortality was 2.77(95% C1, 1.36–5.66) times that of the early diagnosisgroup. In a multivariate analysis, after adjusting for age,comorbid illness, and serum biochemical measurements, time ofdiagnosis did not remain significantly associated with mortalityrisk. In this analysis, age, pulmonary infection, and low serumalbumin were significant predictors of mortality. CONCLUSIONS.: Patients with a late diagnosis have a higher mortality riskduring the first 6 months of maintenance dialysis. This increasedrisk is related to comorbid conditions, some of which couldbe prevented by predialysis care. Interventions to promote earlydiagnosis of CRF and adequate predialysis follow-up need tobe evaluated if the survival of patients with chronic renalfailure is to improve.     

Reducing high phosphate levels in patients with chronic renal failure undergoing dialysis: a 4-week, dose-finding, open-label study with lanthanum carbonate.

BACKGROUND: The majority of patients with end-stage renal disease on dialysis are hyperphosphataemic. Lanthanum carbonate has been shown to be a highly effective phosphate binder in pre-clinical studies. A 4-week, open-label, dose-titration trial was conducted to assess the ability of lanthanum carbonate to control phosphate levels in patients with chronic renal failure. METHODS: This preliminary study was of 6 weeks duration: 2 weeks of washout followed by 4 weeks of dose titration. Patients (n = 59) were titrated on the basis of weekly serum phosphate levels from a daily dose of 375 mg lanthanum carbonate to a maximum dose of 2250 mg. Patients were maintained on the dose that controlled serum phosphate to between 1.30 and 1.80 mmol/l (4.03-5.58 mg/dl). Serum phosphate levels represented the main efficacy assessment. Safety was also evaluated. RESULTS: Most patients were successfully titrated to 1500 and 2250 mg lanthanum/day (mean dose at end of titration: 1278 mg). At completion of the study 70% of patients achieved a serum phosphate of 相似文献   

Peritoneal dialysis for chronic renal failure in a patient with methylmalonic acidaemia

Chronic renal failure is a common complication of methylmalonic acidaemia (MMA). It is usually managed with haemodialysis and renal transplantation. We report the use of continuous cycling peritoneal dialysis (CCPD) for 20 months in a paediatric patient with chronic renal failure due to MMA. This procedure resulted in the elimination of 950 μmol methylmalonate (MM) per day and a fall in the plasma MM concentration from 3.9 to 0.74 mmol/l. As a result of this treatment, the frequency at which this patient was hospitalised was markedly reduced prior to a successful renal transplantation.     

Fibronectin in patients with chronic renal failure undergoing dialysis

Fibronectin (FN) levels were determined in 64 cases with chronic renal failure (CRF), some of whom were undergoing dialysis. FN levels were 14.9 +/- 7.6 mg/dl in CRF (n = 20), 13.4 +/- 4.3 mg/dl in patients on continuous ambulatory peritoneal dialysis (CAPD) (n = 20) and 16.7 +/- 7.2 mg/dl in patients on hemodialysis (HD) (n = 24). All the levels were significantly lower than in normal subjects (23.1 +/- 4.6 mg/dl). Serum FN was compared with some nutritional indices. Positive correlations were found between serum FN and nitrogen balance (BN), serum prealbumin (PreA) and transferrin (Tf) in all the patients. With serum albumin (Alb), however, this correlation was only found in patients undergoing dialysis. Negative correlations were found between serum FN and the ratio of serum urea to serum creatinine (Surea/Scr) in CAPD and HD patients. In 10 CAPD patients, the low serum FN levels went up after increased protein intake. This indicates that it was the result of malnutrition due to decreased protein intake. Serum FN level reflects a negative BN earlier and better than serum PreA, Tf and Alb. It is a sensitive, reliable and simple index for judging the nutritional protein status and the effect of nutritional treatment in patients with CRF undergoing dialysis.     

Transplantation versus dialysis in diabetic patients with renal failure

Studies suggesting that transplantation is better than dialysis for diabetic patients with renal failure may be biased by the more favorable pretreatment prognosis of transplanted patients. Therefore, to provide a fairer comparison we controlled for pretreatment clinical state, categorized treatment received, and assessed mortality, major morbid events, and hospitalization in 51 diabetic patients who began therapy between 1970 and 1980. Fourteen patients were treated by transplantation and 37 by dialysis. The mean waiting period for transplantation was 5 months. The average age of transplanted patients was 40.9 years and of dialyzed patients 59.6 years. When we controlled for this age disparity and other factors (duration of diabetes and heart failure) that affect prognosis in end-stage renal disease (ESRD), the mortality with both transplantation and dialysis was similar to that expected from the overall mortality rate of the 51 study patients. Treatment received had no effect on mortality; the observed deaths compared with deaths expected from pretreatment status were 8 and 7.3 for transplantation and 30 and 30.7 for dialysis. We also compared major morbid events (blindness, amputation, stroke, severe heart failure, and myocardial infarction) and hospitalization in transplanted patients with the 24 dialyzed patients who survived long enough (5 months) to be eligible for transplantation. The number of major morbid events was 2.7 per 10 patient-years in the transplanted group and 3.4 in the dialyzed group. Hospitalization was 151.3 d/yr in transplanted patients and 55.6 d/yr in dialyzed patients (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

慢性肾衰竭腹膜透析患者的预后分析

目的分析慢性肾衰竭腹膜透析患者的生存率及预后影响因素。方法回顾性调查2003年1月至2011年6月在我院规律随访的353例腹膜透析患者,总结患者的预后和退出原因,比较死亡患者与继续腹膜透析患者临床指标差异,分析患者死亡的危险因素和独立危险因素。结果353例患者中退出159例,其中死亡74例,死亡原因主要是心血管疾病。腹膜透析患者1年、2年、3年、4年的生存率分别为92％、80％、68％、58％。Logistic回归分析显示,年龄、糖尿病肾病、血红蛋白、血白蛋白和血肌酐是患者死亡的危险因素。COX回归分析显示,年龄、血红蛋白和血肌酐是死亡的独立危险因素（均P〈0．05）。结论根据年龄、血红蛋白和血肌酐水平可以对腹膜透析患者预后做初步判断,重视患者的营养状况,有利于改善预后、降低死亡率。     

结肠透析联合尿毒清颗粒保留灌肠治疗慢性肾衰竭疗效的Meta分析

目的 评价结肠透析联合尿毒清颗粒保留灌肠治疗慢性肾衰竭疗效.方法 计算机检索Cochrane图书馆资料库、MEDLINE（美国国立医学图书馆）、EMbase（荷兰医学文摘数据库）、万方数据、中国知网（CNKI）、中国生物医学文献数据库（CBM）.同时手工检索结肠透析联合尿毒清颗粒保留灌肠治疗慢性肾衰竭疗效的随机对照试验,检索时限均为建库至2013年11月,并追溯纳入研究的参考文献.由两位研究者按照纳入与排除标准独立筛选文献、提取资料和评价质量后,采用RevMan 5.1软件进行Meta分析.结果 共纳入9篇文献.其中8篇文献质量评价为C级,1篇文献评为B级.Meta分析显示,慢性肾衰竭患者经过结肠透析联合尿毒清颗粒保留灌肠治疗后：①血肌酐水平明显降低,差异有统计学意义（MD=-122.28,95％ CI：-172.43～-72.14,P＜0.01）;②血尿素氮水平明显降低,差异有统计学意义（MD=-4.08,95％ CI：-5.88～-2.27,P＜0.01）;③肌酐清除率明显升高,差异有统计学意义（MD=-2.79,95％ CI：1.82～3.75,P＜0.01）.结论 结肠透析联合尿毒清颗粒保留灌肠治疗慢性肾衰竭疗效确切.但由于目前的临床研究质量总体偏低,尚需进行严格的、多中心的随机双盲对照实验研究进一步证实.     

Effects of late referral to a nephrologist in patients with chronic renal failure

BACKGROUND: We lack information about the role of late diagnosis of end-stage renal disease (ESRD), late nephrological referral and its impact on biochemical variables and first hospitalization in East Anatolia, Turkey. METHODS AND RESULTS: For a total of 101 ESRD patients, dialysis was initiated between January 1998 and December 2002 at the Yuzuncu Yil University Hospital. Early referral (ER) and late referral (LR) were defined as the time of first referral or admission to a nephrologist greater or less than 12 weeks, respectively, before initiation of haemodialysis (HD). RESULTS: The need for urgent dialysis was less among the early referral cases compared with the late referral cases (P = 0.03). Patients with LR started dialysis with lower levels of haemoglobin (8.6 vs 9.5 g/dL, P < 0.05) bicarbonate (16 vs 12 mEq/lt, P < 0.03) and albumin (2.9 vs 3.29 mg/dL, P < 0.02) and with higher serum levels of blood urea nitrogen (173 vs 95 mg/dL, P < 0.001), creatinine (10 vs 7.9 mg/dL, P < 0.001) and potassium (5.3 vs 4.8, P < 0.04). Hospitalization duration beginning at dialysis was significantly longer in the LR group (27.3 +/- 24) compared with the ER group (13.4 +/- 7.5, P < 0.001). When the groups were compared in terms of distance between the patients home and hospital, there were significantly more patients living far away from hospital (i.e. >100 km) in the LR group compared with the ER (P < 0.0001) group. CONCLUSION: Early referral to a nephrology unit and/or early diagnosis of ESRD results in better biochemical variables, shorter first hospitalization length and a higher percentage of elective construction of AVF and the availability to start with an alternative dialysis modality (i.e. CAPD).     

血液透析和腹膜透析患者生活质量比较

目的调查我院维持中心血液透析、腹膜透析治疗患者的生活质量，为临床合理选择治疗方案提供参考。方法对维持目前透析方式6个月以上的中心血液透析、腹膜透析患者，通过查阅病历资料、门诊随诊和问卷调查等方式，调查透析患者现阶段的生活质量（KDQOL～SF）。结果完成病例调查86例，其中血液透析36例，腹膜透析50例。两组患者在性别、年龄、文化程度、付费方式、收入、原发病、透析时间等背景上没有显著差异。腹膜透析组在总体健康、精神健康、情感职能、躯体疼痛以及肾病负担、社交质量、症状与不适、肾病影响、患者满意度等指标得分高于血液透析组。结论腹膜透析患者在生活质量的某些维度上优于血液透析患者，值得进一步推广。     

Beneficial influence of recombinant human erythropoietin therapy on the rate of progression of chronic renal failure in predialysis patients.

BACKGROUND: Partial correction of anaemia with recombinant human erythropoietin (rHuEpo) has been shown to markedly improve the general condition and quality of life of predialysis patients, but the effects of rHuEpo therapy on blood pressure and the rate of progression of chronic renal failure (CRF) are still disputed. In particular, no study evaluated the time duration until the start of maintenance dialysis in treated patients, compared to untreated predialysis patients. METHODS: We retrospectively evaluated the rate of decline of creatinine clearance (Delta Ccr) and the duration of the predialysis period in 20 patients with advanced CRF treated with rHuEpo (Epo+ group), and in 43 patients with a similar degree of CRF but with less marked, asymptomatic anaemia, not requiring rHuEpo therapy (Epo- group). All patients were submitted to identical clinical and laboratory surveillance. All received similar oral supplementation with B(6), B(9), and B(12) vitamins and oral iron supplementation. Maintenance dose of subcutaneous epoetin was 54.3+/-16.5 U/kg/week (median dose 3300 U/week). RESULTS: Initial and final haemoglobin (Hb) levels were 8.8+/-0.7 and 11.3+/-0.9 g/dl in the Epo+ group, vs 10.9+/-1.2 and 9.5+/-0.9 g/dl in the Epo- group. In the Epo+ group, Delta Ccr declined from 0.36+/-0.16 during the preceding 24 months to 0.26+/-0.15 ml/min/ 1.73 m(2)/month after the start of rHuEpo therapy (P<0.05). No significant variation was observed in the Epo- group. Time duration until the start of dialysis was 16.2+/-11.9 in the Epo+ group, compared to 10.6+/-6.1 months in the Epo- group (P<0.01). Slowing of progression was observed in 10 Epo+ patients, whereas no significant variation in Delta Ccr occurred in the other 10. There was no difference in previous Delta Ccr rate, nor in Hb or blood pressure levels while on rHuEpo therapy between the two subgroups. CONCLUSIONS: Our study affords conclusive evidence that rHuEpo therapy did not result in accelerated progression of CRF in any treated predialysis patients, nor deleterious increase in blood pressure, but instead resulted in significant slowing of progression and substantial retardation of maintenance dialysis. Such encouraging results remain to be validated in a large prospective, randomized study.     

Comparison of peritoneal dialysis and haemodialysis after renal transplant failure

Background. A growing number of patients are returning to dialysisafter renal transplant failure. The aim of this study is todetermine whether peritoneal dialysis (PD) is a safe and goodtreatment option for these patients. Methods. All patients returning to PD or haemodialysis (HD)after renal transplant failure before 1 October 2002 at theUniversity Hospital Gasthuisberg, Leuven, Belgium, were evaluated.Data were collected until death, retransplantation (reTx), transferto HD or PD or until 1 January 2003. Results. Twenty-one patients starting PD (PDpostTx-group) and39 patients starting HD (HDpostTx-group) after renal transplantfailure were included in the study. There were no significantdifferences in age, sex, serum albumin- and CRP-levels at baseline.The total time on renal replacement therapy at transplant failureand time to transplant failure did not differ between the twogroups either. Furthermore, the baseline comorbidity was similarin both groups. During follow-up, the outcome did not differsignificantly between the two groups. However, there was a tendencytowards higher patient survival and reTx tended to be more frequentin the PDpostTx-group. Moreover, patients in the HDpostTx-grouptended to accrue more new comorbidity. The incidence of peritonitisand the evolution of dialysis adequacy (renal and peritonealKt/V and creatinine clearances) with time in the PDpostTx-groupwas similar to that seen in our centre's PD patients who hadnever undergone transplantation before. Conclusions. This study suggests that the outcome in patientsstarting PD after renal transplant failure is at least as goodas the outcome in those starting HD. Although these observationalfindings warrant further confirmation, PD therefore can be regardedas a safe and good treatment option for patients returning todialysis after renal transplant failure.     

Choice of dialysis modality for management of pediatric acute renal failure

Acute renal failure in children requiring dialysis can be managed with a variety of modalities, including peritoneal dialysis, intermittent hemodialysis, and continuous hemofiltration or hemodiafiltration. The choice of dialysis modality to be used in managing a specific patient is influenced by several factors, including the goals of dialysis, the unique advantages and disadvantages of each modality, and institutional resources. This review will examine these aspects of acute renal failure management, with the goal of providing practical guidance regarding modality selection to the physician involved in the management of pediatric acute renal failure. Received: 13 July 2001 / Revised: 25 September 2001 / Accepted: 26 September 2001     

Role of ageing, chronic renal failure and dialysis in the calcification of mitral annulus

Mitral annulus calcification, a common lesion of the elderly(over age 60 years), has been detected with increased frequencyand at younger ages in patients with uraemia. To date a pathogenicrole for dialysis and secondary hyperparathyroidism has beensuggested only on the basis of older dialytic age and increasedserum iPTH observed in the affected individuals. Because thisis a potentially dangerous lesion we deemed it useful to evaluatemore completely the respective roles of possible pathogeneticfactors in uraemic individuals. Evaluation included echocardiography, ECG, limb radiography,and serum assays. A total of 225 dialysis (HD) patients, 67chronic renal failure (CRF) patients on conservative treatmentand 67 normal subjects were studied. Mitral annulus calcificationwas detected in 87 of 225 (38.6%) HD patients, 11 of 67 (16.4%)CRF and six of 67 (8.9%) normals. In HD, patients with calcificationwere older and on longer-term renal replacement therapy comparedto those without calcification. They also had greater valuesof iPTH, BGP, AP, and Rx score of secondary hyperparathyroidism.Mitral annulus calcification was associated more frequently(x2= 14.8; P< 0.0001) with rhythm and cardiac conductiondefects, but not with ectopic calcifications. Multiple stepwiseregression analysis, with mitral annulus calcification scoreas dependent variable, selected dialysis duration, age, andiPTH (r_m= 0.368) as the most predictive parameters, with thefirst two carrying most of the information. The stratificationof patients according with these two parameters showed a progressiveincrease in the frequency of calcification both with HD durationand age. Moreover, compared to those without, patients withcalcification in the third, fourth, and fifth decades invariablyshowed significantly greater dialytic ages, while in the firstyear of HD they were significantly older. Finally, in all subjectsa progressive increase (x²= 34.4; P< 0.000001) of prevalenceof mitral annulus calcification in normals (0%), CRF (8.5%),and HD (36.7%) was observed only in those aged less than 60years, but not over age 60 (normals=30%; CRF = 35%; HD= 42.3%;x²= NS). Over age 60, ageing and dialysis do not have additiveeffects. In conclusion, our data show that dialysis duration plays amajor role in the development of mitral annulus calcificationmainly in younger patients (under age 60) with the possibilityof an increased mortality rate of affected patients. The pathogeneticmechanism seems to differ from that of other ectopic calcification,while secondary hyperparathyroidism seems to play an ancillaryrole.