CAPD与CCPD对钙、磷和PTH转运的对比研究

目的:探讨持续非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)与持续循环腹膜透析(con-tinuous cyclic peritoneal dialysis,CCPD)对钙、磷、甲状旁腺激素(parathyroid hormone,PTH)及血肌酐、尿素氮转运的影响。方法:选择2010年1月～2012年12月在北京大学深圳医院腹透中心常规CAPD治疗透析不充分并伴继发性甲状旁腺功能亢进的腹透患者20例,行腹膜平衡试验(peritoneal equilibration test,PET)了解腹膜转运特性,并计算基础Kt/V,然后给予CCPD治疗10d,检测CCPD治疗前后血及腹透液肌酐、尿素氮、Ca2+、P3-、Ca×P、iPTH,记录患者每日超滤量和尿量;比较CAPD与CCPD两种透析模式对上述指标影响。结果:CCPD治疗10d后总Kt/V由基线的1.73±0.33升高至2.30±0.37(P<0.05),Ccr/w由(47.43±7.61)L·wk-1·1.73m-2升高(61.69±10.52)L·wk-1·1.73m-2(P<0.05);血磷由(2.39±0.52)mmol/L降至(2.03±0.43)mmol/L(P<0.01);钙磷乘积由(66.73±15.84)mg2/dl2降至(58.81±13.64)mg2/dl2(P<0.05);iPTH由(84.85±15.84)pmol/L降至(58.81±13.64)pmol/L,差异均有统计学意义(P<0.05)。结论:短期CCPD能增加腹膜对小分子毒素(Cr、BUN)的清除,提高Kt/V和CCr值,并能降低血磷、iPTH水平。     

解毒益气活血方治疗糖尿病肾病的临床观察

目的:观察中药解毒益气活血方联合基础西药对糖尿病肾病(DKD)的作用效果并初步探索其可能的机制。方法:回顾性分析85例临床DKD患者,分为对照组(42例)和治疗组(43例),两组在治疗前基线水平的各项指标差异无统计学意义(P0.05),具有可比性;对照组用基础西药控制血糖血压治疗,治疗组在相同的基础治疗上加用中药解毒益气活血方。比较两组患者主观临床症状改善、尿蛋白肌酐比值(UP/Cr)、尿组织转化生长因子β_1(TGF-β1)、尿视黄醇结合蛋白(RBP)和尿β_2微球蛋白(β_2-MG)、血肌酐、血脂、血脑钠肽(BNP)、血Ⅳ型胶原(Col-Ⅳ)和TGF-β_1水平的变化。结果:经过12周的治疗后,治疗组各种症状改善率明显高于对照组(P0.05或P0.01);治疗组血BNP、TC、TG、血Col-Ⅳ、血TGF-β_1、尿RBP、尿β2-MG、尿TGF-β_1、UP/Cr和血压较治疗前均有明显下降(P0.05或P0.01),除血压外,上述指标治疗组较对照组下降更明显(P0.05);FBG、Scr两组之间差异无统计学意义(P0.05)。结论:解毒益气活血方联合西医基础治疗DKD疗效比单用西药好,其肾保护机理可能与降低BNP、TGF-β_1,改善脂质代谢和肾小管间质病变等有关。     

螺内酯治疗腹膜透析合并慢性心力衰竭患者的疗效和安全性

目的:评估螺内酯治疗维持性腹膜透析患者合并慢性心力衰竭的疗效和安全性。方法:经2月观察期后,29例维持性腹膜透析及31例肾功能正常的心力衰竭患者入选并完成研究。基线前观察期给予包括ACEI、ARB等基础用药。治疗开始所有入组病人均予螺内酯片20 mg,每日1次,治疗6月。测定基线、治疗后1周及此后每月的血钾浓度,测定基线、治疗后3月、6月的左心室射血分数(LVEF)、左心室质量指数(LVMI)、B型钠尿肽(BNP)和血醛固酮(ALD)浓度。结果:(1)与肾功能正常组比较,治疗6月后腹膜透析组LVEF、LVMI、BNP变化差异无统计学意义(P0.05)。(2)与基线值比较,腹膜透析组治疗6月后LVEF明显提高[(52.42±4.71)%vs(40.12±5.11)%,P0.01],LVMI明显降低[(120.42±19.72)g/m~2vs(135.93±22.75)g/m~2,P0.05]。BNP明显降低[(3 898.2±1 052.7)pg/ml vs(1 535.4±1 044.2)pg/ml,P0.05]。(3)与治疗前比较,腹膜透析患者治疗后血醛固酮水平有所升高,但差异无统计学意义。(4)所有腹膜透析患者在治疗期间血钾浓度均未超过6.0 mmol/L,但与基线值比较,治疗后1周时血钾水平升高[(4.78±0.75)mmol/L vs(4.35±0.54)mmol/L,P=0.05],其余时间点的差异均无统计学意义(P0.05)。结论:螺内酯应用于腹膜透析并心力衰竭患者与肾功能正常患者同样能有效改善心功能,且对血钾影响小,安全性良好。     

药用炭联合血液透析滤过治疗尿毒症皮肤瘙痒的临床疗效分析

目的观察药用炭联合血液透析滤过治疗尿毒症皮肤瘙痒的临床效果。方法选择2009年1月至2015年11月仙桃市中医医院肾病内科就诊的尿毒症伴皮肤瘙痒患者78例,分为对照组(每周3次单纯血液透析)、血液透析联合血液滤过组(血滤组,每周2次血液透析和1次血液透析滤过)、治疗组(在每周2次血液透析和1次血液透析滤过基础上使用药用炭口服),每组26例,连续治疗3个月,比较3组患者治疗前、后皮肤瘙痒评分、血磷、血β2微球蛋白、血甲状旁腺素、血尿素氮、血肌酐等指标的变化及治疗有效率。结果 3组患者治疗后血磷、血β2微球蛋白、血清甲状旁腺素、血尿素氮、血肌酐均降低,与治疗前比较,差异有统计学意义(P0.05);对照组、血滤组、治疗组治疗后总有效率分别为42.31%,69.24%,88.47%,治疗组在总有效率上优于对照组和血滤组(P0.05);3组治疗前皮肤瘙痒评分分别为(33.28±5.72)分、(34.12±5.88)分、(35.20±4.82)分,治疗后皮肤瘙痒评分分别为(21.28±3.56)分、(12.28±2.87)分、(5.25±2.12)分,与治疗前比较,差异具有统计学意义(P0.05);3组间治疗后皮肤瘙痒评分比较,差异具有统计学意义(P0.05)。结论血液透析联合血液透析滤过及口服药用炭能够明显缓解尿毒症性皮肤瘙痒,同时降低血磷、血β2微球蛋白、血清甲状旁腺素、血肌酐、尿素氮等,疗效显著。     

维持性腹膜透析患者口干的影响因素及干预对策浅析

腹膜透析(peritoneal dialysis,PD)是终末期肾病(end stage renal disease,ESRD)患者常见的有效肾脏替代疗法之一[1].尽管PD技术目前已相对成熟,但维持性腹膜透析( maintenance peritoneal dialysis,MPD)患者的症状负担依然严重.据报告, ...     

不同血液净化方式对ESRD患者血清FGF-23清除效果观察

目的:观察不同血液净化方式清除终末期肾病(ESRD)患者血清成纤维细胞生长因子23(FGF-23)的效果,为ESRD患者选择合理血液净化方式提供参考依据。方法:选择我院2013年4月~2015年2月收治的60例行维持性血液透析的ESRD患者作为研究对象,根据随机数字表法分为:血液透析(HD)组、血液透析+血液透析滤过(HD+HDF)组和血液透析+血液灌流(HD+HP)组,每组各20例。治疗12周后比较三组患者的血清FGF-23、血肌酐(Scr)、尿素氮(BUN)、β2微球蛋白(β2-MG)、血钾、血磷、血钙、甲状旁腺素(PTH)及肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、IL-1β水平变化情况。结果:治疗后HD+HDF组、HD+HP组FGF-23、β2-MG、PTH、血磷均显著低于治疗前,Hb均显著高于治疗前(P0.05);HD组治疗前后各项指标变化不明显(P0.05)。三组患者治疗后血钾、血钙、BUN、Scr、Alb比较差异无统计学意义(P0.05);治疗后HD+HDF组、HD+HP组TNF-α、IL-1β、IL-6均显著低于HD组(P0.05),HD组治疗前后无明显变化(P0.05);三组患者感染、出血、心衰竭及内瘘阻塞发生率比较差异无统计学意义(P0.05)。结论:HD+HDF及HD+HP对ESRD患者血清FGF-23等中大分子物质均有较好的清除效果,并能改善患者机体炎症反应程度。     

不同血液净化模式对尿毒症患者皮肤瘙痒及生活质量的影响

目的探讨尿毒症性皮肤瘙痒患者应用不同血液净化对其疗效及生活质量的影响。方法回顾性分析2013年1月至2014年12月本院诊治的120例尿毒症性皮肤瘙痒患者临床资料,按照不同血液净化治疗方式分为两组(各60例),对照组患者采用血液透析(hemodialysis,HD)治疗;研究组患者接受HD+血液透析滤过(hemodialysis filtration,HDF)+血液灌流(hemoperfusion,HP)治疗,对比两组患者症状改善情况、生化指标以及生活质量评分。结果研究组睡眠、食欲、高血压、皮肤瘙痒改善有效率分别为78.79%(26/33)、80.00%(28/35)、60.98%(25/41)、95.00%(57/60),均显著高于对照组的58.06%(18/31)、63.64%(21/33)、48.89%(22/45)、80.00%(48/60)(P0.05);同时两组在治疗后生化指标(血肌酐、尿素氮、血磷、血甲状旁腺素、血β_2-微球蛋白)均发生显著改善[研究组分别为(234.7±58.9)μmol/L、(10.3±3.1)mmol/L、(1.1±0.8)mmol/L、(98.5±59.1)pmol/L、(15.4±6.5)mg/L],对照组分别为(461.5±184.7)μmol/L、(18.1±7.3)mmol/L、(2.8±1.0)mmol/L、(275.8±138.7)pmol/L、(28.0±7.1)mg/L],研究组改善幅度比对照组更大,组内、组间比较差异均有统计学意义(P0.05或P0.01)。治疗后,研究组生活质量指标[生命质量量表(Quality of Life,QOL)、世界卫生组织生存质量测定量表(The World Heakh Organization Quality of Life,WHOQOL)、生活质量评价量表(the MOS item short from health survey,SF-36)]评分分别为(63.8±5.3)分、(64.7±4.7)分、(65.1±5.4)分,对照组分别为(59.8±6.1)分、(58.7±4.1)分、(59.1±4.2)分,研究组比对照组高(P0.05或P0.01)。结论尿毒症性皮肤瘙痒患者应用HD+HP+HDF治疗效果及相关生化指标改善显著,且可有效提升其生活质量,具有一定临床研究价值。     

邯郸地区应用生理钙透析液对持续性腹膜透析患者钙磷代谢的影响

目的观察邯郸地区持续性腹膜透析患者随腹膜透析时间延长,应用生理钙透析液(Dianeal PD4)对其血钙、血磷及全段甲状旁腺素(intact parathyroid hormone,iPTH)水平的影响。方法回顾性分析2006年2月至2014年3月在我院住院首次诊断为终末期肾脏疾病(end-stage renal disease,ESRD)并行持续性不卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPE))治疗大于12个月的77例资料完整患者的临床资料,在应用生理钙透析液(钙浓度为1.25 mmol/L)进行维持性腹膜透析,并配合口服碳酸钙及骨化三醇条件下,观察透析后3、6、12个月血钙、血磷、iPTH、碱性磷酸酶(alkaline phosphatase,ALP)和血白蛋白、总白蛋白、尿素氮、肌酐、尿酸等各项生化指标水平,分析透析前后校正血钙、血磷、iPTH、ALP等指标变化情况,同时观察患者使用生理钙透析液有无低血压、抽搐、不宁腿、瘙痒等不适。结果患者血钙、磷、尿素、肌酐、尿酸、白蛋白、血红蛋白在生理钙透析液透析后3、6、12个月与透析初始比较,差异均有统计学意义(P0.05),而透析后3、6、12个月之间比较,差异均无统计学意义(P0.05)。患者iPTH在腹透开始后逐渐上升,但在透析后3、6个月与透析前比较,差异无统计学意义(P0.05),而透析12个月后与透析前比较差异有统计学意义(P0.05)。患者ALP和总白蛋白水平在透析前后无明显变化。结论邯郸地区应用生理钙透析液进行维持性腹膜透析的患者,在配合口服钙剂及活性维生素D制剂情况下,可有效改善患者钙磷代谢紊乱,从而防治继发性甲状旁腺功能亢进症及肾性骨病的发生。     

大黄牡丹汤治疗腹膜透析导管移位疗效观察

正腹膜透析(peritoneal dialysis,PD)作为目前终末期肾脏疾病(end-stage renal disease,ESRD)替代治疗方法之一,随着透析导管、连接管路的不断改进,持续性非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)成为了一种有效、方便、相对血液透析经济,可以居家进行的透析治疗方式。透析     

甲状旁腺切除加自体移植术对尿毒症患者近期临床症状及钙磷代谢的影响（附20例临床分析）

目的观察甲状旁腺切除加自体移植(parathyroidectomy with autotransplantation,PTX+AT)对尿毒症继发性甲状旁腺功能亢进症(secondary hyperparathyroidism,SHPT)患者近期临床症状及各项生化指标的影响。方法回顾性分析20例SHPT手术前和手术后短期内的临床症状、血清全段甲状旁腺激素(intact parathyroid hormone,i PTH)、血钙、血磷等变化以及术后近期疗效及并发症的发生情况。结果 20例尿毒症继发性甲状旁腺功能亢进症患者,术前i PTH为(1648±797)pg/m L,甲状旁腺切除后,术后1w i PTH为(125±263)pg/m L,P0.01,差异具有统计学意义。术前血钙(2.58±0.25)mmol/L、血磷(2.30±0.73)mmol/L;术后第1天血钙(1.97±0.46)mmol/L、血磷(1.92±0.81)mmol/L,术后1 w血钙(1.99±0.46)mmol/L、血磷(1.38±0.66)mmol/L。术后1w 15例患者(占总失眠人数100%)失眠症状,13例患者(占总皮肤瘙痒人数80%)皮肤瘙痒症状、3例患者(占不安腿人数100%)不安腿症状明显好转,12例患者(占骨关节痛患者80%)骨关节疼痛症状、5例患者(占肌无力患者60%)肌无力症状有所改善。术后5位患者出现抽搐,4例患者出现声音嘶哑,经相应处理后,患者症状明显改善。结论甲状旁腺切除在短期内显著改善尿毒症继发性甲状旁腺功能亢进患者的骨关节痛、皮肤瘙痒、肌无力、失眠等临床症状,同时缓解高钙,高磷血症。     

Cardiovascular disease in children with chronic kidney disease

More than a decade ago, cardiovascular disease (CVD) was recognized as a major cause of death in children with advanced CKD. This observation has sparked the publication of multiple studies assessing cardiovascular risk, mechanisms of disease, and early markers of CVD in this population. Similar to adults, children with CKD have an extremely high prevalence of traditional and uremia-related CVD risk factors. Early markers of cardiomyopathy, such as left ventricular hypertrophy and dysfunction, and early markers of atherosclerosis, such as increased carotid artery intima-media thickness, carotid arterial wall stiffness, and coronary artery calcification, are frequently present in these children, especially those on maintenance dialysis. As a population without preexisting symptomatic cardiac disease, children with CKD potentially receive significant benefit from aggressive attempts to prevent and treat CVD. Early CKD, before needing dialysis, is the optimal time to both identify modifiable risk factors and intervene in an effort to avert future CVD. Slowing the progression of CKD, avoiding long-term dialysis and, if possible, conducting preemptive transplantation may represent the best strategies to decrease the risk of premature cardiac disease and death in children with CKD.     

Cardiovascular disease in patients with chronic kidney disease

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with renal failure. Patients with chronic kidney disease have significant CVD, and carry a high cardiovascular burden by the time they commence renal replacement therapy (RRT). The severity of CVD that has been observed in dialysis patients lead to a growing body of research examining the pathogenesis and progression of CVD during the progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD) (ie, predialysis phase). Multiple factors are involved in the development of CVD in CKD. More importantly, critical and key factors seem to develop early in the course of CKD, and result in preventable worsening of CVD in this patient population. Anemia is common in patients with CKD, and has been shown to have an independent role in the genesis of left ventricular hypertrophy (LVH) and subsequent CVD. Unfortunately, it is underdiagnosed and undertreated in patients with CKD. Early intervention, and better correction of anemia, seems to gain a great momentum in the prevention and management of CVD in CKD. Hypertension is another risk factor that has been targeted by the National Kidney Foundation Task Force on CVD in chronic kidney disease. This article reviews the different factors involved in the pathogenesis of CVD in CKD and the evidence supporting early and aggressive intervention.     

Surgery of aortic disease with coronary heart disease

From 1978 through 1989, 1200 patients underwent attempted coronary surgery. Seventy-six CABG-patients were recognized aorto-vascular disease. Thirty-one CABG-patients were operated with vascular surgery. Operative mortality of CABG was 0% (0/76). Operative mortality of vascular surgery was 3.2% (1/31). Total operative mortality was 1.1% (1/91).     

Cardiovascular disease in children with chronic kidney disease

In children with end-stage renal disease (ESRD), cardiovascular disease (CVD) mortality has not changed for the past 3 decades. Cardiac disease remains the second most common cause of death. Recent data demonstrate a high incidence and prevalence of traditional and chronic kidney disease (CKD)-related CVD risk factors in children. Early markers of cardiomyopathy, such as left ventricular hypertrophy (LVH) and left ventricular dysfunction (LV dysfunction), and early markers of atherosclerosis, such as increased carotid artery intima-media thickness (IMT) and carotid arterial wall stiffness, are frequently found in this patient population. Early identification of modifiable risk factors and treatment of asymptomatic CVD might lead to decrease of cardiovascular morbidity and mortality in young adults who developed CKD during childhood.     

Alzheimer's disease with refluxes

This is a report concerning a unique combination of Alzheimer's disease with the following refluxes: buccosalivary, gastroesophageal, vesicoureteral, urethroprostatic and urethrovesicular, along with neurogenic bowel and neuropathic bladder. A second patient with Alzheimer's disease and vesicoureteral reflux is reported. The possible etiopathology of these unusual refluxes and their relation to Alzheimer's disease are discussed.