营养不良对腹膜透析预后影响及处理对策

蛋白质-能量营养不良(PEM)是腹膜透析(PD)患者常见的并发症,并随着透析时间的延长而升高,严重地影响着患者的生活质量、住院率及生存率。PEM可分为原发性(Ⅰ型)和继发性(Ⅱ型)两大类。导致PEM的主要因素有炎症、糖尿病、腹膜高转运及腹膜透析患者的年龄等。防止腹膜透析患者出现PEM的主要对策包括营养支持、使用氨基酸腹膜透析液、改善微炎症状态、充分透析、控制容量负荷、纠正代谢性酸中毒、保护残余肾功能等。另外自动化腹膜透析(APD)具有透析剂量大、交换次数多、腹内透析液存留时间短等特点,因而可以较好防治腹膜透析患者的PEM。     

应用氨基酸腹膜透析治疗CAPD患者的营养不良

应用氨基酸腹膜透析治疗ＣＡＰＤ患者的营养不良胡伟新，俞雨生关键词腹膜透析：氨基酸；营养不良在ＣＡＰＤ患者中蛋白质及蛋白质－能量营养不良非常普遍，原因有多种，如营养成分摄人不足、尿毒症导致蛋白质代谢异常等，而透析本身造成蛋白质和氨基酸丢失及分解代谢亢进...     

腹膜透析患者合并营养不良-慢性炎症-心血管疾病综合征的临床表现

腹膜透析病人的营养不良、心血管疾病和炎症三者之间存在密切关系[1] ,本观察旨在进一步探讨这类病人中是否也存在营养不良 炎症 心血管疾病 (ＭＩＡ)综合征[2 ] 及其临床表现。1 资料与方法 :来自于北京大学第一医院、第三医院、北京复兴医院、北京市工人疗养院的持续性非卧床腹膜透析(ＣＡＰＤ)病人共 90例 ,其中男 3 6例 ,女 5 4例 ,腹透时间 3～ 84(2 2 9± 19 7)个月 ,均稳定ＣＡＰＤ至少 3个月 ,近 1个月来未感染过腹膜炎 ,没有严重心力衰竭、不稳定心绞痛、活动性肝病、创伤及手术等合并因素。收集以下资料 :(1)一般资料 :包括年龄…     

如何预防和纠正腹膜透析患者的营养不良

营养不良（蛋白质-能量营养不良）是腹膜透析（PD）患者常见的严重并发症，与患者的预后密切相关。PD患者营养不良的发生率随着透析时间的延长而升高，国外报道发生率在18％～56％之间，国内报道约为43．2％。尽管PD患者营养不良发生的原因十分复杂，但临床主要表现为机体蛋白储备下降（体重下降和低血清肌酐水平等）和内脏蛋白水平下降（低血清白蛋白和前白蛋白浓度等），这也使患者死亡风险显著增高。因此，有效防治PD营养不良对于提高患者生活质量、改善远期预后具有重要意义。本文就近年来国内外PD营养不良防治的进展作一综述。     

综合营养风险因素对腹膜透析患者营养不良及预后的预测价值

目的 研究不同营养状况腹膜透析(PD)患者握力、karnofsky活动指数(KPS)评分、饮食摄入和生化及营养指标与其营养不良的关系,探寻预测PD患者营养不良及预后的最佳指标。方法 根据改良主观定量整体性营养评估法(MQ-SGA)评分将130例PD患者分为营养良好组(<10分,110例)和营养不良组(≥10分,20例),收集所有患者的一般资料、实验室检查结果、握力、KPS评分、饮食摄入指标及综合营养风险因素数量并进行组间比较。危险因素采用单因素及多因素logistic回归分析评估。采用受试者工作特征(ROC)曲线筛选PD患者营养不良的预测因素。影响因素采用Cox比例风险回归分析评估。采用Kaplan-Meier曲线比较累积生存率。结果营养良好组年龄、空腹血糖、超敏C反应蛋白(hsCRP)水平及糖尿病病史患者比例均低于营养不良组,血肌酐、血白蛋白、血镁、前白蛋白水平及握力、KPS评分、每日能量摄入(DEI)均高于营养不良组(P<0.05)。营养不良组男性患者握力明显低于营养良好组男性,营养良好组男性患者握力明显高于同组女性,营养良好组男性和女性的KPS评分均明显高于营养不良组...     

腹膜透析患者营养状态评价及影响因素探讨

目的　评估长期腹膜透析患者的营养状态 ,并探讨其影响因素。方法　采用主观整体营养评估法及有关生化指标评估 3 0例长期腹膜透析患者的营养状态 ,同时观察营养与透析充分性、腹膜转运功能的关系。结果　 3 0例中营养良好的 2 0例 ( 66 67% ) ,营养不良的 10例 ( 3 3 3 3 % ) ;营养与透析充分性正相关 ;营养与腹膜的转运功能有关 ,高平均转运膜的患者营养状态最佳。结论　营养不良的发生率为 3 3 3 3 % ,引起营养不良的主要原因为透析不充分 ,腹膜的转运功能不良     

六君子汤联合金匮肾气丸治疗肾脏病腹膜透析相关营养不良的疗效

<正>腹膜透析(PD)主要适用于急、慢性肾衰竭、中毒性疾病等,对于严重腹膜炎以及腹膜缺损患者不适用〔1〕。PD造成的并发症尤其是由于透析造成的疝气、渗漏以及营养不良〔2〕。营养不良不仅降低患者生活质量,还会对患者治疗积极性造成一定的影响。本文通过对我院肾脏病PD相关营养不良患者进行辅助治疗,探究中药联合治疗的效果。1资料与方法1.1资料选取2011年2月至2014年2月我院收治的肾脏     

维持性腹膜透析治疗尿毒症的营养和代谢评价

本研究评价了１４例维持性腹膜透析治疗患者的营养和代谢状态。与正常人相比，患者的体重、理想体重百分率和血白蛋白显著降低，血糖、血甘油三酯和胆固醇显著增高。根据体重和白蛋白标准，患者营养不良发生率分别是５７．１４％和８９．７１％，１４例患者中有５例高甘油三酯血症，３例高胆固醇血症，１例高血糖。血肌酐水平同体重之间存在显著负相关（ｒ＝－０．４７６）．提示维持性腹膜透析治疗的尿毒症，存在高发生率的营养代谢异常。临床肾科工作者应加以预防和治疗，以延长患者的生存期和提高生存质量。     

残余肾功能对腹膜透析患者的重要性

临床上有很多证据业已证实残余肾功能（residual renal function，RRF）对透析患者，尤其是腹膜透析（peritoneal dialysis，PD）患者的重要性。RRF不仅能有效清除小分子物质和尿毒症产生的毒素，还可以维持机体水、盐平衡，控制血磷水平，对防止血管钙化、心脏肥大等方面起保护作用。过去对终末期肾脏疾病（end—stage renal disease，ESRD）或透析阶段患者的RRF未采取任何保护措施。近来越来越多的研究认为残余肾在PD患者中具有独立的地位和作用，不能简单地将残余肾清除率和腹膜清除率等同看待，应重视对其保护。本文将RRF对PD患者的重要性作一综述，探讨对RRF的保护策略。     

六君子汤合金匮肾气丸辅助治疗肾脏病腹膜透析相关营养不良疗效观察

目的 观察六君子汤合金匮肾气丸辅助治疗肾脏病腹膜透析相关性营养不良的疗效.方法 将142例肾脏病腹膜透析相关性营养不良患者随机分为观察组和对照组各71例,观察组采用六君子汤合金匮肾气丸联合西医（降糖、降压、降钙素以及促红细胞生成素、进食优质蛋白等）治疗,对照组单纯采用西医治疗,观察两组治疗前后白蛋白、前白蛋白、胆碱酯酶、血红蛋白及改良主观全面营养评价法得分（SGA评分）.结果 与同组治疗前比较,两组白蛋白、前白蛋白、胆碱酯酶、血红蛋白水平均升高,SGA评分均降低（P均＜0.05）;与对照组比较,观察组治疗后白蛋白、胆碱酯酶、血红蛋白水平升高,前白蛋白水平降低,SGA评分降低（P均＜0.05）.结论 六君子汤合金匮肾气丸辅助治疗肾脏病腹膜透析相关性营养不良的疗效确切.     

Prevention of malnutrition in peritoneal dialysis patients

Malnutrition is a frequent and serious problem for patients treated by peritoneal dialysis. Patients' survival depends on their nutritional status at the initiation of the dialysis treatment. Main malnutrition factors are inflammation, insufficient dialysis dose, peritoneal glucidic absorption and protein loss within the dialysate. These patients show a relationship between malnutrition, inflammation and cardiovascular diseases. To prevent malnutrition, it is necessary to reduce inflammation by improving dialysis solutions' biocompatibility and optimising the sodium regulation. The peritoneal membrane exposure to both glucose and its degradation products must also be reduced. In order to restrict protein losses, especially when peritoneal hyper permeability occurred, dialysis solutions containing amino acids can be used. Early dialysis treatment and a progressive increase of the dialysis dose corresponding to the decrease of the residual renal function can also be recommended.     

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??Abstract??Protein-energy malnutrition (PEM) is a common complication in peritoneal dialysis patients.The morbidity increases with the extension of the duration of dialysis.PEM seriously affect patients?? quality of life??hospitalization rate and mortality.The main factors leading to PEM are inflammation??diabetes??high peritoneal transporter and elder age of patients.The main countermeasures to prevent PEM in PD patients include nutritional support??use of amino acid peritoneal dialysis solution??improvement of micro-inflammatory state??adequate dialysis??better fluid volume control??correction of metabolic acidosis??and the protection of residual renal function.In addition??automated peritoneal dialysis (APD) has the advantage of delivering higher doses of dialysis??more exchanges??shorter dwelling time??and thus might be more effective in management of PEM in PD patients.     

Left ventricular function in patients under peritoneal dialysis treatment

M-Mode echocardiogram and systolic time intervals were obtained in 24 patients with end-stage chronic renal failure before and after peritoneal dialysis in order to evaluate their left ventricular function. Before dialysis 9 patients (group A) showed an echocardiographic pattern of dilated cardiomyopathy, i.e. increased left ventricular end-diastolic dimension (EDD) and volume (EDV), reduction of fractional shortening (FS%), of circumferential fiber shortening (Vcf) and of ejection fraction (EF). Seven patients (group B) had the morphological and functional features of asymmetric septal hypertrophy: ratio of interventricular septum to posterior wall thickness (IVS/PWT) greater than 1.3, reduced EDD and EDV. Eight uraemics (group C) had no specific feature of cardiac disease, but only aspecific echocardiography signs of myocardial derangement. Peritoneal dialysis appeared to be associated with gradual improvement of the contractile state in group A patients, with reduction in echocardiographic asymmetric septal hypertrophy in group B uraemics, and with an aspecific increase in cardiac performance in group C patients. It is concluded that: end-stage chronic renal failure may have echocardiographic pattern of dilated or asymmetric hypertrophic cardiomyopathy; peritoneal dialysis significantly improves the morphological and functional derangements of both clinical conditions.     

腹膜透析患者充血性心力衰竭的发生与治疗

目的 :探讨腹膜透析 (PD)患者充血性心力衰竭 (CHF)发生的原因及治疗。方法 :选择我院 2 0 0 2年发生CHF的PD患者 10例 ,收集患者从透析开始至发生CHF时的尿量 (UV)和超滤量 (UFV)变化 ,并通过严格限制患者水盐摄入控制CHF ,比较CHF发生时及限制水盐摄入 3个月后体重 (BW )、UV、UFV、2 4h出液量的变化。结果 :发生CHF的PD患者UV和UFV随透析时间的延长而逐渐减少。严格限制水盐摄入 3个月后BW由( 5 8.6 1± 14 .6 2 )kg下降至 ( 5 5 .78± 14 .0 4 )kg( P <0 .0 1) ,CHF的症状改善 ,高渗液体的用量减少。结论 :容量超负荷是PD患者发生CHF的重要原因 ,严格限制水盐摄入是防止PD患者发生CHF简便而有效的措施     

The latest trends in the treatment peritonitis of the patients on peritoneal dialysis

Peritonitis is still one of the major complications ambulatory peritoneal dialysis (CAPD). The initial empiric therapy for peritonitis should be effective against most grampositive organisms as well as gramnegative organisms. Intraperitoneal administration antibiotics has the advantage of a high concentration of the antibiotics at the site of infection. The treatment should provide broad coverage of all organisms, without side-effects or risk for the patient and should not provoke the emergence of resistant germs. The present guidelines of the ad hoc advisory committee are of great value in this regard. The ISPD guidelines for treatment of peritonitis recommended an empirical therapy based on the association of a first-generation cephalosporin with an aminoglycoside or ceftazidime.     

Elevated osteoprotegerin is associated with inflammation, malnutrition and new onset cardiovascular events in peritoneal dialysis patients

Backgrounds

Osteoprotegerin (OPG) is known to regulate bone mineral metabolism and to be also associated with inflammation, cardiovascular disease (CVD) and mortality. Malnutrition-inflammation-atherosclerosis (MIA) syndrome is commonly found and closely linked to mortality in dialysis patients. The aim of this study was to investigate the associations between OPG and MIA syndrome in prevalent peritoneal dialysis (PD) patients.

Methods

Prevalent PD patients for more than 6 months were prospectively followed up from March 2005 to May 2010. At baseline, OPG, hs-CRP, albumin, and %lean body mass (LBM) by creatinine kinetics were checked, and subjective global assessment (SGA) was performed. New-onset cardiovascular events were evaluated during the study period. Based on the median level of OPG, patients were classified as lower OPG (LO) group (n = 88) and higher OPG (HO) group (n = 88).

Results

A total of 176 patients (age 52.0 ± 11.8 years, male 50.6%, duration of PD 105.3 ± 67.2 months) were recruited and followed. In HO group, age, hs-CRP level and Charlson's comorbidity indices were higher, whereas serum albumin level, %LBM and SGA score were significantly lower than LO group. OPG levels were positively correlated with inflammatory markers, whereas negatively correlated with nutritional status. Cardiovascular events occurred in 51 patients during the study period. Newly developed cardiovascular events were significantly common in HO group (n = 36, 40.9%) than LO group (n = 15, 17%, p = 0.002). Cox regression analysis revealed that higher OPG level (per 1-SD increase in OPG, HR: 1.44; 95% CI: 1.03–2.00; p = 0.034) was a significant risk factor for cardiovascular events even after adjustments for demographic and biochemical parameters.

Conclusion

OPG was significantly correlated with markers of systemic inflammation and malnutrition and was a significant predictor of CVD in PD patients. These findings suggest OPG might be a prognostic indicator of MIA syndrome in prevalent PD patients.     

Encapsulating peritoneal sclerosis in patients on peritoneal dialysis

Encapsulating peritoneal sclerosis (EPS) is an uncommon but one of the most serious complications in patients on long-term peritoneal dialysis. EPS is characterised by a diffuse thickening and/or sclerosis of the peritoneal membrane which leads to a decreased ultrafiltration and ultimately to bowel obstruction. We present four cases of EPS and discuss the clinical manifestations, multifactorial aetiology, diagnosis, treatment, prognosis, and prevention. We end with a proposal for the development of an EPS prevention guideline.     

Erosive spondyloarthropathy in peritoneal dialysis patients

Erosive spondyloarthropathy (ESA) is common in long-term hemodialysed patients. However, it has been little recognized in peritoneal dialysis (PD) patients. In a retrospective study, we found severe ESA in 7 of the 87 (8%) patients undergoing PD in our center. Characteristics of our population were advanced age and short duration of dialysis (27±20 months). ESA patients were older than non ESA (74±4 vs 68±11 yrs,p<0.01). Secondary hyperparathyroidism and dialysis amyloid arthropathy were also possible pathogenic factors. Patients were followed for 4 years or until death and remained stable in most ESA cases. We conclude that ESA is age-related, is as frequent in PD as in HD populations and is not related to one single underlying mechanism.     

Nutrition in patients on peritoneal dialysis

Protein-energy wasting (PEW) is prevalent among patients on dialysis and has emerged as an important risk factor for morbidity and mortality in these patients. Numerous factors, including inflammation, inadequate dialysis, insufficient nutrient intake, loss of protein during dialysis, chronic acidosis, hypercatabolic illness and comorbid conditions, are involved in the development of PEW. The causes and clinical features of PEW in patients on peritoneal dialysis and hemodialysis are comparable; assessment of the factors that lead to PEW in patients receiving peritoneal dialysis is important to ensure that PEW is managed correctly in these patients. For the past 20 years, much progress has been made in the prevention and treatment of PEW. However, the results of most nutritional intervention studies are inconclusive. In addition, the multifactorial and complicated pathogenesis of PEW makes it difficult to assess and treat. This Review summarizes the nutritional issues regarding the causes, assessment and treatment of PEW, with a focus on patients receiving peritoneal dialysis. In addition, an in-depth overview of the results of nutritional intervention studies is provided.