多囊肾病患者行连续性不卧床腹膜透析及血液透析的疗效比较

目的 对比进入终末期肾病（ESRD）的多囊肾病（PKD）患者行连续性不卧床腹膜透析（CAPD）及血液透析（HD）治疗的临床疗效。 方法 回顾性分析2001年1月至2007年12月期间在我科行透析治疗3个月以上的PKD患者,共29例患者入选,分为CAPD组（10例,34.5％）和HD组（19例,65.5％）,选择10例年龄及性别与CAPD组匹配非PKD的CAPD患者作为对照组。记录患者一般资料、透析初始资料、并发症、生存时间、退出透析或死亡等结局。采用Kaplan-Meier法,Log-Rank检验进行生存分析。 结果 CAPD组1年、3年及5年存活率分别为 90％、75％及25％;HD组为94.4％、67.6％及48.3％;对照组为83.3％、44.4％及22.2％,3组患者存活率差异无统计学意义（P > 0.05）。CAPD组与对照组Kt/V[（2.09±0.97）/周比（1.93±0.59）/周]、Ccr[（58.5±9.1） L&#8226;周-1&#8226;（1.73 m2）-1比（55.0±9.5）L&#8226;周-1&#8226;（1.73 m2）-1]、腹膜炎的发生率（0.62次/病人年比0.30次/病人年）、首次腹膜炎时间[（23.5±4.0）个月比（20.0±15.8）个月]、腹透管出口感染次数（0 次比 1次）、发生疝的例数（1例比0例）、腹透液渗漏的发生次数（0次比0次）差异均无统计学意义（均P > 0.05）。HD组2例发生脑出血（10.5％）,皆死亡;10例（52.6％）发生囊肿出血,其中5例因反复囊肿出血行手术治疗;2例因出血严重行单侧肾脏切除。CAPD组无脑出血发生,仅1例（10％）发生囊肿出血,该囊肿出血患者经保守治疗后好转。HD组出血并发症高于CAPD组（P < 0.05）且较严重。 结论 PKD患者与非PKD患者行CAPD治疗其预后及并发症的发生比例类似。PKD患者行CAPD治疗与HD治疗的预后同样较好,且行CAPD时出血并发症的风险较少。除非透析前存在疝或患者不耐受,PKD肾衰竭患者既可选择HD也可选择CAPD作为初始的肾脏替代治疗方式,PKD不是CAPD治疗的禁忌证。     

腹膜透析联合血液透析对终末期肾脏疾病患者心血管病变的改善作用

目的通过对腹膜透析联合血液透析(peritoneal dialysis combined with hemodialysis,PHD)后与联合治疗前相关指标进行比较,探讨联合治疗对终末期肾脏疾病(end stage renal disease,ESRD)患者心血管病变的改善作用。方法回顾性分析济宁医学院附属医院肾内科14例腹膜透析(peritoneal dialysis,PD)治疗不充分的ESRD患者,改用PHD治疗后的临床疗效。随访观察患者的一般状况、临床表现、营养状态,收集其治疗前后生化指标、甲状旁腺素、β_2微球蛋白(β_2-microglobulin,β_2-MG)、颈动脉内中膜厚度(carotid intima media thickness,CIMT)、收缩压、舒张压、左室射血分数、B型钠尿肽(B type natriuretic peptide,BNP)进行分析。结果经过PHD治疗后患者饮食好转,恶心、呕吐等消化道症状消失,曾反复心力衰竭的3例患者行PHD治疗后未再出现,皮肤瘙痒及不宁腿症状明显减轻。PHD前与PHD治疗后比较,血磷:(1.76±0.41)mmol/L与(1.48±0.28)mmol/L,P0.05;甲状旁腺素:(367.93±166.66)ng/L与(237.07±76.21)ng/L,P0.05;BNP:(1 521.7±701.0)μg/L与(712.1±535.0)μg/L,P0.01;左室射血分数:(49.7±3.1)%与(52.2±1.8)%,P0.05;颈动脉内中膜厚度:(1.65±0.36)mm与(1.72±0.33)mm,P0.05,PHD治疗后较PHD前无明显改变。结论 PHD能减轻患者的临床症状,改善患者的营养状态,降低血磷,减轻继发性甲状旁腺功能亢进,延缓动脉硬化进展,可作为一种新的肾脏替代治疗模式在临床推广。     

23例终末期肾病患者透析时机影响因素的调查分析

目的 评估基层医院终末期肾病患者的透析时机,探讨过晚透析的影响因素及改进措施.方法 以郸城县人民医院透析科2007年7月1日至2009年7月1日开始透析的所有非糖尿病性终末期肾病患者为研究对象,分析其开始透析时血肌酐、肾小球滤过率、尿毒症症状、尿毒症心、脑血管并发症、首次透析情况,调查过晚透析的影响因素.结果 (1)进入透析时肾小球滤过率平均为(3.6±0.9)ml/min;(2)所有患者均有尿毒症并发症、营养状态下降,30.4%患者需急诊透析;(3)91.3%患者系透析时机过晚,其原因以经济原因多见,其次与就诊晚和认识不足有关.结论 基层医院开始血液透析的终末期肾病患者多数为透析时机过晚.经济原因、就诊过晚及认识不足是影响透析时机的关键因素.     

The quality of life in end stage renal disease care

Abstract The improved prognosis and survival statistics of both renal transplantation and dialysis have focused attention on the quality of life offered by these treatments. Using a standardized questionnaire, we assessed the quality of life of 612 patients undergoing renal replacement therapy at our center. Of these patients, 359 had been transplanted and 253 patients were on dialysis. Concerning the sociodemographic data, only the time on specific treatment was longer in dialysis patients than in transplanted patients (49.2 versus 55.6 months, P < 0.05). Most complaints were more common in dialysis patients than in transplanted patients. Only the side effects of medication were seen more in transplanted patients ( P < 0.005). Life satisfaction was higher in transplanted patients than in dialysis patients. Dialysis patients were more anxious ( P < 0.05) and more depressed ( P < 0.001) than transplanted patients. Transplanted patients also felt that they had more social support than did dialysis patients. Overall life quality was almost equal between patients on hemodialysis and patients on peritoneal dialysis, and between patients on the waiting list for transplantation and those not on the waiting list. Despite a significantly better quality of life after renal transplantation, the percentage of patients working remained unchanged. (57.5% versus 57.8%, P = n.s.). We conclude that despite an improved quality of life after renal transplantation, these patients are economically not more productive than patients on dialysis.     

A prospective analysis of testicular androgenic function in recipients of a renal allograft

Eighteen adult males with end stage renal disease (ESRD) were studied to determine the serum levels of gonadotropins (LH and FSH), prolactin (PRL) and testosterone. All of the patients were studied longitudinally while undergoing maintenance hemodialysis (HD) and six months after renal transplantation. Prior to transplantation, significantly high levels of gonadotropins and PRL were observed. During HD the serum testosterone levels tended to be subnormal in most of the uremic patients and low normal in some of the subjects. Renal transplantation led to a significant improvement (P < 0.05) in serum testosterone. Elevated gonadotropin and PRL levels observed in patients on HD returned to the normal range in most of the patients after successful renal transplantation.     

贵阳市维持性血液透析患者生活质量调查

目的了解贵阳市终末期。肾脏疾病（end stage renal disease,ESIm）接受维持性血液透析患者的一般状况、病因构成和生活质量现状。方法收集贵阳市12个血液透析中心ESRD血液透析患者756例患者的一般资料、透析方法、肾脏病和生活质量问卷（KDQOL-SF36量表）等信息并进行分布特征描述。结果756例患者中,男女之比为1．45：1．00;平均年龄（49．1±14．7）岁,原发病前三位分别为慢性肾小球肾炎407例（占53．84％）、糖尿病肾脏病132例（占17．46％）、高血压。肾损害124例（占16．40％）;患者月均总医疗费用为（6072．55±3381．01）元;不同透析时间的血液透析患者’肾脏病和透析相关生活质量各维度得分具有显著差异（P〈0．05）。结论贵阳市维持血液透析患者中,其原发病以慢性肾小球肾炎为主;透析时间〉60个月的血液透析患者生活质量、一般健康相关生活质量各维度得分较低。     

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.     

Psychosocial adjustment to end-stage renal failure: comparing haemodialysis,continuous ambulatory peritoneal dialysis and transplantation

Seventy-three children and adolescents in end-stage renal failure (ESRF) undergoing haemodialysis (n=32), continuous ambulatory peritoneal dialysis (CAPD) (n=28) or with a functioning transplant (n=13), were assessed, with their parents, on adjustment to dialysis and psychological functioning. Quantitative assessment techniques were used; the three treatment groups were compared using the Mann-Whitney U test. Findings showed a number of advantages of transplantation over dialysis, and of CAPD over haemodialysis. Children with transplants suffered less functional impairment (P=0.007), less social impairment (P=0.001) and fewer practical difficulties associated with treatment (P=0.000) than children undergoing dialysis. Parents of children with transplants also reported fewer practical difficulties than parents of children on dialysis (P=0.002). Dialysis and transplant groups did not differ on children's or parents' reports of psychological stress associated with treatment, parents' reports of marital strain, children's and parents' levels of anxiety and depression or children's behavioural disturbance. Compared with children undergoing hospital haemodialysis, those using CAPD suffered less social impairment (P=0.004), reported better adjustment to dialysis (P=0.031) and fewer practical problems associated with treatment (P=0.005), had lower depression scores (P=0.054), and showed less behavioural disturbance (P=0.013). Parents of children undergoing either CAPD or hospital haemodialysis reported similar practical difficulties, psychological stress or marital strain associated with treatment, but mean depression and anxiety scores were lower in the parents of children undergoing CAPD (P=0.042 andP=0.054). The findings have clear implications for clinical practice and may help to choose the most appropriate renal replacement therapy for children in ESRF.     

糖尿病合并终末期肾病肾移植术后应用他克莫司与环孢素A的比较

目的比较应用小剂量、低谷值浓度的他克莫司(FK506)和环孢素A(CsA)对糖尿病合并终末期肾病肾移植患者的疗效和安全性。方法选择因糖尿病合并终末期肾病行尸肾移植的患者共64例,随机分成两组,术后应用小剂量FK506组(33例)和应用CsA组(31例)。术后根据血糖水平调整胰岛素用量。比较两组急性排斥反应发生率、血糖水平、胰岛素用量的变化及对血压、血脂代谢和肝功能的影响。结果FK506组和CsA组1年人/肾存活率分别为96.97%/93.94%和96.77%/90.32%,差异无统计学意义(P>0.05)。FK506组和CsA组急性排斥反应发生率分别为12.12%(4例)和35.48%(11例),差异有统计学意义(P<0.05)。术后1个月内,FK506组和CsA组胰岛素平均用量分别为(34.35±12.14)U/d和(28.15±8.33)U/d;术后1年,FK506组和CsA组胰岛素平均用量分别为(14.09±4.22)U/d和(13.05±2.17)U/d,两组同期比较,胰岛素用量差异无统计学意义(P>0.05)。FK506组中有21例(63.63%)需要降压治疗,5例(15.15%)需要降血脂治疗,3例(9.09%)出现肝功能损害,需要护肝治疗;CsA组中有28例(90.32%)需要降压治疗,13例(41.94%)需要降血脂治疗,11例(35.48%)出现肝功能损害,需要护肝治疗,差异均有统计学意义(P<0.05)。结论终末期糖尿病肾病肾移植的患者使用小剂量、低谷值浓度的FK506疗效较好,副作用较小;对糖代谢的影响与CsA相近。     

Erythrocyte susceptibility to oxidative stress in chronic renal failure patients under different substitutive treatments

An increased oxidative stress is now considered one of the major risk factors in chronic renal failure (CRF) patients that may be exacerbated by dialysis. It has been postulated that this increased oxidative stress might cause an augmented red blood cell (RBC) membrane lipid peroxidation with the consequent alteration in membrane deformability. The aim of this study was to evaluate RBC susceptibility to an in vitro induced oxidative stress and RBC antioxidant potential in different groups of CRF patients undergoing different substitutive treatment modalities. Fifteen end-stage CRF patients were evaluated in conservative treatment, 23 hemodialysis (HD) patients, 15 continuous ambulatory peritoneal dialysis (CAPD) patients, 15 kidney transplanted patients, and 16 controls. Their RBCs were incubated with the oxidative stress-inducing agent tert-butylhydroperoxide both in the presence and in the absence of the catalase inhibitor sodium azide, and the level of malondialdehyde (MDA) (a product of lipid peroxidation), was measured at 0, 5, 10, 15, and 30 min of incubation. In addition, the RBC content of reduced glutathione (GSH) was measured by HPLC. As opposed to the controls, RBCs from end-stage CRF patients exhibited an increased sensitivity to oxidative stress induced in vitro, both in the absence and presence of a catalase inhibitor, as demonstrated by a significantly higher level of MDA production at all the incubation times (P < 0.05). Different substitutive treatments had different impacts on this phenomenon; CAPD and kidney transplantation were able to normalize this alteration while HD was not. GSH appeared to be related to the increase in RBC susceptibility to oxidative stress; its content being significantly elevated in end-stage CRF and HD patients as compared with CAPD and transplanted patients and controls (P < 0.05). No significant changes were observed in the RBC glutathione content during the HD session. The increase of GSH in RBCs of end-stage CRF and HD patients seems to indicate the existence of an adaptive mechanism under increased oxidative stress occurring in vivo. Unlike HD, the beneficial effect of CAPD on the anemia of dialysis patients might partly be due to a condition of lower oxidative stress that might in addition counterbalance the cardiovascular negative effects of dislipidemia of CAPD patients.     

不同血液净化治疗方法对终末期肾病难治性高血压患者的临床观察

目的 不同血液净化方法治疗维持性血液透析患者难治性高血压的疗效观察.方法 60例终未期肾病难治性高血压患者按随机数字表法分为血液透析组,血液透析联合血液透析滤过组,血液透析联合血液灌流组,每组15例患者.血液透析联合血液透析滤过再联合血液灌流组,观察治疗前及治疗16周后所有患者血压变化及肾素、血管紧张素Ⅱ、全段甲状旁腺激素的水平变化.结果 各组患者治疗后血压及肾素、血管紧张素Ⅱ、全段甲状旁腺激素水平与治疗前比较差异有统计学意义(P＜0.05),而治疗组中血液透析联合血液透析滤过再联合血液灌流组与血液透析联合血液灌流组、血液透析联合血液透析滤过组治疗后比较,血压变化及肾素、血管紧张素Ⅱ、全段甲状旁腺激素水平与治疗前比较差异有统计学意义(P＜0.05).结论 在维持血液透析的治疗基础上联合应用血液透析滤过及血液灌流能有效的控制终未期肾病难治性高血压.     

Renal transplantation, chronic dialysis, and chronic renal insufficiency in children and adolescents. The 1995 Annual Report of the North American Pediatric Renal Transplant Cooperative Study

The 1995 Annual Report of the North American Pediatric Renal Transplant Cooperative Study summarizes data voluntarily collected from 123 centers on 5,197 children and adolescents grouped into three cohorts: (1) patients who received renal transplants on or after 1 January 1987 (n = 3,066), (2) patients who were maintained on peritoneal dialysis (PD) or hemodialysis (HD) on or after 1 January 1992 (n = 1,488), and (3) patients treated for chronic renal insufficiency (CRI) on or after 1 January 1994 (n = 643). The transplant and dialysis information update previous registry data whereas the CRI information reflects 1st-year registry data. Three-year graft survival rates were 83% and 66% for living donor grafts and cadaver donor (CD) grafts, respectively. Triple drug maintenance therapy with prednisone, cyclosporine, and azathioprine was used by >70% of all transplant recipients through 5 years of follow-up. The 2-year CD survival has steadily improved from 65% in 1987 to 82% in 1992. Fifty malignancies have been reported, the majority of which are lymphoproliferative disorders. The 2-year patient survival posttransplantation is 95%. Mortality rates for the youngest patients have drastically improved over the past 2 years. Approximately two-thirds of patients in the dialysis cohort are maintained on PD; automated PD remains the preferred modality. Overall, the peritonitis rate is one infection every 13.3 patient months, the frequency of infection being greatest in the youngest patients. Whereas the primary reason for dialysis modality termination is transplantation, approximately 40% of the entire dialysis cohort (PD and HD) were not considered active transplant candidates. Baseline CRI data revealed the most common primary diagnoses to be obstructive uropathy (24%) and aplastic/hypoplastic/dysplastic kidneys (19%). The standardized height deficit in the CRI cohort was greatest in the youngest patients and those with the most impaired renal function.     

组合型人工肾治疗慢性肾衰竭疗效的观察

目的对组合型人工肾（血液灌流HP联合血液透析HD）治疗慢性肾衰竭（CRF）的疗效进行评价。方法将2006年2月1日至2007年4月30日期间在我院住院的50例CRF患者分为两组,治疗组行HP＋HD治疗,对照组行HD治疗,每组25例。治疗组在接受常规血液透析的同时每周接受一次血液灌流。对照组行血液透析,5小时后结束,每周透析2～3次。观察两组治疗前后肾功能、血电解质及临床表现的变化。结果两组治疗后血尿素氮、肌酐明显下降,差异无统计学意义;治疗组临床症状较对照组明显改善,差异有统计学意义。结论HP＋HD治疗CRF的疗效优于HD。     

腹膜透析和血液透析对难治性心衰患者睡眠和生活质量的影响

目的探讨腹膜透析(peritoneal dialysis,PD)和血液透析(hemodialysis,HD)对难治性充血性心力衰竭(refractory congestive heart failure,RCHF)患者睡眠质量和生活质量的影响。方法回顾分析2010年01月1日至2017年12月31因RCHF在南京大学医学院附属南京鼓楼医院肾脏科接受PD(31例)或HD(17例)治疗患者的临床和随访资料。收集患者透析前和6个月后临床、实验室检查资料、简明健康调查问卷(the MOS item short from health survey,SF-36)和匹兹堡睡眠质量指数量表(Pittsburgh sleep quality index,PSQI)数据,通过自身前后对照比较两种治疗方式对患者临床、实验室指标以及睡眠和生活质量的影响,Logistic回归分析透析方式对患者生活质量的影响。结果两组患者临床心功能分级和B型脑钠肽水平在治疗后均较治疗前显著改善(P<0.01),两种治疗方式间比较无显著差异(P>0.05);两组患者左心射血分数在治疗后均无明显改善(P>0.05)。HD患者除在催眠药和日间功能障碍外,其他5项睡眠质量指标均有显著改善(P<0.05),PD治疗患者除在催眠药外,其他6项睡眠质量指标均有显著改善(P<0.05)。两种治疗方式均显著改善患者PSQI总分值(P<0.05),两种治疗方式间比较PSQI总分值无显著差异(P>0.05)。HD对除情感职能外的其他7项生活质量指标均有显著改善作用(P<0.01);PD对全部8项生活质量指标均有显著改善(P<0.01)。治疗6个月后,除生理功能外,PD在其他生活质量指标均好于HD(P<0.05)。Logistic回归显示PD与患者更好的生理职能和情感职能相关(P<0.01)。结论PD与HD一样可改善RCHF患者近期的临床症状和睡眠质量,但PD生活质量改善上优于HD。     

Comparing aortic stiffness in kidney transplant recipients, hemodialysis patients, and patients with chronic renal failure

Pan CR, Schmaderer C, Roos M, von Eynatten M, Sollinger D, Lutz J, Heemann U, Baumann M. Comparing aortic stiffness in kidney transplant recipients, hemodialysis patients, and patients with chronic renal failure.
Clin Transplant 2011: 25: E463–E468. © 2011 John Wiley & Sons A/S. Abstract: Background: The poor cardiovascular survival of patients with renal insufficiency is improved by transplantation. Carotid‐femoral pulse wave velocity (PWV) is able to predict independently overall and cardiovascular mortality. PWV is elevated in renal insufficiency. Consequently, PWV may change according to the improvement in renal function after kidney transplantation. Methods: In a cross‐sectional setting, PWV was determined in 40 renal transplant recipients (RTx) and compared to the PWV of 40 age‐ and gender‐matched patients with comparable renal insufficiency (CKD) and 40 age‐ and gender‐matched hemodialysis patients (HD). Results: RTx and CKD patients had comparable eGFR (RTx: 42.9 ± 18.4, CKD: 48.3 ± 29.1 mL/min/1.73 m²) and protein/creatinine ratio (RTx: median 172.5, 25th percentile 97.75, 75th percentile 344.5, CKD: median 183.272, 25th percentile 100.00, 75th percentile 470.00 mg/g creatinine). There was no significant difference in PWV between RTx 3–12 months post‐transplant and CKD or HD patients (RTx: 9.65 ± 1.57, CKD: 9.98 ± 3.91, HD: 10.27 ± 2.89 m/s; n = 20 pairs). Similarly, PWV in transplant patients >12‐month post‐transplant was similar to that of CKD and HD patients (RTx: 9.71 ± 2.23, CKD: 9.36 ± 2.74, HD: 9.84 ± 3.41 m/s; n = 20 pairs). Discussion: We could not detect significant differences in PWV comparing RTx with age‐ and gender‐matched CKD patients.