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1.
血液透析早期死亡原因及危险因素分析   总被引:1,自引:0,他引:1  
目的 了解终末期肾病患者早期死亡的原因和危险因素.方法 对我院1997年1月~2006年12月92例开始血液透析后3个月内死亡患者按糖尿病和非糖尿病分组并进行回顾性分析.结果 796例终末期血液透析患者中,早期死亡92例(占11.6%),其中糖尿病组患者早期死亡率为31.2%,非糖尿病组患者为7.9%.肺水肿为最常见的透析指征,心血管事件为最常见的死亡原因.两组年龄、血浆白蛋白、内生肌酐清除率比较有显著性差异.两组患者透析前管理率、择期透析率均较低,结论老年、糖尿病患者有更高的早期死亡率,高龄、糖尿病、低蛋白血症、心血管并发症是早期死亡的危险因素,有效的透析前管理和出现严重并发症之前开始透析也许能改善患者的预后.  相似文献   

2.
Background: Chronic kidney disease (CKD) is an increasingly health disease all around the world with a high burden of mortality and cardiovascular (CV) morbidity rate. Even when renal replacement therapy is reached, more than half patients die, mainly for CV causes due either to uremia‐related cardiovascular risk factors (such as anemia, hyperhomocysteinemia, mineral bone disease–CKD with hyperparathyroidism, oxidative stress, hypoalbuminemia, chronic inflammation, prothrombotic factors) or to traditional ones (age, male gender, diabetes, obesity, hypertension, smoking, insulin levels, family history, dyslipidemia). Among the latter causes dyslipidemia represents one of the major, potentially correctable risk factor. Methods and Results: Statins have demonstrated to effectively and safely reduce cholesterol levels in CKD patients. Here we will examine the effects of statins on CV risk factors in CKD patients and particularly in patients on dialysis treatment, in the light of the unfavorable results of the large trials 4D and AURORA, recently published, underlining the role of malnutrition/inflammation as confounding factor. Probably it will be that only with a real prevention, starting statins even in the early stages of CKD, as indicated by post hoc analysis of large trials, that we will reach results in reducing the mortality rate in CKD patients. In the meanwhile, all the other remediable CV risk factors have to be at the same time corrected.  相似文献   

3.
BACKGROUND: For patients with chronic renal insufficiency, rates of referral to nephrologists are highly variable, and little is known about the effect of such consultation on clinical outcomes. We sought to determine whether early or frequent access to nephrologist care prior to the initiation of dialysis was associated with a difference in mortality rates in the first year after dialysis began. METHODS: We identified all patients in the New Jersey Medicaid and Medicare programs who began maintenance dialysis during a 6-year period and who had been diagnosed with renal disease more than 12 months prior to dialysis. Use of nephrologist services was documented during this 1-year period, along with other clinical and sociodemographic variables. The outcome measure of our analysis was mortality in the first year after initiation of dialysis. RESULTS: From multivariate analyses, we found that patients who did not see a nephrologist until 90 days or less before initiation of dialysis had a 37% higher likelihood of death in the first year of dialysis compared with patients with earlier referral (95% confidence interval, 1.22-1.52; P<.001). Similarly, those who saw a nephrologist on fewer than 5 occasions in the year prior to dialysis had a 15% higher mortality rate in the first year of dialysis compared with those who had had 5 or more nephrologist visits (95% confidence interval, 1.03-1.28; P =.01). CONCLUSIONS: For patients with long-standing renal disease, earlier consultation with a nephrologist and more frequent specialist encounters is associated with lower mortality in the first year of dialysis. These findings need to be confirmed in younger and less indigent patients as well.  相似文献   

4.
Diabetic nephropathy and diabetes related nephropathies represents one of the most common causes of end‐stage renal disease (ESRD), and diabetic patients with chronic renal failure represent the most important high risk cohort of uraemic patients requiring renal replacement therapy. Interventions to slow progression of kidney disease and measures to reduce the risk of cardiovascular disease are highly effective in early renal damage and should be the main task of nephrologists, but diabetic patients are more frequently referred late to the nephrologist. Factors involved in the rate of mortality of diabetic patients with ESRD are multiple, including nutritional status, comorbidity, age, etc, but the duration and quality of pre‐dialysis nephrological care constitute a key for improving outcomes of diabetic patients with ESRD.  相似文献   

5.
Vascular calcification is a frequent complication of uremic patients. In addition to classical risk factors such as age, male gender, smoking, inflammation, hypertension, dyslipidemia, and diabetes, which also exist in the general population, patients with chronic renal failure have other risk factors such as oxidative stress, inflammation, hyperparathyroidism, hypoparathyroidism, hypercalcemia, hyperphosphatemia, and overtreatment with calcium and vitamin D. These latter risk factors may even have a better predictive value than classical risk factors for coronary heart disease in uremic patients.  相似文献   

6.
This article explores some of the factors which may contribute to the persistence of the differences in outcome between European and US hemodialysis patients. A higher comorbidity of incident and prevalent renal replacement therapy patients, different vascular access policies with less use of arteriovenous fistulas, shorter dialysis times, and higher reutilization of dialysis membranes in the USA may, among other factors, explain the higher mortality compared to Europe and Japan. No major differences in patient referral to the nephrologist, in residual renal function at the start of dialysis, nor in the dialysis dose based on Kt/V urea data were noted.  相似文献   

7.
Inflammatory and atherosclerotic interactions in the depleted uremic patient   总被引:37,自引:0,他引:37  
Despite the improvements in dialysis technology, the cardiovascular mortality rate is still unacceptably high among dialysis patients. It is obvious that traditional risk factors, such as hypertension, chronic heart failure (CHF), dyslipidemia and diabetes mellitus, may account for a large part of the increased cardiovascular mortality rate in these patients. However, based on recent research it could be speculated that other, non-traditional risk factors might also contribute to the high cardiovascular mortality rate in dialysis patients. Chronic inflammation, as evidenced by increased levels of pro-inflammatory cytokines and C-reactive protein (CRP), is a common feature in dialysis patients and is associated with an increased cardiovascular morbidity and mortality. Indeed, elevated levels of pro-inflammatory cytokines (such as TNF-alpha, IL-1 and IL-6) may cause malnutrition and progressive atherosclerotic cardiovascular disease by several pathogenetic mechanisms, which will be discussed in this review. Based on the strong associations observed between malnutrition, inflammation and atherosclerosis in patients with chronic renal failure (CRF) we have proposed that these features constitute a specific syndrome (MIA), which carries a high mortality rate. As elevated levels of pro-inflammatory cytokines may play a central part in the vicious circle of malnutrition, inflammation and atherosclerosis, further research is needed to investigate whether or not different anti-cytokine treatment strategies may improve survival in dialysis patients.  相似文献   

8.
Hyperhomocysteinemia refers to an elevated circulating level of the sulfur-containing amino acid homocysteine and has been shown to be a risk factor for vascular disease in the general population. In patients with renal failure, hyperhomocysteinemia is a common feature. The underlying pathophysiological mechanism for this phenomenon is unknown. Proposed mechanisms include reduced renal elimination of homocysteine and impaired nonrenal disposal, possibly because of inhibition of crucial enzymes in the methionine-homocysteine metabolism by the uremic milieu. Absolute or relative deficiencies of folate, vitamin B6, or vitamin B12 may also play a role. Several case-control and prospective studies have now indicated that hyperhomocystenemia is an independent risk factor for atherothrombotic disease in patients with predialysis and end-stage renal disease. In renal patients, plasma homocysteine concentration can be reduced by administration of folic acid in doses ranging from 1 to 15 mg per day. In more than 50% of the cases, however, the homocysteine concentration remains above 15 micromol/L. The effects of vitamin B12 or vitamin B6 are unclear. Large intervention trials are now needed to establish whether homocysteine-lowering therapy will reduce atherothrombotic events in patients with renal failure. These studies are now planned or are ongoing.  相似文献   

9.
OBJECTIVE: To determine the incidence, clinical course, and risk factors associated with the onset of chronic renal failure in sickle cell anemia and sickle C disease. DESIGN: A prospective, 25-year longitudinal demographic and clinical cohort study. A matched case-control study was conducted to determine risk factors. PATIENTS: A total of 725 patients with sickle cell anemia and 209 patients with sickle C disease who received medical care from the hematology service in a large municipal hospital. Most were observed from birth or early childhood. MEASUREMENTS: Thirty-six patients developed sickle renal failure: 4.2% of patients with sickle cell anemia and 2.4% of patients with sickle C disease. The median age of disease onset for these patients was 23.1 and 49.9 years, respectively. Survival time for patients with sickle cell anemia after the diagnosis of sickle renal failure, despite dialysis, was 4 years, and the median age at the time of death was 27 years. Relative risk for mortality was 1.42 (95% Cl, 1.12 to 1.81; P = 0.02) compared with patients who did not develop renal insufficiency. MAIN RESULTS: Histopathologic studies showed characteristic lesions of glomerular "drop out" and glomerulosclerosis. Case-control analysis showed that ineffective erythropoiesis with increasingly severe anemia, hypertension, proteinuria, the nephrotic syndrome, and microscopic hematuria were significant pre-azotemic predictors of chronic renal failure. The risk for sickle renal failure was increased in patients who had inherited the Central African Republic beta s-gene cluster haplotype. CONCLUSIONS: The pre-azotemic manifestations of hypertension, proteinuria, and increasingly severe anemia predict end-stage renal failure in patients with sickle cell disease. The rate of progression of renal insufficiency is genetically determined. Treatment of the uremic phase has been dismal, underscoring the need for the development of useful pre-azotemic therapeutic modalities.  相似文献   

10.
For patients with chronic renal failure (CRF), correct nutrition can not only improve the quality of life but also the prognosis. Whereas the diet recommendations in the early phases of chronic renal insufficiency aim to inhibit progression of the disease, in advanced stages of renal failure the main concern is a sufficient caloric nutrition. Malnutrition is an insidious complication, because it is mostly initally diagnosed in advanced stages of CRF but even when mildly present can significantly affect survival. CRF patients have an increased energy requirement but normally supply too little energy. This favors a protein energy malnutrition, which can already be present in 20-25% of predialysis patients and up to 70% of dialysis patients. The simultaneous presence of malnutrition, inflammation and atherosclerosis (MIA syndrome) has been recorded in up to 70% of dialysis patients and is correlated to a particularly high mortality rate.  相似文献   

11.
Diabetes patients with advanced renal failure profit from a structured care combining early referral to a nephrologist with different options of renal replacement therapy. Kidney transplantation (preemptively) is currently only available in exceptional cases. Decision-making for dialysis includes patient preferences, medical and social aspects. Peritoneal dialysis (PD) is an option in cases with limited life expectancy, initial treatment before hemodialysis (HD) and as a bridging to transplantation. Integrated care includes a timely switch from PD to HD while using the initial advantages of PD (improved survival of initial treatment period, better quality of life and prolonged residual renal function). Supportive care to avoid disease-specific complications, such as amputation, infection, cardiac infarction, stroke and depression, is a cornerstone in the improvement of survival for diabetic patients undergoing renal replacement therapy.  相似文献   

12.
Haemolytic uremic syndrome (HUS) and HIV-associated nephropathy (HIVAN) are common renal diseases in the course of HIV-infected patients. CASE REPORT: We report the case of a 13-month-old Caucasian boy hospitalised for a verocytotoxin positive HUS associated with HIV infection. After the acute phase of HUS the creatinine level returned to normal values. Because of progressive renal failure with severe overload hypertension and glomerular proteinuria despite antiretroviral therapy and angiotensine converting enzyme inhibitor, the child required peritoneal dialysis 12 months later. Clinical and biological course together with pathological findings were consistent with both typical HUS and HIVAN. CONCLUSION: This is the first paediatric case of typical HUS revealing a HIVAN. The association of HUS and HIVAN may explain the progression to end-stage renal failure despite antiretroviral therapy associated with angiotensine converting enzyme inhibitor and a good control of HIV replication. HIVAN is rare in children and may occur in the early phase of HIV infection even not only in black patients.  相似文献   

13.
This study was carried out to determine the frequency and to quantitate the severity of calcium-phosphate deposits in end-stage kidneys. In 57 of 59 end-stage kidneys obtained from patients with a variety of different renal diseases, calcium levels were greater than 2 standard deviations (SD) above control values. The mean calcium concentration was 157 ± 24 mmol/kg dry defatted tissue in the end-stage kidneys as compared to 17 ± 1 mmol/kg in the control kidneys. Histologically, calcium was deposited in the cortical tubular cells, basement membranes and interstitium. It would appear that calcification occurred during the course of renal failure rather than terminally in that the kidney calcium concentration bore no relationship to the calcium × phosphate product, and the calcium concentration in the kidneys of uremic patients undergoing dialysis (144 ± 23 mmol/kg) was no greater than that found in uremic patients not undergoing dialysis (188 ± 62 mmol/kg). It is suggested that calcification may damage the diseased kidney accelerating the rate of renal functional deterioration.  相似文献   

14.
Nephropathy in diabetics is the number two complication of this disease with a prevalence of 20%–50% in the German outpatient population. Compared to type 1 diabetes with the typical glomerular diabetic lesions, nephropathy in type 2 diabetes is heterogeneous and frequently the result of hypertensive/vascular or immunological disease. Glomerular filtration rate (formula clearance) and albuminuria/proteinuria are reliable prognostic factors, both associated with cardiovascular morbidity and mortality. Baseline therapy to ameliorate renal failure includes control of the risk factors hyperglycemia, hypertension, and hyperlipidemia together with lifestyle changes. The therapeutic focus in advanced disease stages includes secondary consequences of renal failure (bone disease, acid-base and electrolyte disturbances, anemia, malnutrition). Timely preparation for renal replacement therapy is mandatory. Diabetic patients of all ages benefit from renal transplantation; combined pancreas-kidney transplantation is an option for younger type 1 diabetics. The diabetic patient benefits most from a multidisciplinary and multiprofessional therapy approach with individual therapeutic goals provided by the general practitioner, diabetologist, cardiologist, and nephrologist. Therapeutic targets in advanced kidney disease are based on limited evidence.  相似文献   

15.
BACKGROUND: Cholesterol crystal embolism syndrome (CCE) is an increasing end-stage renal disease cause. Few cases have been described on dialysis, despite the high prevalence of the predisposing factors. METHODS: The diagnostic criteria of the present study were: skin lesions, myalgia, fatigue, fever and acute inflammatory serologic signs, in the presence of severe vasculopathy. The precipitating factors were: anticoagulation, endovascular intervention and ulcerated atherosclerotic plaque. RESULTS: Between October 2003 and September 2005, CCE was diagnosed in 6 dialysis patients (of 200-210 on chronic treatment): 5 males, 1 female, median age 59.5 years (47-70) and end-stage renal disease follow-up 11.5 years (3-25). All had severe vasculopathy, 5 cardiopathy, and 4 were failed graft recipients. The treatment included: peritoneal dialysis, daily dialysis, 'conventional' hemodialysis (2 cases) and hemodiafiltration. The diagnosis was based on the clinical-laboratory picture in 1 patient. In the 5 others clues were present (dicumarol therapy, angioplasty, femoral artery thrombosis, CCE predialysis and ulcerated aortic plaque). The therapeutic approach consisted of corticosteroids (5 cases), statins (4 cases) and prostaglandin analogues (4 cases). CONCLUSION: The differential diagnosis of CCE should also be considered in dialysis patients (necrotic lesions, limb pain and vasculitis-like signs).  相似文献   

16.
Chronic renal failure is associated with a significant cardiovascular risk due to an increased incidence of cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia). Cardiovascular mortality is due to an increased incidence of left ventricular hypertrophy, ischemic heart disease and chronic heart failure. Management focuses on risk factors, mainly high blood pressure in patients with mild to moderate chronic kidney disease, but it often fails in patients with chronic kidney failure.  相似文献   

17.
The observation that antiplatelet therapy may decrease the incidence of Epo-induced hypertension in dialysis patients remains a subject of particular interest. The aim of the present study was to test this hypothesis in patients at the predialysis stage. Predialysis patients with renal anemia were treated with EPO (6000 IU/week) for 6-12 months. Patients were divided into two groups, one of which received antiplatelet therapy and the other did not, and a comparison was made between them with respect to the incidence of EPO-induced hypertension. Logistic regression analysis was used to determine the risk factors for developing hypertension during the EPO therapy. Such predictors included age, gender, antecedent of hypertension, antiplatelet drugs and diabetes mellitus. Overall, 66 patients were enrolled in the study and 18 developed hypertension (27%). Out of the 35 patients not receiving antiplatelet therapy, 15 developed hypertension (43%). In contrast, out of the 31 patients receiving antiplatelet therapy, only 3 (10%) developed hypertension (p=0.003 by Chi square test). Multiple regression analysis showed that the best predictive variables for the development of hypertension were antecedent of hypertension (odds ratio: 0.064, p=0.0118), and use of antiplatelet drugs (odds ratio: 5.081, p=0.0295). The present data provide evidence that antiplatelet therapy may prevent EPO-induced hypertension in predialysis patients. However, the mechanism to explain such an effect still remains to be elucidated.  相似文献   

18.
Falls are an important health problem and the risk of falling increases with age. The costs due to falls are related to the progressive decline of patients' clinical conditions, with functional inability inducing increasing social costs, morbidity and mortality. Renal dysfunction is mostly present in elderly people who often have several comorbidities. Risk factors for falls have been classified as intrinsic and extrinsic, and renal dysfunction is included among the former. Chronic kidney disease per se is an important risk factor for falls, and the risk correlates negatively with creatinine clearance. Vitamin D deficiency, dysfunction of muscles and bones, nerve degeneration, cognitive decline, electrolyte imbalance, anemia, and metabolic acidosis have been reported to be associated with falls. Falls seem to be very frequent in dialysis patients: 44% of subjects on hemodialysis fall at least once a year with a 1-year mortality due to fractures of 64%. Male sex, comorbidities, predialysis hypotension, and a history of previous falls are the main risk factors, together with events directly related to renal replacement therapy such as biocompatibility of the dialysis membrane, arrhythmias, fluid overload and length of dialysis treatment. Peripheral nerve degeneration and demyelination as well as altered nerve conduction resulting in muscular weakness and loss of peripheral sensitivity are frequent when the glomerular filtration rate is less than 12 mL/min. Moreover, depression and sleep disorders can also increase the risk of falls. Kidney function is an important parameter to consider when evaluating the risk of falls in the elderly, and the development of specific guidelines for preventing falls in the uremic population should be considered.  相似文献   

19.
Acute renal failure is a common clinical problem in the intensive care unit (ICU) and is associated with significant morbidity and mortality. There is no "magic bullet" to prevent acute renal failure or to modify the clinical course of established renal failure. The approach to therapy is directed to the early initiation of dialysis therapy. Continuous dialysis therapy is becoming the preferred form of dialysis in the ICU.  相似文献   

20.
Diabetes associated end stage renal disease has now become the most common cause of renal replacement therapy in the industrialized countries. Survival rates of diabetic patients treated with dialysis are considerably lower than in general dialysis patients, above all due to excess cardiovascular mortality. Therefore, kidney transplantation and combined kidney-pancreas transplantation should be considered as therapy of choice, since they significantly improve mortality and morbidity. Patients who are not suitable for transplantation can be treated by either peritoneal dialysis or hemodialysis. Mortality rates are comparable between both treatment regimes during the first two years of dialysis. Technical survival of both, peritoneal dialysis and hemodialysis, will be inferior in diabetic patients compared to non-diabetic patients. Furthermore, an earlier initiation of dialysis treatment in patients with diabetes mellitus compared to non-diabetic patients is usually necessary, because diabetic patients are less resistant to uremic toxins at comparable glomerular filtration rates.  相似文献   

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