吸附式透析清除尿毒症中分子物质

背景:常规血液透析主要清除尿素氮、肌酐等小分子质量毒素,但对中分子物质清除很少.随着透析时间的延长,大量中分子物质在患者体内蓄积,从而引发一系列并发症.目的:比较吸附式透析(血液灌流联合血液透析)与常规血液透析对尿毒症患者血液中分子物质的清除作用.方法:维持性血液透析患者随机分为吸附式透析组及常规血液透析组各30例.吸附式透析组先将血液灌流器与透析器串联实施吸附透析(血液灌流器安置在透析器之前),治疗120 min后取下灌流器,继续实施血液透析120 min,常规血液透析组实施常规血液透析240 min.治疗前后检测肝功、肾功、血清电解质、血细胞数及中分子毒素浓度,并观察临床症状的变化.结果与结论:吸附性透析能显著清除患者体内的中分子物质,单次使用治疗120 min后中分子物质浓度显著下降,与单纯血液透析组相比差异有显著性意义(P < 0.05).吸附式透析组治疗后血小板水平均较治疗前明显降低(P < 0.05),并与单纯透析组相比有显著性意义(P < 0.05).两组肝功、肾功指标、电解质浓度差异无显著性意义.吸附式透析组皮肤瘙痒、睡眠障碍及肌肉疼痛等症状有不同程度改善.     

高通量透析对中分子毒素清除的临床研究及应用

高通量透析（HFD）为采用高通透性透析器在容量控制的透析机上进行维持性血液透析，属于一种高效血液净化治疗方法，它的临床运用有效弥补了普通透析的不足。由于其对中大分子物质清除能力较普通血液透析强，透析效率高。作者自2001年开展至今共进行505例次高通量透析，旨在探讨和HFD透析效率及对中分子物质清除能力的评价，现总结如下。     

高通量透析对中分子毒素清除的临床研究及应用

高通量透析(HFD)为采用高通透性透析器在容量控制的透析机上进行维持性血液透析,属于一种高效血液净化治疗方法,它的临床运用有效弥补了普通透析的不足。由于其对中大分子物质清除能力较普通血液透析强,透析效率高[1]。作者自2001年开展至今共进行505例次高通量透析,旨在探讨和HFD透析效率及对中分子物质清除能力的评价,现总结如下。1临床资料选择长期维持性透析患者40例,男性25例,女性15例,年龄(35.10±12.09)岁。其中原发病为慢性肾小球肾炎35例、狼疮性肾炎2例、梗阻性肾病3例,随机分血液透析(HD)组及HFD组各20例。所有患者均在容量…     

中药浴非透析疗法对尿毒素的清除作用

慢性肾功能不全有效的治疗方法通常是以血液透析、腹膜透析来清除体内储存的尿毒素,达到改善临床症状,延长寿命的目的,但费用昂贵,使许多患者经济上无法负担.近年来虽然应用非透析疗法,如低蛋白饮食加用开同、尿毒清等治疗,仍同样因费用问题不能满足贫困地区患者的需求.为此,我们于1998年6月开始,依据透析疗法的平衡原理研究中药浴对尿毒素的清除作用,取得了较满意的疗效,报告如下.     

高通量透析对中分子物质和细胞因子的影响

〖目的〗研究高通量透析对维持性血液透析患者中分子物质和细胞因子水平的影响.〖方法〗 55例患者随机分组后分别进行高通量透析(n＝30例)和常规血液透析(n＝25),每周透析2～3次.于透析前,透析后即刻,透析12个月后检测两组患者血浆BUN,Cr,P3-,β2微球蛋白(β2-MG),甲状旁腺激素(PTH)、IL-1β、IL-6、IL-8和TNFα水平,并于透析20 min后检测透析液中的IL-1β、IL-6、IL-8和TNFa水平,对两组的指标进行了比较.〖结果〗对P3-,β2-MG,PTH的清除率高通量透析组优于常规血液透析组(P＜0.05),对BUN,Cr的清除率两组相比较无显著差异;首次高通量透析后IL-8和TNFa与透析前比较显著升高(P＜0.05),透析1年后血浆IL-1β、IL-6、IL-8和TNFa呈下降趋势,但与透析前和常规血液透析1年后比较无显著差异;高通量透析组透析液中IL-1β、IL-6、IL-8、TNFα和β2-MG水平高于常规血液透析组(P＜0.05).〖结论〗高通量透析对中分子物质和磷离子的清除率优于常规血液透析,对细胞因子的影响近似于常规血液透析.     

高通量透析不同超滤量对溶质清除的影响

目的 观察高通量透析在不同超滤量情况下对维持性血液透析患者体内毒素清除效率及皮肤瘙痒程度的影响. 方法 选择维持性血液透析患者80例随机分成治疗组及对照组,均进行高通量透析治疗但治疗组超滤量大于对照组,2组患者均每周血液透析治疗3次,每次4h,共观察6个月;在观察的0、6个月时分别检测两组患者的透析前后血肌酐（Cr）、血磷（p）、β2-微球蛋白（β2-MG）浓度,计算单次透析溶质清除率,取两次结果均值比较;应用改良Duo评分系统评估治疗前后瘙痒程度变化;比较两组患者跨膜压及不良反应的发生情况.以上结果均行t检验或χ^2检验.结果 经过上述治疗后两组患者血肌酐下降率差异无统计学意义（t =1.094,P=0.277,P＞0.05）;治疗组p、β2-MG的下降率均大于对照组（t值分别为-2.138和-12.815,P值分别为0.036和0.01,P＜0.05）;治疗组患者皮肤瘙痒降低程度大于对照组（t=-3.556,P=0.01,P＜0.05）;治疗组跨膜压高于对照组（t值10.22,P值0.001,P＜0.01）;两组不良反应发生率无统计学差异（χ^2=值分别为0.346、0.157和0.125,P值分别为0.556、0.692和0.723,P＞0.05）. 结论 高通量透析时增加超滤量在保证对小分子毒素充分清除的基础上,增加了大、中分子毒素的清除,可以明显减轻维持性血液透析患者顽固性皮肤瘙痒症状,可更大程度的发挥高通量透析的优势,不增加不良反应发生.     

血液透析串联血液灌流对病人血液中分子物质清除效果

目的探讨血液透析串联血液灌流对尿毒症病人血液中中分子物质清除的效果。方法将40例慢性尿毒症病人随机分为联合组及对照组，联合组采用血液透析串联血液灌流治疗，连续4周；对照组采用单纯血液透析治疗，连续4周。治疗前后抽取血液检测中分子物质的含量，并观察两组血压、皮肤瘙痒、睡眠不良等症状改善情况。结果两组治疗后，中分子物质均有下降，但联合组中分子物质下降的程度显著大于对照组（t=2．54，P〈0．05），皮肤瘙痒症状改善显著好于对照组（x^24．86，P〈0．05）。结论尿毒症病人血液透析串联血液灌流治疗可有效清除中分子物质及减轻皮肤瘙痒，改善血液净化效果，提高病人生存质量。     

CAPD对中分子量物质清除效果的观察

人们对於引起尿毒症毒性物质的研究经历了160年的漫长道路。至70年代初Babb提出了中分子量物质学说,将这领域之研究推向了新的阶段。但目前国内有关该方面的文章很少,特别是CAPD对中分子是物质清除的资料,迄今未见报导。我科自1985年从事这项研究工作,兹将结果介绍分析於后。 1 材料和方法 病例资料 慢性肾衰(CKF)14例,女7例,男7例。急性肾衰(ARF)2例,均为男性。慢性透析时间最长为29个病人月,短者2个病人月,平均为8个病人月。急性透析在10天左右治疗方法为一日透析四次,每次入液量2000ml。其中有腹膜炎者2例,均在治疗中。标本留取系采集隔夜(至少在腹腔内停留小时以上)透出液2ml,同时抽空腹血2ml分别送检。为监测是否空腹同时测血糖含量,以确保检验结果的准确性。     

活性炭与树脂对尿毒症患者中分子物质、甲状旁腺素的体外吸附研究

目的分析探讨活性炭和树脂对尿毒症患者体内的中分子物质总量(middle molecular substances,MMS)及甲状旁腺素(parathyroid hormone,PTH)的清除性能差异。方法取维持性透析患者的血液,随机分为4组,分别用AC活性炭、MR1、MR2、MR3树脂4种吸附剂进行体外吸附,检测吸附前后血液中的MMS和PTH,结合吸附剂的孔结构检测,分析活性炭与树脂对MMS、PTH的清除性能差异。结果同组内吸附前后比较,4组血样的MMS、PTH水平均显著降低(P<0.01;MMS指标P值分别为0.006、0.001、0.001、0.000,PTH指标P值均为0.000)。对MMS清除水平,AC组最高(32.73%±3.29%),MR1组(22.96%±7.18%)最低,且2组比较有统计学意义(P<0.05;P=0.027),而3种树脂间MMS清除水平差异无统计学意义。对PTH清除水平,MR1组最高(90.52%±4.05%),MR2组次之(77.43%±3.65%),MR3组较小(63.71%±1.49%),AC组最低(36.53%±4.95%),且4组差异显著(P<0.01;P值均为0.000)。结论活性炭由于孔径分布范围广,能吸附的毒素分子量范围更广,对中分子物质总量清除更有利;大孔吸附树脂具有较为集中的孔径分布,对以PTH为目标的单一中分子毒素清除更有利。     

Hyperlipidemia in uremic patients in dialysis

Serum concentrations of cholesterol, triglycerides, high density lipoprotein-cholesterol (HDL-C), apoproteins (apo) A and B were compared in 36 hemodialysis patients and in 20 normal controls. Hyperlipidemia was present in 22 patients (59.4%); 15 of them had simple hypertriglyceridemia and 7 had combined hyperlipidemia (i.e., hypertriglyceridemia and hypercholesterolemia). All hemodialysis patients, whether normo- or hyperlipidemic, had normal apo A and low HDL-C serum concentrations. Positive risk factors for atherosclerosis other than low HDL-C (high serum apo B concentration and low apo A/apo B ratio) were present in hyperlipidemic patients only, with no difference between those with simple hypertriglyceridemia and combined hyperlipidemia. These results suggest that the risk for atherosclerosis related to lipid abnormalities may be considered as substantial in hyperlipidemic hemodialysis patients, but not in normolipidemic ones, regardless of the cholesterolemic values.     

Fluorescent substances in uremic and normal serum

We measured the fluorescence, at various excitation (Ex) and emission (Em) wavelengths, of serum ultrafiltrates and fractions of serum resolved by chromatography on Sephadex G15, studying both normal subjects and patients in chronic renal failure requiring hemodialysis. We found hitherto undescribed fluorescence at Ex 380 nm/Em 440 nm and Ex 400 nm/Em 460 nm, the intensity being greatly increased in patients with chronic renal failure in comparison with normal subjects (p less than 0.005). This fluorescence persisted unaltered when serum was filtered through membranes having cutoffs ranging from 10 000 to 500 Da. Each serum fraction resolved by gel chromatography demonstrated a characteristic fluorescence, which was generally much more intense in uremics. The most intense fluorescence (Ex 380 nm/Em 440 nm and Ex 400 nm/Em 460 nm) was emitted in the higher-Mr fractions.     

Small and middle molecular weight solute clearance in nocturnal intermittent peritoneal dialysis.

OBJECTIVES: To determine the dialysate-to-plasma (D/P) concentration ratios and peritoneal dialytic clearance (CI(D)) of substances with a wide range of molecular weights in subjects receiving a simulated nocturnal intermittent peritoneal dialysis (NIPD) session. DESIGN: Open-label single-dose study. SUBJECTS: Six end-stage renal disease patients undergoing peritoneal dialysis (PD). SETTING: Clinical research center of a university-affiliated hospital. INTERVENTIONS: Subjects received intravenous gentamicin and vancomycin on the first day of the study. Subjects received no PD until their return on the following day, when subjects underwent a simulated NIPD session utilizing four 2- to 2.5-L peritoneal dialysate dwells of 2 hours. Blood and dialysate samples were collected immediately before the session and after each dialysate dwell for determination of urea, creatinine, gentamicin, vancomycin, and beta2-microglobulin (beta2M) concentrations. Each solute's D/P concentration ratio and peritoneal CI(D) were calculated. MEASUREMENTS AND MAIN RESULTS: The (mean +/- SD) 2-hour D/P concentration ratios were 0.78 +/- 0.05 (urea), 0.49 +/- 0.11 (creatinine), 0.38 +/- 0.08 (gentamicin), 0.11 +/- 0.06 (vancomycin), and 0.07 +/- 0.03 (beta2M). Peritoneal CI(D) values (mL/min of dialysis) were 19.0 +/- 2.8 (urea), 12.1 +/- 3.5 (creatinine), 8.4 +/- 2.8 (gentamicin), 2.7 +/- 1.5 (vancomycin), and 1.7 +/- 0.8 (beta2M).The D/P concentration ratios and peritoneal CI(D) values for urea, creatinine, and gentamicin were significantly different from vancomycin and beta2M (repeated measures ANOVA, p < 0.05). Beta2-microglobulin peritoneal CI(D) was strongly related to gentamicin peritoneal CI(D) (r = 0.96, p < 0.05). CONCLUSION: Small molecular weight solutes have significantly greater D/P and peritoneal CI(D) than middle molecular weight solutes in NIPD. In NIPD, daily peritoneal CI(D) of beta2M is lower than that reported in continuous ambulatory PD. NIPD also results in lower drug CI(D) than that reported in continuous ambulatory PD studies.     

不同透析频率在尿毒症血液透析患者中的应用效果

目的：比较不同透析频率在尿毒症血液透析患者中的应用效果。方法选取2011年1月至2013年12月期间于我院进行血液透析治疗的81例尿毒症患者为研究对象,根据透析频率分为 A 组(每周透析4次,n =19)、B组(每周透析3次,n =33)、C 组(每周透析2次,n =29)。比较3组一般情况、营养状况指标、钙磷代谢状况、微炎症指标、并发症发生率和转归情况。结果开始透析时3组各临床资料比较差异均无统计学意义(P >0.05)。透析1年后,A 组血红蛋白(Hb)显著高于 B 组(P <0.05),A 组血清白蛋白(ALB)、前白蛋白(PA)、Hb 均显著高于 C 组,而血肌酐(SCr)和尿素氮(BUN)均显著低于 C 组(P <0.05),B 组的 ALB、PA 均显著高于 C 组(P <0.05)。A 组的血钙(Ca)显著高于 B 组和 C 组,而血磷(P)、甲状旁腺激素(PTH)显著低于 B 组和 C 组(P <0.05)。A 组的超敏 C 反应蛋白(hs-CRP)、白细胞介素6(IL-6)水平均显著低于 C 组(P <0.05)。A 组的感染发生率和病死率均显著低于 C组(P >0.05)。结论透析频率增加有助于改善营养状况和微炎症状态,降低感染的发生风险,从而改善尿毒症患者的预后,故推荐对每周透析3次的患者增加透析频率,在经济条件允许情况下可采用每周透析4次的高通量透析方案。     

Pancreatic enzymes in uremic patients with or without dialysis

One hundred thirty blood samples from 87 patients with renal failure, but without abdominal pain, were analyzed for blood urea nitrogen (BUN), creatinine, amylase, p-isoamylase, and lipase simultaneously. We found that 74, 78, and 80% of the patients had hyperamylasemia, hyperisoamylasemia, and hyperlipasemia. None had amylase higher than five times the upper limit. A few patients (2.3%) had lipase elevated to more than 10 times the upper limit. No significant change of pancreatic enzyme level was noted as a result of hemodialysis, but a significant amount of amylase was removed from the circulation in patients receiving intermittent peritoneal dialysis. Significantly lower pancreatic enzyme levels were observed in patients with less impairment of renal function. We conclude that elevation of pancreatic enzymes in uremic patients is more frequent and more extensive than most articles indicate, and that the extent of increase is related more to renal function than to the modalities of dialysis the patients received.     

尿毒症透析患者情绪障碍与营养状况的关系

目的探讨尿毒症透析患者营养指标与情绪障碍的关系。方法64例尿毒症透析患者使用Hamilton焦虑表（HAMA）和Hamilton抑郁表（HAMD）评估焦虑与抑郁水平作为应变量,体重指数（BMI）、皮褶厚度（SF）、上臂肌围（AMC）、血清白蛋白（ALB）、前白蛋白（PA）、转铁蛋白（TF）、血红蛋白（Hb）、胆固醇（Ch）、血清肌酐（Cr）等九项营养指标设为协变量,用Logstic回归分析法对上述资料进行统计分析。结果肯定、明显、严重焦虑31例（48.4%）;轻、中、重度抑郁34例（53.1%）。焦虑：BMI、ALB、PA、Hb其OR值分别为2.427、3.286、1.209、1.746;抑郁：BMI、SF、AMC、PA、ALB、Hb其OR值分别为3.173、2.581、1.320、1.123、2.615、1.839。结论尿毒症透析患者各项营养不良指标中BMI、SF、AMC、ALB、PA、Hb与情绪障碍关系密切。