儿童腹膜透析

腹膜透析（peritoneal dialysis）是重要肾脏替代治疗手段,1923年由德国Ganter医生第一次将这种方法用于治疗尿毒症,1948年Bloxsom及Powell首次尝试采用腹膜透析治疗小儿急性肾功能衰竭,并很快推广到世界范围,腹膜透析现在已经成为儿童肾衰竭肾脏替代治疗的主要方法,目前在全球急慢性肾损伤肾替代治疗患者中,进行腹膜透析的比例约15％,各地区开展情况差别很大,北美占30％ ～45％,欧洲占25％ ～40％,我国大陆占10％左右[1].     

儿童慢性肾脏病替代治疗

儿童慢性肾脏病(chronic kidney disease,CKD)的替代治疗包括血液净化和肾脏移植,虽然肾移植是最有效的治疗方法,但由于儿童生理特点及肾源等问题,我国目前仍以透析治疗为主。1儿童慢性肾脏病替代治疗现状腹膜透析(peritoneal dialysis,PD)、血液透析(hemodial-ysis,HD)均属血液净化(blood purification)的范畴,指将患者的血液在体外通过净化装置,除去血液中某些致病物质,达到净化血液目的技术总称。     

31例慢性肾衰竭患儿临床分析

目的探讨慢性肾衰竭(CRF)的病因、临床及病理、治疗和转归。方法31例CRF患儿,根据血尿素氮(BUN)、肌酐(Cr)、内生肌酐清除率(Ccr)对其进行肾功能分级。结果肾衰竭失代偿期、肾功能衰竭期、终末肾分别为3例、15例、13例。放弃治疗死亡7例,失访10例。14例随访6个月～8年,8例在治疗原发病的基础上采取内科综合治疗,6例终末肾患儿行肾替代治疗,腹膜透析、血液透析各3例,1例腹膜透析无效死亡,1例血液透析1年后行肾移植术,随访8年,肾功能稳定。结论CRF病因甚多,临床多呈非特异性表现。在积极治疗原发病的基础上,对终末期肾衰患儿应尽早予肾替代疗法,保护残存肾功能,提高生活质量。     

31例慢性肾衰竭患儿临床分析

目的 探讨慢性肾衰竭（CRF）的病因、临床及病理、治疗和转归。方法31例CRF患儿，根据血尿素氮（BUN）、肌酐（Cr）、内生肌酐清除率（Ccr）对其进行肾功能分级。结果肾衰竭失代偿期、肾功能衰竭期、终末肾分别为3例、15例、13例。放弃治疗死亡7例，失访10例。14例随访6个月～8年，8例在治疗原发病的基础上采取内科综合治疗，6例终末肾患儿行肾替代治疗，腹膜透析、血液透析各3例，1例腹膜透析无效死亡，1例血液透析1年后行肾移植术，随访8年，肾功能稳定。结论CRF病因甚多，临床多呈非特异性表现。在积极治疗原发病的基础上，对终末期肾衰患儿应尽早予肾替代疗法，保护残存肾功能，提高生活质量。     

急性肾衰竭的血液净化疗法

急性肾衰竭 (ARF)是儿科临床的危重症。腹膜透析、血液透析技术挽救了无数ARF患者 ,现已远远超出了肾脏替代的治疗范畴 ,统称为血液净化技术。但在儿童特别是婴幼儿中应用血液净化技术治疗ARF ,需要肾脏专科医生与ICU医生的协作和共同努力 ,以提高救治成功率[1] 。1　常用血液净化方法ARF时 ,肾脏作为重要排泄器官而言已丧失功能 ,因而需通过透析 (弥散和对流 )及超滤排除体内代谢废物及潴留的水 ,保持内环境的稳定。儿科治疗ARF的常用方法有腹膜透析 (PD)、血液透析 (HD)、连续性肾脏替代治疗 (CR RT) [2 ,3 ] 。1.1　PD　PD仍…     

腹膜透析治疗小儿肾功能衰竭临床分析

目的 探讨腹膜透析对儿童肾功能衰竭治疗的效果.方法 对2003年6月至2008年4月应用腹膜透析治疗的11例急慢性肾功能衰竭患儿临床资料及随访结果 进行分析.结果 11例患儿无一例死亡,急性肾功能衰竭平均在院透析时间15.5 d,慢性肾功能衰竭平均在院透析时间22.8 d.治疗前后血尿素氮、肌酐分别由(34.03±8.44) mmol/L和(710.09±167.54) μmol/L降至(15.94±4.93) mmol/L和(233.87±92.71) μmol/L,差异有非常显著性(P＜0.01).血钠由(130.91±9.15) mmol/L升至(139.46±3.98) mmol/L,差异有显著性(P＜0.05).血碳酸氢根由(14.56±2.07) mmol/L升至(22.47±3.29) mmol/L,差异有非常显著性(P＜0.01).随访时间1个月至5年不等.5例急性肾功能衰竭患儿肾功能和尿常规均正常.1例慢性肾功能衰竭患儿规律透析后行肾移植,3例仍于院外透析中.结论 经济、实用、有效的腹膜透析辅以综合治疗可成为儿童急慢性肾功能衰竭较好替代治疗方法 .     

腹膜透析在新生儿心脏直视术后的应用

目的 探讨心脏直视术后腹膜透析在治疗新生儿急性肾功能衰竭方面的应用.方法 2006年1月至2008年9月,我院共有131例新生儿先天性心脏病患儿接受体外循环下心脏直视手术,其中男88例,女43例;年龄1 h至28 d;体重1.13～5.10kg,平均(3.34±0.54)kg;其中13例患儿在术后因罹患急性肾功能衰竭而接受腹膜透析治疗,男9例,女4例;年龄1 h至28 d;体重为1.13～4.80kg,平均(3.25±0.72)kg.3例患儿在术中经胸骨正中切口下方的腹膜切口间接放置腹膜透析管,另外10例患儿则在术后经脐旁腹壁切口直接放置.透析液采用百特专用腹膜透析液,并根据病情的需要选择不同渗透压的液体.常规透析方案为:首次透析选用1.5%腹膜透析液,剂量为10～30 ml/kg;输入15min,滞留30 min,引出15min;根据患儿病情变化调整腹膜透析液的浓度、滞留时间比.结果全部患儿均无腹膜透析禁忌证.11例肾功能恢复,2例死亡.无腹膜透析并发症发生.结论 腹膜透析是治疗新生儿心脏直视术后急性肾功能衰竭的有效方法 ,并发症发生率低,操作简单,经济实用.     

儿童慢性腹膜透析相关腹膜炎危险因素的病例对照研究

目的 分析终末期肾病（ESRD）患儿慢性腹膜透析（CPD）相关腹膜炎(简称腹膜炎)发生的危险因素,为儿童腹膜炎防治提供依据。方法 回顾性收集复旦大学附属儿科医院（我院）开展ESRD患儿CPD 以来的全部病历,依据连续随访记录,以是否出现CPD分为腹膜炎组和非腹膜炎组,分析两组人口学指标、CPD指标和透析充分性指标。并行多因素分析探讨发生腹膜炎的危险因素。结果 2001年至2014年在我院接受CPD治疗的109例ESRD患儿进入本文分析,男60例（55%）、女49例。开始腹膜透析的中位年龄9.9岁,中位透析病程13.4月。连续性非卧床腹膜透析（CAPD）15例,自动腹膜透析（APD）94例（86.2％）。43例（39.4%）仍接受CPD治疗,50例（45.9%）成功行肾移植,7例（6.4%）转行血液透析治疗,6例（5.5%）死亡,3例（2.8%）失访。1、2、3和5年的生存率分别为97.1%、93.3%、90.1%和90.1%。33例发生57例次腹膜炎,平均腹膜炎发生率为1次/35.1病人月。单因素分析显示,开始透析时身高SDS（P=0.01）、透析病程（P<0.001）和白蛋白水平（P=0.01）腹膜炎组和非腹膜炎组差异有统计学意义。多因素Logistic回归分析显示,开始透析时身高SDS<-2.0（OR=12.746,95％CI：2.436~66.675,P=0.003）和透析病程>1年（OR=8.162,95%CI：2.514~26.500,P<0.001）是腹膜炎发生的独立危险因素。结论 开始透析时身高SDS<-2.0和透析病程>1年是儿童CPD相关腹膜炎发生的独立危险因素。     

腹膜透析与血液透析治疗儿童急性肾功能衰竭的疗效比较

目的 为探讨血液净化治疗儿童急性肾功能衰竭的效果,对我院进行的腹膜透析(peritoneal dialysis,PD)与血液透析(hemodialysis,HD)病例进行临床对比分析.方法 回顾性分析我院1997年1月至2011年12月收治的急性肾功能衰竭行血液净化治疗74例儿童的临床资料,其中PD45例,HD 29例,分别比较腹膜透析组(PD组)与血液透析组(HD组)的疗效及并发症.PD组采用间歇性腹膜透析法,每天透析8次;HD组初次诱导透析,以后隔天透析1次.结果 PD组尿毒症症状(纳差、恶心、呕吐、乏力)明显改善时间(5.6±2.3)d,HD组(3.2±1.7)d,差异有统计学意义(P＜0.05),HD组尿毒症症状改善快于PD组.透析1周后血生化指标尿素氮、肌酐、尿酸、HCO3-与透析前比较差异无统计学意义(P＞0.05).透析治疗时间上,HD组(10.4±2.5)d,PD组(11.2±3.6)d,差异无统计学意义(P＞0.05).透析并发症方面,PD组总并发症20.0％,HD总并发症65.4％,HD组并发症多于PD组.结论 PD与HD在治疗儿童急性肾功能衰竭方面,改善尿毒症症状HD快于PD,但PD不良反应发生率低于HD,且PD操作简单、安全性高、费用低,可作为儿童急性肾功能衰竭的首选净化方式.相对而言,HD起效快,对于急性肾功能衰竭、药物中毒及食物中毒等中毒性疾病则首选HD.     

从病理生理学探讨儿童慢性肾衰竭的营养、感染和骨代谢的一些问题

慢性肾衰竭(CRF)是各种原因引起的肾脏损害并进行性恶化,病情发展至晚期所出现的一系列临床综合征。各种血液净化疗法及肾移植是治疗该病的重要手段。但上述两种治疗方法需支付高额医疗费用,且不能解决该病的早、中期的防治问题。因此,采用非透析疗法治疗CRF,对缓解患儿症状,保护残存肾功能,延缓CRF的进展、推迟或减少透析的治疗方法和措施,对于远多于透析患儿数倍的早期CRF     

Familial bilateral renal agenesis and hereditary renal adysplasia

This paper reports three kindreds (A, B, C) with familial bilateral renal agenesis (BRA). Etiologically, BRA is considered a multifactorially determined disorder; pathogenetically it is viewed as a developmental field defect involving absence of both kidneys and ureters in all cases, and in other cases an associated spectrum of related field defects which range from absence of the uterus and vagina to sirenomelia. In BRA, Potter's syndrome represents a symptomatic deformity complex due to oligohydramnios.Two additional kindreds (D and E) in this paper show that unilateral absence of a kidney may occur in relatives of a propositus with severe bilateral renal adysplasia. The former defect is designated unilateral renal aplasia and is presumed to be a less severe form of bilateral renal adysplasia. In these two families, and in two others from the literature, autosomal dominant inheritance seems responsible for the presence of unilateral aplasia and bilateral adysplasia in different family members; this newly recognized genetic trait, is being designated hereditary renal adysplasia (HRA). In women with unilateral renal aplasia the associated tubal and uterine malformation may be responsible for prematurity plus an increased risk of spontaneous abortion.The opinions or assertions in this paper are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large.Supported, in part, by NIH Grants GM 15422, 5 K04-HD 18982, and by a Grant from the National Foundation — March of Dimes. Contributed, in part, as paper No. 1609 from the University of Wisconsin Genetics Laboratory.     

Recurrent exercise-induced acute renal failure in renal hypouricemia

We describe a male patient with four episodes of acute renal failure after strenuous exercise occurring between the age of 14 and 25 years. He was found to have low serum uric acid (0.4mgdl⁻¹ after recovery) and high fractional excretion of uric acid. A benzbromarone, pyrazinamide test suggested that renal hypouricemia was due to defective proximal tubular reabsorption of uric acid at a pre-secretory site. A renal biopsy revealed acute tubular necrosis, a renal computer tomography scan showed patchy contrast enhancement and a treadmill exercise test induced an immediate fall in creatinine clearance. These findings suggest that the cause of acute renal failure was renal vasoconstriction rather than obstruction by uric acid crystals.     

Increased renal parenchymal echogenicity in ifosfamide-induced renal fanconi syndrome

Three children who presented with a Fanconi syndrome induced by the chemotherapeutic drug ifosfamide were found to have renal abnormalities on sonogram examinations. Renal echographic changes consisted in hyperechogenicity of the parenchyma with good corticomedullar differentiation. After discontinuation of the chemotherapy, the serum and urine metabolic abnormalities due to proximal tubulopathy were completely or greatly improved. Imaging studies at that time showed a complete resolution of the renal hyperechogenicity. We suggest that in patients exposed to ifosfamide, renal sonogram may be of value to monitor the tubular toxicity of this drug. In these patients, urine and serum monitoring as well as prospective echographic follow-up kidney abnormalities may lead to earlier detection of ifosfamide-induced Fanconi syndrome as well as earlier detection of disease reversibility. © 1995 Wiley-Liss, Inc.     

Imaging chronic renal disease and renal transplant in children

At Great Ormond Street Hospital we have the highest number of paediatric renal transplant patients in Europe, taking cases from across the United Kingdom and abroad. Our caseload includes many children with rare complicating medical problems and chronic renal failure related morbidity. This review aims to provide an overview of our experience of imaging children with chronic renal failure and transplants.     

End stage renal disease due to bilateral renal malakoplakia

Malakoplakia typically affects the bladders of immunocompromised adults who have defective intracellular killing of Escherichia coli. Renal malakoplakia is rare in children and generally has a good outcome. In the case presented, however, it caused end stage renal failure in a 5 year old girl. The management dilemmas surrounding renal transplantation are highlighted.