Comparative study of acetate and bicarbonate hemodialysis in children with chronic uremia

Comparative studies on 5 children suffering from chronic uremia were performed regarding the efficacy of acetate and bicarbonate hemodialysis. Clinical symptoms, acid-base and blood gas analysis, serum osmolality, blood pressure and EEG were examined. On authors experience the patients tolerated better the bicarbonate dialysis. Laboratory data and blood pressure were found to be closer to the normal values too. The abnormality of EEG made after bicarbonate dialysis were not so expressed than that of acetate dialysis. On the basis of this examinations the authors suggest the bicarbonate hemodialysis in uremic patients with severe cardiovascular and/or neurological complications.     

维持性血透患者经济负担调查与分析

目的调查维持性血透患者经济负担情况及其对透析预后的影响。方法随访调查2006年1月～2008年10月在广西血液净化中心进行维持性血透的尿毒症患者。结果368例患者中医保200例,新农合84例,自费84例。医保组的医疗费高于新农合及自费组,但个人负担显著低于后2组。医保组透析频率高于另2组,长期存活患者也明显多于另2组。结论各种基本医疗保险制度能减轻血透患者的经济负担,但患者负担仍过重。需进一步完善透析患者的医保及新农合政策,以减轻患者经济负担。     

尿毒症血液透析与腹膜透析的经济学比较研究

摘要:目的　对2种透析方式进行费用效用分析,为患者自主选择透析方式提供依据。方法　采用KDQOL-SFTM1.3量表随访调查四川省人民医院的稳定期透析患者264名。结果　腹透组费用相对较低;两种透析方式对患者生命质量均有改善,血透对总体生命质量、躯体健康总评（PCS）的改善优于腹透;腹透组每获得一个QALY的花费低于血透组。结论　腹透组更具有费用效用优势,且随着自购药费用的下降,该优势更加明显。     

杭州市腹膜透析和血液透析治疗费用与疗效的比较研究

为比较腹膜透析和血液透析的费用和效果,对浙江大学附属第一医院和杭州市中医院的腹膜透析和血液透析者进行问卷调查。结果显示：（1）腹透者花费的年透析费用和因透析发生的年总医疗费用低于血透者;（2）腹透者可以间隔较长的时间到医院就诊,对于患者的治疗比较方便;（3）腹膜透析对生命质量的改善优于或至少不低于血液透析;（4）腹透并发症住院率高于血透。故建议积极推广腹膜透析,同时提高腹膜透析服务质量,降低其并发症发生率。     

Quality of life of patients in renal replacement therapy in Brazil: comparison of treatment modalities

Purpose

This study aimed to analyze and compare the quality of life of renal replacement therapy patients undergoing hemodialysis, peritoneal dialysis and those with renal transplantation in Brazil. In addition, we aimed to verify factors associated with patients?? quality of life and the relationship between quality of life and treatment modality, socioeconomic and demographic conditions as well as aspects related to the disease and health services.

Methods

A representative sample of the dialysis units and transplant centers was obtained. Structured questionnaires were used to interview 3,036 patients in one of three treatment modalities: hemodialysis, peritoneal dialysis and renal transplant. Information was collected about socioeconomic and demographic characteristics and quality of life measures.

Results

There were significant differences between renal transplants and both forms of dialysis for all dimensions of the SF-36. Hemodialysis patients showed better results in the dimensions of functional capacity, physical aspects and social aspects, compared to peritoneal dialysis patients. Renal transplant patients had the best mean score in the physical component of quality of life. There were no significant differences among treatment groups regarding the mental component of quality of life. The physical and mental components were associated with comorbidities and age; however, older patients had better mental quality of life but worse physical quality of life. Patients in a higher socioeconomic class and patients that were not hospitalized also reported better quality of life. Unmarried and male patients presented better physical quality of life. The dialysis units and transplant centers influenced the patients?? quality of life.

Conclusions

Renal transplant patients have the best quality of life of the three treatment modalities. It is necessary to increase access to renal transplants.     

Systematic review of the effectiveness of home versus hospital or satellite unit hemodialysis for people with end-stage renal failure

BACKGROUND: Home hemodialysis offers potential advantages over hospital hemodialysis, including the opportunity for more frequent and/or longer dialysis sessions. Expanding home hemodialysis services may help cope with the increasing numbers of people requiring hemodialysis. METHODS: We sought comparative studies or systematic reviews of home versus hospital/satellite unit hemodialysis for people with end-stage renal failure (ESRF). Outcomes included quality of life and survival. We searched MEDLINE, EMBASE, HealthSTAR, CINAHL, PREMEDLINE, and BIOSIS. Two reviewers independently extracted data and assessed the quality of the studies included. RESULTS: Twenty-seven studies of variable quality were included. People on home hemodialysis generally experienced a better quality of life and lived longer than those on hospital hemodialysis. Their partners, however, found home hemodialysis more stressful. Four studies using a Cox proportional hazards model to compare home with hospital hemodialysis reported a lower mortality risk for home hemodialysis. Of two studies using a Cox model to compare home with satellite unit hemodialysis, one reported a similar mortality risk, whereas the other reported a lower mortality risk for home hemodialysis. CONCLUSIONS: Home hemodialysis was generally associated with better outcomes than hospital hemodialysis and (more modestly so) satellite unit hemodialysis, in terms of quality of life, survival, and other measures of effectiveness. People on home hemodialysis, however, are a highly selected group. Home hemodialysis also provides the opportunity for more frequent and/or longer dialysis sessions than would otherwise be possible. It is difficult to disentangle the true effects of home hemodialysis from such influencing factors.     

血液透析与腹膜透析的卫生经济学研究概述

目的 比较血液透析与腹膜透析人群的费用、效果及其影响因素，分析其疾病经济负担，剖析现行医疗保险补偿模式对透析技术的影响，进而为临床合理应用透析技术及透析相关政策的调整和完善提供参考依据。方法 采用回顾性调查方法，对首次透析时间在1995-1998年间的上海市6所医院155例血液透析患者和223例腹膜透析患者的费用和效果进行比较。用多元回归法分析费用的影响因素，用COX回归方法分析死亡风险的影响因素，用Logistic回归法分析生命质量的影响因素。回顾性调查210例存活者的疾病负担。运用政策分析法分析补偿模式对透析技术应用的影响。结果 血液透析与腹膜透析人群的死亡风险、生命质量以及医疗费用并无显著差异，而统计描述差异是由于两类人群透析初始的健康状况不均衡造成的。透析人群疾病伤残程度很高，疾病经济负担沉重，负债透析的现象普遍。结论 医疗保险对腹膜透析与血液透析的费用补偿方式差异，造成血液透析技术的过度利用，进一步加重了各方费用的负担。因此，有必要从筹资、补偿模式、供方医疗行为规范等方面调整和完善透析相关政策。     

Portable water-treatment systems for hemodialysis

The supply of treated water for the hemodialysis machine is an integral part of the hemodialysis process. Without high-quality water, hemodialysis patients may be exposed to dangerous concentrations of toxic contaminants. Water treatment for hemodialysis is generally performed in two types of systems for various applications: large central systems and small portable systems. Most chronic hemodialysis patients receive treatment in dialysis centers and hospital dialysis units, where the water is treated by central systems. However, portable water-treatment systems are used for some bedside intensive care unit (ICU) dialysis needs, in centers with a small number of patients (e.g., in nursing homes and rural areas), and for home dialysis. In this study, we evaluated five portable water-treatment systems from four suppliers. We rated two systems Preferred with Conditions, one system Acceptable, and two Not Recommended.     

Treatment of uremic patients by automated peritoneal dialysis: study of 78 cases

BACKGROUND: Automated peritoneal dialysis has been increasingly used in recent years. The quality of life is improved in patients on automated peritoneal dialysis with more time for work, family and social activities compared to patients on continuous ambulatory peritoneal dialysis. AIM: We report our experience concerning patients on continuous ambulatory peritoneal dialysis. METHODS: From July 1997 to June 2003, we review retrospectively 78 patients with chronic renal failure treated by automated peritoneal dialysis. Tenckhoff catheter was used for all patients with 1 cuff in 39 cases (35.5%) and 2 cuffs in 71 cases (64.5%). RESULTS: There were 46 males and 32 females. Their mean age was 38.6 +/- 14.5 years. Their main nephropathies were glomerular in 23 patients (29.%), diabetic in 20 patients (25.6%) and vascular in 19 patients (24.4%). Among the 78 patients, 61 (78.2%) were autonomous while 17 (21.8%) were assisted by a member of their family. The mean period of therapy was 25.5 months (3 to 61 months). Peritonitis was the main complication, it was observed in 45 cases after a mean delay of 17 months (1 to 38 months). The mean rate of peritonitis was 36.5 months/patient. Their etiology was identified in 21 (46.7%) cases (8 septic manipulations of catheter and 13 tunnel infections). The principal organism isolated in peritoneal fluid were 18 gram-positive cocci (13 staphylococcus aureus, 4 coagulase-negative staphylococci, 1 streptococcus) and 10 gram-negative bacilli. The outcome of peritonitis was favourable in 39 cases (86.7%). The actuarial technique survival at 1, 3 and 5 years was respectively 94.6%, 80.1% et 49.3%. The actuarial patient survival at 1, 3 and 5 years was respectively 93.3%, 76.8% et 52.2%. At the end of the study, 43 patients (56.4%) left the automated peritoneal dialysis program: 22 (28.2%) were shifted to hemodialysis, 15 (19.3%) died, 6 (7.7%) were transplanted and 1 patient (1.3%) was shifted to continuous ambulatory peritoneal dialysis. CONCLUSION: Our experience concerning automated peritoneal dialysis is recent with a small number of patients. Our results were acceptable and we have to encourage and extend automated peritoneal dialysis to the most new patients with end-stage renal failure.     

Outbreak of bloodstream infection with the mold Phialemonium among patients receiving dialysis at a hemodialysis unit.

BACKGROUND: Molds are a rare cause of disseminated infection among dialysis patients. OBJECTIVE: We evaluated a cluster of intravascular infections with the mold Phialemonium among patients receiving hemodialysis at the same facility in order to identify possible environmental sources and prevent further infection. DESIGN: Environmental assessment and case-control study. SETTING: A hemodialysis center affiliated with a tertiary care hospital. METHODS: We reviewed surveillance and clinical microbiology records and performed a blood culture survey for all patients. The following data for case patients were compared with those for control patients: underlying illness, dialysis characteristics, medications, and other possible exposure for 120 days prior to infection. Environmental assessment of water treatment, dialysis facilities, and heating, ventilation, and air-conditioning (HVAC) systems of the current and previous locations of the dialysis center was performed. Samples were cultured for fungus; Phialemonium isolates were confirmed by sequencing of DNA. Investigators observed dialysis access site disinfection technique. RESULTS: Four patients were confirmed as case patients, defined as a patient having intravascular infection with Phialemonium species; 3 presented with fungemia, and 1 presented with an intravascular graft infection. All case patients used a fistula or graft for dialysis access, as did 12 (75%) of 16 of control patients (P=.54). Case and control patients did not differ in other dialysis characteristics, medications received, physiologic findings, or demographic factors. Phialemonium species were not recovered from samples of water or dialysis machines, but were recovered from the condensation drip pans under the blowers of the HVAC system that supplied air to the dialysis center. Observational study of 21 patients detected suboptimal contact time with antiseptic agents used to prepare dialysis access sites. CONCLUSION: The report of this outbreak adds to previous published reports of Phialemonium infection occurring in immunocompromised patients who likely acquired infection in the healthcare setting. Recovery of this mold from blood culture should be considered indicative of infection until proven otherwise. Furthermore, an investigation into possible healthcare-related environmental reservoirs should be considered.     

A prospective study of infections in hemodialysis patients: patient hygiene and other risk factors for infection

We performed a prospective randomized study on 71 patients on chronic outpatient hemodialysis to determine whether a sterile technique was better than a clean technique for preparation of the skin over the vascular access site prior to cannulation. In addition, we wanted to determine overall and site-specific infection rates, microbial etiologies of infection, and risk factors for infection. The overall infection rate was 4.7 infections per 100 dialysis months; the vascular access-site infection rate was 1.3 infections per 100 dialysis months; and the rate for bacteremia was 0.7 cases per 100 dialysis months. Staphylococcus aureus was the most common pathogen, but infections were equally divided between gram-positive cocci and gram-negative bacilli. Advanced age (P = 0.02), a low Karnofsky activity score (P = 0.05), poor hygiene (P = 0.0004) and number of hospitalizations (P = 0.0002) were risk factors for infections in general while only poor hygiene (P = 0.002) was a risk factor for vascular access-site infection. Sterile preparation of the skin over the vascular access site was no more effective at preventing infection than was clean technique (P = 0.80). Maintenance of good personal hygiene may be one of the most important measures for prevention of infections in hemodialysis patients.     

透析的疾病经济负担研究

目的：测定我国血液透析和腹膜透析的疾病经济负担，为建立合理的透析治疗费用支付范围和标准提供决策依据。方法：根据血透和腹透患者的年直接医疗费用、直接非医疗费用和间接费用计算经济负担。结果：血透和腹透患者的年总费用分别是98204元和84141元，其中直接医疗费用分别是80988元和76205元，直接非医疗费用分别是6014元和3522元，间接费用分别是11132元和4414元；医保部分每年为每位血透患者和腹透患者分别负担总费用的65．8％和72．0％。血透患者和腹透患者的负债率分别是8．2％和3．6％。结论：透析对患者和医保部门来说经济负担都是沉重的，需要多方面积极采取措施，控制费用，提高疗效。     

Characteristics of Connecticut patients receiving services for end-stage uremia.

Data are presented on the characteristics of all patients with end-stage uremia who were treated in Connecticut hemodialysis programs over a 7-year period. Of the total of 353 patients, 103 patients died, 37 had successful transplants and discontinued dialysis, no information was available for one patient, and the remaining 212 patients continued to receive treatment in 1 of the 12 hemodialysis programs. The mean age of active chronic hemodialysis patients was 43.6 years; about 83 percent of all active patients were under age 55. Twenty-two percent were nonwhite; the nonwhite caseload appeared high in relation to the percent of nonwhite population. Of the 212 active patients, 78 percent were dialyzed at in-center programs and 22 percent at home; one patient obtained dialysis from a new limited-care program. The largest group (28 percent) of active patients had been in dialysis less than 7 months, about one-fourth had been dialyzing for 7-12 months, and about 13 percent of the total active population had been in dialysis between 19 and 24 months. The average period for active patients to be in dialysis was 17 months. The advent of Federal reimbursement for hemodialysis, as well as changes in the criteria for the selection of patients and increased physician awareness, can result in significant increases in the future population of patients receiving dialysis. To prevent overburdening of existing in center programs, expansion of training facilities statewide for home care dialysis is suggested.     

Outbreak of hemolytic reactions associated with chlorine and chloramine residuals in hemodialysis water]

OBJECTIVE: To investigate the process of water contamination and to assess the subsequent outbreak in the hemodialysis center. METHODS: In September 2000, sixteen patients undergoing chronic hemodialysis at a dialysis center in Minas Gerais, Brazil, experienced hemolytic reactions compatible with toxic symptoms due to chlorine and chloramine water contamination. Chlorine and chloramine concentrations in samples obtained from various sites of the dialysis center's water treatment and distribution system were measured. Case-patients were identified by reviewing medical records and nursing notes for all dialysis sessions carried out during the study period. Interviews with technicians, nursing and medical staff members were conducted. RESULTS: Reaction rate was significantly higher (p<0.028) during the outbreak period (September 25 to 27, 2000) than the pre-outbreak period (September 18 to 20, 2000). All patients with toxic symptoms had been under dialysis with water treated by reverse osmosis equipment and had used dialysers manually reprocessed. Chlorine and chloramine residuals concentrations found in the dialysis water as well as in the dialysers were at levels higher than regulations, 相似文献   

Differences in quality of life of hemodialysis patients between dialysis centers

Purpose

Hemodialysis patients undergo frequent and long visits to the clinic to receive adequate dialysis treatment, medical guidance, and support. This may affect health-related quality of life (HRQOL). Although HRQOL is a very important management aspect in hemodialysis patients, there is a paucity of information on the differences in HRQOL between centers. We set out to assess the differences in HRQOL of hemodialysis patients between dialysis centers and explore which modifiable center characteristics could explain possible differences.

Methods

This cross-sectional study evaluated 570 hemodialysis patients from 24 Dutch dialysis centers. HRQOL was measured with the Kidney Disease Quality Of Life-Short Form (KDQOL-SF).

Results

After adjustment for differences in case-mix, three HRQOL domains differed between dialysis centers: the physical composite score (PCS, P?=?0.01), quality of social interaction (P?=?0.04), and dialysis staff encouragement (P?=?0.001). These center differences had a range of 11?C21 points on a scale of 0?C100, depending on the domain. Two center characteristics showed a clinical relevant relation with patients?? HRQOL: dieticians?? fulltime-equivalent and the type of dialysis center.

Conclusion

This study showed that clinical relevant differences exist between dialysis centers in multiple HRQOL domains. This is especially remarkable as hemodialysis is a highly standardized therapy.     

Changes in plasma free and phospholipid-bound choline concentrations in chronic hemodialysis patients.

BACKGROUND: Choline deficiency may develop in malnourished patients, those with cirrhosis, and those who require total parenteral nutrition. Previous data has suggested an important role for the kidneys in the maintenance of choline homeostasis. OBJECTIVE: This study was undertaken to determine the change in plasma choline during hemodialysis and to determine if it was lost in the dialysate. DESIGN: Thirteen adult patients (10 men, 3 women) who had required hemodialysis for a mean of 10.8 years were studied. Dialysis was performed 3 times weekly for 4 hours using either a cellulose acetate or polysulfone dialyzer membrane. Venous and arterial blood, and dialysate samples were taken for measurement of plasma free and phospholipid-bound choline concentration before beginning dialysis and after each hour of dialysis. An in vitro system was devised to determine if choline could bind to a significant degree to the dialysis membrane. RESULTS: Plasma free choline concentration was increased above normal (11.7 +/- 3.7 nmol/mL) at baseline and declined progressively during dialysis. In contrast, plasma phospholipid-bound choline concentration increased progressively during dialysis. The decrease in plasma free choline (-1.8 +/- 0.3 nmol/mL(-1)/h(-1); P = 1.6 x 10(-6)) was almost entirely related to that which was removed during dialysis, although the magnitude of the loss was not correlated with the increase in plasma phospholipid-bound choline concentration (125 +/- 20.5 nmol/mL(-1)/h(-1); P < 1.2 x 10(-6)). Patients lost a mean of 246 pmol of free choline during hemodialysis. Choline did not bind to the dialysis membrane. CONCLUSION: Plasma free choline concentration is elevated before dialysis, and choline is lost to a significant degree in the dialysate. Further investigation is necessary to determine whether a transient, dialysis-induced choline deficiency develops, and whether there is a role for choline supplementation in these patients. The choline homeostatic mechanism requires further investigation in renal failure patients.     

血液透析和腹膜透析患者生活质量调查

目的：了解血液透析和腹膜透析病人的生活质量及与生活质量有关的因素。方法：采用健康生活量表36项（SF-36）问卷调查31例腹膜透析病人和46例血液透析病人。结果：两组病人的一般资料和生活质量无显著差异。多元逐步回归分析发现,教育程度和治疗依从程度进入回归模型。结论：血液和腹膜透析这两种方式在体力、精神方面均无显著差异,受教育程度高和治疗依从性好可显著提高患者生活质量。     

An outbreak of gram-negative bacteremia in hemodialysis patients traced to hemodialysis machine waste drain ports.

OBJECTIVE: To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 1996-January 31, 1997). DESIGN: Retrospective cohort study. Reviewed infection control practices and maintenance and disinfection procedures for the water system and dialysis machines. Performed cultures of the water and dialysis machines, including the waste-handling option (WHO), a drain port designed to dispose of saline used to flush the dialyzer before patient use. Compared isolates by pulsed-field gel electrophoresis. SETTING: A hemodialysis center in Maryland. RESULTS: 94 patients received dialysis on 27 machines; 10 (11%) of the patients had gram-negative bacteremias. Pathogens causing these infections were Enterobacter cloacae (n = 6), Pseudomonas aeruginosa (n = 4), and Escherichia coli (n = 2); two patients had polymicrobial bacteremia. Factors associated with development of gram-negative bacteremias were receiving dialysis via a central venous catheter (CVC) rather than via an arterio-venous shunt (all 10 infected patients had CVCs compared to 31 of 84 uninfected patients, relative risk [RR] undefined; P<.001) or dialysis on any of three particular dialysis machines (7 of 10 infected patients were exposed to the three machines compared to 20 of 84 uninfected patients, RR = 5.8; P = .005). E cloacae, P aeruginosa, or both organisms were grown from cultures obtained from several dialysis machines. WHO valves, which prevent backflow from the drain to dialysis bloodlines, were faulty in 8 (31%) of 26 machines, including 2 of 3 machines epidemiologically linked to case-patients. Pulsed-field gel electrophoresis patterns of available dialysis machine and patient E cloacae isolates were identical. CONCLUSIONS: Our study suggests that WHO ports with incompetent valves and resultant backflow were a source of cross-contamination of dialysis bloodlines and patients' CVCs. Replacement of faulty WHO valves and enhanced disinfection of dialysis machines terminated the outbreak.     

快速加温透析配液设备的临床应用

目的：探讨快速加温透析配液设备的临床应用的可行性,了解应用该设备配液透析后,患者的血清钠,二氧化碳结合力（CO2CP）,以及pH值是否与传统配液法结果相一致。方法：抽取维持性血液透析（MHD）的患者20例,将其随机分成A组和B组,每组10例。A组MHD患者使用快速加温透析配液设备配制碳酸氢盐液进行透析,而B组患者使用传统配液法配制碳酸氢盐液进行透析。随访4周,测定每次透析前后患者血清钠,CO2CP以及pH值水平。结果：1A组与B组的血清钠水平比较其差异无统计学意义（t=0.845,P〉0.05）;2A组与B组的CO2CP以及pH值其差异无统计学意义（t=0.779,t=0.695;P〉0.05）。结论：冬天配制碳酸氢盐液时可使用快速加温透析配液设备,并未影响患者透析质量,同时省时省力省费用,提高工作效率。