长期深静脉留置双腔导管血液透析的临床应用

目的 :探讨长期血液透析留置双腔导管的效果和退出原因 ,延长其使用期限。　 方法 :随访血液透析患者留置导管的使用情况和并发症 ,记录导管使用终点。　 结果 :①实施深静脉留置长期带涤纶环导管术 1 39例次 ,其中 1 0例次为再次置管 ;经颈内静脉入路 1 0 4例次 (成功率 98% ) ,经颈外静脉切开插管 1 3例次 (成功率 81 % ) ,经锁骨下静脉 2 2例次 (成功率 95 % )。置管成功率 1 0 0 %。②导管使用期限 :平均 (1 4 5± 1 0 4 )个月 ,使用留置导管时间分别为 :>72个月 1例 ,>36个月 7例 ,≥ 2 4个月 1 8例 ,≥ 1 2个月 37例次 ,≥ 6个月 4 2例次 ,<6个月 30例次 (大部分在继续使用 ) ,其余失访。观察导管使用终点 6 5例次 ,约占 4 6 % ,导管退出时平均使用时间 3～ 4 6 (1 0 2± 8 3)个月。退出原因 :患者死亡 4 0例 ,其余为感染拔管、导管拔脱、血流不畅和肾移植。在导管使用终点 ,90 % (5 8/ 6 5 )的导管功能良好。③导管透析充分性 :1 1 4例患者透析后尿素下降率平均 70 % ,平均Kt/V达 1 5 5。与内瘘透析患者Kt/V =1 5 0±0 33(n =30 )比较无显著差别。④导管动静脉端反接对透析效果影响 ,比较 35例导管动静脉端正接和反接 ,血流量2 0 0～ 2 5 0ml/min ,单次透析正接Kt/V =1 5 5± 0 4 3,反接     

Safety and Efficacy of Tandem Hemodialysis and Plasma Exchange in Children

Background and objectives

Patients with immune-mediated kidney disease and liver failure often require plasma exchange (PE) and hemodialysis (HD). Combining both methods (i.e., connecting the PE and HD circuits in series [tandem dialysis]) should allow for a more efficient treatment. This work reviews the authors’ experience with tandem blood purification.

Design, setting, participants, & measurements

Chart review was utilized to retrospectively analyze the efficacy and tolerability of 92 combined PE/HD (cPE/HD) sessions in 26 children in comparison with 113 sequential PE/HD (sPE/HD) treatments performed in 32 children between 1988 and 2012 at the University of Heidelberg Center for Pediatric and Adolescent Medicine. Eleven children received both treatment modalities.

Results

The mean treatment duration was 3.8±2.2 hours per cPE/HD and 5.9±1.6 hours per sPE/HD session (P<0.001). Dialyzer surface areas per body surface area (in meters squared) and blood flow rates were similar. Although a 3-fold higher initial bolus of heparin was administered with cPE/HD, the heparin dose per hour was similar with both modalities and the total heparin load was only slightly lower with cPE/HD, with a median 2939 IU/m² per session (interquartile range, 1868, 4189) versus 3341 IU/m² per session (interquartile range, 2126, 4792). In sessions with regional anticoagulation, equal citrate and calcium infusion rates were applied. Plasma turnover, ultrafiltration rates, and solute removal were comparable. Procedure-related problems developed in 14.0% of cPE/HD and 7.0% of sPE/HD sessions (P=0.37). Clinical symptoms occurred in 19.6% and 6.2% (P=0.05), necessitating treatment discontinuation in 12.0% and 5.3% of the sessions (P=0.14). Intra-individual comparison of both dialysis methods in 11 children reconfirmed these findings.

Conclusions

cPE/HD is a time-saving procedure relative to sPE/HD, but may be associated with a higher rate of procedure-related and clinical adverse events.     

Comparative Effectiveness of Two Catheter Locking Solutions to Reduce Catheter-Related Bloodstream Infection in Hemodialysis Patients

Background and objectives

Infection is the second leading cause of death in hemodialysis patients. Catheter-related bloodstream infection and infection-related mortality have not improved in this population over the past two decades. This study evaluated the impact of a prophylactic antibiotic lock solution on the incidence of catheter-related bloodstream infection and mortality.

Design, setting, participants, & measurements

This prospective, multicenter, observational cohort study compared the effectiveness of two catheter locking solutions (gentamicin/citrate versus heparin) in 555 hemodialysis patients dialyzing with a tunneled cuffed catheter between 2008 and 2011. The groups were not mutually exclusive. Rates of catheter-related bloodstream infection and mortality hazards were compared between groups.

Results

The study population (n=555 and 1350 catheters) had a median age of 62 years (interquartile range=41–83 years), with 50% men and 71% black. There were 427 patients evaluable in the heparin period (84,326 days) and 322 patients evaluable in the antibiotic lock period (71,192 days). Catheter-related bloodstream infection in the antibiotic lock period (0.45/1000 catheter days) was 73% lower than the heparin period (1.68/1000 catheter days; P=0.001). Antibiotic lock use was associated with a decreased risk of catheter-related bloodstream infection compared with heparin (risk ratio, 0.23; 95% confidence interval, 0.13 to 0.38 after multivariate adjustment). Cox proportional hazards modeling found that antibiotic lock was associated with a reduction in mortality (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58 in unadjusted analyses; hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.75 after multivariate adjustment). The rate of gentamicin-resistant organisms decreased (0.40/1000 person-years to 0.22/1000 person-years) in the antibiotic lock period (P=0.01).

Conclusions

The results of this study show that the use of a prophylactic, gentamicin/citrate lock was associated with a substantial reduction in catheter-related bloodstream infection and is the first to report a survival advantage of antibiotic lock in a population at high risk of infection-related morbidity and mortality.     

高通量透析对血脂代谢影响的临床观察

目的：通过应用高通量透析器进行血液透析（ＨＰＤ）与常规血液透析（ＣＨＤ）相比较,了解ＨＰＤ对血脂代谢的影响。方法：将５０例常规血透患者随机分成实验组和对照组,ＨＰＤ组和ＣＨＤ组分别用Ｆ６０和Ｆ６进行备注透析３年,观察两且患者血脂变化情况。结果：实验过程中ＨＰＤ组患者血清甘油三酯（ＴＧ）、低密度脂蛋白（ＬＤＬ）降低,高密度脂蛋白（ＨＤＬ）升高;ＣＨＤ组患者ＴＧ、ＬＤＬ升高,ＨＤＬ降低;两组胆固醇（Ｃ     

高通量血液透析对糖尿病肾病血液透析患者预后影响分析

目的分析糖尿病肾病血液透析患者应用高通量血液透析治疗的预后影响。方法选取该院自2015年10月—2016年10月收治的36例糖尿病肾病血液透析患者作为观察对象,随机分为两组,18例观察组患者给予高通量血液透析治疗,18例对照组患者给予低通量血液透析治疗。观察两组患者的心脑血管不良事件的发生率,对比两组患者治疗后1年、3年的生存情况。结果观察组患者不良事件发生率27.8%,对照组患者不良事件发生率38.9%(χ^2=3.568,P<0.05)。观察组1年生存率83.3%及3年生存率72.2%,明显优于对照组的77.8%和44.4%(χ^21=5.214,χ^22=4.523,P<0.05)。结论高通量血液透析对糖尿病肾病血液透析患者预后效果好,可有效降低患者的心、脑血不良事件发生率,改善了患者的生存质量。     

不同抗凝剂及透析膜对维持性血透患者止凝血状态的影响

目的观察不同抗凝剂及透析膜透析对维持性血液透析(MHD)患者止凝血状态的影响。方法10例MHD患者通过自身对照,先后给予普通肝素(UFH)、低分子量肝素(LMWH)抗凝以及醋酸膜(CA)、聚砜膜(PS)进行血液透析治疗。患者分为UFH-CA组、UFH-PS组、LMWH-CA组、LMWH-PS组等四组,检测其血浆D-二聚体,GMP-140及APTT、血清BUN水平。结果透析前各组血浆D-二聚体、GMP-140水平及APTT间差异均不显著。透析后,各组血浆D-二聚体及GMP-140显著升高（P＜0.05）,其中GMP-140升高幅度UFH-CA组显著高于其他三组（P＜0.05）,UFH抗凝组较LMWH抗凝组APTT明显延长（P＜0.05）。透析器复用三次后,KT／V均明显下降（P＜0.01）,UFH抗凝组较LMWH抗凝组下降明显（P＜0.05）。结论PS膜对血小板的活化作用弱于CA膜;与UFH相比,LMWH抗凝对纤溶系统、血小板及APTT的影响较小,有助于改善透析膜生物相容性和减少出血倾向。     

血液透析患者血小板聚集功能的变化

对１５例维持性血液透析（ＨＤ）患者进行了血小板聚集试验和部分凝血参数测定。结果显示，ＨＤ组血小板聚集率和血小板ＡＴＰ释放均显著低于正常对照组（Ｐ＜０．０１），表明ＨＤ患者存在血小板功能缺陷。血液透析后血小板聚集率和血浆血栓烷Ｂ２水平显著增高（Ｐ＜０．０１），提示血透过程中血小板被激活。凝血多数测定结果显示ＨＤ组血浆纤维蛋白原和ＶＷＦ水平显著高于对照组（Ｐ＜０．０５），而抗凝血酶Ⅲ活性和纤溶酶原活性则低于对照组（Ｐ＜０．０５）。作者初步讨论了这些变化的机理及其对止血凝血功能的影响，认为它们是引起ＨＤ患者出血倾向和血栓栓塞现象的重要原因。     

Which patients benefit from hemodialysis therapy in hepatorenal syndrome?

BACKGROUND AND AIM: Hepatorenal syndrome (HRS) occurs in patients with advanced liver cirrhosis and has a poor outcome. The aim of the present study was to investigate which patients with HRS are likely to benefit from hemodialysis. METHODS: Data were collected prospectively from 30 patients with Child-Pugh C liver cirrhosis and HRS. Patients were either treated with continuous veno-venous hemodialysis (CVVHD) if they were mechanically ventilated, or with intermittent hemodialysis (HD) if they were not mechanically ventilated. Prognosis was assessed by the Child-Pugh and by the Model for End-Stage Liver Disease (MELD) score. The primary aim of the study was the analysis of overall and 30-day patient survival during hemodialysis therapy. To identify predictive factors of survival, variables obtained before the initiation of dialysis therapy were evaluated. RESULTS: Patients' 30-day survival was 8/30 (median survival time 21 days). Among patients treated with mechanical ventilation, 30-day survival time was 0/15 while 8/15 patients without mechanical ventilation survived more than 30 days (P < 0.001). Using a multivariate model, the relative hazards for serum albumin, international normalized ratio (INR) and catecholamine therapy were not different from one another (P > 0.05), indicating that these parameters were not independent predictors of survival. Mechanical ventilation was an independent risk factor for 30-day (relative hazard 6.6 [1.6-27.7], P < 0.001) and overall survival (relative hazard 6.3 [1.5-26.5], P = 0.01). Child-Pugh (P < 0.01) and the MELD (P < 0.01) score were predictive for overall survival independent of mechanical ventilation. CONCLUSIONS: Patients with HRS without mechanical ventilation may benefit from hemodialysis, whereas hemodialysis seems to be futile in patients with mechanical ventilation.     

维持性血液透析患者与微炎症反应

30%～50%维持性血液透析(maintenance hemodialysis,MHD)患者血浆炎症因子如C反应蛋白(CRP)和白细胞介素6(IL-6)水平升高。研究发现患者的炎症反应状态与高死亡率有关。MHD患者炎症反应相关因素包括患者本身的原因(如氧化应激、感染、肥胖、遗传和免疫因素)以及透析相关原因(如透析膜的生物相容性和透析液纯度)。了解微炎症反应的发生机制,预防并治疗可能的相关因素,有利于改善MHD患者的炎症状态,降低其死亡率。     

血液透析患者合并脑出血(附7例临床分析)

本文报告385例因各种原因接受血液透析的患者,发生脑出血7例(1.8％),均有严重高血压.临床特点是比其它脑出血患者年轻,出血量大,脑水肿重,急性期容易发生抽搐和消化道出血,治疗困难,预后极差.7例均在发病后平均30h内死亡.因此,作者认为应采取积极的预防措施,其中尤为重要的是控制高血压.     

促红细胞生成素改善慢性肾功能衰竭血透患者红细胞质量

目的：探讨重组促红细胞生成素（ｒＨｕＥＰＯ）替代治疗慢性肾功能衰竭（ＣＲＦ）贫血患者的红细胞质量改变。方法：选择４３例ＣＲＦ维持性血透贫血患者，２４例应用ｒＨｕＥＰＯ治疗，１９例应用输血治疗，分别观察两组治疗前、后，血红蛋白（Ｈｂ）、血球压积（Ｈｃｔ）、脂质过氧化物（ＬＰＯ）、超氧化物歧化酶（ＳＯＤ）和Ｎａ＾＋－Ｋ＾＋－ＡＴＰａｓｅ活性变化以及分析Ｎａ＾＋－Ｋ＾＋ＴＡＰａｓｅ活性与ＬＰＯ，ＳＯＤ之     

血透膜对白介素-1β、肿瘤坏死因子-α、白介素-6基因表达及血浆水平的影响

目的：评价不同透析膜血液透析的生物相容性。方法：定量反转录多聚酶链反应、细胞原位杂交技术和酶联免疫吸附方法。结果：在分组设计与拉丁交叉设计中，ＩＬ－１β、ＴＮＦ－α及ＩＬ－６血浆水平无论铜仿膜、聚甲基丙烯酸甲酯膜（ＰＭＭＡ）或聚砜膜血透时各组间差异不明显（Ｐ值均＞０．０５）；ＩＬ－１β、ＴＮＦ－α与ＩＬ－６ｍＲＮＡ在正常人外周血单个核细胞中无表达，而尿毒症未透析患者和血透患者外周血单个核细胞中均有表达，其中血透者的表达水平明显高于尿毒症未透析患者。反转录多聚酶链反应和细胞原位杂交检测发现铜仿膜血透时各细胞因子基因表达水平均显著高于ＰＭＭＡ与聚砜膜（Ｐ＜０．００１），而ＰＭＭＡ与聚砜膜间无差异（Ｐ＞０．０５）。结论：尿毒症（未透析）及血透均可激活外周血单个核细胞。从细胞因子基因表达水平看，铜仿膜生物相容性较ＰＭＭＡ与聚砜膜差。作者认为这一方法在评价透析膜的生物相容性上优于血浆水平测定。     

透析膜对血浆细胞因子水平的影响及临床意义

探讨使用不同透析器膜材料的血透患者血浆ＩＬ－１和ＴＮＦα的水平变化及其与临床的关系。