高钠透析液在糖尿病肾衰竭患者血透中的临床应用

目的:观察高钠透析液对糖尿病肾衰竭维持血透患者的影响。方法:选取糖尿病肾衰竭维持血透患者30例,采用自身对照研究方法,分别用135 mmol/L、140 mmol/L及145 mmol/L钠浓度的透析液透析8周,观察疗效和不良反应发生的情况。结果:与使用135 mmol/L钠浓度透析液比较,使用140 mmol/L钠浓度的透析液可以显著降低低血压和肌痉挛的发生(P0.05)。与使用145 mmol/L钠浓度透析液比较(P0.05),使用140 mmol/L钠浓度的透析液不增加口渴及高血压等副作用。结论:对糖尿病肾衰竭维持血透的患者使用140mmol/L钠浓度的透析处方可以降低患者不良反应发生率。     

高钠透析液对糖尿病肾衰竭血透患者的临床应用

目的：观察不同钠浓度透析液对糖尿病肾衰竭维持血透患者的影响，寻求糖尿病肾衰竭维持血透患者的个体化透析处方，减少透析不良反应。方法：选取我院血液透析室糖尿病肾衰竭维持血透患者30例，采用自身对照研究方法，分别用135mmol/L、140mmol/L及145mmol/L钠浓度的透析液透析8周，观察不同钠浓度下透析不良反应发生的情况，并对透析指标进行评估。结果：（1）使用140mmol/L钠浓度的透析液可以显著降低低血压和肌痉挛的发生，透析效果较好。（2）使用140mmol/L钠浓度的透析液不增加口渴及高血压等副作用。结论:对糖尿病肾衰竭维持血透的患者使用较高钠浓度的透析处方可以降低患者不良反应发生率，是简便提高透析质量的方法。     

可调钠透析预防失衡综合征和低血压30例临床观察

目的 探讨可调钠透析预防失衡综合征和低血压的效果以及长期应用可调钠透析对血钠的影响。方法 将30例终末期肾功能衰竭（肾衰）患者随机可调钠透析组（A组）和恒定正常钠透析组(B组），分别进行可调钠透析与恒定正常钠透析，对比观察两组病人的失衡综合征，低血压发生率及血钠的变化。结果 A组进行血透786次，发生失衡综合征48例次（6．11％），发生低血压59例次（7．51％）；B组进行血透665例次，失衡综合征及低血压发生率分别为123例次（18．50％），119例次（17．89％），两组比较差异有非常显著性（P＜0．001）；两组透析前后比较和各组间血钠比较，差异无显著性（P＞0．05）。结论 可调钠透析能有效预防失衡综合征及低血压的发生，可使透析后血钠维持正常水平。     

个体化透析方案预防DN血液透析中的低血压

采用随机单盲设计DN患者先后接受常规血液透析8周,个体化可调钠透析8周2种透析方法的透析次数,持续时间,透析液成分（钠浓度除外）,超滤量等均基本相同。结果：个体化可调钠透析低血压的发生率（4．9％）,明显低于常规透析（89．9％）,P〈0．01。结论：个体化可调钠透析对预防DN透析中低血压的发生疗效显著。     

可调钠血液透析对糖尿病肾衰竭患者透析低血压的作用分析

目的探讨可调钠血液透析对糖尿病肾衰竭患者透析低血压的作用。方法选取2015年7月—2017年9月于该院行血液透析的50例糖尿病肾衰竭患者为研究对象,随机分为观察组25例和对照组25例,对照组给予常规血液透析,观察组行可调钠血液透析,对比两组低血压发生情况和透析前后的血压浓度。结果两组患者透析后血钠浓度均有一定的提高,但提高,差异无统计学意义(P0.05)。观察组透析后血钠浓度和对照组对比,差异无统计学意义(P0.05)。两组透析中血压值和透析前对比,差异有统计学意义(P0.05),观察组透析中血压值变化和对照组对比(P0.05)。观察组低血压发生几率和对照组对比,差异有统计学意义(P0.05)。结论在糖尿病肾衰竭患者透析在应用可调钠血液透析可以降低低血压发生几率,不会影响正常的透析效果。     

维持性血液透析患者透析相关性低血压的防治

目的 分析透析相关性低血压发生的病因,探讨针对主要病因进行个体化透析治疗在降低低血压发生率中的重要性.方法 对血液透析过程中发生低血压的21例患者进行自身前后对照分析,前1个月收集低血压患者的病因资料,第2个月为调整分析期,运用柏拉图分析法结合鱼骨图解析,找出低血压主要病因,针对主要病因进行宣教及调整治疗方案;第3个月再次统计低血压发生率及具体病因,比较干预治疗前后低血压发生率及病因的变化.结果 低血压主要病因是脱水量/干体重＞5％、糖尿病、透析过程中进餐、透析前不合理服用降压药物等,21例患者干预前后2个月共行血液透析534例次,干预后低血压发生率明显下降,干预前后低血压发生率分别为7.7％ (39/260)和3.3％(9/274),两组比较差异有统计学意义(P＜0.01).透析相关性低血压多出现在透析后3小时.结论 对不同患者寻找低血压病因,针对主要病因进行重点宣教及个体化透析,可明显降低血液透析过程中低血压的发生率.     

在血液透析中不同透析模式对患者血压的影响

目的观察比较三种透析模式在血液透析中对患者血压的影响。方法对5例经常出现透析性低血压的维持性透析患者分别采用：低温及钠浓度调节联合不同超滤率透析方案、钠浓度调节联合不同超滤率透析方案与常规透析方案三种透析模式进行透析,每例患者每种透析模式观察30次,比较透析时低血压的发生率、超滤量及透析间期体重增长情况。结果三种透析模式低血压的发生率分别为10.00%、18.00%及42.67%,组间两两比较,差异有统计学意义（P〈0.01）。超滤量、透析间期体重增长量在三种模式之间差异无统计学意义（P〉0.05）。结论低温及钠浓度调节联合不同超滤率透析及钠浓度调节联合超滤率透析方案可降低透析相关性低血压发生率,但超滤量、透析间期体重无明显变化。     

低钙透析液对血甲状旁腺素及钙磷代谢的影响

目的:研究应用钙离子 1 .25mmol/L透析液进行透析 3个月对患者iPTH及钙磷水平的影响。　方法:维持性血液透析患者 6例,试验前用钙离子 1. 5mmol/L透析液每周透析 3次,每次透析 4h,均使用F6透析器(聚砜膜,面积 1 3m2 )。使用钙离子 1 25mmol/L透析液透析 3.个月,此期患者饮食中钙磷的摄入量稳定,用药不变。使用钙离子 1 25mmol/L透析液之前检测透析前血iPTH,透析前后血钙和血磷浓度。3个月后复查透析前血iPTH,透析前后血钙和血磷浓度,并检测使用钙离子 1. 25mmol/L透析液单次透析前、透析后及下一次透析前的血iPTH和血钙、血磷浓度。　结果:单次透析使用钙离子浓度 1 25mmol/L的透析液透析 4h,透后血钙浓度下降,透后血iPTH[ (219 .2±143. 3)ng/L]较透前[ (157. 5±107 .1)ng/L]明显升高 (P<0. 05),至下次透析前血钙浓度及血iPTH(157. 7±125 .3ng/L)基本恢复至上次透析前水平。使用钙离子 1 25mmol/L透析液透析 3个月后,iPTH水平较未使用时明显上升[ (157. 5±107 .1)ng/Lvs(82. 5±43 .7)ng/L,P<0 .05]。　结论:单次应用钙离子 1 .25mmol/L透析液进行透析, 透后血iPTH升高,但是至下一次透前血iPTH基本恢复至上次透前水平。长期应用 ( 3个月)钙离子 1 25mmol/L透析液进行透析,钙负荷减轻,血iPTH水平升     

不同治疗方法对高龄血液透析患者低血压的干预效果

随着透析技术的进步和透析质量的提高，透析人群中老年患者比例大量增加。高龄患者多伴有心血管并发症。透析治疗中常因低血压诱发心律失常，甚至循环衰竭，严重危害健康及生命，因此及时有效地预防透析过程中的低血压尤为重要。本文通过对26例老年透析病人（共1616次透析）按不同时间采取不同的干预方法比较其低血压发生率，发现低温可调钠透析结合参附制剂可有效预防高龄患者低血压的发生。现报告如下：     

可调钠透析预防透析低血压的临床观察

透析低血压是血液透析常见的并发症之，其发生率达20％～50％，透析低血压导致透析不充分和趋滤困难，甚至威胁生命。反复发生透析低血压，不利于长期维持性血液透析治疗，影响透析病人的生活质量。高钠透析可明显减少透析中低血压的发生率。但高钠透析可引起病人口渴、血压升高以及透析间期体重增加过多，给下一次透析脱水造成困难。为降低透析过程中低血压的发生率，减少不良反应，我们采用可调钠透析方法，取得了较满意的疗效，现总结报告如下。     

Impact of Dialysate Sodium Concentration Lowering on Home Blood Pressure Variability in Hemodialysis Patients

Blood pressure variability is an independent risk factor for mortality and cardiovascular events in hemodialysis patients. Dialysate sodium concentration may not only have effects on blood pressure but also on blood pressure variability. We investigated whether dialysate sodium concentration lowering could decrease home blood pressure variability in hemodialysis patients. Forty‐three hemodialysis patients at their dry weight assessed by bioimpedance methods with pre‐dialysis serum sodium >136 mmol/L were recruited. Firstly, patients underwent a 1‐month standard dialysis with dialysate sodium concentration of 138 mmol/L, and then the dialysate sodium concentration was decreased to 136 mmol/L for 8 weeks. Home blood pressure was assessed on waking up and at bedtime for 1 week. Coefficient of variation was used to define home blood pressure variability. After the intervention, whole‐day systolic blood pressure variability decreased from 5.7 ± 2.6% to 4.3 ± 1.7% and evening systolic blood pressure variability decreased from 7.9 ± 4.1% to 6.2 ± 3.1%. Morning systolic blood pressure variability had a reduction from 7.8 ± 2.4% to 5.9 ± 3.3% but did not achieve statistical significance (P = 0.077). Whole‐day, morning and evening systolic blood pressure were decreased significantly. Less changes were observed in diastolic blood pressure parameters. Interdialytic weight gain mildly but significantly decreased. Volume parameters, dietary sodium intake and incidence of adverse events were similar throughout the study period. Lowering dialysate sodium concentration could improve home blood pressure variability among hemodialysis patients who had achieved their dry weight.     

1.5mmol/L钙浓度透析液对血清总钙和全段甲状旁腺激素及血压的影响

目的 针对血液透析患者出现的高钙血症，观察将透析液钙浓度从1．75mmol／L(HCaD)降低到1．5mmol／L(LCaD)后对血清钙、磷、全段甲状旁腺激素(iPTH)和血压的影响。方法选择存在高钙血症、使用HCaD的稳定HD患者32例，改用LCaD透析3个月。记录LCaD治疗前后透析中症状、透析前后收缩肜舒张压和心率、血清总钙以及透析前全段甲状旁腺激素(iPTH)。结果 LCaD治疗3个月后收缩压趋于正常，高钙血症得到纠正，低iPTH患者血清iPTH水平升高，LCaD没有影响活性维生素D的疗效。结论 LCaD的使用有利于血液透析患者高钙血症的纠正和血压的控制。     

Electrolyte concentration during haemodialysis and QT interval prolongation in uraemic patients.

AIMS: To assess the effect of different combinations of potassium and calcium concentrations on QT interval in the dialysis bath in uraemic patients. METHODS AND RESULTS: Sixteen haemodialysis (HD) patients underwent a 24 h Holter recording before and during HD sessions with six randomized combinations of electrolytes concentrations of the dialysis bath (K(+), 2 and 3 mmol/L; Ca(2+), 1.25, 1.5, and 1.75 mmol/L). The effect of different dialysis baths on QT interval was significant (P < 0.05). The longest mean QTc was observed with the lowest K(+) (2 mmol/L) and Ca(2+) concentrations (1.25 mmol/L), whereas the shortest mean QTc was observed with the highest K(+) (3 mmol/L) and Ca(2+) concentrations (1.75 mmol/L). QTc was >440 ms in 9 of 16 patients (56%) at the lowest Ca(2+) and K(+) concentrations, and in 3 of 16 patients (18%) at the highest electrolytes level. Changes in QTc during the HD sessions were inversely correlated with that in total Ca and Ca(2+) plasma concentrations (P < 0.0001). CONCLUSION: Changes in ventricular repolarization duration associated with HD largely depend on the concentrations of Ca(2+) and K(+) in the dialysis bath. These findings may have important implications for the choice of the electrolytes concentration of the dialysis bath during the HD session.     

Effects of Sodium Concentration and Dialysate Temperature Changes on Blood Pressure in Hemodialysis Patients: A Randomized,Triple‐Blind Crossover Clinical Trial

The present study investigated the effects of different temperatures and sodium dialysate concentration on blood pressure in hemodialysis patients. Following Williams’ design, hemodialysis patients were randomly assigned into four dialysis modes. Dialysate temperature was set at 37°C for modes A and C and, 35°C for modes B and D. Sodium concentration was set at 138 mmol/L in modes A and B, while it changed from 150 mmol/L to 138 mmol/L in modes C and D. Using analysis of variance for repeated measures, the mean values of systolic and diastolic blood pressure were investigated. The mean values of systolic and diastolic blood pressure in modes C and D had a significant difference with the values in mode A. The mean values of systolic and diastolic blood pressure in patients dialyzed with mode B had a significant difference with the values in those dialyzed with mode D. Moreover, there were significant differences in the incidence of hypotension between A and other modes and between B and modes C and D, but this difference was not significant between modes C and D. In order to reduce intradialytic blood pressure fluctuations and hypotension, the nursing staff are recommended to gradually reduce dialysate sodium concentration.     

Arterial hypertension in the hemodialysis patient. A model of salt-sensitive hypertension in man]

In uremic patient treated by hemodialysis (HD), a low potassium intake and a salt load due to diet and or a high sodium concentration in dialysate are often associated to refractory hypertension. Numerous reports in general population, based on epidemiologic and demographic data, have pointed to the relationship between sodium intake and hypertension. The degree of blood pressure fall in patients who have evidence of salt-sensitivity varies directly with the severity of the hypertension, being most prominent in those with higher pressures. Recent studies have suggested that a reduction of dialysate sodium can control hypertension in maintenance haemodialysis patients. In this study, five hypertensive haemodialysis patients were assigned to a regime of lowering the dialysate sodium concentration from 142 to 135 mmol/L in combination with an attempt to lower salt intake by advising the patients to eat a NaCl-restricted diet of no more than 6-8 g/day. During the period under study, dialysis time was kept constant. A significant increase of ultrafiltrate sodium concentration was observed during the first week after lowering the dialysate sodium concentration. Post dialysis systolic and diastolic pressures showed a clear trend to fall (systolic pressure 174 +/- 18 vs 118 +/- 13 mmHg, diastolic pressure 96 +/- 7 vs 75 +/- 13 mmHg) without a change of dry weight. The reduction of the mean arterial pressure on 48 h was demonstrated with ambulatory blood pressure recording. The results of this study suggest that reducing the dialysate sodium concentration lead to a decrease in peripheral resistance. A link between sympathetic overactivity as it is found in haemodialysis patients and sodium load could be a stimulating hypothesis. It is concluded that increasing dialysate sodium in short dialysis is responsible for the high prevalence of arterial hypertension often insufficiently controlled by antihypertensive medication. In hemodialysis patients with refractory hypertension, the lowering of the dialysate sodium concentration is indicated.     

Low-dose diuretic and/or dietary sodium restriction when blood pressure is resistant to ACE inhibitor.

AIM: To compare the efficacy of indapamide (1.25 mg daily) and low-salt diet (<100 mmol/day) separately and in combination in essential hypertensive patients with inadequate BP response to perindopril. DESIGN AND METHODS: Randomized double-blind, double-dummy, crossover design. The randomized treatments were indapamide 1.25 mg daily, sodium chloride 80 mmol daily, the combination of indapamide and sodium chloride and placebo. All patients received perindopril 4 mg daily and maintained a low-sodium diet. RESULTS: 19 patients entered and 17 completed the study. Prior to randomization, average clinic sitting blood pressure was 162/101 mm Hg and average 24-h urine sodium excretion was 157 mmol/day. Compared to the phase in which patients received perindopril with sodium repletion, clinic and ambulatory BPs were significantly reduced (p<0.01) in all the other phases. Indapamide had a greater effect on BP than dietary sodium restriction, and in combination their effects were additive. The effect of indapamide on ambulatory BP persisted throughout 24 h, but the effect of the low-salt diet was predominantly observed during waking hours. CONCLUSIONS: In hypertensives with BP resistant to the angiotensin converting enzyme (ACE) inhibitor perindopril, the diuretic indapamide had greater additional efficacy and longer duration of action than dietary sodium restriction. In combination they had additive effects on BP.     

Impact of clinical and echocardiographic parameters assessed during acute decompensation of chronic heart failure on 3-year survival

BACKGROUND: It is unclear whether established risk factors affecting the prognosis of chronic heart failure (CHF) have the same predictive value when assessed during acute haemodynamic decompensation of CHF. AIM: To investigate the impact of selected clinical and echocardiographic parameters assessed in patients with CHF during emergency admission due to acute CHF decompensation, on 3-year survival. METHODS: This retrospective study involved 100 consecutive patients with CHF (60 women and 40 men at the mean age of 70.4+/-9.8 years), admitted to hospital due to angina pectoris symptoms or pulmonary oedema. In the echocardiographic study performed within the first 48 hours of in-hospital stay, standard parameters as well as right ventricular systolic pressure (RVSP) were evaluated. In order to identify biological, clinical and echocardiographic factors affecting 3-year survival, both uni- and multivariable Cox proportional hazards regression analyses were carried out. RESULTS: Forty-four patients died during 3-year follow-up. Univariate regression analysis revealed that age >60 years, sodium serum concentration <140 mmol/L, RVSP >35 mmHg and reduced left ventricular ejection fraction <50% were associated with an increased risk of death. However, multivariate regression analysis showed that only age and sodium concentration were independent risk factors. CONCLUSIONS: Age of over 60 years and sodium concentration below 140 mmol/L seen during acute decompensation were found to be independent predictors of unfavourable outcome in terms of mortality in 3-year follow-up of patients with CHF.     

Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry.

AIMS: Hyponatraemia has been shown to be an independent predictor of mortality in selected patients with heart failure enrolled in clinical trials. The predictive value of hyponatraemia has not been evaluated in unselected patients hospitalized with heart failure. METHODS AND RESULTS: OPTIMIZE-HF is a registry and performance-improvement programme for patients hospitalized with heart failure and includes a subgroup with 60-90 day follow-up data. The relationship between admission serum sodium concentration and clinical outcomes was analysed in 48,612 patients from 259 hospitals. Admission serum sodium levels were analysed both as a continuous variable and by grouping patients with admission Na < 135 and Na > or = 135 mmol/L. Patients with hyponatraemia (Na <135 mmol/L) at the time of hospital admission had modest differences in baseline clinical characteristics and management during hospitalization compared with patients who had serum sodium > or =135 mmol/L. Patients with hyponatraemia were more likely to be Caucasian, have lower admission systolic blood pressure, and receive intravenous inotropes during hospitalization. Patients with hyponatraemia had significantly higher rates of in-hospital and follow-up mortality and longer hospital stays, although no difference in re-admission rates was observed. After adjusting for differences with multivariable analysis, the risk of in-hospital death increased by 19.5%, the risk of follow-up mortality by 10%, and the risk of death or rehospitalization by 8% for each 3 mmol/L decrease in admission serum sodium below 140 mmol/L. CONCLUSION: Hyponatraemia in hospitalized patients with heart failure is relatively common and is associated with longer hospital stays and higher in-hospital and early post-discharge mortality. Re-admission rates were equally high in patients with or without hyponatraemia.     

Citrate anticoagulation and adverse events

Several patients with heparin intolerance were dialysed with tri-sodium citrate as anticoagulant without acute clinical problems (good tolerance). After some weeks however problems arose. In all patients an alkalosis developed: the pre dialysis bicarbonate level rose progressively from 27 mmol/l to 40 mmol/l. This could be tempered by lowering the dialysis fluid bicarbonate concentration from 37 mmol/l to 25 mmol/l. A second problem was a progressive rise in pre dialysis sodium level from a mean of 136 mmol/l to 150 mmol/l. Adapting the dialysis fluid sodium concentration from 140 mmol/l towards 132 mmol/l could solve this. The third problem was a progressive rise in serum aluminium level in patients from 3 microg/l to 38 microg/l. After excluding water, concentrate, dialysis fluid, drug intake, etc... as possible sources, we controlled the aluminium level in the glass bottle containing tri-sodium citrate. We noted the very high value of 35,300 microg/l. After replacing the glass bottles with polyvinylchloride bags with a negligible aluminium content, the serum aluminium levels returned back to normal. It is known that citrate chelates the aluminium present in the glass of bottles or vials.