终末期肾衰竭透析患者血脂改变的临床观察

目的：观察连续性非卧床腹膜透析(CAPD)和维持性血液透析(MHD)患血脂水平改变。方法：对634例CAPD和45例MHD患血脂水平进行测定，并以40例正常人作对照。结果：CAPD和MHD患血TG和apoB显增高，血HDL—c、apoAl、apoAl／apoB均显低于正常，以上指标在血、腹透组之间部分存在显性差异。CAPD组在发生腹膜炎后血LDL—c、apoB较未发生之前显增高。结论：CAPD和MHD患脂质紊乱相当常见，以前更为突出。当发生腹膜炎时脂质代谢紊乱更加严重。     

干细胞治疗急慢性肾衰竭的机制及前景

终末期肾衰竭是各种慢性肾脏病进行性发展的最终结果,只能实施血液透析、腹膜透析和肾移植,前二者称为不完全替代治疗,透析的同时需补充促红细胞生成素等,且并发症多、生存质量不高;肾移植为完全替代,然而由于供体短缺、免疫抑制、外科手术并发症[1 ]以及长期等待肾移植所造成的较差的移植效果[2],因此急需一种新的、更先进的方法用于肾衰竭的治疗.本文就干细胞用于急慢性肾衰竭的治疗综述如下.     

38例血液透析治疗10年以上慢性肾衰竭患者的生存质量分析

目的：探讨长期血液透析治疗患者的生存质量.方法：对38例血液透析治疗10年以上的慢性肾衰竭患者进行横断面临床研究,项目包括营养状况评估,贫血、钙磷代谢紊乱、继发性甲状旁腺功能亢进、微炎症状态等相关指标的检查,以及患者生活状况的调查.结果：在38例患者中,血压控制在正常范围的患者17例,占44.7%;1级高血压的患者18例,占47.4%.营养正常的患者15例,占39.5%;轻中度营养不良的患者21例,占55.3%;重度营养不良的患者仅2例.血红蛋白是（108.8±15.4）g/L,血清总蛋白是（69.0±11.6）g/L,白蛋白是（38.5±7.0）g/L,铁蛋白是（322.4±242.6）ng/ml,转铁蛋白饱和度是（31.3±11.5）%,高敏C反应蛋白水平是（3.6±3.1）mg/L.其中正常的患者23例,占60.5%;钙磷乘积＜55 mg2/dl2的患者30例,占78.9%;全段甲状旁腺激素＜500 pg/ml的患者21例,占55.3%.生活能自理的患者35例,占92.1%;坚持体育锻炼的患者13例,占34.2%;与亲属关系和睦的患者36例,占94.7%;对目前生活质量满意和较满意的患者32例,占84.2%.结论：慢性肾衰竭的患者通过血液透析治疗,完全能够长期、高质量地存活.     

血液透析与腹膜透析对终末期肾衰竭患者脂质影响的调查与分析

目的：调查血液透析和腹膜透析对终末期肾衰竭患者脂质代谢的影响。方法：采用回顾性分析的方法调查尿毒症患者共96例,腹透及血透各48例,比较其各自透析前后脂质改变及透析后两组脂质改变有无差异。结果：（1）腹透治疗组三酰甘油（TG）、低密度脂蛋白（LDL）、极低密度脂蛋白（VLDL）较透析前明显升高（P〈0.01）,总胆固醇（TC）较透析前升高（P〈0.05）,高密度脂蛋白（HDL）较透析前降低（P〈0.05）,LP（a）较透析前无统计学差异;（2）血透组LDL、TG、LP（a）较透析前明显升高（P〈0.05）,HDL较透析前降低无统计学意义;（3）腹透组与血透组血脂变化比较：TG、LDL二者的升高腹透组较血透组明显（P〈0.05）,LP（a）升高血透较腹透明显（P〈0.05）。结论：透析会加重终末期肾衰竭患者的脂质异常,腹膜透析表现更明显,腹膜透析与血液透析存在统计学差异。血液透析在LP（a）的升高应引起重视。     

肾性骨病临床研究近况

肾性骨病即肾性骨营养不良(Renal Ostcxxlystrophy，ROD)，是终末期肾衰竭的严重并发症，也是目前影响维持性透析和肾移植患者生存质量的突出问题。近1年来，各国学者对该病进行了较多的研究，在临床方面取得了一些新的进展。     

不同透析剂量对CAPD患者生存质量的影响

目的评估不同透析剂量对持续性非卧床腹膜透析（CAPD）患者生存质量的影响,以寻求更合理的符合中国人特点的腹膜透析剂量。方法将稳定的CAPD3个月的患者随机分为2组,即低剂量组（2L／次,3次／天）和常规剂量组（2L／次,4次／天）。每半年对两组患者进行生存质量、营养状态、炎症状态、残余肾功能、严重心血管事件发生率进行评估,持续2年,比较两组之间的差异,使用KDQOL-SFTM1．2生存质量表进行调查,根据Hays提供的方法进行评分,SPSS10．0软件包分析数据。结果①随着透析时间的延长,患者的生存质量评分逐渐增加;②低剂量组与常规剂量组患者的KDTA和SF-36总分无显著性差异,在KDTA的4个分支领域及SF-36的2个分支领域评分高于常规剂量组;③两组患者的营养状态、全身微炎症状态、高血压的控制、严重心血管事件的发生率无明显差别;④低剂量组残余肾功能优于常规剂量组。结论低透析剂量较常规透析剂量能更好的保护残余肾功能,值得推荐。     

新型冠状病毒疫情下肾脏替代治疗策略

新型冠状病毒(2019 novel coronavirus,2019-nCoV)感染是一种传染力强,人群普遍易感,高度致病性的一种呼吸道病毒,已对社会造成巨大危害。终末期肾脏病患者的普遍免疫力低下,属于新型冠状病毒的高危人群,致死率高。在新型冠状病毒疫情下,如何实施肾脏病患者的肾脏替代治疗,本文结合新型冠状病毒的传播特点和不同肾脏替代治疗方式的优缺点,为新型冠状病毒疫情下肾脏病的替代治疗方案制定和实施提供参考。     

血液透析及腹膜透析患者生活质量评价及相关因素分析

目的：评估血液透析及腹膜透析患者的生活质量及相关影响因素。方法：随机抽取腹膜透析患者28例及血液透析患者28例,采用肾脏疾病生存质量专用量表KDQOL-SFTM量表对透析患者进行生活质量评估。比较血液透析患者和腹膜透析患者健康相关生活质量（HRQOL）的差异,并采用多元回归分析法探索分析透析人群HRQOL的影响因素。结果：血液透析患者和腹膜透析患者在KDQOL-SFTM量表各维度得分上差异无统计学意义,除外社会功能（SF）。血液透析患者SF得分高于腹膜透析患者（63.94±25.08vs48.66±23.41,P〈0.05）。影响血液透析患者生活质量的因素包括：性别、年龄、透析龄、文化程度、钙磷乘积、血红蛋白（Hb）、甲状旁腺激素（PTH）等。上述因素对血液透析患者的HRQOL影响占14.1%～55.6%。影响腹膜透析患者生活质量的因素包括：性别、年龄、透析龄、体重指数（BMI）、糖尿病（DM）、Hb、血白蛋白（Alb）、PTH、铁蛋白、腹透方式、每日交换液量等。上述因素对腹膜透析患者的HRQOL影响占14.7%～58.6%。结论：透析患者的骨矿物质代谢紊乱、贫血严重影响生活质量。除此之外,腹膜透析患者的生活质量还受BMI、DM、营养状态、腹透龄的影响。临床中应积极纠正上述影响因素以提高透析患者的生活质量。     

Surgical Interventions for Renal Replacement Therapy from the View of Nephrologists

Summary BACKGROUND: The number of patients with end-stage renal disease (ESRD) is increasing worldwide at a rate of approximately 5 % per year. In Austria, 6049 patients were suffering from ESRD in the year 2001, an annual rate of 1093 patients. Higher age of patients and co-morbidities are forcing nephrologists to find the optimal renal replacement therapy (RRT) and access modality for the individual patient. METHODS: For patients with ESRD needing RRT, both nephrologist and surgeon should be consulted to ensure optimal management and treatment including vascular access surgery. Patients planned for peritoneal dialysis (PD) are treated with the cooperation of a visceral surgeon. A catheter is inserted into the pelvic area to enable solution exchange. In patients who are to undergo hemodialysis (HD), nephrologists have to decide whether the cardiac condition is suitable for surgical access creation such as fistula or graft. Otherwise alternative hemodialysis devices such as a central venous catheter (CVC), or subcutaneously implantable ports (Dialock^®), have to be discussed. Access function is routinely monitored during dialysis treatment, but still remains the weak component of extracorporeal RRT responsible for 40 % of hospitalization of HD patients. RESULTS: At the dialysis unit of the University Hospital of Graz, 107 patients were under RRT (70 HD and 37 PD), and 235 patients were hemodialyzed in private units in Graz in 2001. 81 ESRD patients were newly enrolled in the chronic HD program. 131 HD accesses were created in new HD patients and patients under treatment for chronic HD. 36 patients developed HD access complications and in these patients, 181 surgical and/or radiological interventions were performed. CONCLUSIONS: In 12 % of the HD patients in Graz, access problems occurred. These patients have a high frequency of surgical and radiological interventions. Access monitoring and measurement of recirculation may help to reduce the complication rate by 38 %. Before onset of RRT, patients need special management to ensure the best dialysis modality. ESRD patients who are suffering from cardiac diseases, diabetes mellitus, or bad peripheral vascular status need a multidisciplinary approach with nephrologists, cardiologists, surgeons and radiologists working together to find the optimal access for dialysis treatment.     

Chronic peritoneal dialysis in the tenth decade of life

In this retrospective study we present our experience with chronic peritoneal dialysis in nine patients with ESRD in their 10th decade of life (90 years) at the Toronto Western Hospital. A family member or a private nurse assisted all patients in dialysis procedure. The co-morbid illnesses, survival, hospitalizations and complications related or unrelated to peritoneal dialysis were reviewed. Four patients started dialysis before and five after their 90th birthday, their mean age was 90.61 ± 4.04 years. All patients had three or more co-morbid illnesses at the start of dialysis. Total duration of PD treatment was 210 patient months with a median duration of 25 months (range 4–68 months). Of the nine patients, four died after a mean follow up of 38.5 months on dialysis. Of the remaining five, one was transferred to hemodialysis after remaining for 10 months on peritoneal dialysis and the other four are continuing on PD for a mean duration of 9.25 months. Peritonitis (1/13.4 patient months) and exit site infection (1/100.5 patient months) responded to treatment. Hospitalization rate was one admission per 2.5 patient years. Most often, the cause of hospitalization was unrelated to PD, e.g., cardiovascular events, pneumonia and peripheral vascular disease etc. Patient survival at 1, 3 and 5 years was 88%, 58% and 24% respectively. The technique survival was 69%, 47% and 23% at 1, 3 and 5 years respectively. We conclude that continuous peritoneal dialysis is a safe and suitable treatment even in nonagenarians (90 years) ESRD patients.     

南京市江宁地区血液透析与腹膜透析患者生活质量比较

目的 调查南京市江宁地区终末期肾病维持性血液透析与腹膜透析患者的生活质量并分析其相关因素.方法 选取江宁地区血液透析35例患者及腹膜透析30例患者,所有患者均检测生化指标、血红蛋白浓度,计算残余肾功能,并调查文化程度;用健康生活质量SF-36量表对维持性透析患者进行生活质量评估,并对生活质量的影响因素进行分析.结果 血液透析患者和腹膜透析患者在健康生活质量SF-36量表各维度得分比较差异无统计学意义(P＞0.05).影响血液透析患者生活质量的因素包括透析龄、血红蛋白浓度、甲状旁腺激素等.影响腹膜透析患者生活质量的因素包括透析龄、文化程度、腹膜透析剂量等.结论 贫血、甲状旁腺机能亢进严重影响终末期肾病透析患者生活质量.除此之外,腹膜透析患者的生活质量还受文化程度、透析剂量、腹透龄的影响.临床工作中应充分考虑上述因素对患者生活质量的影响从而选择适宜的透析质量方式并纠正影响因素以提高患者生活质量.     

腹膜透析患者中医证型及其影响因素的临床观察

目的：观察腹膜透析（PD）患者中医证型的分布与变化,分析影响证型的相关因素,为中医药治疗干预提供参考.方法：共96例PD患者,记录病史、症状体征与舌脉,进行中医辨证分型,同一患者当中医证型发生变化时进行连续性观察,并观察中医证型与透析龄、临床合并症及实验室指标间的关系.结果：（1）证型分布：本虚证以脾肾气虚证、脾肾阳虚证为主,分别占43.8%、26.0%,标实证依次为湿浊证、血瘀证、风动证、湿热证、水气证,以湿浊、瘀血证多见;（2）证型的变化：血瘀、湿热、湿浊等标实证可随病情发生变化;（3）证型与透析龄的关系：透析龄＜24个月脾肾气虚、脾肾阳虚证与湿浊证多见,透析龄≥24个月脾肾阳虚、阴阳两虚、血瘀、风动证较多,组间比较差异有统计学意义（P〈0.01或〈.05）;（4）证型与临床合并症的关系：发生腹膜炎与非腹膜炎时比较湿热证增多,脾肾阳虚证减少,发生容量超负荷与非容量超负荷时比较水气证明显增多,但组间比较差异无统计学意义（P〉0.05）;（5）证型与实验室指标的关系：本虚证中阴阳两虚、脾肾阳虚证患者血Hb明显下降,血CRP升高,阴阳两虚证血Alb下降,脾肾阳虚证血iPTH升高,肝肾阴虚、气阴两虚证血TG升高,差异均有统计学意义（P〈0.05）,各标实证实验室指标比较差异无统计学意义（P〈0.05）.结论：PD患者的中医证型本虚证以脾肾气虚与脾肾阳虚证为多,标实证主要为湿浊、血瘀证,透析龄、临床合并证及某些实验室指标是影响中医证型的因素.     

终末期肾衰竭腹膜透析患者的转归及其危险因素分析

目的:探讨影响终末期慢性肾衰竭连续性不卧床腹膜透析患者死亡危险因素及其防治对策.方法:对1999年8月～2003年8月期间我院52例慢性肾衰竭腹膜透析患者的资料进行回顾性临床分析.其中死亡组22例、存活组30例,分析其死亡原因和影响因素.结果:(1)52例腹膜透析患者死亡组的22例中,死于心血管病变13例(占59.1%),腹膜炎3例(占13.6%),肺部感染2例(占9.1%),严重营养不良2例(占9.1%),其他2例(占9.1%).(2)死亡组年龄、性别分布与存活组比较无统计学差异(P＞0.05);与存活组比较,死亡组的体重、平均动脉压明显升高,血浆白蛋白明显降低,均有统计学差异(P＜0.05).(3)死亡组的透析龄、透析液总剂量、腹腔超滤量、尿量及液体总清除量与存活组比较均无统计学差异(P＞0.05);然而死亡组的水肿发生率明显高于存活组,分别为68.2%及43.3%(P＜0.05).(4)死亡组透析初始时的尿素氮、肌酐、肌酐清除率、血色素、总胆固醇、甘油三酯与存活组相比无统计学差异(P＞0.05).(5)糖尿病腹膜透析患者的水肿发生率和病死率均明显高于非糖尿病患者(P＜0.05),16例糖尿病患者有11例死亡,非糖尿病患者36例中有11例死亡(病死率分别为68.8%VS 30.6%).结论:心血管疾病是终末期肾衰竭腹膜透析患者最主要的死亡原因.容量超负荷、糖尿病、控制不良的高血压、营养不良以及透析时机过迟都是影响终末期肾衰竭患者心血管病死亡的主要危险因素.积极维持体液平衡、控制血压及糖尿病合并症,并根据患者的残余肾功能、临床症状、合并症情况和营养状态综合考虑,及时开始CAPD治疗,将有助于改善患者的预后.     

Peritoneal dialysis for chronic renal failure in a patient with methylmalonic acidaemia

Chronic renal failure is a common complication of methylmalonic acidaemia (MMA). It is usually managed with haemodialysis and renal transplantation. We report the use of continuous cycling peritoneal dialysis (CCPD) for 20 months in a paediatric patient with chronic renal failure due to MMA. This procedure resulted in the elimination of 950 μmol methylmalonate (MM) per day and a fall in the plasma MM concentration from 3.9 to 0.74 mmol/l. As a result of this treatment, the frequency at which this patient was hospitalised was markedly reduced prior to a successful renal transplantation.     

同种异体肾移植后CD4+、CD8+、CD16+、CD19+、CD56+变化及临床意义

目的了解对比肾移植受者术后体内淋巴细胞免疫表型的变化情况及其临床意义.方法采用多种单克隆抗体及流式细胞仪,对肾移植受者术后的淋巴细胞免疫表型进行了化验监测,分析了淋巴细胞免疫表型变化与免疫用药及并发症的关系.结果移植受者淋巴细胞免疫表型阳性细胞数普遍偏低(P＜0.05),肾移植后顺利恢复组的淋巴细胞免疫表型阳性细胞与健康对照组无差异(P＞0.05),肾移植后并发症组受者CD4+、CD8+阳性细胞数低于临床正常值,NK细胞及CD19+阳性细胞数减少(P＜0.05).肾移植后急排组的NK细胞及CD19+阳性细胞数明显增加,CD4+/CD8+比值偏高(P＜0.05).结论淋巴细胞免疫表型可用于评价移植受者的免疫状态,临床上根据受者的化验结果综合评价受者的免疫抑制状态,并作为调整免疫抑制剂用量的参考指标.     

Gastric Emptying in Patients on Renal Replacement Therapy

In addition to gastrointestinal tract symptoms such as nausea, vomiting, and loss of appetite, impaired gastric emptying time (GET) may be related to nutritional parameters and nutritional status of patients on renal replacement therapy (RRT). Patients on RRT are affected by several factors such as uremic toxins, the presence of dialysate in the peritoneal cavity, and the drugs used against renal allograft rejection. In this study, we investigated the gastric emptying time and its relationship with biochemical and nutritional parameters in patients on RRT: those on hemodialysis and peritoneal dialysis, and renal transplantation patients. Seventy‐five patients, 44 on hemodialysis, 16 on peritoneal dialysis, and 15 renal transplant patients, were included in the study. They were examined for gastric emptying time using a radioisotopic method. The results were compared with the GET of healthy subjects. Each group of patients was evaluated in terms of hemoglobin, hematocrit, blood urea nitrogen (BUN), creatinine, blood glucose, total protein, albumin, serum lipids, parathyroid hormone (PTH) and body mass index and biceps and triceps skinfold. The mean GET of patients on RRT was significantly longer than the mean GET of healthy subjects (87.8 ± 23.4 vs. 55 ± 18 min, p < 0.05). The mean GET of each therapy subgroups was significantly longer than the healthy subjects (the mean GET was 85.1 ± 22.4 min for hemodialysis, 87.7 ± 31.8 min for peritoneal dialysis, and 94.6 ± 16.7 min for renal transplant patients, respectively, p < 0.05). On the other hand, the differences in the mean GET between the three therapy subgroups were not statistically significant (p > 0.05). In addition, time on replacement therapy inversely and blood glucose positively correlated with GET in renal transplant patients. In conclusion, GET was longer in patients on all three RRT modalities than in healthy subjects. GET was not significantly different in dialysis patients and renal transplant patients.     

Renal Transplantation

Summary BACKGROUND: Clinical renal transplantation has been performed successfully since 1955. With the introduction of Cyclosporin A to the market, 1982, results markedly improved, and allogeneic renal transplantation became a standard therapy in the treatment of end stage kidney failure. Life expectancy and quality of life is superior in kidney recipients in comparison with patients on dialysis. METHODS: In our center 699, renal transplantations have been performed since 1968. 98.1 % of the transplanted kidneys were from cadaveric donors, 1.9 % from living related donors. Mean age of the recipients was 30.7 ± 13.9 years from 1968 to 1983, and is now 45.9 ± 13.1 (1999 to 2002). The kidneys are normally transplanted to the common iliac vessels in end-to-side fashion. A Politano-Leadbetter antirefluxive implantation of the ureter is obligatory. RESULTS: 5-year graft survival was 19.4 % from 1968 to 1983, 74.3 % from 1984 to 1995, and 81.2 % from 1995 to 1998. Typical surgical complications are hematoma, lymphocele, ureter stenosis and ureter necrosis. The rate of necessary reoperations is 3.9 %. 5-year patient survival is 90 %. Heart disease (50 %), cancer (16 %), and sepsis (15 %) are the most frequent causes of death after renal transplantation. CONCLUSIONS: Renal transplantation continues to be the optimal treatment of terminal kidney failure. New immunosuppressive agents have improved the outcome after kidney transplantation. Enlargement of the donor pool is being attempted by the acceptance of older organs and by the acceptance of pediatric organs for adult recipients, too.