维持性血液透析患者透析充分性与血浆脑钠肽水平关系

K/DOQI指南指出终末期肾病(ESRD)患者血透充分与否对提高维持性血透(MHD)患者的生存和生活质量起着重要作用.脑钠肽(BNP)是一种以心脏分泌为主的多肽,在调节血压、血容量、水盐平衡等方面发挥着重要作用.我们通过测定MHD患者BNP水平,探讨其与透析充分性之间的关系.     

维持性血液透析患者透析充分性与血浆脑钠肽水平关系

K/DOQI指南指出终末期肾病(ESRD)患者血透充分与否对提高维持性血透(MHD)患者的生存和生活质量起着重要作用.脑钠肽(BNP)是一种以心脏分泌为主的多肽,在调节血压、血容量、水盐平衡等方面发挥着重要作用.我们通过测定MHD患者BNP水平,探讨其与透析充分性之间的关系.     

维持性血液透析患者血清BNP水平变化及其临床意义分析

目的:分析维持性血透(maintain hemodialysis,MHD)患者血透前后血清脑钠肽(brain natriuretic peptide,BNP)水平的变化及其意义。方法:以30例非CKD患者为健康对照组,并选择我院60例病情稳定且近期无急性心血管事件的MHD患者,分别检测同一次血透前后血清BNP水平,同时应用心脏超声心动图检测患者左心房内径(LAD)、左心室舒张末内径(LVDd)、左心室收缩末内径(LVDs)、室间隔厚度(IVST)、左心室后壁厚度(LVPWT)、左心室射血分数(LVEF)等,计算左心室心肌重量(LVM),探讨BNP与MHD患者左心室结构、功能和血容量的关系。结果:(1)MHD患者血透前、后血清BNP水平均显著高于对照组(P0.01),且透析后BNP水平较血透前显著下降(P0.01);(2)MHD患者LAD、LVDd、(LVDs、IVST、LVPWT、LVEF、LVM水平均显著高于对照组(P0.01);(3)MHD患者血清BNP水平与LVDd、LVDs、LVPWT、LVM呈显著正相关,与LVEF呈显著负相关,与LAD、IVST无显著相关性;(4)MHD患者单次透析超滤量与血透前后BNP差值呈显著正相关(P0.05)。结论:MHD患者BNP水平普遍升高,并且与左心室功能及血容量负荷密切相关,对评估MHD患者心功能状况、指导超滤量的设置有一定的临床指导价值。     

血液透析串联血液灌流治疗血液透析患者肾性骨病

肾性骨病是维持性血透(MHD)患者的主要并发症之一.我们探讨血液透析串联血液灌流(HD+HF)对MHD患者肾性骨病的作用.     

音乐疗法对维持性血液透析患者抑郁情绪的影响

目的探讨音乐疗法对维持性血液透析(MHD)患者抑郁情绪的影响.方法将存在抑郁情绪的74例MHD终末期尿毒症患者随机均分为观察组和对照组.对照组予常规护理,观察组在此基础上每次血透期间予音乐疗法,采用Zung自评量表(SDS)评定患者抑郁状态的改善情况,并比较两组血透期间的并发症发生率.结果两组治疗后SDS评分比较,差异有显著性意义(P<0.01);观察组干预后SDS评分显著低于干预前(P<0.05),两组血透期间并发症发生率比较,差异有显著性意义(P<0.01).结论音乐疗法可以减轻MHD患者抑郁情绪,减少血透期间并发症的发生.     

血液透析心衰患者内瘘环束缚术的应用

目的 探讨内瘘环束缚术对维持性血液透析(MHD)心衰患者的临床疗效.方法 将100例MHD患者按有/无发生心衰分治疗组(A,60例)与对照组(B,40例),再将A组随机分为手术组(A1,30例)与非手术组(A2,30例);观察治疗前后患者内瘘头静脉管径、流量、疗效及血浆脑钠肽(BNP)、血管内皮生长因子(VEGF)、血红蛋白(Hb)、血肌酐(Cr)等生化指标的变化;并以VEGF、CysC水平对MHD患者心衰的诊断绘制ROC曲线.结果 A1组术后1、2、4周内瘘头静脉管径及流量均明显减小;A1组疗效优于A2组;A组治疗前内痿流量、VEGF、Hb水平低于B组,A1组治疗后VEGF水平高于A2组,CysC水平低于A2组(P＜0.05);多元线性回归分析示:治疗前A组及治疗后A2组CysC与BNP水平呈正相关,Hb、VEGF与BNP水平呈负相关,且VEGF对BNP值影响最大.B组及治疗后A1组各指标与BNP值无线性回归关系,治疗后A2组各指标与BNP值仍存在线性回归关系.ROC曲线示:VEGF、CysC与BNP水平关系密切.结论 心脏补片环束缚术通过缩小头静脉管径降低内瘘流量从而达到治疗MHD心衰患者的目的,其机制可能与调节VEGF、CysC水平而降低BNP浓度有关,VEGF、CysC是监测MHD患者心衰的有效指标.     

维持性血液透析患者血浆脂蛋白相关磷脂酶A_2与心脏结构及功能的关系

目的研究维持性血液透析(maintenance hemodialysis,MHD)患者血浆脂蛋白相关磷脂酶A_2(lipoprotein-associated phospholipaseA_2,Lp-PLA_2)水平与心脏结构及功能的关系。方法选取我院70例透析充分病情稳定的MHD患者(接受透析治疗时间均6个月)收集一般临床资料,采用双抗体夹心酶联免疫吸附法测定血浆Lp-PLA_2浓度,采用免疫荧光法检测血清B型脑钠肽(brain natriuretic peptide,BNP)水平;应用心脏彩超测定左心房内径(left atrial diameter,LAD)、左心室舒张末期内径(left ventricular end-diastolicdiameter,LVEDD)、左心室后壁厚度(left ventricular posterior wall depth,LVPWD)、左心室射血分数(left ventricular ejection fraction,LVEF)等各项指标,计算左心室心肌质量指数(left ventricular mass index,LVMI);分析血浆Lp-PLA_2水平与心脏彩超测定指标的相关性。以40名健康体检者作为正常对照组。结果(1)70例MHD患者中,血浆Lp-PLA_2浓度、BNP、LVEF、LVMI、收缩压均显著高于正常对照组(P0.05)。(2)合并左室收缩功能降低(LVEF50%)、左室肥厚和(或)心功能不全(BNP300 ng/L)的MHD患者血浆Lp-PLA_2浓度均较相关指标正常的MHD患者明显增高(P0.05)。(3)相关分析结果显示:MHD患者血浆Lp-PLA2水平与BNP(r=0.43,P0.05)、LVMI(r=0.58,P0.01)呈正相关,与LⅦF呈负相关(r=-0.67,P0.叭)。(4)多元回归分析显示:MHD患者血浆Lp-PLA_2水平与LVMI(β=0.342,P0.01)和左室收缩功能减退相关(β=-0.396,P0.01)。结论在MHD患者中普遍存在高脂蛋白相关磷脂酶A_2血症;血浆Lp-PLA_2水平能反映左心室结构和功能的变化,对左心室肥厚和左心室功能的评估具有重要作用。     

维持性血液透析死亡病例临床分析

随着血液净化技术的日臻完善,尿毒症维持血透(MHD)患者的生存时间逐步延长.在临床中,明确引起MHD患者死亡的危险因素,并采取相应的对策予以纠正,将会进一步延长患者的生存时间,提高其生存质量.兹将我科近年来死亡的MHD病例的临床资料总结报道如下.     

C-反应蛋白与血液透析患者贫血和红细胞生成素抵抗的关系

C-反应蛋白(CRP)可作为慢性。肾功能衰竭(CRF)和维持性血透(MHD)患者慢性微炎症状态的标志物。我们观察CRP水平与MHD患者贫血及rHuEPO抵抗的关系。     

尿毒症维持性血液透析患者短期生存影响因素分析

目的:探究尿毒症维持性血液透析(maintenance hemodialysis,MHD)患者短期生存影响因素,以期能为后期临床防治提供科学依据。方法:以浙江省台州医院血液净化中心2008年09月～2018年12月期间收治的29例经3～12个月MHD死亡的患者作为死亡组,按1:2匹配对照的方法选择与其同期进行MHD且生存时间≥12个月的58例尿毒症MHD患者作为对照组。采用回顾性病例对照分析方法,收集两组患者开始接受MHD时的各项临床及生化指标;采用单因素、多因素COX回归分析MHD后短期死亡的主要原因及相关危险因素。结果:尿毒症MHD患者短期死亡的主要原因是心脑血管疾病11例(37.9%),其次为感染性疾病6例(20.7%)。死亡组合并糖尿病、心血管疾病、中心静脉导管作为血管通路患者比例明显高于对照组(P0.05),而血透前收缩压、白细胞计数、中性粒细胞比例、血浆白蛋白、前白蛋白、总胆固醇、左心室射血分数(left ventricular ejection fraction,LVEF)水平明显低于对照组(P0.05)。单因素COX回归分析显示,合并心血管疾病、中心静脉导管作为血管通路、透析前收缩压、白细胞计数、前白蛋白、白蛋白、总胆固醇、LVEF与患者死亡相关(P0.05)。多因素COX回归分析显示,血透前合并心血管疾病、透前低收缩压、低血浆白蛋白是尿毒症MHD患者短期死亡的独立危险因素。结论:尿毒症MHD患者的短期死因主要是心脑血管疾病和感染性疾病。开始血透前合并心血管疾病、透前低收缩压、低血浆白蛋白的MHD患者短期死亡率高。积极治疗基础病、加强合并症防治、改善营养状态、纠正透前低血压能提高尿毒症MHD患者的短期生存率,延长生存时间。     

Nocturnal hemodialysis

With the increasing number of patients with end stage renal disease comes an increasingly urgent need for renal replacement therapy that is both clinically effective and cost effective. This article explores some of the advantages of nocturnal hemodialysis as well as some of the barriers to its use.     

高通量血液透析与低通量血液透析的透析效果比较

目的 比较高通量血液透析(HFHD)、低通量血液透析(LFHD)对维持性血液透析患者的综合疗效.方法 32例维持性血透患者,随机分为高通量血液透析组(n=16)和低通量血液透析组(n=16),分别每2周透析5次,每次4.5h.分别于首次透析前、透析后取血检测患者血清BUN、Cr、K+、Na+、Ca2+、P3++、β2-MG、Alb及iPTH.同时观察患者的临床症状变化情况.治疗1年后复查并比较上述指标.结果 高通量透析组对iPTH及β2-MG的清除高于低通量血液透析组(p＜0.05).两组Urea、Cr清除率及KT/V值无统计学差异(p＞0.05),透析前后两组K+、Na+、Ca2+、P3+无统计学差异(p＞0.05).高通量透析组患者的临床症状较低通量透析组明显改善,血清白蛋白变化无明显差异(p＞0.05).结论 高通量血液透析对中大分子物质的清除明显优于低通量血液透析,并能改善患者的临床症状,不会引起蛋白质过多的丢失,对小分子物质清除与低通量血液透析具有同样的效果.     

The cost of hemodialysis in a large hemodialysis center

To assess the cost of hemodialysis (HD) delivered at our center according to the treatment protocols based on the current Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines, we analyzed our cost data during the period from 1st of January 2007 to 30th of June 2010. The methods were used to determine both direct costs (related to dialysis treatment such as dialysis disposables, dialysis related drugs, medical personnel, out-patient medications, laboratory and other ancillary services) and overhead costs (building, maintenance and engineering costs, housekeeping, and administrative personnel). During the study period, an average of 2,500 HD sessions per month were performed for 200 patients. The mean total cost per HD session was calculated as 297 US dollars (USD) [1,114 Saudi Riyals (SR)], and the mean total cost of dialysis per patient per year was 46,332 USD (173,784 SR). Direct costs contributed to 81.15% of the total cost from which the personnel cost represented 41.11% and dialysis disposables represented 13.64%, while medications (outpatient and intravenous dialysis related medications including albumin, erythropoiesis stimulating agents, iron and vitamin D?) accounted for 12.47% of the total cost. Our total cost level is well below the average cost in the industrialized countries.     

Conversion of temporary hemodialysis catheters to tunneled hemodialysis catheters

PURPOSE: To determine the feasibility and clinical outcomes of conversion of temporary to tunneled hemodialysis catheters using the same venous insertion site. METHODS: Data from 42 patients with existing temporary hemodialysis catheters referred for placement of tunneled hemodialysis catheters were retrospectively reviewed. In these patients, the temporary catheter was exchanged for a peel-away sheath, and a tunneled catheter was inserted using the existing venous access site. Technical success, procedural complications, and clinical outcomes were evaluated. Hemodialysis records were reviewed to assess catheter patency during a 30-day follow-up period. RESULTS: The study group consisted of 20 males and 22 females (mean age: 58 years). All 42 temporary catheters were successfully converted to tunneled hemodialysis catheters without immediate procedure-related complications. Follow-up data were available for 32 patients (total: 3038; median 71 catheter days). Nine catheters were removed for infection, yielding a catheter infection rate of 0.30/100 catheter days; three catheters were removed for blood flow <200 ml/min. 13 patients had catheters removed when catheters were no longer needed. Three patients died with working catheters. The patency rate was 72% at 30 days, with four catheters functioning at the end of the study period. CONCLUSION: Conversion of a temporary hemodialysis catheter to a tunneled hemodialysis catheter using the same venous insertion site is a safe procedure that avoids complications associated with venotomy and allows conservation of other central venous access sites. Patency and infection rates in these catheters are comparable to several studies of catheter exchange and de novo placement of tunneled hemodialysis catheters.     

单中心维持性血液透析患者透析现状调查分析

目的对单中心维持性血液透析（MHD）患者进行现状调查分析，为透析质量持续改进提供参考依据。方法选择南京军区福州总医院血液净化科412名MHD患者的临床资料进行回顾性分析。结果412例MHD患者中，高磷血症358人（86．99％），钙磷乘积大于55mga／dl。194人（47．15％），iPTH达标率为13．59％。首次透析使用血管通路为临时中心静脉留置导管者345人（83．74％），而以动静脉内瘘作为长期血管通路者395人（95．87％）。412例血红蛋白值为99．35±21．38g／L，其中女性95．50±23．66g／L，男性105．4±11．21g／L，两者均低于正常值（P〈0．05）；其中血红蛋白≥100g／L占46．8％，血红蛋白≥110g／L占26．70；乙型肝炎抗原标志物和丙型肝炎抗体的阳性率分别为14．08％和9．47％；尽管有服用降压药物，本组大于140／90mmHg的高血压患者仍有343人（83．25％），其中使用3种以上降压药物的为315人（76．45％）。全部患者中每周透析三次者仅为214人（51．94％），透析频次与医保种类密切相关，每周透析三次患者的构成比，省医保）市医保）居民医保）自费。结论本中心MHD患者中，仍有部分患者未能很好的控制血磷、PTH水平，贫血、高血压的发生率仍高且达标率低，而医保类型的报销额度一定程度上制约了透析充分性，透析质量有待持续改进。     

Short daily hemodialysis rapidly improves nutritional status in hemodialysis patients

BACKGROUND: Malnutrition is a common problem in maintenance hemodialysis patients and is associated with increased mortality and morbidity. Interventions such as oral or intravenous nutritional supplements have often failed to improve nutritional status. We studied the effect of a daily dialysis program on nutritional parameters. METHODS: Eight patients treated with standard hemodialysis (SHD) 4 to 5 hours three times per week were converted to daily hemodialysis (DHD) 2 to 2.5 hours six times per week. Serum albumin, prealbumin, and total cholesterol were evaluated every three months. Anthropometry and dietary evaluation were performed every six months. RESULTS: Serum albumin rose from 39.0 +/- 2.6 to 42.0 +/- 3.1 and 43.0 +/- 2.6 g/L, prealbumin from 0.36 +/- 0.04 to 0.41 +/- 0.05 and 0.42 +/- 0.1 g/L, total cholesterol from 1.7 +/- 0.4 to 1.9 +/- 0.4 and 1.8 +/-0.3 g/L at baseline and at 6 and 12 months, respectively, after switching patients to DHD. Daily protein intake increased from 1.29 +/- 0.20 g/kg/day to 1.48 +/- 0.60 and 1.90 +/- 0.70 (P < 0.05). These changes were accompanied by a dry body weight increase of 2.4 +/- 1.6 kg (P < 0.005) at month 6 and 4.2 +/- 2.8 kg at one year (P < 0.05). Lean body mass increased from 47.7 +/- 4.9 kg to 49.1 +/- 5.9 (P < 0.05) and 50.5 +/- 6.2 (P < 0.05). CONCLUSIONS: Daily hemodialysis appears to be a suitable method to improve nutritional status in maintenance dialysis patients.     

Intensive hemodialysis associates with improved survival compared with conventional hemodialysis

Patients undergoing conventional maintenance hemodialysis typically receive three sessions per week, each lasting 2.5-5.5 hours. Recently, the use of more intensive hemodialysis (>5.5 hours, three to seven times per week) has increased, but the effects of these regimens on survival are uncertain. We conducted a retrospective cohort study to examine whether intensive hemodialysis associates with better survival than conventional hemodialysis. We identified 420 patients in the International Quotidian Dialysis Registry who received intensive home hemodialysis in France, the United States, and Canada between January 2000 and August 2010. We matched 338 of these patients to 1388 patients in the Dialysis Outcomes and Practice Patterns Study who received in-center conventional hemodialysis during the same time period by country, ESRD duration, and propensity score. The intensive hemodialysis group received a mean (SD) 4.8 (1.1) sessions per week with a mean treatment time of 7.4 (0.87) hours per session; the conventional group received three sessions per week with a mean treatment time of 3.9 (0.32) hours per session. During 3008 patient-years of follow-up, 45 (13%) of 338 patients receiving intensive hemodialysis died compared with 293 (21%) of 1388 patients receiving conventional hemodialysis (6.1 versus 10.5 deaths per 100 person-years; hazard ratio, 0.55 [95% confidence interval, 0.34-0.87]). The strength and direction of the observed association between intensive hemodialysis and improved survival were consistent across all prespecified subgroups and sensitivity analyses. In conclusion, there is a strong association between intensive home hemodialysis and improved survival, but whether this relationship is causal remains unknown.