长期颈内静脉留置导管对透析充分性的影响

目的 观察长期颈内静脉留置导管对透析充分性的影响。探讨定期尿激酶治疗对改善导管功能和透析充分性的作用。方法颈内静脉插管时间小于3个月及大于3个月的维持性血液透析患者各12例,记录透析前后体重、脱水量、透析血流速,检测透析前后、透析结束后1h血尿素氮,计算尿素清除指数（Kt／V）、溶质清除指数（SRI）。每2周重复尿激酶封管,3个月后复查上述指标。结果颈内静脉导管留置时间超过3个月者,透析血流速下降、Kt／V、SRI降低;经过定期尿激酶治疗,透析血流速、Kt／V、SRI与近期插管透析者无差异。结论颈内静脉导管留置3个月以上,会出现导管功能不良,透析充分性下降;定期尿激酶治疗,可以有效保持导管功能,提高透析效率。     

两种血管通路血液透析患者透析效果比较及并发症的护理

目的探讨以带涤纶套隧道双腔深静脉长期导管为血管通路进行透析治疗的充分性、并发症发生的情况及护理对策。方法选取我院肾内科维持性血液透析患者65例,其中留置带涤纶套隧道双腔深静脉导管的患者32例,自身动静脉内瘘的患者33例。对比分析两组患者透析充分性指标及并发症发生情况,针对并发症实施护理。结果两组患者的血红蛋白、白蛋白、总蛋白、总胆固醇、甘油三酯、KT／V、URR、PCR差异均没有显著的统计学意义（P〉0．05）。导管组患者的平均年龄明显高于内瘘组患者的平均年龄（P〈0．05）;两组患者透析后的尿素氮、血肌酐以及尿酸水平都明显低于透析前的水平（P〈0．05）。导管组血流不畅、血栓栓塞以及感染的并发症发生率均明显高于动静脉内瘘组的患者（P〈0．05）,而出血发生率低于动静脉内瘘组（P〈0．05）。结论对于心肺功能差或血管条件差,动静脉内瘘难以建立的患者,采用带涤纶套隧道双腔深静脉长期导管为血液透析通路能够达到良好的效果。只要采取有效的预防护理措施,可减少并发症的发生,明显延长导管的使用寿命,保证维持性血液透析治疗的顺利进行,提高患者生活质量,延长透析患者的生存时间。     

两组维持性血液透析病人δKt／V值比较及病因、死因分析

目的观察每周透析3次两亚组（a、b组）患者δKt／V差异，对A、B两组患者的病因、死因、病死率进行比较、分析。方法采用德国Fresenius4008s透析机及随机附带OCM（联机尿素监测器）组件。输入患者的身高、体重、年龄和红细胞压积（HCT），随机测定每周透析3次患者的Kt／V值5次及δKt／V值。结果〉50岁每周透析3次的患者是36例，≤50岁的患者是18例，两组δKt／V值分别是0．1916、0．1709，P〉0．05，两组差异无显著性。〉50岁患者因糖尿病肾病导致尿毒症的占首位，其次是原发性高血压病，这两种病因明显高于≤50岁的患者。〉50岁的患者病死率是24．4％，≤50岁患者的病死率是7．4％，前者明显高于后者，其中心血管意外是重要死因。结论A、B两组病人病死率不同，主要是传统的危险因素不同，年龄是传统的危险因素之一，与原发病有关，与原发病的治疗、转归有关。心脑肾并发症越多，进入透析后病死率越高。a、b两亚组每周透析3次，每次透析4～5h患者，δKt／V均能达到良好的标准，两组差异无显著性，进而说明充分透析后，两者病死率不同，主要还与进入透析后血压、血糖、血脂、血红蛋白、钙磷代谢等不能达到理想水平有关。营养不良、炎症、动脉粥样硬化综合症（MIAS）在短期内对患者的影响占主导地位，导致大部分患者5年内死亡。老年患者尤为显著。NO合成减少，血管收缩和高血压，急性冠脉综合症，使得患者因心血管意外死亡占首位。     

应用平衡尿素氮准确评价透析充分性

尿素清除指数(KT/V)是评价血液透析充分性的主要指标之一,由透析前后的血尿素氮(BUN)浓度决定。由于透析后尿素氮的瘘管和心肺再循环以及反跳的影响,用透后即时的尿素浓度结果将过高估计KT/V。透析后30～45 min体内尿素氮达到平衡,这时的尿素氮浓度将精确反映透析是否充分。但透析后30 min再抽血测定尿素氮在临床工作中很不方便。为了解决这一问题,有人提出在透析结束前30min抽血测定尿素浓度来估算KT/V值较为精确。我们也在这方面进行了研究,现报道如下。     

定期尿激酶封管对血液透析患者长期深静脉留置导管的影响

目的探讨定期应用尿激酶对血液透析（HD）患者长期深静脉留置导管留置时间、血流量、透析充分性的影响。方法我科行长期深静脉留置导管留置时间超过3个月以上的患者74例,其中定期尿激酶封管组48例,常规肝素封管组26例。定期尿激酶封管组平时采用常规肝素封管,每隔2 w使用10万U尿激酶封管1次;常规肝素封管组采用1.25万U肝素注射液常规封管。记录两组患者透析前后体重、透析血流量,检测透析前后血尿素氮,计算尿素清除指数（Kt/V）,记录导管留置时间。结果定期尿激酶封管组患者导管留置时间、血流量、Kt/V明显高于常规肝素封管组（P〈0.05或P〈0.01）。结论定期应用尿激酶封管可使长期深静脉留置导管时间延长,同时可提高患者透析血流量、提高透析效率及充分性。     

维持性血液透析长期深静脉留置导管与动静脉内瘘对比分析

 目的 探讨维持性血液透析长期深静脉留置导管对患者微炎症、营养状态及并发症的影响。方法 选择维持性血液透析患者80例, 其中长期深静脉留置导管36例（导管组）, 动静脉内瘘44例（内瘘组）, 比较两组患者TNF-α、IL-6、hs-CRP、Hb、Alb、PA、TF、Hb, 计算患者KT/V、URR、nPCR、SGA评分及并发症、住院事件。结果 导管组与内瘘组比较, 患者TNF-α、IL-6、hs-CRP明显升高, 差异有统计学意义（P<0.05）。导管组患者hs-CRP水平与Alb、PA、TF及Hb均呈显著负相关。同内瘘组比较, 导管组患者的Alb、PA、TF及Hb明显下降, 蛋白分解率增高, SGA评分营养不良例数增加（P<0.05）。两组透析患者KT/V、URR差异均无统计学意义, 但导管组长期并发症包括血栓栓塞、导管感染及住院事件显著增高（P<0.05）。结论 长期深静脉留置导管能影响患者微炎症、营养状态, 长期并发症多、住院事件高, 对患者生存质量有一定影响, 应严格把握使用指征。     

可调钠透析预防透析相关性低血压的临床观察

目的：探讨使用可调钠透析对透析相关性低血压的预防作用。方法：按常规血液透析模式（钠140mmol/L）和可调钠透析模式（起始钠148mmol/L,结束钠138mmol/L）分为两组,记录透析中的血压及患者症状变化情况并比较两组低血压的发生率,测定透析前后血钠浓度。结果：常规血液透析模式低血压的发生率为39.35%,可调钠透析模式低血压的发生率为16.77%,可调钠透析组低血压发生率明显低于常规血液透析组,P〈0.05,有统计学意义。结论：可调钠透析对维持性血液透析患者透析相关性低血压能进行有效预防,减少低血压的发生率,提高透析的耐受性及充分性。     

血液透析患者血清钙磷控制与继发性甲状旁腺功能亢进症的横断面研究

目的分析长期血液透析患者血清钙、磷控制与继发性甲状旁腺功能亢进症的发生情况,指导临床治疗。方法选择我院2012年12月之前血液透析时间大于6个月的患者79例,回顾性分析记录患者血清钙、磷、钙磷乘积、甲状旁腺素浓度、年龄、透析龄、Kt/V等指标并进行统计分析。结果 79例血透患者平均校正血清钙（1.97±0.21）mmol/L,平均血磷（1.93±0.52）mmol/L,平均钙磷乘积（47.82±12.98）mg^2/dl2,平均甲状旁腺素（iPTH）浓度（398.32±282.34）pg/ml;血清磷达标率为30.4%,血清校正钙达标率为20.5%;血清iPTH达标率为32.9%,血清Ca×P达标率为75.9%;高磷血症发生率为63.3%,继发甲状旁腺功能亢进发生率为55.7%,低钙血症发生率为76.9%。单因素分析显示血清磷浓度、年龄、透析龄与iPTH控制水平相关;多元Logistic回归分析显示透析龄和血磷与甲状旁腺水平呈正相关,是继发甲状旁腺功能亢进的独立危险因素。结论血磷、透析龄是影响继发甲状旁腺素异常代谢独立危险因素。长期血液透析患者需要将血磷、校正血清钙维持在KDOQI指南建议的目标范围内,发生继发甲状腺旁腺功能亢进的危险才能降低。     

老年腹膜透析患者微炎症与营养状况及透析充分性间关系的探讨

目的探讨老年腹膜透析(peritoneal dialysis,PD)患者微炎症状态、营养状况与透析充分性的关系。方法按照超敏C-反应蛋白(hs-CRP)≤5 mg/L和hs-CRP>5 mg/L,将腹膜透析患者分为两组,比较两组间营养状况指标及透析充分指标与炎症指标的关系。结果两组患者血清白蛋白(ALB)、转铁蛋白(TF)、前白蛋白(PA)、血红蛋白(HGB)、hs-CRP、尿素清除率(Kt/V)、标准化蛋白分解率(nPCR)、改良定量主观整体评估(MQSGA)间差异有统计学意义(P<0.05)。结论老年腹膜透析患者存在微炎症状态。微炎症状态与营养不良及透析充分性密切相关。     

67例长期腹膜透析患者转归分析

[摘要]目的分析长期腹膜透析患者的临床资料,探讨其临床特点及临床转归。 方法对本院腹透龄超过1年的67例腹膜透析患者进行回顾性分析,根据其临床转归分为维持腹透组、转向血透组、转向移植组及死亡组。分析各组间近期血清白蛋白、透析充分性指标、水清除指标、血压水平及残肾功能。结果死亡组血清白蛋白及尿素清除指数（Kt/V）水平低于其余3组（P＜005）。维持腹透组水清除指标高于其余3组（P ＜005）。维持腹透组及转向移植组残肾功能高于其余2组（P＜005）。死亡组患者死亡前3个月Kt/V及肌酐清除率均低于死亡前1年（P＜005及P＜001）。死亡组24例中有10例死于心脑血管疾病。结论心脑血管疾病是死亡的首位病因,透析不充分、营养不良以及血压控制不佳都是死亡的重要原因,残肾功能可影响预后。     

Comparative analysis of the efficacy and biocompatibility of various methods of dialysis

BACKGROUND/AIM: The efficacy and biocompatibility of hemodialysis have a singnificant impact on dialysis patient morbidity and mortality rate. The aim of our study was to compare the efficacy and biocompatibility of different hemodialysis modalities in our patients. METHODS: A total of 55 patients were included in the study, and on the basis of dialysis modality, they were divided in four groups: group I--post-dilution on-line hemodiafiltration (n=15), group II--bicarbonate high-flux polysulphone hemodialysis (n=15), group III--bicarbonate low-flux polysulphone hemodialysis (n=15), and groupe IV--bicarbonate cuprophane hemodialysis (n=10). The efficacy was evaluated on the basis of urea reduction rate (URR), urea Kt/V index and serum beta2-microglobuline reduction rate, and the biocompatibility was evaluated on the basis of the leukocyte count fall during the first fiftheen minutes of dialysis session, and of the serum C-reactive protein (CRP) level. RESULTS: The highest mean URR was achieved in the group I (70.53 +/- 6.49%), and it was significantly higher in comparison with the average URR in the group IV (54.8 +/- 6.35%) (p = 0.001). The average value of urea Kt/V index in the group I (1.48 +/- 0.22) was significantly higher in comparison with the average value in the group II 1.30 +/- 0.22 (p < 0.05), group III (1.05 +/- 0.22), and group IV (0.98 + 0.22) (p = 0.001). Serum beta2-microglobuline reduction rate was 68.93 +/- 8.25% in the group I, and 58.86 +/- 7.98% in the groupe II (p = 0.01). During the first 15 minutes of hemodialysis the leukocyte number was decreased by 12.57 +/- 9.35% in the group 1, 13.61 +/- 9.64% in the group 11, 18.3 +/- 13.24 in the group III and 62.3 +/- 15.4 in the group IV, on average. The mean serum level of CRP was 9.4 +/- 6.47 mg/l in the group IV, and less than 3.5 mg/l in the group I of the patients (p = 0.001). CONCLUSION: Postdilution on-line hemodiafiltration in comparison with standard hemodialysis provided the more effective elimination of small and middle uremic toxins molecules and a significantly higher degree of biocompatibility. The patients treated with standard hemodialysis frequently do not achieve the minimal value of urea Kt/V index prescribed by National Kidney Foundation-Dialysis Outcomes Quality Inatiatives standards. These patients also have significantly higher serum CRP values which suggest the state of chronic microinflammation.     

Determination of the delivered hemodialysis dose using standard methods and on-line clearance monitoring

BACKGROUND/AIM: Delivered dialysis dose has a cumulative effect and significant influence upon the adequacy of dialysis, quality of life and development of co-morbidity at patients on dialysis. Thus, a great attention is given to the optimization of dialysis treatment. On-line Clearance Monitoring (OCM) allows a precise and continuous measurement of the delivered dialysis dose. Kt/V index (K = dialyzer clearence of urea; t = dialysis time; V = patient's total body water), measured in real time is used as a unit for expressing the dialysis dose. The aim of this research was to perform a comparative assessment of the delivered dialysis dose by the application of the standard measurement methods and a module for continuous clearance monitoring. METHODS: The study encompassed 105 patients who had been on the chronic hemodialysis program for more than three months, three times a week. By random choice, one treatment per each controlled patient was taken. All the treatments understood bicarbonate dialysis. The delivered dialysis dose was determined by the calculation of mathematical models: Urea Reduction Ratio (URR) single-pool index Kt/V (spKt/V) and by the application of OCM. RESULTS: Urea Reduction Ratio was the most sensitive parameter for the assessment and, at the same time, it was in the strongest correlation with the other two, spKt/V indexes and OCM. The values pointed out an adequate dialysis dose. The URR values were significantly higher in women than in men, p < 0.05. The other applied model for the delivered dialysis dose measurement was Kt/V index. The obtained values showed that the dialysis dose was adequate, and that, according to this parameter, the women had significantly better dialysis, then the men p < 0.05. According to the OCM, the average value was slightly lower than the adequate one. The women had a satisfactory dialysis according to this index as well, while the delivered dialysis dose was insufficient in men. The difference between the women and the men was significant. CONCLUSION: The application of OCM has shown that it is the most rigorous parameter for the assessment of adequacy and that its regular use would contribute to increasing of the delivered dialysis dose and improvement of the treatment quality.     

Comparison of Clinical Performance of VectorFlow and Palindrome Symmetric-Tip Dialysis Catheters: A Multicenter,Randomized Trial

PurposeTo compare clinical performance of 2 widely used symmetric-tip hemodialysis catheters.Materials and MethodsPatients with end-stage renal disease initiating or resuming hemodialysis were randomized to receive an Arrow–Clark VectorFlow (n = 50) or Palindrome catheter (n = 50). Primary outcome was 90-d primary unassisted catheter patency. Secondary outcomes were Kt/V ([dialyzer urea clearance × total treatment time]/total volume of urea distribution), urea reduction ratio (URR), and effective blood flow (Q_B).ResultsPrimary unassisted patency rates with the VectorFlow catheter at 30, 60, and 90 d were 95.5% ± 3.3, 87.2% ± 7.3, and 80.6% ± 9.8, respectively, compared with 89.1% ± 6.2, 79.4% ± 10.0, and 71.5% ± 12.6 with the Palindrome catheter (P = .20). Patients with VectorFlow catheters had a mean Kt/V of 1.5 at 30-, 60-, and 90-day time points, significantly higher than the mean Kt/V of 1.3 among those with Palindrome catheters (P = .0003). URRs were not significantly different between catheters. Catheter Q_B rates exceeded National Kidney Foundation–recommended thresholds of 300 mL/min at all time points for both catheters and were similar for both catheters (median, 373 mL/min). Catheter failure, ie, poor flow rate requiring guide-wire exchange or removal, within the 90-day primary outcome occurred in 3 VectorFlow subjects and 5 Palindrome subjects (P = .72). Infection rates were similar, with 0.98 infections per 1,000 catheter days for VectorFlow catheters compared with 2.62 per 1,000 catheter days for Palindrome catheters (P = .44).ConclusionsThe 90-day primary patency rates of Palindrome and VectorFlow catheters were not significantly different, and both achieved sustained high Q_B through 90 day follow-up. However, dialysis adequacy based on Kt/V was consistently better with the VectorFlow catheter versus the Palindrome.     

Tesio catheter: radiologically guided placement, mechanical performance, and adequacy of delivered dialysis

PURPOSE: Tunneled catheters are an alternative means of vascular access for patients in need of hemodialysis who cannot undergo dialysis through a surgical shunt. This study was undertaken to evaluate the performance of the Tesio dialysis catheter. MATERIALS AND METHODS: A prospective study of the Tesio catheter was performed. Follow-up data regarding catheter function and adequacy of dialysis were obtained from nine hemodialysis facilities. RESULTS: Seventy-nine Tesio catheters were placed in 71 patients. Immediate technical success was 99% (78 of 79 catheters). The procedure complication rate was 9% (seven catheters). Only two complications required intervention: one fatal air embolism and one chest wall hematoma. Sixty-seven catheters in 60 patients were followed up for a total of 4,367 catheter days. Overall, catheter-related infection occurred in 9% (six of 67 catheters). Primary catheter patency was 87% at 1 week, 82% at 1 month, 72% at 3 months, and 66% at 6 months. Mean blood flow was 286 mL/min immediately after insertion, 301 mL/min at 3 months, and 306 mL/min at 6 months. Adequate dialysis dose as reflected by a urea reduction ratio of 60 or more or a urea kinetic modeling, or Kt/V, value of 1.2 or more was observed on at least one occasion for 74% and 76% of catheters, respectively. CONCLUSION: The Tesio catheter is a reasonable means of vascular access for patients who undergo dialysis but are not candidates for surgical shunt placement.     

Restless legs syndrome prevalence in patients on chronic hemodialysis in central Serbia

BACKGROUND/AIM: Restless legs syndrome (RLS) is a sensorymotor disorder and the core feature of this syndrome is a distressing, irresistible need or urge to move the legs. RLS is one of the most troublesome conditions experienced by endstage renal disease patients treated with regular hemodialysis, and is significantly associated with their increased mortality. The aim of this study was to assess the prevalence of RLS in the patients with end-stage renal failure in the three dialysis centers in central Serbia, and to investigate the association of the syndrome with clinical characteristics and biochemical variables. METHODS: A cross-sectional multicentric study in which 166 consecutive hemodialysis patients were evaluated using a standard questionnaire based on diagnostic criteria elaborated by the International Restless Legs Syndrome Study Group was performed. All patients were reinterviewed and clinically examined by a qualified neurologist. The data on the patients with and without RLS were compared. RESULTS: The prevalence of RLS was 22.96% (95% CI, 16.57% to 29.35%). There was no significant difference in duration of hemodialysis and clinical characteristics when we compared the patients with RLS with those without RLS. We found significantly higher levels of blood urea nitrogen and creatinine and lower level of Kt/V index in the patients with RLS, which might point to inadequate dialysis in these patients. CONCLUSION: In our study the prevalence of RLS in the patients on the regular hemodialysis was 22.96%. The obtained results are similar to those of other studies using the same methodology in the white population on the regular hemodialysis.     

Impact of arteriosclerosis on the functioning of arteriovenous fistula for hemodialysis

BACKGROUND/AIM: Numerous clinical studies have shown that the incidence of artheriosclerosis is higher in patients with progressive renal insufficiency. The aim of this study was to examine the incidence of artheriosclerosis in patients on chronic hemodialysis and its influence on survival and functioning of vascular access. METHODS: The study was organized as one-year prospective study. All the patients had arteriovenous fistulas native as a vascular access. The study analyzed demographic, biochemical, clinical and Doppler echomorphological characteristics of the patients in order to make an evidence of artheriosclerotic incidences as compared to functioning arteriovenous fistulas for hemodialysis. RESULTS: The examined patients were of the mean age 55.7+/-12.68 years. Of them, 53.8% were males and 46.2% females. Functioning arteriovenous fistulas for haemodialysis were found in 56.8% of the examined patients. Concentration of hemoglobin was a significant parameter of functioning fistula (group with complications--89<--14.034 vs. group with no complications-- 96.6+/-17.71;p = 0.0489. An amount of urea removed (URR) was a statistically more significant parameter among the patients without fistula complications: (group with complications--58.67+/-7.92% vs. group with no complications--62.80+/-7.53%; p = 0.037). A Cox regressive analysis of an index of Doppler parameters of the carotid arteries found no statistical significance between the examined groups. There was a positive correlation between artheriosclerosis and the age, as well as the time on dialysis. In multiple regression, where intima media is a dependent and the age and time on dialysis independent variables, the regressive model was statistically significant (F = 8.22, p = 0.001). Both independent variables had statistically significant inclinations, p < 0.01. CONCLUSION: Anemia and the level of urea elimination, as a statistically significant indicator of hemodialysis adequacy, were in correlation with the risk for fistula complications. B-mode ultrasonography of the carotid arteries is a significant non-invasive method for detecting artheriosclerosis. Intima-media thickness of the carotid arteries was an important marker of artheriosclerosis correlating significantly with the age and time on dialysis, but not with the traditional risk factors.     

慢性肾病维持性血液透析患者抑郁状态现状及影响因素研究

目的调查慢性肾脏病(CKD)维持性血液透析患者抑郁状态的现状,分析其抑郁发生的影响因素。方法选择2016年2-10月中国医科大学本溪市中心医院门诊血液透析室的108例患者与同期门诊体检的120名健康人为研究对象,采用《PHQ-9抑郁症筛查量表》对其进行抑郁状态的评估。再将108例血液透析患者分为抑郁组(n=56)和非抑郁组(n=52),比较两组患者的临床观察指标及实验室检查指标。结果血液透析组患者中抑郁发生概率为51.9%(56/108),健康对照组为4.2%(5/108),组间比较,差异有统计学意义(P<0.05)。血液透析患者中,抑郁组与非抑郁组的性别比例、文化程度、婚姻状况、对疾病预后的了解情况、血红蛋白、血浆白蛋白比较,差异均有统计学意义(P<0.05),体质量、透析时间、血肌酐、尿素氮、血钙、血磷、甲状旁腺素比较,差异均无统计学意义(P>0.05)。结论慢性肾脏病维持性血液透析的患者,其抑郁症的发生概率远高于健康对照组,而且,患者的年龄越大、血红蛋白越低、单身、越是对疾病预后基本了解,抑郁程度越高。     

乌灵胶囊对维持性血液透析患者炎症状态的影响

目的观察乌灵胶囊对维持性血液透析（MHD）患者微炎症状态的影响并探讨其缓解抑郁、改善睡眠的机理。方法对60例MHD患者治疗前后进行睡眠指数、抑郁症状评分、超敏C反应蛋白（hs—CRP）、血红蛋白（Hb）、甲状旁腺激素（PTH）及血浆白蛋白（AIb）评估,并比较治疗前后组内差异是否有统计学意义。结果治疗结束时Hb、hs-CRP、AIb及睡眠指数及抑郁评分均较治疗开始前明显好转,差异有统计学意义（P〈0．05）。PTH、Kt／V变化不显著,差异无统计学意义（P〉0．05）。结论乌灵胶囊可显著改善血液透析患者的睡眠质量,减轻透析患者抑郁症状,可能同抑制MHD患者体内的微炎症反应有关。