自动化腹膜透析救治尿毒症并发急性左心衰15例临床体会

目的 探讨自动化腹膜透析(APD)对于慢性肾衰行规律性腹膜透析患者合并急性左心衰的疗效.方法 对本院15例慢性肾衰行规律性腹膜透析患者并发急性左心衰进行自动化腹膜透析(APD)治疗进行回顾性分析;患者入院后将腹膜透析方式由CAPD改为APD治疗,方式为NIPD,观察APD治疗前后患者呼吸困难、紫绀程度、肺部啰音等左心衰症状及水肿、体重和腹透液超滤量的变化,同时监测左室射血分数(LVEF)、收缩压等心功能指标.结果 15例患者经APD治疗后,平均疗程52.20±10.69h,平均腹透液超滤量为5526.67 +682.92ml,急性左心衰3例治愈,11例好转,1例无效者改行血液透析,治疗后较治疗前左室射血分数增加,收缩压下降.结论 使用自动化腹膜透析加强超滤脱水,对于因容量负荷过重并发急性左心衰的慢性肾衰规律性腹膜透析患者治疗有效.     

腹膜透析治疗尿毒症心肌病的临床研究

目的:明确尿毒症心肌病的致病因素,控制其发生或发展,减少尿毒症心肌病的发病率,提高尿毒症患者的生存质量.方法:以腹膜透析为基础,观察治疗前后肾功能、左心功能、左心结构变化.结果:腹膜透析治疗尿毒症心肌病,治疗后左心功能、左心结构、临床症状均有明确改善.结论:腹膜透析可以更好地保存终末期肾病(ESRD)患者残存肾功能,减少心脏等严重并发症,提高患者生活质量.     

常染色体显性遗传性多囊肾病患者行腹膜透析的疗效分析

目的 探讨腹膜透析治疗进入终末期肾脏病(ESRD)常染色体显性遗传性多囊肾病(ADPKD)患者的可行性及疗效.方法 回顾性分析2003年10月至2011年2月期间在本院行腹膜透析治疗的11例ADPKD患者的临床资料.其中6例合并多囊肝,术前经影像学及家系调查确诊.11例均采用外科手术方法进行置管.观察术中术后并发症、导管相关性并发症、腹膜透析相关并发症、尿毒症症状改善情况、生存时间、退出透析或死亡等结局.结果 11例手术均获成功,术中经过顺利,术后均未出现并发症.术后住院时间平均为12天.11例患者术后随访12 ～54个月,平均30个月.随访期间11例患者尿毒症症状均有改善,平均生存时间为31.6个月.1例因腹膜炎拔管重置,1例于透析14个月后转为血液透析治疗,1例因消化道出血死亡,1例因心力衰竭死亡.结论 腹膜透析治疗ADPKD患者安全有效,ADPKD患者也可以选择腹膜透析作为初始的肾脏替代治疗.     

常染色体显性多囊肾病患者行腹膜透析疗效评价

目的:对比常染色体显性多囊肾病与原发病非糖尿病性肾病患者腹膜透析疗效,明确多囊肾导致终末期肾病患者行腹膜透析治疗可行性。方法:临床纳入我院腹膜透析龄超过3个月,原发病为多囊肾病及非糖尿病性肾病患者各30例,回顾性收集两组患者临床资料,分析比较两组患者进入透析前及透析后4周、3个月、6个月、12个月24 h尿量、血肌酐、尿素氮、血清钾、血清钙、血清磷、血红蛋白等指标;对两组患者进行生活质量评分;观察两组患者的腹膜透析相关并发症。结果:进入腹膜透析治疗前,两组患者的年龄、性别、体重、血压、24 h尿量无明显差异,多囊肾病患者的肾脏长径显著高于非糖尿病性肾病患者组。在行腹膜透析治疗4周、3个月、6个月、12个月后,两组患者的KT/V、血肌酐、尿素氮、血清钾、血清钙、血清磷、血红蛋白、白蛋白对比,差异均无统计学意义,生活质量评分亦差异无统计学意义;首次出现腹膜透析相关性腹膜炎的时间(15.8±12.8)月vs(16.5±10.9)月、腹膜炎发生率(0.024次/人°,0.025次/人°月)以及腹膜炎致病菌构成比差异均无统计学意义。结论:与原发病非糖尿病性肾病患者一样,多囊肾患者增大的肾脏对腹膜透析的效果无明显影响。多囊肾患者进入终末期肾病阶段排除其他特殊禁忌证,可将腹膜透析作为首选肾脏治疗方案。     

每日透析滤过治疗尿毒症难治性高血压的疗效观察

目的 观察费森尤斯4008ARrTplus治疗模式下延时每日透析滤过治疗尿毒症并发难治性高血压患者的临床疗效.方法 回顾性分析15例尿毒症并发难治性高血压患者经延时每日透析滤过治疗后血压控制情况及治疗前、后血甲状旁腺激素水平、体重改变.结果 15例患者经过延时每日透析滤过治疗后收缩压、舒张压、平均动脉压、血甲状旁腺激素...     

连续性血液滤过与间断性血液超滤治疗糖尿病肾病并发难治性充血性心衰观察

糖尿病肾病作为终末期肾衰竭的主要病因之一,是心脑血管疾病的高危因素,国外资料表明,大多数糖尿病肾病病人在未进入尿毒症前,就死于心衰、心梗等严重心脑血管事件。尤其4期糖尿病肾病患者常合并顽固性心衰和高度水肿,药物治疗难以凑效,导致这一人群的高病死率。近年来研究表明,血液净化技术应用于抢救糖尿病肾病并发难治性心衰获得明显效果。我院曾对20例患者分别采用血液超滤疗法（UF）、连续性静脉静脉血液滤过（CVVH）获得较好效果,现报告如下。     

腹膜透析治疗糖尿病肾病尿毒症的研究进展

糖尿病患者有广泛的血管病变,所以腹膜透析是糖尿病尿毒症病人肾脏替代治疗的主要方式.腹膜透析液中含有大量的葡萄糖,所以对接受腹膜透析的糖尿病患者,血糖的控制显得尤为重要.而且健康教育对于患者的生存质量也起到重要的作用.还要积极预防各种并发症.腹膜透析的预后也各不相同.本文就近年来腹膜透析治疗糖尿病肾病尿毒症的研究进展作一综述.     

腹膜透析治疗难治性心力衰竭12例

腹膜透析除了作为肾衰竭的替代治疗外,还应用于其他多个领域.难治性心力衰竭(心衰)患者心功能已处于极度失代偿状态,加之患者长期用药,对强利尿剂也会产生抵抗,最终各器官功能衰竭死亡,临床治疗十分棘手.我院对12例难治性心衰采用了间歇性腹膜透析(IPD)治疗,效果满意,现报告如下.     

糖尿病腹膜透析患者住院原因及临床特点分析

目的：分析糖尿病腹膜透析患者住院原因及其临床特点。方法：回顾性分析近2年在我院规律腹膜透析的76例患者住院时的临床资料,按患者原发病分为糖尿病肾病组及非糖尿病肾病组,分析两组患者住院原因,比较两组患者的血红蛋白,血清白蛋白,血脂,钙、磷,钠、钾等临床生化指标,根据超声心动图结果,比较两组患者心功能情况。结果：共有76例患者纳入观察,其中男29例,女47例,平均年龄（61.5.4±16.8）岁,平均透析龄（35.2±30.1）月,糖尿病患者31例,非糖尿病患者45例,观察期间76例患者共住院136例次,糖尿病腹透患者住院原因主要为腹膜炎,心功能不全、胃肠道疾病及肺部感染,非糖尿病腹膜透析患者住院原因主要为腹膜炎、脑血管疾病及胃肠道疾病,糖尿病腹透患者心功能更差,左心室肥厚更为突出,血清白蛋白,血钾及血磷水平低于对照组,差异有统计学意义。结论：糖尿病腹膜透析患者反复住院的原因主要为腹膜炎、心血管疾病及胃肠道疾病。与非糖尿病腹透患者相比,糖尿病腹透患者营养状况差,心血管并发症更严重。对糖尿病腹透患者更应早期关注透析相关并发症,以减少住院率的发生。     

血液透析与腹膜透析患者微炎症反应比较及其与营养状况、心血管疾病关系的研究

目的 研究血液透析、腹膜透析两种透析方式对慢性肾衰尿毒症患者微炎症状态的影响,探讨微炎症状态与营养状况、心血管疾病的关系.方法 选择2011年1月至2012年6月沈阳市红十字会医院肾内科住院的尿毒症患者64例(血液透析30例、腹膜透析34例)及健康对照者30例,检测C反应蛋白、白介素6、尿素氮、肌酐、白蛋白、前白蛋白、血红蛋白,计算体重指数.根据主观综合性营养评价将患者分为营养良好组、营养不良组.记录透析处方和心血管并发症.结果 本组尿毒症患者C反应蛋白、白介素6较对照组显著升高(P＜0.01),血液透析组C反应蛋白、白介素6显著高于腹膜透析组(P＜0.05).尿毒症各组内营养良好组C反应蛋白、白介素6较营养不良组显著升高(P＜0.05),合并慢性心衰组C反应蛋白、白介素6较无心衰并发症组显著升高(P＜0.05).C反应蛋白与白蛋白、前白蛋白呈显著负相关,与尿素氮、肌酐、血红蛋白无显著相关性.结论 血液透析患者微炎症状态比腹膜透析患者严重,尿毒症患者微炎症状态与营养不良及心血管疾病密切相关.     

Refining the Model of Urea Kinetics: Compartment Effects

A 70-year-old female with chronic congestive heart failure requires maintenance hemodialysis because of end-stage diabetic nephropathy. She is dialyzed on Monday, Wednesday, and Friday for 2 hours using a dialyzer with an average urea clearance of 250 ml/min. Dry weight is 50 kg. Predialysis blood urea nitrogen (BUN) on Wednesday is 50 mg/dl; postdialysis BUN is 15 mg/dl. A single-compartment, variable-volume model of urea kinetics revealed the following: 1.5 hours of dialysis are sufficient to maintain Kt/V at 1.1/dialysis; protein catabolism is 0.92 g/kg/day; her volume of urea distribution is 43% of body weight. Provided the blood access device and dialysis equipment are functioning properly and the blood specimens are drawn and measured correctly, are the model predictions valid?     

How to predict nephropathy in type 1 diabetic patients

OBJECTIVE: Do exaggerated increases in blood pressure and albuminuria during exercise occur earlier than microalbuminuria and which type of test is most predictive of diabetic nephropathy? MATERIAL AND METHODS: A total of 33 insulin-dependent normoalbuminuric men (mean duration of diabetes 14 years; mean age 28 years) and 34 age-matched apparently healthy control subjects were studied. Urinary albumin excretion, heart rate and blood pressure were measured during fixed workload (150 W) and fixed heart rate (155 beats/min) tests. Mean follow-up time was 13.1 +/- 3.2 years. A urinary albumin level in early-morning urine persistently >30 mg/l was considered a sign of diabetic nephropathy. RESULTS: Sixteen patients reached the endpoints of the study. Eleven had developed microalbuminuria and five macroalbuminuria (persistent levels of urinary albumin >300 mg/l). Of the latter patients, two needed dialysis. Systolic blood pressure and albumin excretion during the fixed heart rate test were higher in diabetic patients who developed signs of nephropathy than in control subjects and diabetic subjects with persistent healthy kidneys. Such differences were not found in the fixed workload test. There were no differences in glycated haemoglobin, blood pressure levels or albumin excretion at baseline between the two diabetic groups. CONCLUSIONS: To predict the development of diabetic nephropathy it seems important to choose a fixed heart rate test. High levels of systolic blood pressure in such a test were associated with the development of micro- and macroalbuminuria.     

Increased subcutaneous insulin requirements in diabetic patients recently commenced on peritoneal dialysis.

BACKGROUND: Diabetic patients often have reduced insulin requirements when they progress to renal failure. Since peritoneal dialysis (PD) solution contains glucose, the insulin requirement of these patients often increases after commenced on PD. However, the change in insulin requirement has not been studied systematically. METHODS: We study 60 consecutive patients (32 male) with diabetic nephropathy newly started on PD. Their insulin requirement before and 6 months after initiation of dialysis is compared. Clinical factors affecting insulin requirement are explored. RESULTS: All patients received a standard 6 l/day dialysis exchange. The mean age was 60.3 +/- 8.9 years. Twelve patients did not require insulin before PD; four of them were started on insulin 6 months after dialysis. The average dosages of insulin 6 months before and after PD were 0.27 +/- 0.28 and 0.37 +/- 0.29 unit/kg/day, respectively (paired t-test, P < 0.001). The increment in dosage was 0.103 +/- 0.216 unit/kg/day. The dosage of insulin requirement correlates with the small solute transport of the peritoneal membrane, as represented by the mass transfer area coefficient (MTAC) of creatinine (r = -0.307, P = 0.017) and haemoglobin level (r = 0.284, P = 0.028), but not with body mass index (BMI). The change in insulin dosage correlates with the number of 2.5% dialysis cycle required per day (r = 0.433, P = 0.001), but not with peritoneal transport status or BMI. In patients who did not receive hypertonic exchange, the dosage of insulin increased by 1.5 +/- 11.1 unit/day. Each extra 2.5% 2 l exchange results in a 7.5 unit/day (95%CI 3.2-11.8, P = 0.001) increase in insulin requirement. CONCLUSION: Diabetic patients have a minimal increase in insulin requirement after initiation of PD per se, but the dosage of insulin increased markedly after exposure to hypertonic glucose solution. Our result provides a basis for the dosage adjustment of insulin in diabetic patients newly commenced on PD.     

浅谈腹膜透析患者的血压管理

腹膜透析患者的高血压患病率达80%以上,难治性高血压导致卒中、心血管事件发病率不断增加,是患者死亡和退出腹膜透析的主要原因。2015年国际腹膜透析协会(ISPD)关于成人腹膜透析患者心血管和代谢指南指出,持续腹膜透析患者目标血压应<140/90 mmHg,并与年龄无关。腹膜透析患者血压控制不佳的影响因素纷繁复杂,但常见原因是容量超负荷和残肾功能减退。腹膜透析患者高血压防治策略包括容量负荷的准确评估与干预、残余肾功能的有效保护、透析处方的及时调整,降压药物的正确选择以及以病人为中心的团队管理等五个方面。     

Icodextrin and peritoneal dialysis: advantages and new applications

The impact of icodextrin (ico) on peritoneal dialysis (PD) extension and patient survival is well established. Predominantly, ico-based solutions were prescribed in high-transporter PD patients. Advantages of the ico-based solutions include increased biocompatibility, avoidance of glucotoxicity, enhanced ultrafiltration failure (UF), sodium removal rates, better metabolic and blood pressure control. Bimodal solutions and twice daily exchanges of ico-based solutions are two newly introduced strategies to avoid glucose exposure and/or enhance UF in PD patients with UF failure. In addition, a simplified schedule of PD using a single nocturnal exchange of ico in patients with refractory congestive heart failure may represent an alternative option to manage fluid removal and azotaemia. The use of a simplified schedule of PD with only two ico exchanges or a single ico exchange is a challenging approach for end-stage renal disease patients with preserved residual function who desire to initiate PD.     

Changes of serum advanced glycation end products (AGEs), matrix metalloprotein-2 (MMP-2), and urinary microalbuminuria (mALB) in diabetic nephropathy and their predictive value for heart failure

BackgroundDiabetic nephropathy is a common complication in diabetic patients, with a high rate of disability and mortality. This study aims to explore the changes in serum advanced glycation end products (AGEs), matrix metalloprotein-2 (MMP-2), and urinary microalbuminuria (mALB) in diabetic nephropathy and their predictive value for heart failure.MethodsThe 134 patients with diabetic nephropathy treated in our hospital from January 2014 to December 2017 were enrolled and divided into two groups resulting in 64 cases in an observation group with heart failure, and 70 cases without heart failure in a control group. In addition, 80 patients with simple diabetes who were treated during the same period were selected as the simple diabetes group. Levels of AGEs, MMP-2, and mALB between the groups were compared, risk factors affecting diabetic nephropathy patients with heart failure were analyzed, and an ROC curve was drawn to evaluate the predictive value of AGEs, MMP-2, and mALB for heart failureResultsThe levels of AGEs and mALB in the diabetic nephropathy group were significantly higher than those in the simple diabetes group, and the levels of MMP-2 were significantly lower than those in the simple diabetes group (P<0.05). The levels of AGEs and mALB in the observation group were significantly higher than those in the control group, and the levels of MMP-2 were significantly lower than that in the control group (P<0.05). Smoking history hypertension history, blood creatinine (abnormal increase), blood uric acid (abnormal increase), AGEs (abnormal increase), MMP-2 (abnormal decrease), and mALB (abnormal increase) were independent risk factors affecting diabetic nephropathy patients with heart failure. The area under the ROC curve of AGEs, MMP-2, mALB, and their combined detection were: 0.821, 0.909, 0.897, and 0.991, respectively, showing the area under the curve of combined detection to be the largest.ConclusionsAGEs, MMP-2, and mALB have high predictive value for heart failure in patients with diabetic nephropathy. Their sensitivity and specificity are high, indicating they may hold considerable clinical value.     

Tolvaptan alleviates excessive fluid retention of nephrotic diabetic renal failure unresponsive to furosemide

Patients with diabetic nephropathy develop nephrotic syndrome and may show limited response to conventional therapy. They often require earlier initiation of renal replacement therapy because they become refractory to diuretics, and experience excessive fluid retention. We aimed to investigate the efficacy of tolvaptan, an oral arginine vasopressin type 2 receptor antagonist, in a case series of 14 severe diabetic renal failure patients who were severely refractory to maximal doses of furosemide and had excessive fluid retention despite preserved cardiac function and residual renal function. All 14 patients experienced immediate and sustained water diuretic effects, resulting in alleviation of congestive heart failure. None required initiation of renal replacement therapy. Tolvaptan promptly increased urine volume and free water clearance, reversed progressive fluid retention, and alleviated congestive heart failure. Thus, tolvaptan could serve as a potential adjunct therapy for severe diabetic renal failure patients with excessive fluid retention and congestive heart failure.     

终末期糖尿病肾脏病腹膜透析时胰岛素用药途径的探讨

目的比较终末期糖尿病肾脏病患者腹膜透析时不同途径给予胰岛素时腹膜炎的发生率。方法将50例行持续性非卧床腹膜透析（CAPD）的终末期糖尿病肾脏病患者随机分组，腹腔注射组25例，于腹腔内注射胰岛素；皮下注射组25例，于皮下注射胰岛素。比较2组透析前后收缩压、舒张压、尿量、超滤量及腹膜透析后腹膜炎发生率。结果2组透析前后收缩压、舒张压、尿量、超滤量均无统计学差异（P〉0．05）。腹腔注射组发生腹膜炎共11例次，发生率为1次／26．0个患者月；皮下注射组发生腹膜炎共13例次，发生率为1次／22．9个患者月。结论终末期糖尿病肾脏病患者行CAPD时，腹腔内注射胰岛素不会增加腹膜炎的发生率，对依从性好的患者是首选方法。     

Effect of long-term administration of prostaglandin I(2) in incipient diabetic nephropathy

BACKGROUND/AIMS: Diabetic nephropathy is one of the primary diseases of refractory renal failure and heads the list of patients undergoing dialysis. Therefore, it is very important to get treatment in incipient nephropathy. METHODS: Twenty-seven patients in incipient diabetic nephropathy of type 2 diabetes mellitus who showed signs of microalbuminuria were randomly, but not blindly, assigned to two groups, either the beraprost sodium (PGI(2)) group or the control group, and effects of the preparation on urinary albumin excretion or other parameters were examined for 24 months. RESULTS: Urinary albumin excretion was significantly decreased after 18 months in beraprost sodium group; however, there was no change in the control group. Difference was observed between the two groups after month 12; however, it was not significant (p = 0.0673 at month 24). Three factors that affect urinary albumin excretion, e.g. blood pressure, blood sugar and protein intake, were almost constant during the study period. The level of creatinine clearance was significantly decreased in beraprost sodium group after 24 months as compared with the control group. CONCLUSION: In this study, we found that the long-term 24-month administration of PGI(2) preparation, beraprost sodium, decreased albuminuria in patients of incipient diabetic nephropathy. The possible mechanisms are that the PGI(2) may have alleviated constriction effect of angiotensin II on efferent glomerular arteriole and attenuated glomerular hyperfiltration, and inhibited growth of mesangial cells by platelet-derived growth factor as well.     

糖尿病肾病尿毒症患者血液透析与腹膜透析的疗效对比观察

目的：探讨治疗糖尿病肾病（DN）尿毒症较理想的透析方法，方法：对62例作血液透析（HD）和34例作持续性非卧床腹膜透析（CAPD）和DN尿毒症患进行比较，观察两组患透析前后的血液生化指标；生存率，死亡原因，透析后主要并发症。结果：透析前合并有高血压，心脏肥大，冠心病或年龄大于60岁，行CAPD治疗后出现并发症的机会较HD少（P＜0．05）。结论：透析前合并有高血压，心脏肥大，冠心病或年龄大于60岁的DN尿毒症患以选择CAPD治疗较佳。