腹膜透析和血液透析并发症的护理

腹膜透析治疗尿毒症并发肺水肿病例:女,49岁,间断水肿,尿少伴头晕乏力贫血2年,加重11天,于1987年12月8日,以慢性肾小球肾炎、尿毒症期、高血压缓进型Ⅲ期收入院。重度贫血貌,BUN30.3mmol/L,Cr1078.5umol/L,Co_2 Cp18.1mmol/L,尿量24小时<500ml,入院3天后病情加重,神志恍惚,呼吸急促,不能平卧,面色苍白,出冷汗,双肺布满湿啰音,即在局麻下手术插管行IPD透析治疗,小量透析液灌注,由于心力衰竭及其它原因,每组无超滤,病情加重,气急,不能平卧,故1.5％腹透析500ml中加60ml复方氨基酸,每透析周期可超滤300ml左右液体,3天后用1.5％腹透液     

终末期肾病患者血液透析和腹膜透析治疗的成本效果研究

各种原发性或继发性慢性肾脏疾病进行性发展．最终成为终末期肾病(ESRD)。终末期肾病是一种严重危害健康的难治性疾病．为患者、社会及国家带来了沉重的经济负担。本文就其现状及血液透析(血透)、腹膜透析(腹透)两种治疗方式卫生经济学研究作一简要综述。     

血液透析和腹膜透析患者生存比较

目的 比较血液透析和腹膜透析患者的生存情况,探讨影响透析患者生存的主要危险因素。 方法 研究对象为2005年1月1日至2008年12月31日期间新进入透析且年龄≥18岁患者,随访至2009年3月31日。应用Kaplan-Meier法、log-rank检验及Cox回归模型分析患者的生存资料。 结果 共460例透析患者入选,其中247例起始采用血透治疗,213例起始采用腹透治疗。两组患者的基线资料,包括开始透析年龄、体质量指数（BMI）、估算肾小球滤过率（eGFR）、平均动脉压、进入透析治疗前心脑血管事件、Charlson并发症指数（CCI）等的差异均无统计学意义。中位随访时间为17.9（0.25,51）个月。意向治疗分析结果中,Kaplan-Meier生存曲线显示血透总体生存率优于腹透（P ＜ 0.05,log-rank检验）;透析1年内两组生存率差异无统计学意义（P = 0.14）,而透析1年后腹透患者的生存率显著低于血透患者（P ＜ 0.05）。亚组分析结果显示,≥65岁的非糖尿病肾病血透组生存率显著高于腹透组（P ＜ 0.05）。Cox回归分析显示,经混杂因素调整后,两种透析方式本身对透析生存无明显影响（HR,HD：PD = 0.778,95%CI 0.483~1.254,P = 0.303）;而年龄（HR = 1.051,95%CI 1.030~1.073,P ＜ 0.01）、透前有脑血管意外史（HR = 2.032,95%CI 1.125~3.670,P ＜ 0.05）、透前CCI≥5（HR=2.592,95%CI 1.230~5.465,P ＜ 0.05）、前白蛋白（HR = 0.022,95%CI 0.001~0.768,P ＜ 0.05）为透析患者生存率的主要影响因素。 结论 透析龄≤1年的血透和腹透生存率无显著差异;透析龄>1年的血透患者生存率可能逐渐高于腹透患者。老年非糖尿病患者血透生存率可能高于腹透。年龄、透前脑血管意外史、透前CCI≥5为影响透析生存率的主要危险因素。     

腹膜透析和血液透析患者胃肠道症状的调查分析

目的探讨腹膜透析和血液透析患者胃肠道症状的发生情况。方法选择2015年7~8月在我院肾内科进行腹膜透析和血液透析的患者为研究对象,其中腹膜透析患者(腹膜透析组)89例,血液透析患者(血液透析组)102例,采用胃肠道症状分级评分量表(gastrointestinal symptom rating scale,GSRS)和GerdQ自评量表进行问卷调查评估患者胃肠道症状的发生情况及严重程度。了解患者的年龄、性别、透析时间、糖尿病史、吸烟史及激素或非甾体类药物用药史,记录体质量指数(body mass index,BMI)、血红蛋白(hemoglobin,Hb)、校正钙(corrected calcium,cC a)、血磷、全段甲状旁腺素(intact parathyroidhormone,iP TH)、血白蛋白(serum albumin,Alb)、血肌酐(SCr)、尿素氮(BUN)、尿素清除指数(Kt/V)等指标。采用t检验,χ~2检验进行组间比较,并对Kt/V达标患者的胃肠道症状与各项指标进行逐步多元回归分析。结果 2组患者的年龄、性别、透析时间、吸烟史、服用激素或非甾体类药物史、糖尿病肾脏疾病比例差异无统计学意义,但是血液透析组患者具有更高的Alb、BUN水平及Kt/V值达标率。腹膜透析组胃肠道症状分级评分1分的发生率为83.1%,血液透析组为82.4%。腹膜透析组胃肠道症状分级评分明显高于血液透析组[(4.7±4.3)分比(3.8±3.3)分;P=0.004]。腹膜透析组烧心(P=0.029)、反酸(P=0.001)和恶心呕吐(P=0.004)发生率明显高于血液透析组。GerdQ自评量表评分结果显示,腹膜透析组有胃食管反流症状的患者16例(占18.0%),血液透析组8例(占7.0%),2组比较差异有统计学意义(P=0.048)。逐步多元回归分析提示,腹膜透析和血液透析患者胃肠道评分与BMI呈正相关(B=0.28,P=0.005)、与Hb水平呈负相关(B=-0.057,P=0.002)。结论多数透析患者具有消化道症状,腹膜透析患者更易出现胃食管反流现象,BMI及Hb水平与胃肠道症状具有相关性。     

血液透析&#65380;腹膜透析和肾移植的成本-效果分析

目的 探讨我院行血液透析(HD)&#65380;腹膜透析(CAPD)和肾移植(KT)3种终末期肾脏病(ESRD)替代疗法第1&#65380;第2年的成本-效果比&#65377;方法 回顾性研究上述3种疗法患者开始治疗两年内的成本&#65380;对工作的影响&#65380;以及现阶段的生活质量(用SF-36量表),并进行有关分析&#65377;结果 KT组第1年的费用高于另外两组(P < 0.001);在第2年则明显低于另外两组(P=0.005),后两组间差异无统计学意义&#65377;KT组的睡眠质量&#65380;回返工作的比例均优于另外两组&#65377;在精神健康&#65380;生理职能和精力方面,KT组与CAPD组均优于HD组&#65377;在生理机能&#65380;一般健康状况&#65380;社会功能&#65380;情感职能上,KT组优于CAPD与HD组,后两组差异无统计学意义&#65377;结论 KT组从第2年开始体现其费用上的优势,而CAPD与HD两组之间在医疗成本上无显著差异&#65377;肾移植的治疗效果在整体上优于CAPD和HD,CAPD的治疗效果略优于HD&#65377;随着KT近期和远期存活率的提高,KT应是成本-效果比最好的ESRD替代治疗方法&#65377;     

老年腹膜透析和血液透析患者贫血比较

目的比较老年腹膜透析(PD)患者和血液透析(HD)患者贫血的情况,为临床治疗老年贫血提供依据。方法收集武汉市第一医院腹膜透析中心和血液透析中心年龄大于65岁老年患者的相关资料,按照透析方式不同将其分为PD组79例和HD组152例,比较2组患者之间贫血情况及相关指标的差异。结果 PD组与HD组血红蛋白(Hb)和铁蛋白(SF)水平比较,差异有统计学意义(P0.05)。不同性别各组Hb、C反应蛋白、甲状旁腺素及SF的比较结果显示,男性各指标无明显差异(P0.05);女性中PD组Hb及SF水平均高于HD组,差异有统计学意义(P0.05)。Hb90 g/L时,2组SF水平差异有显著统计学意义(P0.05)。通过相关因素logistic回归分析,残余肾功能是引起老年透析患者贫血的独立影响因素。结论贫血在老年PD和HD患者中发生较普遍,且女性贫血差异更显著,一定程度上与残余肾功能存在联系。     

血液透析和腹膜透析患者生活质量比较

目的调查我院维持中心血液透析、腹膜透析治疗患者的生活质量，为临床合理选择治疗方案提供参考。方法对维持目前透析方式6个月以上的中心血液透析、腹膜透析患者，通过查阅病历资料、门诊随诊和问卷调查等方式，调查透析患者现阶段的生活质量（KDQOL～SF）。结果完成病例调查86例，其中血液透析36例，腹膜透析50例。两组患者在性别、年龄、文化程度、付费方式、收入、原发病、透析时间等背景上没有显著差异。腹膜透析组在总体健康、精神健康、情感职能、躯体疼痛以及肾病负担、社交质量、症状与不适、肾病影响、患者满意度等指标得分高于血液透析组。结论腹膜透析患者在生活质量的某些维度上优于血液透析患者，值得进一步推广。     

腹膜透析和血液透析对心肌损伤的影响

目的对比腹膜透析(peritoneal dialysis,PD)和血液透析(hemodialysis,HD)两种透析方式对心肌损伤的影响。方法选择2011年5月至2014年5月就诊于兰州大学第二医院肾内科的200例终末期肾病患者进行回顾性研究,按透析方式将患者分为HD组和PD组。PD组100例,男52例,女48例,透析时间为4~19个月,平均透析时间(14.2±0.9)个月;HD组100例,男48例,女52例,透析时间为4~17个月,平均透析时间(13.2±1.2)个月。所有患者均检测肌红蛋白、肌酸激酶、肌钙蛋白、B型心钠肽、乳酸脱氢酶、超敏C反应蛋白等心肌损伤标志物,比较2组上述指标的差异。结果 2组患者在随访期间无终止透析、肾移植、失访、死亡。2组患者在基线资料特征及指标中无统计学差异(P0.05);但HD组血钾高于PD组(P0.05),血二氧化碳结合力和血清铁蛋白低于PD组(P0.05)。2组患者基线水平透析充分性以及在开始透析前基线水平心脏结构及心功能方面评估,无统计学差异(P0.05)。HD组透析后肌红蛋白、肌酸激酶、肌钙蛋白、B型心钠肽、乳酸脱氢酶分别为187ng/ml、14.5ng/ml、201ng/L、245ng/L、135U/L、10.8mg/L;PD组透析后肌红蛋白、肌钙蛋白、B型心钠肽、乳酸脱氢酶分别为190ng/ml、14.7ng/ml、209ng/L、278ng/L、143U/L、10.1mg/L;随访期间2组心血管疾病发生情况无统计学差异(P0.05)。危险因素分析提示肌钙蛋白、肌红蛋白、肌酸激酶、B型心钠肽可以反映尿毒症患者心机损伤情况。结论 HD和PD两种透析方式对尿毒症患者心肌损伤无明显差异。     

Factors affecting hemodialysis and peritoneal dialysis efficiency

Hemodialysis and peritoneal dialysis are two blood purification techniques that use similar operating systems. The hemodialysis system is based on three components (blood, membrane, and dialysate). The peritoneal dialysis system is based on the same components that can, however, be less manipulated and adjusted. In hemodialysis the blood flow is the main determinant of small solute removal thanks to a prevalently diffusive mechanism. Convection is also used to transport larger solutes across the membrane, but this mechanism relies on the high permeability coefficient of the membrane and high transmembrane pressure leading to high ultrafiltration rates. The membrane can therefore influence the performance of the techniques as far as solute removal and ultrafiltration are concerned. Finally, diffusion is facilitated by an improved distribution of dialysate flow in the dialysate compartment. This can be achieved with a special dialysate pathway configuration based on space yarns or micronodulation of the fibers. In peritoneal dialysis, blood flow and membrane characteristics can be less manipulated or almost not at all. The only variables are dialysate volume, flow, dwell time, and composition. Thanks to modification in these aspects of the dialysate, peritoneal dialysis techniques with different clearances and ultrafiltration rates can be accomplished.     

Prognostic analysis of aged end-stage renal disease patients receiving hemodialysis and peritoneal dialysis

Objective To compare the survival rates of elderly hemodialysis (HD) and peritoneal dialysis (PD) patients and identify their independent prognostic predictors. Methods Patients aging ＞60 years old who initiated dialysis between January 1, 2008 and December 31, 2014 were included. Propensity score method (PSM) was applied to adjust for selection bias. Kaplan-Meier method was used to obtain survival curves and a Cox regression model was used to evaluate risk factors for mortality. Results 447 eligible patients with maintenance dialysis were identified, 236 with hemodialysis and 211 with peritoneal dialysis. 174 pairs of patients were matched, with the baseline data [age, gender, Charlson comorbidity index (CCI) and the primary disease] between two groups showing no significant difference (P＞0.05). Cardiovascular events, cerebrovascular events and infection were major causes of death in both groups and there was no significant difference in the causes of death between two groups (P＞0.05). The overall survival rates at 1 and 5 year were 93.6% and 63.4% respectively in HD group, 91.9% and 61.5% in PD group. The differences of total survival rates between HD and PD patients were not significant (P＞0.05). Cox regression analysis showed age(≥80 year) (P＜0.001, HR=1.058, 95%CI 1.028-1.088), diabetic nephropathy (P=0.001, HR=2.161, 95%CI 1.384-3.373), CCI≥5 (P=0.007, HR=1.935, 95%CI 1.201-3.117) were independent prognostic risk predictors in HD patients; age(≥80 year) (P=0.022, HR=1.043, 95%CI 1.006-1.081), serum albumin level ＜ 35 g/L (P=0.025, HR=1.776, 95%CI 1.075-2.934), and prealbumin (P=0.012, HR=0.968, 95%CI 0.944-0.993) were independent prognostic predictors in PD patients. Conclusions The differences of total survival rates between aged HD and PD patients are not significant. Age, diabetic nephropathy, CCI≥5 and age, serum albumin＜35 g/L, prealbumin＞30 g/L respectively influence the survival of elderly HD and PD patients.     

维持性血液透析与腹膜透析患者生活质量调查

目的 评估维持性血液透析(MHD)与持续非卧床腹膜透析(CAPD)患者生活质量情况,探讨MHD和CAPD患者生活质量的影响因素.方法 选取2016年7月～9月在郑州大学第一附属医院肾脏内科和血液净化中心随访的118例MHD患者和76例CAPD患者的临床和问卷调查资料.采用KDQOL-SFTM 1.3进行问卷分析,评估MHD与CAPD患者的生活质量.结果 MHD患者KDTA评分为(62.4±11.3)分,SF-36评分为(58.3±17.9)分,明显低于一般人群(P＜0.05).在各分维度评分中11个分维度评分略高于美国,6个分维度评分略高于西班牙;与国内广州调查数据相比,各维度评分均有明显改善,且与沈阳和合肥调查数据持平.CAPD患者KDTA评分为(71.4±8.9)分,SF-36评分为(61.6±16.3)分,明显低于一般人群(P＜0.05).在各分维度评分中7个分维度显著高于中国香港,其余均较中国香港偏低;与国内广州调查数据相比各维度评分均有明显改善,且与沈阳和合肥调查数据持平.MHD患者KDTA和SF-36整体评分显著低于CAPD患者(P＜0.05).在KDTA各分维度评分中,CAPD患者均高于MHD患者,且在肾脏疾病对日常生活的影响(EKD)、肾脏疾病导致的生活负担(BKD)、工作情况(WS)、认知功能(CF)、社交质量(QSI)、性功能(SexF)、社会支持(SoS)、患者满意度(PS)方面差异明显(P＜0.05);在SF-36评分中在生理职能(RP)、躯体疼痛(BP)、总体健康(GH)、情感状况(EWB)、情感职能(RE)各维度中,CAPD组患者均高于MHD患者且差异明显(P＜0.05).对于MHD患者,生活质量在性别、文化程度、家庭年收入、医保情况、原发病因、透析龄方面存在差异(P＜ 0.05),且在SGA评分、血白蛋白(ALB)、血红蛋白(HB)、尿素清除指数(Kt/V)、甲状旁腺激素(iPTH)、钙磷乘积(Ca×P)方面均存在相关性(P＜0.05).透析龄、性别(女)、原发病(糖尿病肾病)、iPTH、Kt/V、SGA评分是影响MHD患者生活质量的独立危险因素;对于CAPD患者,职业状况、医保情况、原发病因、透析龄方面存在差异(P＜0.05),且在SGA评分、ALB、HB、Kt/V方面存在相关性(P＜0.05),原发病(糖尿病肾病)、Kt/V、ALB、SGA评分是影响CAPD患者生活质量的独立危险因素.结论 MHD患者和CAPD患者整体生活质量较低,与发达国家和地区存在差距;CAPD和MHD患者生活质量均受不同因素影响,其中原发病(糖尿病肾病)、Kt/V、SGA评分是共同独立影响因素.     

Nutritional status of patients on hemodialysis and peritoneal dialysis

In a cross-sectional study, the nutritional status of 32 patients on hemodialysis (HD) and 16 patients on peritoneal dialysis (CAPD) was determined. Protein-caloric malnourishment assessed from a score system based on triceps skin-fold, midarm muscle circumference, S-transferrin and relative body weight was recorded in 54% of the patients. No significant differences between the nutritional status of HD and CAPD patients were found. Malnutrition was more frequent among patients in early stage dialysis (i.e., dialysis for less than 12 months) than among other patients (p less than 0.02). Frequent assessment of the nutritional status is mandatory for optimal nourishment.     

Comparative mortality of hemodialysis and peritoneal dialysis in Canada

BACKGROUND: Comparisons of mortality rates in patients on hemodialysis versus those on peritoneal dialysis have been inconsistent. We hypothesized that comorbidity has an important effect on differential survival in these two groups of patients. METHODS: Eight hundred twenty-two consecutive patients at 11 Canadian institutions with irreversible renal failure had an extensive assessment of comorbid illness collected prospectively, immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994; vital status was ascertained as of January 1, 1998. RESULTS: The mean follow-up was 24 months. Thirty-four percent of patients at baseline, 50% at three months, and 51% at six months used peritoneal dialysis. Values for a previously validated comorbidity score were higher for patients on hemodialysis at baseline (4.0 vs. 3.1, P < 0.001), three months (3.7 vs. 3.2, P = 0.001), and six months (3.6 vs. 3.2, P = 0.005). The overall mortality was 41%. The unadjusted peritoneal dialysis/hemodialysis mortality hazard ratios were 0.65 (95% CI, 0. 51 to 0.83, P = 0.0005), 0.84 (95% CI, 0.66 to 1.06, P = NS), and 0. 83 (95% CI, 0.64 to 1.08, P = NS) based on the modality of dialysis in use at baseline, three months, and six months, respectively. When adjusted for age, sex, diabetes, cardiac failure, myocardial infarction, peripheral vascular disease, malignancy, and acuity of renal failure, the corresponding hazard ratios were 0.79 (95% CI, 0. 62 to 1.01, P = NS), 1.00 (95% CI, 0.78 to 1.28, P = NS), and 0.95 (95% CI, 0.73 to 1.24, P = NS). Adjustment for a previously validated comorbidity score resulted in hazard ratios of 0.74 (95% CI, 0.58 to 0.94, P = 0.01), 0.94 (95% CI, 0.74 to 1.19, P = NS), and 0.88 (95% CI, 0.68 to 1.13, P = NS) at baseline, three months, and six months. There was no survival advantage for either modality in any of the major subgroups defined by age, sex, or diabetic status. CONCLUSIONS: The apparent survival advantage of peritoneal dialysis in Canada is due to lower comorbidity and a lower burden of acute onset end-stage renal disease at the inception of dialysis therapy. Hemodialysis and peritoneal dialysis, as practiced in Canada in the 1990s, are associated with similar overall survival rates.     

Posttransplant outcomes of peritoneal dialysis versus hemodialysis patients

The impact of dialysis modality on posttransplant outcomes remains controversial. The authors have compared primary failure, delayed graft function (DGF), acute rejection episodes as well as patient and allograft survivals among patients undergoing renal transplantation between 2004 and 2009, according to the modality of hemodialysis (HD) versus peritoneal dialysis (PD). We studied 306 patients (268 HD and 38 PD) with a mean follow-up of 29 ± 16 months. The PD cohort included a predominance of females (68.4% vs 36.2%; P = .001), lower age at transplantation (38 ± 14 vs 46 ± 12 years; P = .004), shorter time on dialysis (33 ± 49 vs 59 ± 157 months; P = .043), and higher rate of living donor grafts (PD 31.6% vs HD 13.1%; P = .003). Donor age (PD 43 ± 13 vs HD 45 ± 14 years; P = .30), human leukocyte antigen mismatch (P = .17), panel reactive antibody values (HD 11 ± 22 vs PD 13 ± 26; P = .55), and hyperimunized patients (HD 3.73%; PD 7.89%; P = .23) were not different. Primary graft failure (3.4% vs 0%; P = .025) and DGF (37.1% vs 13.1%; P = .037) were more frequent among HD patients, but incidences of acute rejection episodes were similar (HD 10.5% vs PD 5.3%; P = 0.19). Neither recipient survival at 1 (97% in PD and HD) or 3 years (HD 90% vs PD 94%; P = .657) nor allograft survival at 1 year (HD 94% vs PD 95%; P = .80) or 3 years: (HD 70%, vs PD 81%; P = .73) were different. Graft function was similar at 1 (HD 64.2 ± 25 vs PD 56.4 ± 24 mL/min; P = .17) and 3 years (HD 62.3 ± 21 vs PD 46 ± 23 mL/min; P = .16). In our study, HD patients showed an higher incidence of DGF and primary allograft failure, but there was no difference in acute rejection episodes, long-term survivals, or renal function.     

Patient mortality in chronic dialysis: comparisons between hemodialysis and peritoneal dialysis

Patients with approaching end-stage renal disease often must choose between hemodialysis or peritoneal dialysis as the initial form of renal replacement therapy. Should nephrologists recommend one form of dialysis as superior to the other? This review focuses on studies that compared patient mortality for these two dialysis techniques. Explanations for the disparate findings of these studies will be put forth. Finally, suggestions regarding what we can recommend to patients are made.     

Nutritional status over time in hemodialysis and peritoneal dialysis

Malnutrition is a risk factor for mortality in the dialysis population. So far, prospective studies comparing the time course of nutritional status in new hemodialysis (HD) and peritoneal dialysis (PD) patients have not been published. The aims of this study were to compare the time course of nutritional status in patients who were starting HD or PD and to identify the baseline determinants of that time course. In this prospective multicenter cohort study, data were collected from 3 (baseline) to 24 mo after the start of dialysis. Repeated measures ANOVA was used to establish the time course of nutritional status. Differences were adjusted for baseline characteristics. A total of 250 consecutive new patients were included: 132 started on HD, and 118 started on PD. A univariate analysis demonstrated a decrease in serum albumin (SA) in patients who started on HD and an increase in patients who started on PD. Body fat increased in PD; LBM did not change. The protein equivalent of nitrogen appearance normalized to ideal weight decreased in PD after 1 yr. In a multivariate analysis, SA at 2 yr was 2.0 g/L (95% confidence interval [CI], 0.3 to 3.8) higher in patients who started on PD compared with patients who started on HD. The increase in body fat was 3.2 kg (95% CI, 1.6 to 4.9) higher in women who started on PD than in others. Patients who had diabetes gained 2.3 kg (95% CI, 0.6 to 4.1) more fat than patients who did not have diabetes. Kt/V(urea) did not affect the time course of nutritional status, but a higher Kt(urea) was associated with a higher SA at 24 mo. Nutritional status at the start of dialysis, gender, and diabetic status might be considered in making the choice for dialysis modality. Furthermore, providing a higher Kt(urea) may improve protein metabolism.