腹腔镜下置Tenckhoff管的临床优势#$NL 作者：洪本林 张文意 李少鹏 杨清渭 李真慧 谢丹莉 林雅萍 陈鸿德

目的：为比较腹腔镜下与常规手术置Tenckhoff管方法的优劣。方法：对我院近5年(2012.2～201710) 63例慢性肾脏病需透析者, 其中男性31例,女性32例,年龄24岁~73岁,平均年龄(52.1+-3.3)岁,采取患者自愿选择的方式,分为腹腔镜下手术置管组(Ⅰ组)30例,常规手术置管组(Ⅱ组)33例,Ⅰ组采用腹腔镜下腹膜透析置管+腹股沟内环口内固定导管,Ⅱ组采用传统开腹手术或套管针置管,其中Ⅰ组腹部有手术史11例,占36.67%,Ⅱ组腹部有手术史2例,占6.06%,记录术前患者的基本情况、平均随访时间,比较两组住院时间及术后近期及远期并发症如切口感染、手术出血、腹腔出血、管周渗漏、导管出口及隧道感染、腹膜炎、疝、导管异位、引流不畅、堵管等方面的差异。结果：随访时间截止至2017年10月, Ⅰ组住院天数7～22天(平均13天), Ⅱ组院天数11～32天(平均32天), (P<0.05)。Ⅰ组切口感染、手术出血、腹腔出血等手术相关并发症明显低于Ⅱ组(均P<0.05);腹膜炎Ⅰ组发生2例,发生率6.7%;Ⅱ组发生5例次,发生率15.2%, (P<0.05)。Ⅰ组发生导管出口及隧道感染者2例,Ⅱ组发生导管出口及隧道感染者3例,差异均无统计学意义(P>0.05)。机械并发症(包括导管移位、导管功能不良、堵管、疝等) Ⅰ组无,Ⅱ组有7例(占21.2%),发生机械并发症其中脐疝2例(占6.1%),导管移位4例(占12.12%),(P<0.05)。结论:腹腔镜引导下Tenckhoff管置管+内固定较常规手术置管的早期及晚期并发症均低,技术存活率高,同时其定位准确、安全,切口愈合快,住院时间短,是目前临床上较为理想的腹膜透析置管方法, 但其住院平均费用较高及麻醉风险高。     

腹腔镜下置Tenckhoff管的临床优势

目的:比较腹腔镜下与常规手术置Tenckhoff管方法的优劣。方法:63例慢性肾脏病需透析患者,采取自愿选择的方式,分为腹腔镜下手术置管组(Ⅰ组)30例,常规手术置管组(Ⅱ组)33例,Ⅰ组采用腹腔镜下腹膜透析置管+腹股沟内环口内固定导管,Ⅱ组采用传统开腹手术或套管针置管,比较2组住院时间、术中及术后早期(1个月内)和晚期(1个月后)并发症如切口感染、手术出血、腹腔出血、管周渗漏、导管出口及隧道感染、腹膜炎、疝、导管移位、引流不畅、堵管等方面的差异。结果:Ⅰ组住院7～22d,平均13 d,Ⅱ组住院11～32 d,平均19 d(P0.05)。Ⅰ组腹腔出血明显少于Ⅱ组(均P0.05);腹膜炎Ⅰ组发生2例(6.7%),Ⅱ组发生4例次(12.1%)(P0.05)。导管出口及隧道感染者Ⅰ组发生2例(6.7%),Ⅱ组发生3例(9.1%),差异无统计学意义(P0.05)。机械并发症(包括导管移位、导管功能不良、堵管、疝等)Ⅰ组无,Ⅱ组有6例(18.2%)。结论:腹腔镜引导下Tenckhoff管置管+内固定较常规手术置管的早期及晚期并发症发生率低,技术存活率高,同时其定位准确、安全,切口愈合快,住院时间短,是目前临床上较为理想的腹膜透析置管方法。     

腹腔镜建立腹直肌隧道在腹膜透析管置入术中的临床应用

目的 比较腹腔镜引导下建立腹直肌隧道行腹膜透析管置入术与常规腹膜透析管置入术(开放式手术置管)患者的疗效及并发症发生率.方法 选择我院2009年1月～ 2011年12月首次置管并接受腹膜透析治疗的终末期肾病患者60例,将60例患者分为腹腔镜建立腹直肌隧道腹膜透析管置入组(A组)和开放式手术腹膜透析管置入组(B组),每组各30例,记录两组患者术前的基本情况、术后并发症、生存时间、退出或死亡等结局.结果 平均随访患者12.5个月,A组发生导管机械性功能障碍(堵管)1例(3.33％),B组5例(16.67％),其中漂管4例,堵管1例,两组比较差异有统计学意义(P＜0.05).A组发生导管周围渗漏1例(3.33％),B组2例(6.67％).A组术后2周发生感染2例,均为皮下隧道炎;B组术后2周发生感染2例,皮下隧道炎和腹膜炎各1例.结论 腹腔镜建立腹直肌隧道进行腹膜透析置管,管周腹膜透析液渗漏率低,较常规手术导管机械性功能障碍发生率明显下降,尤其对有腹腔手术史的患者.     

皮下隧道在预防深静脉导管感染中的应用

目的 :为了观察皮下隧道在减少深静脉导管相关性感染中的作用。方法 :采用连续样本 ,按区组随机化分组对照研究的方法将 2 60例需施行深静脉穿刺置管术的老年患者分成两组。 13 0例采用自创的经简便皮下隧道 (长度 5cm)后股静脉置管 (试验组 ) ,13 0例非经皮下隧道股静脉置管(对照组 )。分别记录两组置管后局部皮肤感染例数、导管头细菌培养阳性例数和外周血细菌培养阳性例数。结果 :试验组和对照组平均留管时间分别为 2 9.97± 12 .81和 2 8.95± 10 .79d ,两组比较无显著性差异 (P >0 .0 5 ) ;导管皮肤出口处细菌培养阳性数分别为 13和 12例 ,两组比较无显著性差异 (P >0 .0 5 ) ;导管头细菌培养阳性数分别为 2和 9例 ,两组比较有显著性差异 (P <0 .0 5 )。结论 :经长度为 5cm的皮下隧道后深静脉置管在减少导管相关性感染发生中有一定的作用。     

腹腔镜下腹膜透析置管术的疗效及安全性

目的:比较腹腔镜下与常规腹膜透析(PD)置管术的疗效和安全性。方法:前瞻性随机入选瑞金医院肾脏内科自2008年12月至2010年4月首次置管并接受PD治疗的ESRD患者共50例,随机分为腹腔镜组(A组)和常规手术组(B组)各25例,记录术前两组的基本情况、并发症、生存时间、退出或死亡等结局;同时对A组患者比较术前、术后肝肾功能。结果:截止2010年6月,5例(10%)死亡,其中A组2例、B组3例,两组10个月生存时间分别为(A组vsB组:86.6%vs82.9%,P0.05)。两组共发生腹膜炎9例(12例次),总腹膜炎发生率为0.29次/患者年,A组腹膜炎发生率(0.24次/患者年)低于B组(0.34次/患者年)(P0.05)。两组首次腹膜炎发生时间分别为A组(31.79士23.8)周,B组(14.93士10.40)周(P0.05)。2次皮下隧道及出口感染均发生于A组(P0.05)。各项机械并发症差异均无统计学意义(P0.05),但A组无漂管发生,而B组却发生4例(P0.05)。A组术前、术后肝肾功能无差异。结论:腹腔镜下PD置管可降低术后近期内PD感染率,从根本上解决PD漂管,而且腹腔镜组患者术后未出现肝肾功能损害。     

Permcath导管与肝素涂层Palindrome导管在老年透析中的临床效果比较

目的观察并比较老年透析患者应用Permcath导管与肝素涂层Palindrome导管后透析充分性,导管凝血功能变化,分析Palindrome导管临床效果与安全性。方法选取45例老年慢性肾衰竭尿毒症患者为研究对象。根据中心静脉置管材料不同分为观察组和对照组,观察组(19例)均采用Palindrome导管置管,对照组(26例)采用常规Permcath导管,所有患者术后均保持随访12个月,记录两组患者置管前与1 w后凝血功能的变化,置管1 w与12个月后透析期间血流速度、尿素清除指数(Kt/V)以及随访期间血栓相关性导管功能不良、感染等并发症的发生率。结果两组患者均保持随访。随访期间观察组感染率为10.5%(2/19),与对照组无明显〔11.5%(3/26),P0.05〕差异。对照组6例出现导管不畅,观察组2例出现导管不畅病例。对照组导管不畅率显著高于观察组(P0.05)。两组患者置管1 w内未出现明显的凝血功能异常,观察组与对照组的凝血酶原时间(PT)、部分活化凝血活酶时间(APT)、国际标准化比值(INR)均无明显差异(P0.05)。观察组12个月后的平均透析血流量、Kt/V较置管1 w时稍有降低,但差异不明显(P0.05);对照组12个月后的平均透析血流量、Kt/V较置管1 w时明显降低(P0.05)。置管后,观察组平均透析血流量、Kt/V明显高于对照组(P0.05)。结论老年透析患者置入肝素涂层Palindrome导管在控制导管相关性并发症、维持透析充分性方面有显著优势。     

腹膜透析导管相关并发症防治进展

腹膜透析(PD)导管相关并发症是导致PD治疗失败的主要原因,包括机械并发症(导管移位、透析液渗漏、导管阻塞、腹疝、内脏损伤、出血)和感染相关并发症(出口、隧道感染)。临床医师应熟练掌握导管相关各种并发症的临床表现,早发现、早治疗,并对高危患者采取有效的预防措施,这样将会大大减少各种并发症的发生,有助于提高PD患者的远期预后。本文拟对腹膜透析导管相关并发症的病因、临床表现、治疗和预防进行综述。     

CCU缺血性心衰患者中心静脉导管相关性感染的危险因素分析与护理研究

目的：对CCU缺血性心衰患者中心静脉导管相关性感染的危险因素和护理进行探讨和分析。方法：对我院2013年12月-2014年12月CCU病房收治的40例缺血性心衰患者导管感染中360例次中心静脉置管患者作为研究对象,对他们的临床特点、危险因素和护理的关系进行研究。结果：①锁骨下静脉插管感染率为18.60%,颈静脉感染率为21.18%,股静脉感染率为33.33%,可知锁骨下静脉的感染率最低、股静脉最高。②感染率与导管留置时间的关系为正比。③单腔、双腔感染率分别是15.87%、41.67%。④真菌感染率是11.76%,革兰阴性和阳性菌的感染率各是27.06%和61.18%。结论：使用中心静脉置管方式治疗严格缺血性心衰病人具有较好的疗效,能够使病人的免疫机能增强,降低置管时长,提高对穿刺位置消毒及管理护士手部卫生的力度,并能够极大程度地降低相关并发症出现的几率。     

老年慢性肾衰竭患者半永久导管相关感染的临床特征及危险因素

目的观察老年慢性肾衰竭患者置入半永久导管后行维持性血液透析期间导管相关感染的临床特征及危险因素。方法回顾性分析留置半永久导管行维持性血液透析的老年患者病例资料,共纳入79例慢性肾衰竭患者。记录半永久导管出口部感染、隧道感染、导管相关菌血症等导管相关感染情况。将出现感染的患者纳入感染组,其他患者纳入未感染组,比较两组性别、平均年龄、平均透析时间、导管留置时间、有无糖尿病、高血压等临床特征,Cox比例风险回归分析半永久导管后进行维持性血液透析期间感染的影响因素。结果入选患者均保持随访1年以上,平均(21.5±8.2)个月,79例置管患者共发生半永久导管相关感染事件者21例(26.6%),其中置管出口部感染11例,隧道感染8例,导管相关菌血症2例。细菌分布:革兰阳性球菌12株(57.1%),其中金黄色葡萄球菌[7株(33.3%)]、表皮葡萄球菌[4株(19.0%)]常见;革兰阴性杆菌8株(38.1%),以大肠埃希菌[3株(14.3%)]、铜绿假单跑菌[3株(14.3%)]常见;真菌1株(4.8%)。感染组平均年龄、平均透析时间、平均导管留置时间、合并糖尿病比例、合并低白蛋白血症比例均显著高于未感染组(P<0.05);而两组性别、有无合并高血压无显著差异(P>0.05)。进一步行Cox比例风险回归分析,合并糖尿病(OR=4.211,P=0.001)、半永久导管留置时间(OR=2.910,P=0.003)、低蛋白血症(OR=1.340,P=0.019)是半永久导管相关感染的危险因素,而平均年龄、平均透析时间对半永久导管相关感染影响较小(P>0.05)。结论老年慢性肾衰竭使用半永久导管行血液透析的患者以置管出口部、隧道感染多见,致病菌以革兰阳性球菌为主,合并糖尿病、半永久导管留置时间、低白蛋白血症是感染的危险因素。     

经皮颈内静脉长期导管在老年维持性血液透析患者中的临床应用

目的：探讨经皮颈内静脉长期导管在老年维持性血液透析患者中的应用及其常见并发症的防治。方法对2009年12月至2012年12月在中南大学湘雅医院行经皮颈内静脉长期置管的15例维持性血液透析老年患者的临床资料进行回顾性分析,观察置管术后情况、导管的使用情况、常见并发症的防治、透析充分性评价等。结果（1）实施颈内静脉长期置管18例次,其中3例为重新置管,置管成功率100%。（2）导管相关并发症：2例患者术后1周内出现置管处局部渗血;1例出现导管出口感染,2例发生导管相关性血流感染;3例患者出现导管血栓形成;2例诊断导管纤维鞘形成;1例因人为损坏出现导管破裂。经过相应处理后均使问题得到解决。（3）导管使用期限：本组患者长期导管使用时间为4～41个月,除1例死亡（原因为脑出血）,3例为重新置管,余患者仍继续使用。（4）透析充分性评价：15例患者平均尿素下降率为72%,平均尿素清除指数达1.54。结论对于血管条件差无法建立动静脉内瘘的老年血透患者,使用颈内静脉长期导管行血液透析可以达到充分透析;提高置管及导管护理技术、加强健康宣教,能延长导管使用年限,减少导管并发症。     

两种不同腹膜透析导管拔除术在老年腹膜透析患者中的临床应用

目的分析两种腹膜透析导管拔除术在老年腹膜透析患者中的应用情况。方法采用回顾性队列研究的方法, 收集2010年8月至2020年5月于山西医科大学第二医院腹膜透析中心移除腹膜透析导管的107例老年腹透患者的临床资料, 分为外科开放式拔管组(外科组)和"pull"技术拔管组(pull组), 比较两组性别、年龄、原发病、透析龄、拔管原因及术前相关化验等指标, 观察两组手术时间、术后住院时间、手术疼痛程度及术后并发症等相关情况。结果外科组的手术时间[(71.2±13.4)min和(19.3±5.6)min, t=16.933, P<0.01]、术后住院时间[(9.5±1.8)d和(2.2±0.5)d, t=10.988, P<0.01]和术中疼痛评分[(4.4±1.6)分和(1.4±1.1)分, t=6.909, P<0.01]及术后24 h的疼痛评分[(3.7±1.4)分和(0.5±0.3)分, t=9.995, P<0.01]均高于pull组, 两组术后并发症发生率(6.8%和5.0%, χ2=0.037, P>0.05)差异无统计学意义。结论外科开放式手术法和...     

Morbimortality study of infection in patients undergoing different types of dialysis in a renal replacement therapy center

IntroductionRenal replacement therapy is the treatment of end-stage chronic kidney disease and can be performed through dialysis catheters, arteriovenous fistulas/grafts, and peritoneal dialysis. Patients are usually immunocompromised and exposed to invasive procedures, leading to high rates of infection and increased mortality.ObjectivesTo compare the prevalence of infection and related deaths, as well as the sensitivity profile of the putative bacteria in patients treated with peritoneal dialysis, arteriovenous fistula hemodialysis and catheter hemodialysis.MethodsThis is case–control study. Six hundred forty-four patients undergoing renal replacement therapy were selected. Patients were divided into three groups according to the modality of dialysis treatment: peritoneal dialysis (126 patients), arteriovenous fistula hemodialysis (326 patients), and catheter hemodialysis (192 patients).ResultsOne hundred sixteen patients (18.01%) developed infection. There was a higher incidence of infection in the peritoneal dialysis group (44 patients; 34.92%; OR: 3.32; CI 95% = 2.13–5.17; p = 0.0001). In the catheter hemodialysis group, 48 patients (25%) had infection (OR: 1.88; CI 95%: 1.24–2.85; p = 0.0035). In the arteriovenous fistula hemodialysis group, 24 patients (7.36%) developed infection (OR: 0.19; CI 95%: 0.12–0.31; p = 0.0001). Five patients (4.31%) died due to infection (four in the peritoneal dialysis group and one in the catheter hemodialysis group). There were no deaths due to infection in the arteriovenous fistula hemodialysis group.ConclusionsPeritoneal dialysis is the treatment with greater risk of infection and mortality, followed by catheter hemodialysis. The lowest risk of infection and mortality was observed in arteriovenous fistula hemodialysis group.     

Lipids, lipoproteins and apolipoproteins A-I and B and apolipoprotein losses in continuous ambulatory peritoneal dialysis

Comparison of lipid, lipoprotein and apolipoprotein levels was made between 3 groups: continuous ambulatory peritoneal dialysis patients (n = 5); haemodialysis patients (n = 15) and normals (n = 31). Continuous ambulatory peritoneal dialysis (CAPD) patients showed significantly elevated total cholesterol, low density lipoprotein (LDL)-cholesterol and apolipoprotein B (apo B) levels compared with haemodialysis and normal groups. Both CAPD and haemodialysis (HD) showed reduced levels of high density lipoprotein (HDL)-cholesterol and apolipoprotein A-I (apo A-I). Measurement of apo A-I and apo B in dialysate during a 6 h CAPD session indicated significant losses of apo A-I to dialysate with negligible losses of apo B. Grossly elevated apo B and reduced apo A-I indicates that CAPD patients are at increased risk of coronary heart disease and that their risk is probably greater than for haemodialysis patients.     

Effects of low glucose degradation products peritoneal dialysis fluid on the peritoneal fibrosis and vascularization in a chronic rat model

In the present study, we examined the effects of a new peritoneal dialysis fluid (PDF) with a low level of low glucose degradation products (GDP) on the functional and structural stability of the peritoneal membrane (PM). Male Sprague-Dawley rats were divided into three groups: group C (n = 8), without dialysate infusion; group P (n = 12), infused with low-level GDP solution (4.25% Physioneal, pH 7.0-7.4); and group D (n = 12), infused with conventional solution (4.25% Dianeal, pH 5.2, adjusted to pH 7.0). In groups D and P, animals were infused through a permanent catheter with 25 mL of PDF, twice daily for 8 weeks. Lipopolysaccharide was added into the PDF immediately before infusion on days 8, 9 and 10 in the two dialysis groups. When compared with group P, group D showed a higher glucose mass transfer at weeks 6 and 8, D/P urea at week 8, TGF-beta1 at weeks 4 and 8, and VEGF level at week 8. The submesothelial matrix layer of the parietal peritoneum was significantly thickened in group D and the lectin-stained blood vessels in this layer were well-visualized in group D compared with group P. There were significantly more peritoneal blood vessels in group D than group P. The transforming growth factor-beta induced gene-h3 (betaig-h3) and TGF-beta1 levels in the peritoneal effluent correlated with the submesothelial thickness, which correlated with the dialysate-to-plasma ratio (D/P) of protein and, inversely, with the rate of glucose transport (D/D(0) glucose, where D is glucose concentration in the dialysate and D(0) is glucose concentration in the dialysis solution before it is infused into the peritoneal cavity). The present study showed that low-GDP PDF effectively attenuated the peritoneal vascularization and fibrosis related to conventional solution.     

Inflammation in peritoneal dialysis

In patients on peritoneal dialysis, peritoneal membrane alterations with inadequate peritoneal membrane function may be induced during long-term therapy. Chronic inflammation triggers malnutrition and atherosclerotic cardiovascular disease contributing to high mortality. The role of catheter, peritonitis and peritoneal dialysis fluids is argued. A neutral pH, a lesser presence of glucose degradation products generated during heat sterilization and accelerating the production of advanced glycosylation end-products (AGEs) could be reduced with better biocompatibility of peritoneal dialysis fluids.     

Effects of starting hemodialysis with an arteriovenous fistula or central venous catheter compared with peritoneal dialysis: a retrospective cohort study

ABSTRACT: BACKGROUND: Although several studies have demonstrated early survival advantages with peritoneal dialysis (PD) over hemodialysis (HD), the reason for the excess mortality observed among incident HD patients remains to be established, to our knowledge. This study explores the relationship between mortality and dialysis modality, focusing on the role of HD vascular access type at the time of dialysis initiation. METHODS: A retrospective cohort study was performed among local adult chronic kidney disease patients who consecutively initiated PD and HD with a tunneled cuffed venous catheter (HD-TCC) or a functional arteriovenous fistula (HD-AVF) in our institution in the year 2008. A total of 152 patients were included in the final analysis (HD-AVF, n = 59; HD-TCC, n = 51; PD, n = 42). All cause and dialysis access-related morbidity/mortality were evaluated at one year. Univariate and multivariate analysis were used to compare the survival of PD patients with those who initiated HD with an AVF or with a TCC. RESULTS: Compared with PD patients, both HD-AVF and HD-TCC patients were more likely to be older (p<0.001) and to have a higher frequency of diabetes mellitus (p = 0.017) and cardiovascular disease (p = 0.020). Overall, HD-TCC patients were more likely to have clinical visits (p = 0.069), emergency room visits (p<0.001) and hospital admissions (p<0.001). At the end of follow-up, HD-TCC patients had a higher rate of dialysis access-related complications (1.53 vs. 0.93 vs. 0.64, per patient-year; p<0.001) and hospitalizations (0.47 vs. 0.07 vs. 0.14, per patient-year; p = 0.034) than HD-AVF and PD patients, respectively. The survival rates at one year were 96.6%, 74.5% and 97.6% for HD-AVF, HD-TCC and PD groups, respectively (p<0.001). In multivariate analysis, HD-TCC use at the time of dialysis initiation was the important factor associated with death (HR 16.128, 95%CI [1.431-181.778], p = 0.024). CONCLUSION: Our results suggest that HD vascular access type at the time of renal replacement therapy initiation is an important modifier of the relationship between dialysis modality and survival among incident dialysis patients.     

Effects of icodextrin on insulin resistance and adipocytokine profiles in patients on peritoneal dialysis

Icodextrin peritoneal dialysis solution reportedly benefits patients suffering from metabolic derangement due to glucose load from dialysate. However, the effects of icodextrin on insulin resistance and adipocytokine profile remain unclear. Subjects comprised 14 stable patients on peritoneal dialysis for >6 months. Their mean age was 57 +/- 11 years and the mean duration of peritoneal dialysis was 49 +/- 30 months. Patients were classified into groups according to the index of insulin resistance (index of homeostasis model assessment: HOMA-IR): Group A, HOMA-IR < 2.0 (n = 7); and Group B, HOMA-IR >or= 2.0 (n = 7). Glucose peritoneal dialysis solution was subsequently switched to icodextrin once daily during the night. Changes in HOMA-IR and adipocytokine profiles were examined after three months. The glucose absorption dose tended to decrease in both groups after icodextrin introduction, with significant reductions in Group B. No changes were seen in body mass index, fluid status, peritoneal dialysis dose, residual renal function or fasting plasma glucose levels in either group. Plasma insulin levels were unchanged in Group A, but decreased significantly in Group B. The index of insulin resistance was thus unchanged in Group A (from 1.4 +/- 0.4 to 1.5 +/- 0.8) and significantly decreased in Group B (from 5.9 +/- 2.2 to 3.2 +/- 0.6; P < 0.01). Regarding plasma adipocytokine profiles, no changes were found in plasma leptin, tissue necrosis factor-alpha or total plasminogen activator inhibitor-1 levels in either group. Plasma adiponectin levels were unchanged in Group A, but significantly increased in Group B. Icodextrin solution could ameliorate insulin resistance by decreasing insulin levels due to a reduction in the glucose load and an increase in plasma adiponectin levels.     

Urgent-start peritoneal dialysis

Peritoneal dialysis is an important form of kidney replacement therapy. Most patients presenting with an unplanned, urgent need for dialysis are prescribed haemodialysis, leading to peritoneal dialysis underutilisation. Urgent-start peritoneal dialysis refers to treatment that is commenced within 2 weeks of catheter placement. Urgent-start peritoneal dialysis represents an efficacious, cost-effective alternative to the conventional approach of commencing dialysis. There is a paucity of evidence to guide management, however experience with the technique is increasing. This article overviews the rationale and practical application of urgent-start peritoneal dialysis.     

Controlled study of renal osteodystrophy in patients undergoing dialysis. Improved response to continuous ambulatory peritoneal dialysis compared with hemodialysis

To assess the effect of different dialysis modalities on renal osteodystrophy, a controlled study was performed in six patients undergoing continuous ambulatory peritoneal dialysis and six hemodialysis-treated patients. All patients were enrolled at the initiation of dialysis, and age, sex, cause of renal failure, prior treatment of renal osteodystrophy, and baseline serum and bone histologic variables were similar in the two groups. After initial blood samples and bone biopsy specimens (with double-tetracycline labels) were obtained, renal osteodystrophy in both groups received comparable treatment with aluminum hydroxide to maintain serum phosphorus levels between 3.5 and 5.5 mg/dl, and with calcium carbonate and calcitriol to maintain total serum calcium levels between 10 and 11 mg/dl. Blood and bone samples were obtained again after nine months. All patients were asymptomatic at the beginning and end of the study. Phosphorus values were well controlled, and total calcium increased similarly in both groups. Although ionized calcium levels increased in both groups, the final level was higher in hemodialysis-treated patients than in patients undergoing continuous ambulatory peritoneal dialysis (2.82 +/- 0.07 meq/liter and 2.5 +/- 0.05 meq/liter, respectively; p = 0.005). Amino-terminal parathyroid hormone levels normalized in both groups, and histologic improvement of osteitis fibrosa occurred in a similar proportion of patients in both groups; however, quantitative improvement was greater in the hemodialysis-treated patients. Osteomalacia, assessed qualitatively and by dynamic histomorphometric measurements, was ameliorated to a much greater degree in patients undergoing continuous ambulatory peritoneal dialysis compared with hemodialysis-treated patients. Bone aluminum staining was absent in all biopsy specimens. Overall, bone histologic findings improved to a greater degree in patients undergoing continuous ambulatory peritoneal dialysis. When patients undergoing continuous ambulatory peritoneal dialysis or hemodialysis and receiving similar treatment for renal osteodystrophy were compared, patients treated with continuous ambulatory peritoneal dialysis appeared to have a greater improvement in their metabolic bone disease.     

腹带加压预防腹膜透析患者术后并发症的临床观察

目的探讨腹带加压对腹膜透析患者伤口拆线时间、伤口渗液、出血及隧道口炎、导管移位发生率的影响,为防治腹膜透析并发症提供新的治疗方法。方法根据腹膜透析术后是否采用腹部伤口腹带加压,将患者分为腹膜透析插管后3个月内腹带加压组(A组)和未使用腹带加压对照组(B组),观察两组患者的伤口拆线时间、伤口渗液、出血及透析管相关隧道口炎、导管移位的发生率。结果 (1)A组平均拆线时间为(11.2±0.8)d,B组平均拆线时间为(13.4±0.7)d,两组比较有统计学差异(P0.01)。(2)术后A组有1例患者发生伤口渗血,而B组有8例患者出现伤口渗血,明显高于A组(P0.05);术后A组有1例隧道口炎发生,而B组有7例患者在术后3个月发生隧道口炎,与A组比较有统计学差异(P0.05),两组患者予以规范抗感染治疗后均治愈。(3)A组有1例患者在术后第2天出现管周渗液,发生率为2.94%;B组有1例患者在术后第1天出现管周渗液,发生率为3.03%,两组比较无统计学差异(P0.05)。(4)A组有1例患者出现导管移位,发生率为2.94%;B组有1例患者出现导管移位,发生率为3.03%,两组比较无统计学差异(P0.05)。结论腹带加压可缩短手术后拆线时间,可减少术后腹部伤口渗血及隧道口炎的发生率,极大地减少了术后并发症的发生,可促进患者早日康复,能有效延长腹膜透析患者的透析时间和治疗效果,减少腹透早期退出率,提高患者生活质量。