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。     

Significance of screening for Fabry disease among male dialysis patients

Background Fabry disease is an X-linked disorder resulting from a deficiency of the lysosomal enzyme alpha-galactosidase A(α-Gal A). Renal insufficiency is a very important manifestation and affects the prognosis of patients. Recently, a renal variant type that is characterized by low plasma α-Gal A activity and a milder phenotype, but which progresses to end-stage renal failure, has been reported. In this study, we clarified the incidence of this atypical variant of Fabry disease in hemodialysis patients. Methods We measured plasma α-Gal A activity in 450 male dialysis patients who had never been diagnosed with Fabry disease. Results The mean of the α-Gal A activity of the patients was 9.75 ± 3.20 nmol/h/ml, while the controls with classical Fabry (n = 3) were 0.52–1.04 nmol/h/ml. Among the patients, one patient was found to exhibit low α-Gal A activity in plasma (3.18 nmol/h/ml) and in leukocytes (0.639 nmol/h/mg). This patient was a 43-year-old Japanese man who had been on regular dialysis since the age of 23. He did not present typical clinical signs of classical Fabry, such as acroparesthesias or hypohidrosis, but did present renal insufficiency and severe left ventricular hypertrophy which had developed only recently, suggesting a variant form of Fabry disease. Sequencing of the DNA of this patient revealed a deletion of a single amino acid of valine in 10252. Conclusions A case of an atypical variant of Fabry among 450 male dialysis patients (0.22%) was found in the survey. This indicates the potential for undiagnosed Fabry disease among dialysis patients. The results of this study indicate the significance of screening for Fabry disease among male dialysis patients.     

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。     

Growth of children following the initiation of dialysis: a comparison of three dialysis modalities

Maintenance dialysis usually serves as an interim treatment for children with end-stage renal disease (ESRD) until transplantation can take place. Some children, however, may require dialytic support for an extended period of time. Although dialysis improves some of the problems associated with growth failure in ESRD (acidosis, uremia, calcium, and phosphorus imbalance), many children continue to grow poorly. Therefore, three different dialysis modalities, continuous ambulatory peritoneal dialysis (CAPD), cycler/intermittent peritoneal dialysis (CPD), and hemodialysis (HD), were evaluated with regard to their effects on the growth of children initiating dialysis and remaining on that modality for 6–12 months. Growth was best for children undergoing CAPD when compared with the other two modalities with regard to the following growth parameters: incremental height standard deviation score for chronological age [–0.55±2.06 vs. –1.69±1.22 for CPD (P<0.05) and –1.80±1.13 for HD (P<0.05)]; incremental height standard deviation score for bone age [–1.68±1.71 vs. –2.45±1.43 for CPD (P=NS) and –2.03±1.28 for HD (P=NS)]; change in height standard deviation score during the dialysis period [0.00±0.67 vs. –0.15±.29 for CPD (P=NS) and –0.23±.23 for HD (P=NS)]. The reasons why growth appears to be best in children receiving CAPD may be related to its metabolic benefits: lower levels of uremia, as reflected by the blood urea nitrogen [50±12 vs. 69±16 mg/dl for CPD (P<0.5) and 89±17 for HD (P<0.05)], improved metabolic acidosis, as indicated by a higher serum bicarbonate concentration [24±2 mEq/l vs. 22±2 for CPD (P<0.05) and 21±2 for HD (P<0.05)]. In addition, children undergoing CAPD receive significant supplemental calories from the glucose absorbed during dialysis. CAPD, and possibly, other types of prolonged-dwell daily peritoneal dialysis appear to be most beneficial for growth, which may be of particular importance for the smaller child undergoing dialysis while awaiting transplantation.     

Recombinant human erythropoietin dosage in children undergoing hemodialysis and continuous ambulatory peritoneal dialysis

The efficacy of erythropoietin (EPO) in 11 children on hemodialysis (HD) and 8 on continuous ambulatory peritoneal dialysis (CAPD) (mean age 11.8 years) was compared. The initial EPO dose was 50 U/kg s.c. once a week; the time of observation was 24 weeks. In the CAPD group, the mean hemoglobin (Hb) level increased from 7.7±0.2 to 11.2±0.6 g/dl (P< 0.001) and hematocrit (Hct) from 22.3±1.0 to 32.6±1.4% (P<0.001), while in the HD group the mean Hb rose from 7.7±0.6 to 9.3±0.8 g/dl (P<0.001) and mean Hct from 22.7±2.3 to 27.6±2.8% (P<0.001) after 12 weeks of observation. An increase in Hb to over 10 g/dl was obtained in 87.5% of children on CAPD but in only 10% on HD after 8 weeks of EPO treatment. After 12 weeks of treatment, all children on CAPD had the target Hb level of more than 10 g/dl, while 7 children on HD required increased doses of EPO (100 U/kg per week). We conclude that the EPO dose of 50 U/kg given s.c. once a week is effective for children with anemia on CAPD but is insufficient for children on HD. Received June 17, 1996; received in revised form January 24, 1997; accepted March 4, 1997     

Humoral immunity and frequency of peritonitis in chronic peritoneal dialysis patients

This study was designed to investigate the humoral immune status and immunological abnormalities in relation to the pathogenesis of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The levels of serum and dialysate total protein, immunoglobulins (IgG, IgA, IgM, and IgG subgroups), and C3 were measured at baseline and at the end of the study in 12 children and 10 adult patients on CAPD. The relationship between the levels of immunoglobulin and C3 and the frequency of peritonitis was investigated. Peritonitis occurred at a frequency of one episode every 3.9 and 6.3 patient-months in children at the beginning and at the end of the study, respectively; however, the respective rates for adult patients were one episode every 5.6 and 9.8 patient-months. The levels of serum immunoglobulin and C3 were normal in adults at the beginning and at the end of the study. However, the levels of serum IgG were low in 4 of 12 pediatric patients. Of the 4 patients with low total IgG, IgA was low in 1 and IgM was low in 2 patients. Of 4 patients with low total IgG, 2 also had low IgG1 and IgG2. However, 3 of the patients with normal IgG had low IgG2 levels at the end of the study. The levels of C3 were low in 6 of 12 and in 3 of 10 pediatric patients at the beginning and at the end of the study, respectively. The protein levels of dialysate were increased at 1-year follow-up in both groups, but the difference was only statistically significant in adult patients (P<0.05). No correlation was found between the levels of serum and dialysate immunoglobulin and the frequency of peritonitis in either group. In this study, hypogammaglobulinemia and hypocomplementemia were determined in pediatric patients undergoing CAPD. Although these immunological deficits are not major factors in the occurrence of CAPD-related peritonitis, they may contribute to the frequency of peritonitis. Received: 19 September 2000 / Revised: 7 February 2001 / Accepted: 24 August 2001     

Cellular response to peritonitis among peritoneal dialysis patients

White blood cell counts and differential cell counts were performed on 249 peritoneal dialysis effluents from 48 patients using chronic peritoneal dialysis. The finding of more than 50% polymorphonuclear leukocytes in the dialysate was a more sensitive indicator of peritonitis than was an absolute cell count of 100 cells/microL. This finding was true for patients using intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, and continuous cycling peritoneal dialysis.     

Tuberculosis in children undergoing continuous ambulatory peritoneal dialysis

The incidence of tuberculosis (TB) is increasing worldwide. Due to an impairment of cellular immunity, patients with chronic renal failure are susceptible to reactivation of TB. Seventy patients were treated by continuous ambulatory peritoneal dialysis (CAPD) in our pediatric nephrology department during the years 1989–1997. TB was diagnosed in 4 patients, representing 5.7% of all CAPD patients in our department. One patient had extrapulmonary (TB osteomyelitis) and the others had pulmonary TB. All patients were treated with antituberculous drugs.Two patients with pulmonary TB were cured. Symptoms improved in the other 2 patients but they died at home for unknown reasons. We recommend that all children in regions of high prevalence of TB should be investigated for TB, especially if they have a cough or fever of unknown etiology. Received: 13 January 1998 / Revised: 7 December 1998 / Accepted: 11 December 1998     

Intraperitoneal pressure and hernias in children on peritoneal dialysis

Abdominal wall hernias have been increasingly recognized in patients on continuous ambulatory peritoneal dialysis (CAPD). They are also more frequent in children than in adults. The aim of this study was to determine the influence of intraperitoneal pressure (IPP) on the development of hernias in children on CAPD, and if there was a difference between IPP in children and adults. We studied 14 children aged 11.2±3.2 years, body weight 31.1±9.4 kg, who had undergone CAPD for 16.2±14.4 months. Also, 10 adults were studied, aged 48±18 years, body weight 62.4±13.9 kg, on the CAPD program for 35±27 months. The IPP was measured via a column of dialysate in the peritoneal dialysis line, immediately before the drainage of the peritoneal cavity. The pressure was measured with the patients in the supine position, at the level of the umbilical cicatrix with the zero point located on the mean axillary line. IPP was measured at inspiration and at expiration, and the mean of these two measurements was calculated. The children were divided in two groups : group 1 (n=7) without hernias and group 2 (n=7) with hernias (5 umbilical and 2 inguinal). The IPP of all children was 9.5±2.9 cm H₂O. The IPP was 8.1±2.6 and 10.9±2.6 cm H₂O in groups 1 and 2, respectively (P=0.003). The instilled volume for test was similar in both groups. The IPP of the adults was 13.8±2.8 cm H₂O, which was significantly greater than that of the children (P=0.001). In conclusion, hernia is a common complication in children on CAPD and its prevalence is affected by IPP. Other associated factors may be the presence of anatomically weak sites in the abdominal wall of the children, since IPP is lower in children than in adults. Received: 20 July 1998 / Revised: 26 January 1999 / Accepted: 26 January 1999     

腹膜透析病人合并腹壁疝的临床诊治体会

目的：探讨慢性肾功能衰竭行腹膜透析病人合并腹壁疝者的围手术期治疗方案。方法：2002年1月至2008年7月间285例慢性肾功能衰竭行腹膜透析者中,有45例（15.8%）并发腹壁疝,研究其诊断与治疗方法。其中单侧腹股沟疝20例,脐疝17例,切口疝4例,白线疝1例,腹股沟疝合并脐疝2例,双侧腹股沟疝1例。所有病人均施行腹壁疝无张力修补手术,术后24h后即进行自动化腹膜透析,不常规进行临时替代性血液透析。结果：45例病人共施行了48例次疝修补术,平均手术时间（63±38）min,术后住院4（1～26）d。48例次手术中有7例（14.6%）术后出现并发症,包括切口感染2例、切口出血2例、阴囊水肿2例、腹膜炎1例,经相应治疗后均痊愈。45例病人均得到有效随访,平均随访时间（29±21）个月。术后有38例（84.4%）病人继续行腹膜透析,随访中无病人出现腹壁疝复发或腹透液渗漏。结论：行腹膜透析中病人合并存在腹壁疝者应使用补片进行无张力修补术。术后过渡期内使用自动化腹膜透析可有效避免使用临时替代性血液透析。     

Natural changes in peritoneal equilibration test results in continuous ambulatory peritoneal dialysis patients: a retrospective, seven year cohort survey

We conducted a retrospective, 7 year cohort survey to examine the natural changes in peritoneal equilibration test (PET) results in patients with long-term uneventful continuous ambulatory peritoneal dialysis (CAPD). Thirty-two (17 males, 15 females) patients on CAPD with two or more standard PETs performed more than 6 months apart, in the absence of peritoneal insult, were included. Changes and pattern of PET results were evaluated by the dialysate to plasma ratio of creatinine (D:P-cre), the fourth h dialysate to instilled glucose ratio (D4:Do) and ultrafiltration volume (UF, ml). The subgroups included high (H), high-average (HA), low-average (LA), or low (L) transporters with the dividing ratios (D:P-cre) of >0.81, >0. 65 to 0.81, >0.5 to 0.65, and <0.5, respectively. The median D:P-cre significantly decreased (p = 0.04), but neither the D4:Do nor the final median UF significantly decreased. The change in D:P-cre was strongly and inversely correlated with the initial D:P-cre value (r = -0.68; p < 0.05). A similar relationship was found between the change in the final D4:Do and the initial D4:Do (r = -0.752; p < 0. 01) and between the change in the final UF and the initial UF (r = -0.875; p < 0.01). No correlation was found between the change in D:P-cre and the age of the patient, the time interval between PETs, monthly dialysate glucose exposure, or underlying diabetes/non-diabetes. The final peritoneal transport pattern was altered with 5 (15.6%) patients remaining in the extreme subgroups (H or L) and, by contrast, 84.4% (27/32) of the patients now in the averaged (HA or LA) groups (p < 0.01, chi2 test). We demonstrated a natural "centralization" migration of PET results after long-term uneventful CAPD, which may help to explain why patients with extreme PET characteristics, that is, H or L, continued to do well on CAPD.     

Tuberculous lymphadenitis in patients undergoing continuous ambulatory peritoneal dialysis

The aim of this study was to review the clinical features of tuberculous (TB) lymphadenitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Nine cases of TB lymphadenitis were diagnosed among 910 patients over a period of 10 years. There were five men and four women with a mean age of 51 ± 15.5 years. The TB lymphadenitis involved the cervical lymph nodes in six patients, supraclavicular lymph nodes in two patients and mediastinal lymph nodes in one patient. Six patients presented with clinically enlarged lymph nodes of whom four also had fever. Three other patients were incidentally found to have enlarged lymph nodes on routine chest X-ray or ultrasound examination of the neck. Diagnosis of TB lymphadenitis was made by demonstrating caseating granulomata with or without positive acid-fast bacilli on excisional lymph node biopsy. All patients were cured with standard anti-tuberculosis drugs for 12 months. No recurrence of the TB lymphadenitis was observed after a mean follow-up of 59 ± 30 months. We conclude that TB lymphadenitis is not uncommon among patients on CAPD. A high index of suspicion is needed for early diagnosis of this condition. Prompt initiation of anti-tuberculosis treatment is associated with good prognosis.     

Chronic peritoneal dialysis in paediatrics: Experience of a national registry

The results of the first 3 year' collaboration of the Italian Registry of Paediatric Chronic Peritoneal Dialysis (CPD) (1986–1988) are presented. This Registry acquired data on the majority of the paediatric patients treated with CPD in Italy, thus providing a national picture in a field where few nationwide surveys are available. Patients of less than 15 years of age at the start of dialysis were enrolled and clinical data collected until the age of 19 years. The number of nephrological paediatric centres participating in the Registry increased from 7 in 1986 to 11 in 1988. The total number of patients on CPD was 70 and the percentage of dialysed children treated with CPD ranged from 40.2% to 43.6%. Data on 89 peritoneal catheters were collected: during 1417 dialysis-months 70 catheter-related complications were observed (1:20.8 dialysis-months); actuarial catheter survival was 92.7% at 6 months, 84.8% at 1 year and 68.8% at 2 years. The incidence of peritonitis changed from 1 episode every 10.9 patient-months in 1986 to 1 every 19.8 in 1988. Abdominal hernias were the other main clinical complication observed. The survival of patients was 92.5% at 3 years, while the technique survival at the same time was 84%.     

One year's experience with recombinant erythropoietin in children undergoing continuous ambulatory or cycling peritoneal dialysis

Fourteen patients (aged 5.9–22.1 years) undergoing continuous ambulatory or cycling peritoneal dialysis were treated with recombinant human erythropoietin (rhEPO), which was given intravenously once a week at a dosage of 300 units/kg. The mean haematocrit level increased from 18.5% to 27.5% and the reticulocyte count from 19 to 62 within 1 month. After an average time of 3.1 months rhEPO dosage could be adjusted to 100 units/kg per week to keep the haematocrit level at 30%. Only 1 patient had an exacerbation of hypertension, which required a dosage reduction; other side-effects were not noted.     

Peritonitis in continuous ambulatory peritoneal dialysis in children living in Saudi Arabia

The clinical aspects of peritonitis and catheter infections were reviewed in 64 children on continuous ambulatory peritoneal dialysis living in Saudi Arabia over a period of 6 years. Peritonitis occurred in 41 children (64%). The mean time from starting dialysis to the first episode of peritonitis was 7.2 months. The incidence of peritonitis was 1 episode in 9 treatment months. Gram-negative organisms were responsible for the majority of episodes (42%), followed by Gram-positive organisms (20%), and Candida albicans (6%); 32% were culture negative. Recurrent peritonitis was present in 20 cases. Catheter was replaced in 24 patients: 44% due to recurrent peritonitis. Peritoneal membrane loss occurred in 7 patients, 3 had Candida peritonitis and 3 had recurrent peritonitis due to Pseudomonas. The mortality rate was 4.6% but none of the deaths were related to peritonitis or dialysis. Received August 23, 1995; received in revised form October 2, 1996; accepted October 18, 1996     

Zinc and copper balance in children on continuous ambulatory peritoneal dialysis

We monitored serum zinc and copper levels for 4 months in six patients treated with continuous ambulatory peritoneal dialysis (CAPD). Zinc and copper fluxes were studied during a single dialysis exchange and over a 3-day period. Routine oral trace element supplements were then discontinued for 2 months. Serum zinc levels declined but serum copper levels remained unchanged. One month after oral supplements had been restarted, serum zinc levels returned to normal and serum copper levels rose above initial values. Zinc and copper concentrations in dialysis exchange indicated that the patients absorbed zine and lost copper in significant amounts. The patients had poor dietary intakes of both minerals. These data suggest that patients treated with CAPD benefit from oral zinc supplementation.     

Laparoscopic introduction of a continuous ambulatory peritoneal dialysis (capd) catheter by a two-puncture technique

We describe a laparoscopic two-puncture technique for the placement of a continuous ambulatory peritoneal dialysis catheter. With a mean follow-up period of 8 months the short-term results of the first 19 laparoscopic catheter insertions are evaluated and discussed. It appears to be a simple, safe, and viable procedure with a low morbidity and very good results in the short term. The same technique can also be used in catheter salvage in case of outflow obstruction or cathether migration, thus increasing catheter longevity.     

Cefepime-induced non-convulsive status epilepticus in a peritoneal dialysis patient

Non-convulsive status epilepticus related to cefepime has not been reported in childhood dialysis patients, although several adult cases have been reported. We report a state of acute confusion in a 15-year-old boy on continuous ambulatory peritoneal dialysis (CAPD) receiving cefepime that was diagnosed as status epilepticus by electroencephalography (EEG). The EEG improved after anticonvulsive therapy. All clinical symptoms disappeared dramatically within 24 h of discontinuation of cefepime. The differential diagnosis of confusional states and the mechanisms of the convulsive effects of antimicrobials in chronic renal failure are discussed. The importance that the clinician is aware of the rare side effects of antimicrobials is emphasized.