非卧床持续性腹膜透析方法治疗尿毒症56例临床分析

目的探究分析非卧床性持续性腹膜透析(CAPD)的方法用于治疗尿毒症的临床效果。方法对我院2012年6月~2013年6月行非卧床持续性腹膜透治疗的56例尿毒症患者观察其治疗前后生化指标、生存率、并发症及生活质量的变化。结果接受CAPD后BUG、CR、SCR指标下降,感染及心血管疾病并发症降低,临床症状改善率增加,生活质量有所提高。结论CAPD治疗尿毒症简易、安全、有效,价格低廉,患者的生活质量也有明显的提高。     

Modified Peritoneal Dialysis Catheter Insertion: Comparison with a Conventional Method

Purpose

The conventional trocar and cannula method in peritoneal dialysis (PD) catheter insertion has its limitation in clinical setting. The aim of this study was to compare a modified method for percutaneous PD catheter insertion with the conventional method, and demonstrate advantages of the modified method.

Materials and Methods

Patients at a single center who had percutaneous PD catheters inserted by nephrologists from January 2006 until September 2012, using either a modified method (group M) or the conventional trocar and cannula method (group C), were retrospectively analyzed, in terms of baseline characteristics, complications experienced up to 3 months after the procedure, and the suitability of the procedure for patients.

Results

Group M included 82 subjects, while group C included 66 cases. The overall early complication rate in group M (1.2%) was significantly lower than that in group C (19.7%) (p<0.001). The catheter revision rate during timeframe for early complications was significantly lower in group M (0%) than in group C (6.1%) (p=0.024). When comparing Procedure time (1 h 3 min±16 min vs. 1 h 36 min±19 min, p<0.01), immediate post-procedural pain (2.43±1.80 vs. 3.14±2.07, p<0.05), and post-procedure days until ambulation (3.95±1.13 days vs. 6.17±1.34 days, p<0.01), group M was significantly lower than group C. There was no significant difference in total hospitalization period (14.71±7.05 days vs. 13.86±3.7 days).

Conclusion

Our modified PD catheter insertion method shows its advantages in early complication rate, early complications revision rate, and the patients'' conveniences.     

Comparing Survival between Peritoneal Dialysis and Hemodialysis Patients with Subclinical Peripheral Artery Disease: a 6-Year Follow-Up

Peripheral artery disease (PAD) is known to be an increased mortality risk in patients with end-stage renal disease (ESRD). The aim of this study was to compare patient survival between patients with subclinical PAD undergoing peritoneal dialysis (PD) and hemodialysis (HD). Subclinical peripheral artery was defined as an ankle-brachial index of less than 0.9. This study was conducted from April 2005, and the observation period ended on 30 June 2011. At the end of the follow-up, the status of all patients was assessed and data on mortality were obtained for the entire cohort. A total of 91 patients (61 HD and 30 PD) were included for analyses in this study. Mortality rate was 60.0% (18/30) for PD and 52.5% (32/61) for HD. Kaplan-Meier estimate demonstrate that PD patients had a higher mortality rate than those underwent HD (log-rank p = 0.0039). Cox regression model demonstrated that PD was an independent predictor for further mortality in ESRD patients with subclinical peripheral artery disease.(p = 0.012, HR: 1.776, 95% CI: 1.136-2.775). In multivariate analysis, the HD group still had a greater survival than PD group (p = 0.005, HR:1.916, 95% CI: 1.218-3.015). In patients with subclinical peripheral artery disease, the patient survival is better in HD patients as compared with PD patients.     

Predicting One-Year Mortality in Peritoneal Dialysis Patients: An Analysis of the China Peritoneal Dialysis Registry

This study aims to investigate basic clinical features of peritoneal dialysis (PD) patients, their prognostic risk factors, and to establish a prognostic model for predicting their one-year mortality. A national multi-center cohort study was performed. A total of 5,405 new PD cases from China Peritoneal Dialysis Registry in 2012 were enrolled in model group. All these patients had complete baseline data and were followed for one year. Demographic and clinical features of these patients were collected. Cox proportional hazards regression model was used to analyze prognostic risk factors and establish prognostic model. A validation group was established using 1,764 new PD cases between January 1, 2013 and July 1, 2013, and to verify accuracy of prognostic model. Results indicated that model group included 4,453 live PD cases and 371 dead cases. Multivariate survival analysis showed that diabetes mellitus (DM), residual glomerular filtration rate (rGFR), , SBP, Kt/V, high PET type and Alb were independently associated with one-year mortality. Model was statistically significant in both within-group verification and outside-group verification. In conclusion, DM, rGFR, SBP, Kt/V, high PET type and Alb were independent risk factors for short-term mortality in PD patients. Prognostic model established in this study accurately predicted risk of short-term death in PD patients.     

Citrobacter Peritoneal Dialysis Peritonitis: Rare Occurrence with Poor Outcomes

Introduction: Non-Pseudomonas gram-negative bacteria are responsible for an increasing proportion of cases of peritoneal dialysis (PD)-related peritonitis. The role of Citrobacter species in the etiology of PD-related peritonitis is often underestimated. In the present study, we aimed to describe the clinical features, laboratory findings, and short- and long-term outcomes in PD-related peritonitis caused by Citrobacter.Methods: A retrospective review of all episodes of PD-related peritonitis caused by Citrobacter from a single center between 1990 and 2010 was performed. Clinical features, microbiological data, and outcomes of these episodes were analyzed.Results: Citrobacter species was responsible for 11 PD-related episodes (1.8% of all peritonitis episodes) in 8 patients. Citrobacter freundii was the most common etiologic species (73%), and mixed growth was found in the other 3 episodes (27%). Approximately half (46%) of the episodes were associated with constipation and/or diarrhea. Of the Citrobacter isolates from all episodes, 54% were resistant to cefazolin, and only 18% were susceptible to cefmetazole. All isolates were susceptible to ceftazidime, cefepime, carbapenem, and aminoglycosides. More than half of the patients (54%) were hospitalized for index peritonitis, and 27% of the episodes involved a change in antibiotic medication. One patient had relapsing peritonitis caused by C. koseri (9%). The mortality rate of PD-related peritonitis caused by Citrobacter was 18%, and 89% of surviving patients developed technique failure requiring a modality switch after an average of 12 months of follow-up (range 1.2-31.2 months).Conclusion: PD-related peritonitis caused by Citrobacter is associated with poor outcomes, including high rates of antibiotic resistance, a high mortality rate, and a high rate of technique failure among survivors during the follow-up period.     

肾衰竭持续性自动腹膜透析充分性的智能评价方法

透析充分性是肾衰竭腹膜透析治疗过程中的重要评价依据。首先详细分析了临床症状、KT／V（尿素清除率）、Ccr（肌酐清除率）、营养状态等主要因素对透析充分性的影响，然后建立了一种基于模糊逻辑的综合评价数学模型，并根据各种相关因素对持续性自动腹膜透析（CAPD）治疗过程中透析充分性的影响程度进行模糊化后再做出综合评价。临床实例分析表明，该模糊综合评价方法比单纯利用KT／V和Ccr两种指标来评价的准确率更高，实用性更好。     

血清Cys C测定对于判断早期肾功能损害的应用评价

目的：探讨血清胱抑素蛋白酶抑制剂C（CysC）在早期肾功能损害判断中的相关性评价。方法：运用已建立的颗粒增强免疫透射比浊法测定血清CysC,测定了116例慢性肾脏病患者血中的CysC浓度,同时分别测定了患者血中的Cr、UAER、β2-m常规检测项目,以48例健康人作为对照。结果：慢性肾脏病患者与正常对照组比较及肾功能损害不同时期比较CysC差异有显著意义,各检测指标与Ccr呈相关性,且CysC与Ccr的相关性优于其它指标。结论：血清CysC浓度在慢性肾脏病患者肾功能不同损害期均能准确反映Ccr,即能准确反映肾小球滤过功能,尤其能敏感提示早期肾功能损害,可成为判断肾功能损害程度的敏感指标。     

Palliative Care for Patients with Malignancy and End-Stage Renal Failure on Peritoneal Dialysis

Background:

Many patients on peritoneal dialysis experience a poor quality of life because of a high burden of comorbid conditions. Dialysists must pay more attention to reducing a patient''s pain and suffering, both physical and psychological and improve the quality of life for the patients as much as possible. A consensus regarding eligibility for palliative care and the delivery of these inventions does not currently exist.

Objective:

The present study aimed to describe the implementation of palliative care for end-stage renal failure patients on peritoneal dialysis.

Design:

A report on three cases.

Materials and Methods:

This study included three outpatients on peritoneal dialysis who received palliative care and died between January 2008 and June 2010.

Measurements:

The patients'' comorbidities, nutritional status, and functional status were evaluated using the Charlson comorbidity score, subjective global assessment, and Karnofsky Performance Score index, respectively. The Hamilton depression and Hamilton anxiety scales were also employed. The patients'' clinical manifestations and treatments were reviewed.

Results:

Each patient displayed 11-16 symptoms. The Charlson comorbidity scores were from 11 to 13, the subjective global assessment indicated that two patients were class assigned to “C” and one to class “B”, and the mean Karnofsky index was <40. Among these patients, all experienced depression and two experienced anxiety, Low doses of hypertonic glucose solutions, skin care, psychological services, and tranquillizers were intermittently used to alleviate symptoms, after making the decision to terminate dialysis. The patients died 5 days to 2 months after dialysis withdrawal.

Conclusion:

The considerable burden associated with comorbid conditions, malnutrition, poor functional status, and serious psychological problems are predictors of poor patient prognoses. Withdrawal of dialysis, palliative care, and psychological interventions can reduce patient distress and improve the quality of life before death, with the care provided.     

Coxsackievirus B1 peritonitis in a patient treated with continuous ambulatory peritoneal dialysis: a case report and brief review of the literature

We report a case of viral peritonitis caused by coxsackievirus B1 in a 79-year-old male undergoing continuous ambulatory peritoneal dialysis (CAPD), and review the English language literature. Clinicians should be aware of viral peritonitis in patients on CAPD presenting with a viral syndrome and mononuclear peritoneal dialysis effluent. Currently, viral diagnostic tests are available to confirm the diagnosis and avoid unnecessary treatment with antibiotics.     

小白鼠腹腔渗出细胞吞噬功能的研究

本实验比较糖元、鸡红细胞及两者复合使用对小鼠腹腔渗出细胞的影响,结果表明鸡红细胞和糖元一样能激活巨噬系和组织嗜碱系细胞,影响巨噬系细胞分化,鸡红细胞较糖元快;而影响组织嗜碱系细胞分化,糖元较鸡红细胞快。由于腹腔渗出细胞中存在原、幼巨噬细胞,按照血细胞发育是不可逆回的理论,推测腹腔巨噬细胞不是来源于血液循环中的单核细胞,而是来自血循环中的定向干细胞。本实验在腹腔渗出细胞中,首次发现组织嗜碱系细胞并描写其形态特征。     

腹膜透析机恒温控制系统的研制

作者介绍了腹膜透析机恒温控制系统的工作原理以及各个部件的特点。８０年代发展起来的连续循环腹膜透析技术提高了腹透防感染性能，提高了腹透精确度，减轻了医务人员的工作强度，而且向透析家庭化这个世界发展方向迈进一大步，我们研制的恒温控制系统，是ＣＣＰＤ系统中重要组成部分，经模拟实验证明，该系统操作简单运行准确，系统的所有部件全部国产化，便于批量生产。     

An Unusual Case of Unresolving Tunnel Infection in a Patient on Continuous Ambulatory Peritoneal Dialysis

Atypical mycobacteria remain a rare cause of peritoneal dialysis catheter-related tunnel infection (TI) and poses serious risk because of the resistant nature to most antibiotic therapy. Non-tubercular mycobacterial infections lead to chronicity requiring peritoneal dialysis catheter removal. We report an 82-year-old male, with diabetic nephropathy who had a coinfection with Staphylococcus hominis and Mycobacterium abscessus who presented with pus discharge at exit site and TI. He was treated with relocation of the extraperitoneal part of the catheter with a new exit site without catheter removal and multidrug mycobacterial therapy.     

The Prognostic Value of Abdominal Aortic Calcification in Peritoneal Dialysis Patients

Objective: This study evaluated the prognostic value of the aortic calcification index (ACI), an estimate of abdominal aortic calcification by plain abdominal computed tomography (CT), in terms of left ventricular (LV) diastolic dysfunction, mortality, and nonfatal cardiovascular (CV) events in peritoneal dialysis (PD) patients.Method: PD patients who received both abdominal CT and echocardiography were divided into a low-ACI group (n=46) and a high-ACI group (n=46).Results: During follow-up (median, 35.2 months; range, 3.6 - 111.3), 30 patients (32.6%) died and 10 patients (10.9%) developed nonfatal cardiovascular (CV) events. The 5-year event-free survival rates for mortality and nonfatal CV events were significantly lower in the high-ACI group compared with those in the low-ACI group (35.7% vs. 64.1%, P = 0.01). The ACI was positively correlated with left atrial diameter and ratio of peak early transmitral flow velocity to peak early diastolic mitral annular velocity (E/E'' ratio; a marker of left ventricular diastolic function). Using multivariate analyses, the high-ACI group (vs. low-ACI group, HR 5.25, 95% CI 1.77 - 15.58, P = 0.003) and increased E/E'' ratio (HR 1.16, 95% CI 1.03 - 1.31, P = 0.013) were independent predictors for mortality and CV events. The ACI provided a higher predictive value for adverse outcomes (AUC = 0.755, P = 0.002) than the E/E'' ratio (AUC = 0.543, P = 0.61).Conclusion: The ACI was significantly associated with left ventricular diastolic dysfunction and predicted all-cause mortality and nonfatal CV events in PD patients.     

Compliance Index,a Marker of Peripheral Arterial Stiffness,may Predict Renal Function Decline in Patients with Chronic Kidney Disease

Background: Compliance index derived from digital volume pulse (CI-DVP), measuring the relationship between volume and pressure changes in fingertip, is a surrogate marker of peripheral arterial stiffness. This study investigated if CI-DVP can predict renal function deterioration, cardiovascular events and mortality in patients with chronic kidney disease (CKD).Methods: In this prospective observational study, 149 CKD patients were included for final analysis. CI-DVP and brachial-ankle pulse wave velocity (baPWV) were measured, decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope. Composite renal and cardiovascular outcomes were evaluated, including ≥50% eGFR decline, start of renal replacement therapy, and major adverse events.Results: Patients in CKD stages 3b to 5 had higher baPWV and lower CI-DVP values than those in patients with CKD stages 1 to 3a. Stepwise multivariate linear regression analysis showed that lower CI-DVP (p =0.0001) and greater proteinuria (p =0.0023) were independent determinants of higher eGFR decline rate. Multivariate Cox regression analysis revealed that CI-DVP (HR 0.68, 95% CI 0.46-1.00), baseline eGFR (HR 0.96, 95% CI 0.94-0.98) and serum albumin (HR 0.17, 95% CI 0.07-0.42) were independent predictors for composite renal and cardiovascular outcomes.Conclusions: Compliance index, CI-DVP, was significantly associated with renal function decline in patients with CKD. A higher CI-DVP may have independent prognostic value in slower renal function decline and better composite renal and cardiovascular outcomes in CKD patients.     

Increased Expression of CD25 and HLA-DR on Lymphocytes Recruited into the Peritoneal Cavity in Non-Infected CAPD Patients

The impact of uremia per se, peritoneal dialysis (PD) and hemodialysis (HD) treatment was evaluated on characteristics of lymphocytes. CD4, CD8, CD25 and HLA-DR were analyzed, with flow cytometry, in lymphocytes prepared from peripheral blood of uremic (n = 10) and hemodialysis patients (n = 10). Peritoneal dialysate was also obtained from patients on CAPD (n = 12). A decreased relative and absolute lymphocyte count was observed in peripheral blood from uremic, HD and CAPD patients compared to healthy controls (p < 0.03, p < 0.03 and p < 0.02, respectively). On the other hand, the relative distribution of lymphocytes was significantly higher in peritoneal dialysate compared to peripheral blood of CAPD patients (p < 0.02). Likewise, the absolute CD4 positive lymphocyte count was lower in the peripheral blood from uremic, HD and CAPD patients as compared to healthy controls (p < 0.001, respectively). In CAPD patients the relative distribution of CD4 positive cells (p < 0.001) was lower, while quantitative CD25 level (p < 0.01) and the relative count of HLA-DR (p < 0.0001) was increased in the peritoneal dialysate compared to blood. Taken together a selective activation of lymphocytes in peritoneal dialysate as compared to peripheral blood from uremic, HD and CAPD patients was observed. The altered biological function of the inflammatory cells may therefore explain the increased susceptibility to infectious diseases.     

Agreements between indirect calorimetry and prediction equations of resting energy expenditure in end-stage renal disease patients on continuous ambulatory peritoneal dialysis

Purpose

Equations are frequently used to estimate resting energy expenditure (REE) in a clinical setting. However, few studies have examined their accuracy in end-stage renal disease (ESRD) patients.

Materials and Methods

To investigate agreement between indirect calorimetry and several REE estimating equations in 38 ESRD patients on peritoneal dialysis, we performed indirect calorimetry and compared the results with REEs estimated using 5 equations [Harris-Benedict (HBE), Mifflin, WHO, Schofield, and Cunningham].

Results

Measured REE was 1393.2 ± 238.7 kcal/day. There were no significant differences between measured and estimated REEs except Mifflin (1264.9 ± 224.8 kcal/day). Root mean square errors were smallest for HBE, followed by Schofield, Cunningham, and WHO, and largest for Mifflin (171.3, 171.9, 174.6, 175.3, and 224.6, respectively). In Bland-Altman plot, correlation coefficients between mean values and differences were significant for HBE (r = 0.412, p = 0.012) and tended to be significant for Cunningham (r = 0.283, p = 0.086). In DM patients and patients with overhydration, HBE showed significant underestimation when REE increased.

Conclusion

In ESRD patients on continuous ambulatory peritoneal dialysis (CAPD), REE-estimating equations have no significant differences from indirect calorimetry, except Mifflin. However, HBE showed greater bias than others when REE was high.     

腹膜透析患者体重指数与预后的关系

目的初步探讨体重指数(BMI)对腹膜透析(PD)患者预后的影响。方法119例1999年1月起始行PD治疗患者,按BMI分为低体重组(BMI<20kg/m2)、正常体重组(20≤BMI<25kg/m2)及超重肥胖组(BMI≥25kg/m2)。采集这些患者的年龄、性别、RRF、Kt/V、血清白蛋白(SA)、Hb、CRP、心血管并发症以及转归等,并进行回顾性分析。结果与正常体重的PD患者相比,低体重者死亡率较高(42.11%对21.67%,P<0.05),而超重肥胖患者预后更差(52.5%对21.67%,P<0.01)。超重肥胖的PD患者心血管并发症的死亡率明显高于正常体重者(P<0.01)。Pearson相关分析发现,这些PD患者的BMI与其CRP(r=0.79,P<0.01),SA(r=0.58,P<0.01),Hb(r=0.32,P<0.05)呈正相关,而与其Kt/V(r=-0.36,P<0.05)负相关。Cox比例风险模型显示,BMI≥25kg/m2与PD患者死亡率独立相关(风险比例,1.31;95%可信限,1.20￣1.54;P<0.05)。结论低体重、尤其是超重肥胖PD患者预后不佳,BMI≥25kg/m2是值得关注的死亡危险因素。     

核素^99mTc—DTPA测定GFR与公式估算GFR的相关性研究

目的：探讨核素^99mTc—DTPA测定GFR与MDRD公式、简化MDRD公式估算GFR的相关性。方法：178例CKD患者，用核素^99mTc—DTPA测定GFR，同时测定血清肌酐、尿素氮和白蛋白，根据年龄和性别分别用MDRD和简化MDRD公式估算GFR。结果：核素^99mTc—DTPA测定的GFR与MDRD公式估算的GFR有显著性差异，P=0．0001，MDRD公式高估了GFR；核素^99mTc—DTPA测定的GFR与简化MDRD公式估算的GFR亦有显著性差异，P=0．0001，简化MDRD公式低估了GFR；MDRD公式估算的GFR与核素^99mTc—DTPA测定的GFR呈正相关，r=0．8292，P〈0．01；简化MDRD公式估算的GFR与核素^99mTc—DTPA测定的GFR值呈正相关，r=0．8277，P〈0．01。结论：MDRD公式、简化MDRD公式估算的GFR与核素^99mTc—DTPA测得的GFR有差异，需进一步校正后用于估算GFR。     

Association of Pre- and Post-Donation Renal Function with Midterm Estimated Glomerular Filtration Rate in Living Kidney Donors: A Retrospective Study

PurposeThe estimated glomerular filtration rate (eGFR) at 6 months after donation (eGFR_6m) is strongly associated with the risk of end-stage renal disease in living kidney donors. This study aimed to investigate the incidence of eGFR_6m <60 mL/min/1.73 m² (eGFR_6m <60) and identify the risk factors that can predict the occurrence of eGFR_6m <60 in living kidney donors.Materials and MethodsLiving kidney donors who underwent nephrectomy at Severance Hospital between January 2009 and December 2019 were identified. We excluded 94 of 1233 donors whose creatinine values at 6 months after donation were missing. The risk factors for eGFR_6m <60 were assessed using multivariate regression analysis. The optimal cutoff points for candidate risk factors for predicting eGFR_6m <60 occurrence were determined using the Youden index.ResultsThe eGFR_6m <60 occurred in 17.3% of the participants. Older age (≥44 years), history of hypertension, lower preoperative eGFR (<101 mL/min/1.73 m²), and degree of increase in creatinine levels on postoperative day 2 compared to those before surgery (ΔCr2_pre) (≥0.39 mg/dL) increased the risk of eGFR_6m <60. The addition of ΔCr2_pre to preoperative eGFR yielded a higher predictive accuracy for predicting eGFR_6m <60 than that with preoperative eGFR alone {area under the receiver operating characteristic curve=0.886 [95% confidence interval (CI), 0.863–0.908] vs. 0.862 (95% CI, 0.838–0.887), p<0.001}.ConclusionThe incidence of eGFR_6m <60 was 17.3%. Older age, lower preoperative eGFR, history of hypertension, and greater ΔCr2_pre were associated with the occurrence of eGFR_6m <60 after living donor nephrectomy. The combination of preoperative eGFR and ΔCr2_pre showed the highest predictive power for eGFR_6m <60.     

Impact of Renal Dysfunction on Clinical Outcomes of Acute Coronary Syndrome

Purpose

The present study aimed to compare the clinical outcomes and to investigate prognostic factors of acute coronary syndrome (ACS) in patients with renal dysfunction (RD).

Materials and Methods

The study was a retrospective cohort of 648 adult patients admitted with ACS between October 2005 and December 2006. The estimated glomerular filtration rate (GFR) was classified into 4 levels: 1) normal, GFR greater than 90 mL/min/1.73 m²; 2) mild RD, GFR of 60 to 90 mL/min/1.73 m²; 3) moderate RD, GFR of 30 to 60 mL/min/1.73 m²; and 4) severe RD, GFR less than 30 mL/min/1.73 m². Primary end points were death and complication in hospital courses. Secondary end points were major adverse cardiac event (MACE) during follow-up.

Results

The median follow-up was 505 ± 183 days, the mean age was 63 ± 12 years, and 71.8 percent of the group were men. A graded association was observed between severity of RD and clinical outcomes. Severe RD independently predicted MACE [hazard ratio, 2.731; 95% confidence interval (CI), 1.058 to 7.047, p = 0.038]. Low hemoglobin level was also an independent risk factor for MACE (hazard ratio, 1.155; 95% CI, 1.020 to 1.307, p = 0.022). Use of lipid-lowering therapy (hazard ratio, 0.456; 95% CI, 0.242 to 0.857, p = 0.015) was associated with reduced risk for MACE.

Conclusion

Severe RD and low hemoglobin level were an independent risk factors for the mortality and complications of ACS, while lipid-lowering therapy was associated with reduced risk.