残余肾功能状态是选择腹膜透析的关键

近十多年来,无论是血液透析(HD)还是腹膜透析(PD)均在自身技术上有了飞速发展。随着研究的深入,越来越多的观察发现两种透析模式在不同类型的终末期肾病(ESRD)患者中疗效相差甚远。对于残余尿量较多的ESRD患者,PD不仅能     

腹膜透析患者与残余肾功能

尽管大量研究表明,腹膜透析(PD)和血液透析(HD)患者相比长期存活率并无差别,但大多数国家和地区的注册资料均显示,PD治疗2～3年后,患者退出率明显高于HD,其主要原因是随着透析年限的延长,患者的残余肾功能逐渐下降,导致患者清除水及毒素的能力下降。     

残余肾功能对腹膜透析的影响

３８例腹透患者８０例次的观察研究显示，患者的残余肾肾功能与透析效能，营养状况呈正相关。当ＲＲＦ〉２ｍｌ／ｍｉｎ时，经残余肾清除的尿素氮和肌酐占整个透析排出量的３０％以上，个别患者可达４５％。     

残余肾功能状态对腹膜透析效能的影响

目的:前瞻性观察终末期肾衰(ESRF)患者在腹膜透析(PD)治疗后残余肾功能(RRF)对透析效能及相关临床指标之间的影响。方法:所有患者按残余肾小球滤过率(rGFR)水平将其分为A组(GFR0~2ml/min)、B组(GFR2·1~4ml/min)和C组(GFR>4ml/min)。每3个月进行一次临床随访,全面评估患者的全身情况及透析状态,包括血压、身高、体重、体重指数(BMI)、尿量(UV)、残余肾肌酐清除率(Ccr)、每周总尿素氮表现率(Kt/Vtotal)、每周肌酐总清除率(WCcrtotal)、蛋白氮呈现率(nPNA)、残余肾尿素及Ccr。对比观察不同RRF状态患者透析状况和部分临床及生化指标变化。尿量<100ml/d或Ccr<1·0ml/min视为无尿。结果:三组不同残肾状态患者Kt/vtotal和Ccr分别为1·75±0·35、2·07±0·54、2·46±0·50和53·4±11·2、66·6±11·2、97·6±22·1(L/Wks),各组之间差异非常显著(P<0·001)。三组不同残余肾Kt/v和Ccr分别占总体kt/v的12·4%、27%、45·7%及总体Ccr的18·3%、47·3%和65·3%,三组间相比差异亦显著(P<0·01)。此外,三组间高血压发生率、心胸比例及左心室肥厚(LVH)亦存在一定差异,C组心脏增大的病例明显低于A、B两组。RRF状态与透析效能呈正相关。本组患者除2例在透析治疗时即无尿,128例患者中有31例(24·2%)发生无尿,其中原发病为血管炎综合征及糖尿病肾病各占4例和7例,其无尿发生率分别占本病种的66·7%及25·9%;另20例无尿患者为肾小球肾炎或其它疾病,占此类疾病的20·6%。此外,发生无尿患者中有5例(16·1%)透析时尿量<300ml/d。结论:PD患者的残余肾仍然是清除体内代谢产物的重要途径,同时也影响血压及心血管系统并发症。     

长期腹膜透析与残余肾功能保护

长期腹膜透析与残余肾功能保护俞雨生关键词腹膜透析残余肾功能中图法分类号Ｒ４５９．５大量的研究业已证明，在腹膜透析过程中，维持其良好的透析效能是透析成功的关键。其中维护好腹透患者的残余肾功能（ＲＲＦ）是其核心所在。对于所有的终末期肾衰患者来说，ＲＲＦ的...     

残余肾功能对腹膜透析患者的重要性

临床上有很多证据业已证实残余肾功能（residual renal function，RRF）对透析患者，尤其是腹膜透析（peritoneal dialysis，PD）患者的重要性。RRF不仅能有效清除小分子物质和尿毒症产生的毒素，还可以维持机体水、盐平衡，控制血磷水平，对防止血管钙化、心脏肥大等方面起保护作用。过去对终末期肾脏疾病（end—stage renal disease，ESRD）或透析阶段患者的RRF未采取任何保护措施。近来越来越多的研究认为残余肾在PD患者中具有独立的地位和作用，不能简单地将残余肾清除率和腹膜清除率等同看待，应重视对其保护。本文将RRF对PD患者的重要性作一综述，探讨对RRF的保护策略。     

腹膜透析患者残余肾功能减退临床分析

腹膜透析已广泛用于治疗慢性肾衰竭 (CRF)尿毒症。随着腹膜透析的进行 ,透析患者的生活质量较治疗前明显改善 ,尿毒症的所有临床症状可相应缓解。但随着透析时间的推移 ,患者的内生肌酐清除率 (Ccr)均有不同程度下降 ,尿量亦逐渐减少。Ccr和尿量是评价透析患者残余肾功能的可靠指标。我们对透析患者随访 8～ 10个月 ,认为影响残余肾功能的因素与患者血压 (BP)、血糖 (GLU)及血脂 (TC)的高低相关。对象与方法1.对象 :我院 1997年 9月～ 2 0 0 1年 2月住院患者 60例 ,年龄 3 2～ 85岁 ,平均年龄 45 .6岁 ,男性 45例 ,女性 15例 ,3 0例患…     

残余肾功能对腹膜透析患者心血管系统的影响

目的:观察不同残余肾功能(RRF)对腹膜透析(PD)患者心血管系统的影响. 方法:根据PD患者随访过程中残余肾小球滤过率(rGFR)水平将其分为A组(GFR 0～2 ml/min)、B组GFR(2.1～4 ml/min)、C组GFR(4.1～6.0 ml/min)和D组(>6.0 ml/min).每3个月对患者进行一次临床随访,全面评估患者的伞身情况及透析状态,包括血浆白蛋白(AIb)、收缩压(SBP)、舒张压(DBP)、体重指数(BMI)、尿量(UV)、残余肾肌酐清除率(Ccr)、每周总尿素氮清除率(Kt/V total)、每周肌酐总清除率(WCcr total)、蛋白氮呈现率(nPNA)、心脏超声和胸部平片. 结果:四组不同RRF患者Kt/v total分别为1.66±0.42、1.85±0.40、2.11±0.45、2.60±0.69(P<0.01);四组间心胸比分别为0.54±0.08、0.51±0.07、0.51±0.06、0.50±0.06(P<0.05);左室后壁厚度分别为(10.4±1.79)、(9.96±1.35)、(9.51±1.33)、(9.65±1.40)mm(P<0.05);室间隔厚度分别为(10.9±1.88)、(10.4±1.59)、(10.2±1.59)、(10.1±1.47)mm(P<0.05);此外四组间AIb、SBP、DBP均存在统计学差异(P<0.05). 结论:RRF每下降2 ml/min患者室间隔厚度、左室后壁厚度均增加,且室间隔厚度与RRF呈负相关.RRF对腹膜透析患者心血管并发症有重要影响.     

残余肾功能在腹膜透析中的重要性及保护策略

残余肾功能(residual renal function,RRF)指健存肾单位的滤过、重吸收和内分泌功能。RRF的作用涵盖于容量平衡、钙磷代谢、炎症状态、营养状态、中分子和其他物质清除以及生活质量等方面,在腹膜透析(PD)患者中尤其突出。     

腹膜透析患者代谢综合征发病影响因素及其对残余肾功能的影响

目的 研究腹膜透析患者代谢综合征的发病影响因素及其对腹膜透析患者残余肾功能的影响.方法 选择腹膜透析患者119例,分别于0个月、6个月、12个月、18个月采集试验相关指标,分析代谢综合征的发病率及其发病危险因素以及代谢综合征对患者残余肾功能的影响.结果 代谢综合征的发病率随着透析时间延长而增加,年龄、糖暴露均为腹膜透析过程中新发代谢综合征的独立危险因素,残余肾功能下降的数值与代谢综合征各组分均呈正相关,与三酰甘油、胆固醇、体重指数和空腹血糖的r值和P值分别为0.536、P＜0.05;0.413、P＜0.05;0.351、P＜0.05和0.253、P＜0.05.结论 代谢综合征的发病率随着透析时间延长而增加,年龄、糖暴露均为腹膜透析过程中新发代谢综合征的独立危险因素,残余肾功能为新发代谢综合征的保护性因素,代谢综合征与残余肾功能相互影响.     

影响腹膜透析患者残余肾功能下降速率的因素

目的:比较腹膜透析(PD)患者不同基线水平下残余肾功能(RRF)的下降速率,并分析其相关影响因素。方法:选取行PD置管术的201例新患者,根据估算的肾小球滤过率(e GFR)水平将其分为A组[e GFR6ml/(min·1.73m2)]、B组[e GFR 6~10 ml/(min·1.73m2)]、C组[e GFR10 ml/(min·1.73m2)]。至少每6个月对患者进行一次临床随访,评估患者的全身情况及透析状态,并计算36个随访月每组RRF的平均下降速率。结果:A、B、C三组的RRF平均下降速率分别为-0.089 ml/(min·1.73m2·月),-0.152 ml/(min·1.73m2·月),-0.247 ml/(min·1.73m2·月)(P0.001)。多元线性回归显示基线时心胸比(rs=-0.238);三酰甘油(rs=-0.421)、e GFR(rs=-0.557)、血红蛋白(rs=0.216)分别是B、C组r GFR下降速率的独立影响因素(A组没有纳入变量)。在随访末,C组RRF仍然保持最高的水平且RRF消失的百分比在三组中最低(P0.001),且心力衰竭发生的时间较晚。结论:基线时e GFR高的PD患者RRF下降速率快,但其随访末在3组中仍然保持最高的RRF水平及最低的RRF消失百分比。     

腹膜透析患者残余肾功能下降速率及影响因素

目的:观察终末期肾衰(ESRF)患者腹膜透析(PD)治疗后残余肾功能(RRF)下降的速率。方法:在透析过程中,每3个月评估一次患者体重指数(BMI)、尿量(UV)、残余肾小球滤过率(rGFR)、每周总尿素氮表现率(KT/Vtotal)、每周肌酐总清除率(WCcrtotal)、蛋白氮呈现率(nPNA)及残余肾尿素及肌酐清除率(Ccr)。计算出rGFR、UV等相应的截距和斜率,并建立回归方程。尿量少于100ml/d或Ccr<1.0ml/min视为无尿。结果:130例患者在平均随访14.4个月后,无论是UV还是rGFR均随透析时间的延长呈下降趋势;除2例患者在透析治疗时即无尿,128例患者中有31例发生无尿(占24.2%)。该31例患者自透析开始至发生无尿的时间平均为(12.7±10.2)mo(4～46mo)。与此同时,WCcrtotal、Kt/vtotal及nPCR等反映透析充分性的指标亦与透析时间呈负相关。经Pearson相关系数分析,分别得出透析过程中UV及rGFR的下降速率:UV(ml/d)=1343.9-24.8×透析月;rGFR(ml/min)=5.12-0.13×透析月。糖尿病肾病(DN)、持续性腹膜透析(CAPD)夜间留腹的患者rGFR下降速率相比较非DN及白天腹膜透析(DAPD)的患者更快(P<0.05)。结论:透析患者的RRF随透析时间的延长呈下降趋势,rGFR(ml/min)=5.12-0.13×透析月,DN及CAPD患者的rGFR下降速率较非DN及DAPD患者更快。     

Impact of residual renal function on volume status in chronic renal failure

During the past few years, it has become increasingly evident that residual renal function (RRF) is an important and independent predictor of poor outcome in patients with chronic kidney disease (CKD). Although the causes of this observation are not fully understood, it appears that the loss of RRF impairs both fluid removal and clearance of solutes, which in turn leads to uremic toxicity and increased morbidity and mortality. There is increasing evidence that patients with CKD develop signs of fluid overload already in the early phases of the disease, and this may be a stimulus for inflammatory activation. Recently, an inflammatory component was identified in uremic atherosclerotic and non-atherosclerotic cardiovascular disease (CVD), which have been consistently associated with poor clinical outcome in patients with CKD. Signs of systemic inflammation occur in parallel to the impairment in renal function, and the pathophysiology is most likely multifactorial, including a decrease in cytokine clearance, advanced glycation end-product accumulation, oxidative stress, and principal fluid overload. Additionally, inflammation seems to be a predictor of accelerated loss of renal function. In this article, we discuss the evidence showing that patients with CKD generally have fluid overload, the mechanisms by which impaired renal function may lead to a chronic inflammatory state, and the available information linking fluid overload to accelerated loss of renal function and CVD through inflammation. Inflammation may lead to the development of complications of CKD, in particular CVD, but on the other hand may also lead to a faster progression of renal disease. Strategies aiming to reduce fluid overload may be useful to reduce cardiovascular morbidity and mortality, but also preserve RRF.     

不同腹膜透析模式对尿毒症大鼠残余肾功能的影响

目的:探讨不同腹膜透析模式对尿毒症大鼠残余肾功能的影响。方法:将40只SD大鼠随机分为4组:正常对照组、尿毒症组、尿毒症持续非卧床腹膜透析(CAPD)模型组、尿毒症自动腹膜透析(APD)模型组,每组10只。采用5/6肾脏切除法制作尿毒症大鼠模型,造模成功后再行腹透插管制作尿毒症大鼠腹膜透析模型,观察并记录各组大鼠一般情况,检测血BUN、Cr、ALB等水平,于第10周处死大鼠,腹膜功能检查,并取大鼠肾脏组织HE染色行病理评分。结果:与正常对照组相比,3个模型组大鼠体质量均增长缓慢(P 0. 05),其中尿毒症组慢于CAPD、APD组; 3组大鼠BUN、Cr水平随时间延长而持续上升,ALB水平下降,以尿毒症组最为显著[(17. 89±1. 74) mmol/L、(192. 71±12. 41)μmol/L、(31. 13±2. 50) g/L]。APD组大鼠体质量、残肾质量、ALB水平均高于CAPD组,BUN、Cr水平略低于CAPD组,但2组间差异无统计学意义。CAPD及APD组随着透析时间的延长,腹透超滤量逐渐减少,第28天超滤量明显少于初始腹透(P 0. 05),但2组腹透超滤量减少无统计学差异。与正常对照组比较,3组大鼠肾小球有不同程度硬化,肾小管肾间质萎缩纤维化,肾小球和肾小管间质病理积分均显著升高(P 0. 05),其中尿毒症组升高最明显[(6. 92±1. 29)分、(6. 63±2. 37)分],其次为CAPD组[(5. 30±1. 18)分、(5. 49±1. 68)分]。结论:残余肾功能是腹膜清除效能不能弥补的,必须重视和保护腹膜透析患者的残余肾功能,APD对残余肾功能可起到保护作用。     

Metabolic acidosis in peritoneal dialysis patients: the role of residual renal function

BACKGROUND: Metabolic acidosis (MA) is common in chronic renal insufficiency (CRI) patients, and its pattern changes as renal function deteriorates. Although the prevalence of acidosis in peritoneal dialysis has been reported to be rather high, the causes of it have not been well studied. The present study was performed to examine the prevalence of metabolic acidosis in our continuous ambulatory peritoneal dialysis (CAPD) patients and its possible causes. METHODS: In this cross-sectional study, we analyzed data from patients who received maintenance CAPD in our hospital and had been on dialysis for at least one month. Patients' demographic features, medications, and intercurrent medical conditions were recorded. Data including blood biochemistry, dialysis adequacy, and nutrition were collected. A serum bicarbonate concentration of less than 23 mmol/l was defined as having acidosis. The normal value of the serum anion gap (AG) was defined as 12+/- 4 mmol/l. RESULTS: A total of 154 patients (76 males and 78 females) with age of 60.04+/- 13.92 years and the time on dialysis of 16.83+/- 21.59 months were included in this study. Sixty-six patients (43%) had a serum bicarbonate of less than 23 mmol/l, among whom 12 patients (8%) were identified as having MA with increased AG, 54 (35%) were identified as having MA with normal AG. Patients who had better residual renal function (RRF) had a significantly lower serum bicarbonate level despite their higher total KT/V(urea) as compared to those with lower RRF. In addition, patients with MA and normal AG had the highest RRF and highest total KT/V(urea). All patients with MA and increased AG had significantly lower values of dietary protein intake (DPI) as compared to their values of normalized protein nitrogen appearance (nPNA), and had higher serum urea and phosphate levels as compared with those patients without MA. CONCLUSION: Our study suggested that CAPD patients with better RRF were more susceptible to metabolic acidosis, which was characterized by normal anion gap and hyperchloremia. Thus, we speculate that renal loss of bicarbonate may to a large extent be responsible for the occurrence of MA in these patients.     

The effect of coronary angiography on residual renal function in patients on peritoneal dialysis

BACKGROUND: The risk of intravascular radiocontrast to residual renal function (RRF) in patients on peritoneal dialysis (PD) remains largely unknown. HYPOTHESIS: This study sought to estimate the effect of coronary angiography on RRF in patients on PD. METHODS: All patients at the VA Pittsburgh Healthcare System and University of Pittsburgh who underwent coronary angiography between 1993 and 2005 while on PD and who had RRF measured prior to angiography were identified retrospectively. For patients without a postprocedure RRF recorded, medical records were reviewed to determine whether anuria had developed. The longer-term rate of loss of RRF among cases was compared with a composite rate of decline in RRF among cases before angiography and matched controls. RESULTS: Twenty-nine patients with a mean preprocedure RRF of 4.4+/-3.2 ml/min/1.73m(2) were evaluated. Of these patients, 23 (79%) had postangiography RRF assessments (mean clearance 3.4+/-3.0 ml/min/1.73m(2)). One of the remaining six patients definitely became permanently anuric following angiography, one was lost to follow-up, and there was no postprocedure RRF assessment in four others. The rate of decline in RRF in the cases was similar to the composite rate (0.07 ml/min/1.73m(2)/month vs. 0.09 ml/min/1.73m(2)/month, p=0.53) CONCLUSION: The risk for permanent anuria in patients on PD undergoing coronary angiography appears to be quite small. Patients who do not develop anuria following coronary angiography have the same gradual rate of loss of RRF as other patients on PD. Providers should be vigilant in protecting RRF in patients on PD undergoing coronary angiography.     

不同腹膜透析模式对于尿毒症大鼠残余肾功能的影响

目的:探讨不同腹膜透析模式对尿毒症大鼠残余肾功能的影响。方法:将40只SD大鼠随机分为4组:正常对照组、尿毒症组、尿毒症持续非卧床腹膜透析(CAPD)模型组、尿毒症自动腹膜透析(APD)模型组,每组10只。采用5/6肾脏切除法制作尿毒症大鼠模型,造模成功后再行腹透插管制作尿毒症大鼠腹膜透析模型,观察并记录各组大鼠一般情况,检测血BUN、Cr、ALB等水平,于第10周处死大鼠,腹膜功能检查,并取大鼠肾脏组织HE染色行病理评分。结果:与正常对照组相比,3个模型组大鼠体质量均增长缓慢(P 0. 05),其中尿毒症组慢于CAPD、APD组; 3组大鼠BUN、Cr水平随时间延长而持续上升,ALB水平下降,以尿毒症组最为显著[(17. 89±1. 74) mmol/L、(192. 71±12. 41)μmol/L、(31. 13±2. 50) g/L]。APD组大鼠体质量、残肾质量、ALB水平均高于CAPD组,BUN、Cr水平略低于CAPD组,但2组间差异无统计学意义。CAPD及APD组随着透析时间的延长,腹透超滤量逐渐减少,第28天超滤量明显少于初始腹透(P 0. 05),但2组腹透超滤量减少无统计学差异。与正常对照组比较,3组大鼠肾小球有不同程度硬化,肾小管肾间质萎缩纤维化,肾小球和肾小管间质病理积分均显著升高(P 0. 05),其中尿毒症组升高最明显[(6. 92±1. 29)分、(6. 63±2. 37)分],其次为CAPD组[(5. 30±1. 18)分、(5. 49±1. 68)分]。结论:残余肾功能是腹膜清除效能不能弥补的,必须重视和保护腹膜透析患者的残余肾功能,APD对残余肾功能可起到保护作用。     

Acute heart failure secondary to takotsubo cardiomyopathy in a patient on peritoneal dialysis with residual renal function loss

Takotsubo cardiomyopathy (TTC) is characterized by clinical and electrocardio-graphic signs that mimic myocardial ischemia, typical left ventricular kinesis abnormalities, and no evidence of obstructive coronary disease. It is associated with emotional or physical stress usually in postmenopausal women. A major pathogenetic role is played by excessive sympathetic stimulation of the left ventricle. Only two cases of TTC have been described in patients on hemodialysis and one case has been described in a patient on peritoneal dialysis associated with peritonitis. We observed a case of TTC in a patient on nocturnal intermittent peritoneal dialysis with a transplanted kidney and loss of residual renal function. We found that she had suffered significant emotional stress immediately before the symptoms arose. The clinical features were typical ischemic chest pain and acute heart failure. Beta-blockers were the principal pharmacological treatment. The necessary ultrafiltration was obtained with peritoneal dialysis in automated modality, reducing the abdominal filling volumes according to the patient's compliance and modifying the glucose concentration according to her hemodynamic condition. The obtained ultrafiltration was appropriate and in accordance with the few experiences reported in the literature. The symptoms resolved within a week and the left ventricular kinesis and ejection fraction normalized in almost three weeks. This clinical case suggests that peritoneal dialysis, also in automated mode, can be as effective as extracorporeal ultrafiltration in the treatment of acute heart failure.