Abdominal wall hernias in end-stage renal disease patients on peritoneal dialysis

OBJECTIVE: To describe our experience with hernioplasty in peritoneal dialysis patients and to identify possible risk factors for surgical complications. DESIGN: A 4-year retrospective chart review of data. SETTING: Peritoneal dialysis unit of a university hospital. Patients and METHODS: 58 hernias in 50 patients were included. Detailed surgical technique and complications were recorded. Possible risk factors included age, gender, weight, height, body mass index, previous surgery, diabetes, time on dialysis, emergency surgery, hospital stay, type of hernia, mesh use, blood hemoglobin, and serum urea, creatinine, and potassium. RESULTS: Complications occurred in 12 hernioplasties (4 wound infections, 2 peritonitis, 4 catheter dysfunction, and 5 re-operations). Recurrence rate was 12% without mesh use and 0% with mesh hernioplasty. Dialysis was re-instituted in 96% of cases within 3 days postoperatively. Identified risk factors for complications were diabetes, low weight, low height, small body mass index, and low serum creatinine. CONCLUSIONS: Mesh hernioplasty in peritoneal dialysis patients is advisable. Postoperative dialysis with low volume is feasible after surgery. Prospective studies will corroborate our risk factors for morbidity.     

Sleep related respiratory disorders in end-stage renal disease patients on peritoneal dialysis.

STUDY OBJECTIVE: To assess the possible effects of peritoneal dialysis (PD) on sleep-related respiration, which might result from dialysate bulk load in the abdomen and/or alterations in metabolic control of respiration during sleep. DESIGN: Subjective and objective measures of sleep were prospectively compared on randomly assigned nights with PD fluid (2.0 L) and without PD fluid in the peritoneal cavity in 11 end-stage renal disease (ESRD) patients on PD. SETTING: Tertiary-referral university hospital. PATIENTS AND METHODS: Fifteen consecutive patients on peritoneal dialysis who complained of chronic sleep disturbance and requested sedative were selected. Four patients declined polysomnographic studies. Consequently, 11 ESRD patients (8 males and 3 females) with a mean age of 63 +/- 4 (SEM) years were studied. RESULTS: Eight of the 11 patients reported multiple types of sleep difficulties. Polysomnographic recordings revealed significant primarily obstructive sleep apnea in 6 of 11 patients on at least 1 of 2 nights. Arterial blood pH, paO2, and paCO2 did not differ between nights with and without PD fluid in the peritoneal cavity in the group as a whole. In the 6 patients with sleep apnea, PaO2 was significantly lower (p less than 0.05) during the night with (PaO2 = 78 +/- 7 mmHg) than during the night without PD fluid (PaO2 = 92 +/- 4 mmHg). In the apneic patients, the amount of dialysate drained in the morning was negatively correlated with the minimum arterial oxygen saturation during the night (r = -0.94; p less than 0.005). CONCLUSIONS: This study indicates a significant relationship between PD patients with chronic sleep disturbance and sleep apnea syndrome. These data suggest that apneic patients may be susceptible to complications of dialysate bulk effect on oxygen desaturation.     

Peripheral vascular disease intervention in patients with end-stage renal disease: few complications in those treated with peritoneal dialysis.

BACKGROUND: We assessed the results of peripheral vascular surgery in patients with end-stage renal disease (ESRD) who were being treated with peritoneal dialysis. METHODS: Sixty-seven ESRD patients on peritoneal dialysis who had peripheral vascular surgery were assessed retrospectively for preoperative risk factors, primary and secondary patency rates, and mortalitv. The study group had 48 proximal femoral-popliteal bypasses, 12 distal femoral-popliteal bypasses, and 7 distal femoral-tibial and/or peroneal revascularizations. RESULTS: Among 67 peritoneal dialysis patients, 15 deaths (22%) occurred over 68 months (mean, 14 months). CONCLUSION: Patients on peritoneal dialysis had adequate patency rates and length of survival after peripheral vascular surgery when maintained on peritoneal dialysis.     

Renal replacement therapy in end-stage renal disease patients with chronic liver disease and ascites: role of peritoneal dialysis.

Chronic liver disease and cirrhosis account for several thousand deaths in the United States and often these patients have renal disease that progresses to end-stage renal disease (ESRD), necessitating renal replacement therapy. These patients provide significant challenges to their physicians, especially in the management of their ESRD with dialysis. ESRD patients with chronic liver disease and ascites are more difficult to manage on hemodialysis (HD) due to their hemodynamic status and risk of bleeding. Peritoneal dialysis (PD) offers them a viable alternative, along with a stable hemodynamic status and a lower risk of bleeding. The overall morbidity and mortality as well as the risk of peritonitis appear to be almost similar between cirrhotic and non-cirrhotic PD patients. In the absence of clinical trials comparing HD versus PD in such a population, and despite the limited clinical observations, the authors support PD as a viable and effective form of renal replacement therapy for patients with ESRD and associated chronic liver disease with cirrhosis and ascites.     

腹腔镜在腹膜透析管置入术中的临床应用(附85例报告)

目的 探讨腹腔镜下腹膜透析管置入术的方法及临床价值.方法 2008年7月～2010年3月对85例终末期肾病患者行腹腔镜直视下腹膜透析管置入术,观察术后腹膜透析管功能、术中及术后并发症发生情况,总结腹腔镜在腹膜透析管置入术中的操作经验及腹腔镜手术较传统腹膜透析管置入术的优势.结果 85例患者手术均顺利完成,无1例中转开放,平均手术时间45 min(35～60 min),平均出血量5 mL(2～10mL),术中未见明显并发症.术后随访3～6个月,2例发生腹膜透析管引流不畅,1例透析管末端移位,3例出现透析管周围组织渗液,1例出现阴囊水肿.结论 腹腔镜腹膜透析管置入术安全可靠,能直视下将透析管末端置入并固定于盆腔准确位置,且患者创伤小、恢复快,有较好的临床应用及推广价值.     

肝硬化合并终末期肾病患者腹膜透析问题的研究进展CSCD

肝硬化合并终末期肾病患者肾脏替代治疗方式的选择仍是有争议的问题。本综述将讨论肝硬化合并终末期肾病患者不同肾脏替代治疗方式的利弊,重点讨论腹膜透析在该人群中应用的相关问题。     

终末期肾病腹膜透析患者微炎症状态与营养状况的关系

目的 探讨终末期肾病（ESRD）长期腹膜透析患者血清C-反应蛋白（CRP）和白细胞介素-6（IL-6）水平变化及与营养状况的关系. 方法 检测山东中医药大学第二附属医院肾内科ESRD患者非透析组、腹膜透析组和对照组的CRP、IL-6、血清白蛋白（Alb）、血红蛋白（Hb）、转铁蛋白（TF）、血肌酐（Scr）水平.根据CRP水平将膜透析组分为CRP≤6mg/L组和CRP＞6mg/L组.并比较两组IL-6、Alb、Hb、TF、Scr的水平. 结果 腹膜透析组CRP、IL-6水平明显高于非透析组（P＜0.05）和对照组（P＜0.01）,腹膜透析组CRP、IL-6分别与Alb、Hb、TF呈负相关（r=-0.543～-0.379,P＜0.05）,与Scr无相关关系（r=0.258、0.245,P＞0.05）. 结论 ESRD腹膜透析患者体内存在微炎症状态,CRP、IL-6是终末期肾病腹膜透析患者微炎症状态较好的预测指标,并可反映腹膜透析患者的营养状况.     

日间小剂量递增腹膜透析在终末期肾病患者的应用研究

目的：研究并探讨终末期肾病患者非卧床腹膜透析不同透析模式的临床疗效。方法通过对终末期肾病腹膜透析患者残肾功能较好的患者采取不同的透析模式,将患者随机分为两组：日间小剂量递增组（26例）,透析液总量每日4.5～8 L,夜间不留腹;持续标准透析剂量组（24例）,每日透析液量8 L,夜间留腹,比较两组研究开始与终点的营养指标、血生化指标、透析充分性、残肾功能、胱抑素 C。结果两组患者至观察终点血浆白蛋白、24 h尿量、残肾功能、胱抑素C比较差异有统计学意义（P＜0.05）。两组血K＋、血P3＋、二氧化碳结合力（CO2CP）、24 h超滤量、透析充分性指标每周总尿素氮清除率（Kt/V）、每周总肌苷清除率（Ccr）,比较差异无统计学意义（P＞0.05）,两组置管后1个月内导管堵管、渗漏发生率比较差异无统计学意义（P＞0.05）。两组的每日透析液总量和透析时间均有统计学差异（P＜0.05）。结论（1）残肾功能较好的终末期肾病患者,置管后早期采用日间小剂量递增式腹膜透析可使患者尽早得到治疗,并且不增加早期导管堵管与渗漏;（2）初期应用小剂量递增式腹膜透析可减少残肾功能的丢失,并维持相对较好的营养状况。（3）与持续标准剂量组比较,小剂量递增式腹膜透析可减少腹膜透析初期透析液的用量。     

Tyrosine and N-carbamoyl-tyrosine in end-stage renal disease during continuous ambulatory peritoneal dialysis.

Lower-than-normal tyrosine concentrations of unexplained pathogenesis in plasma and intracellular body water have been reported in patients with chronic renal failure. We found a derivative of tyrosine that is not measured by the usual methods of amino-acid analysis because its alpha-amino group is blocked and cannot react to form other derivatives. An in vivo covalent reaction with urea-derived cyanate forms alpha-amino-carbamoyl-tyrosine (N-C-Tyr) in patients with end-stage renal disease. A longitudinal study of patients with end-stage renal disease who were treated with continuous ambulatory peritoneal dialysis shows that plasma that is obtained within 4 hours of the morning meal contains 70.1 +/- 6 mumol/L of tyrosine (mean +/- SEM) and 77.2 +/- 12 mumol/L of N-C-Tyr (mean +/- SEM). Thus there is a molecule of N-C-Tyr for each molecule of tyrosine present. The carbamoylation index or ratio of N-C-Tyr to tyrosine, blood urea nitrogen, episodes of peritonitis, and changes in dialysis protocol were compared. A reduction in the number of peritoneal dialysis exchanges resulted in parallel increases in carbamoylation index and blood urea nitrogen. Altering dialysis by increasing the number of exchanges or adding supplemental hemodialysis resulted in a decrease in the carbamoylation index with a delayed decrease in blood urea nitrogen. We found a significant increase of N-C-Tyr (p = 0.005) and of the carbamoylation index (p = 0.004) during six episodes of peritonitis compared with 10 periods of no peritonitis in two patients who had multiple episodes of peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

终末期肾脏疾病患者透析治疗的相关因素分析

目的:回顾性分析终末期肾脏疾病透析患者病因、年龄、性别与选择血液透析和全部腹膜透析的关系。方法:收集2003-01/2004-05中南大学湘雅二医院病案统计室、血液净化中心及腹透中心终末期肾脏疾病透析患者资料356例,血液透析患者307例,全部腹膜透析患者49例。血液透析患者采用日本东丽公司,美国百特公司,德国费森-尤斯公司和贝朗公司的血液透析机,采用双醋酸纤维膜、血仿膜和合成膜;空心纤维透析器,透析液为碳酸氢盐透析液,采用肝素(普通肝素或低分子肝素)抗凝,透析时血流量为200～280mL/min,透析液流量为500mL/min,患者透析频率及时间为每周两三次,每次4～4.5h。全部腹膜透析患者采用解剖法置入腹膜透析导管,腹膜透析方法为持续不卧床腹膜透析,腹膜透析外管连接方式为美国百特公司双联系统,腹膜透析液使用含葡萄糖的透析液。分别记录患者姓名、性别、年龄、原发疾病、血尿素氮,肌酐(取患者第一次透析前清晨空腹采血所测数值)、透析的方式等资料,进行统计和分析,分析其病因及其与年龄、性别、透析方式选择的关系。结果:透析患者356例全部进入结果分析。①终末期肾脏疾病透析患者主要病因为慢性肾小球肾炎(52.0%),其次为糖尿病肾病(16.0%),高血压肾病(13.2%),梗阻性肾病(9.0%);男女之比为1.87∶1,平均年龄为(51±16)岁。②腹膜透析患者的平均年龄明显高于血液透析患者[(59±15),(50±16)岁,P<0.05]。86.2%的患者选择血液透析,13.4%选择腹膜透析;糖尿病肾病患者选择腹腹膜透析高于血液透析(P<0.01)。③结缔组织病、慢性肾小球肾炎组患者年龄较小,狼疮平均年龄仅40岁;高血压肾病、糖尿病肾病、梗阻性肾病、痛风、多发性骨髓瘤患者年龄较大,40岁以上患者约95.0%,平均年龄约60岁,与慢性肾炎、狼疮比较,差异有显著性意义(P<0.05)。结论:本组患者以中老年为主,男性多见;终末期肾脏疾病透析患者主要病因为慢性肾小球肾炎,其次为糖尿病肾病;糖尿病肾病首选腹膜透析。     

Plasma cholesterol metabolism in end-stage renal disease. Difference between treatment by hemodialysis or peritoneal dialysis.

Plasma cholesterol metabolism was investigated in normotriglyceridemic patients with end-stage renal disease treated by hemo- or continuous ambulatory peritoneal dialysis (CAPD), and compared with that in a control group with normal renal function. A reversed net transport of free cholesterol from plasma to cultured fibroblasts, as well as greatly reduced levels of plasma cholesterol esterification and cholesterol ester transfer rates to low and very low density lipoproteins (LDL and VLDL), was found in the hemodialysis group compared to the controls. The LDL and VLDL contained increased amounts of free cholesterol and inhibited cholesterol ester transfer when recombined with control plasma. The LDL triglyceride content was doubled in the hemodialysis group, whereas cholesterol esters were decreased. Patients treated by CAPD, in marked contrast, had cholesterol metabolic rates that were within the normal range, as well as normal lipoprotein composition.     

终末端肾病腹膜透析病人营养不良的护理进展

营养不良是终末端肾病腹膜透析病人发生严重并发症和主要死亡原因之一。综述导致终末端肾病腹膜透析病人营养不良的因素、营养状况评估方法以及营养不良的护理研究进展。     

Predictors of renal recovery in Australian and New Zealand end-stage renal failure patients treated with peritoneal dialysis.

OBJECTIVES: The aim of this study was to investigate the factors affecting recovery and durability of dialysis-independent renal function following commencement of peritoneal dialysis (PD). DESIGN: Retrospective, observational cohort study of the Australian and New Zealand PD patient population. SETTING: Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. PARTICIPANTS: The study reviewed all patients in Australia and New Zealand who commenced PD for treatment of end-stage renal failure between 15 May 1963 and 31 December 2004. MAIN OUTCOME MEASURES: The primary outcomes examined were recovery of dialysis-independent renal function and time from PD commencement to recovery of renal function. A secondary outcome measure was time to renal death (patient death or recommencement of renal replacement therapy) following recovery of dialysis-independent renal function. RESULTS: 24663 patients commenced PD during the study period. Of these, 253 (1%) recovered dialysis-independent renal function. An increased likelihood of recovery was predicted by autoimmune renal disease, hemolytic-uremic syndrome, paraproteinemia, cortical necrosis, renovascular disease, and treatment in New Zealand. A reduced likelihood of recovery was associated with polycystic kidney disease and indigenous race. Analysis of a contemporary subset of 14743 patients in whom complete data were available for body mass index, smoking, and comorbidities yielded comparable results, except that increasing age was additionally associated with a decreased likelihood of recovery. Of the 253 patients who recovered renal function, 151 (60%) recommenced renal replacement therapy and 49 (19%) died within a median period of 226 days (interquartile range 110-581 days). The only significant predictors of continued renal survival after renal recovery were autoimmune renal disease and cortical necrosis. CONCLUSIONS: Recovery of renal function in patients treated with PD is rare and determined mainly by renal disease type and race. In the majority of cases, recovery is short term. The apparently high rate of early patient death or return to dialysis after recovery of renal function on PD raises questions about the appropriateness of discontinuing PD therapy under such circumstances.     

Levels of asymmetric dimethylarginine, nitric oxide and lipid peroxidation markers in patients with end-stage renal disease having peritoneal dialysis treatment

ObjectivesIn this study, we aimed to investigate the activities of paraoxonase-1 (PON1) and nitric oxide synthase (NOS) and the levels of asymmetric dimethylarginine (ADMA), nitric oxide (NO), oxidized low-density lipoprotein (oxLDL), ceruloplasmin (CP), thiobarbituric acid-reactive substances (TBARS), malondialdehyde (MDA), 4-hydroxynonenal (HNE) and lipids in serum of patients with end-stage renal disease (ESRD) having continuous ambulatory peritoneal dialysis (CAPD) treatment and controls living in the Antalya region, Turkey.Design and methodsFifty-three patients with ESRD were enrolled in this study and were treated by CAPD. As the control group (n = 32), subjects with normal renal function were included.ResultsSerum PON1 activity and high-density lipoprotein-cholesterol (HDL-C) levels were decreased in ESRD patients whereas ADMA, NO, oxLDL, CP, TBARS, MDA and HNE levels and NOS activity were increased with regard to control group. In CAPD patients, ADMA positively correlated with NO, CP, oxLDL, TBARS and MDA levels whereas negatively correlated with PON1 activity. On multiple logistic regression analysis, risk factors associated with ESRD included CP, TBARS, triglycerides (TG) and very low-density lipoprotein-cholesterol (VLDL-C) levels.ConclusionsOur data have demonstrated that ESRD patients on CAPD treatment exhibit increased lipid peroxidation reactions and decreased antioxidant protection. The assay of serum HNE and MDA may be useful to evaluate the individual accumulation of these toxic aldehydes to test the efficiency of new dialysis strategies in removing them.     

血液透析联合腹膜透析治疗终末期肾病的临床体会

目的 比较血液透析联合腹膜透析与单纯血液透析治疗终末期肾病的疗效。方法 对采用血液透析联合腹膜透析方式与单纯血液透析治疗终末期肾病的患者各9例者进行对照分析，观察两组患者透析前后血液生化指标及透析后主要并发症。结果 采用联合透析后血液中白蛋白、甲状旁腺激素（iPTH）含量较单纯血液（HD组）透析后明显降低（P<0.05），而血红蛋白含量较HD组高（P<0.05）;所观察的各项并发症的出现机会在联合透析组也明显低于单纯血液透析。结论 具备血透和腹透两种通路的终末期肾病患者采用联合方式透析比单纯血液透析治疗更具优越性。     

Metallothionein and dendritic cells in skin of end-stage renal disease patients not on dialysis, or on hemodialysis or peritoneal dialysis.

OBJECTIVE: Renal failure leads to a variety of defects in immune function. The skin, as a major player in the immune system network, also exhibits multiple derangements. The pathogenesis of these defects and derangements are poorly understood; therefore, we studied immune competent cells, dermal dendrocytes (DC), and a special proinflammatory protein, metallothionein (MT), in the skin of these patients. DESIGN: 22 patients with end-stage renal disease (ESRD) but not on dialysis, 18 patients on hemodialysis (HD), 14 patients on peritoneal dialysis (PD), and 35 healthy controls were included in the study. Immunohistochemical staining of skin biopsies for DC and MT was performed with the following antibodies: for DC, antibody against factor XIIIa; and for MT, Dako-MT, E9 (Dako, Carpinteria, California, USA). Measurements were made by counting stained DC per square millimeter, and by optical density (OD) for MT (mean SEM). RESULTS: Metallothionein was increased in the skin of HD (OD 0.42 +/- 0.05, p < 0.01) and PD patients (OD 0.33 +/- 0.04, p < 0.05) compared to controls (OD 0.23 +/- 0.02) and ESRD patients not on dialysis (OD 0.22 +/- 0.05). In contrast, numbers of DC were reduced in patients on PD compared to controls (59 +/- 13 vs 96 +/- 59 DC/mm2, p < 0.01) and increased in patients with ESRD prior to dialysis (141 +/- 13 DC/mm2, p < 0.05). Patients on HD were in-between (105 +/- 20 DC/mm2), with a significant difference versus patients on PD (p < 0.05). CONCLUSIONS: Our data show that the mode of dialysis influences the number of antigen-presenting cells in the dermis. However, in both dialysis modes, a proinflammatory immune status of the skin (MT) was present and, therefore, other regulatory elements for dermal dendrocytes apart from proinflammation exist.