透析初始月的残肾功能及高转运特性对腹膜透析成功率的影响

目的　尽管近年来腹腔感染率有所降低 ,但腹膜透析 (PD)仍有较高的失败率。探讨何种患者行PD有较高的失败率以望指导透析治疗。方法　选择 96例PD病人 ,平均腹透龄 ( 2 3 .1±10 0 )个月。分为两组 :A组为因各种原因 (脑血管意外、营养不良、失超滤、胸腔积液、反复感染等 )终止PD而改血液透析或死亡患者 ( 2 5例 ) ;B组 :PD持续至今者 ( 71例 )。两组的透析量 (DV)、体表面积(BSA)和年龄差异无显著性。对他们透析首月的营养状态、透析充分性、残肾功能及腹膜转运功能进行比较。同时用Kaplan Meier法进行生存率分析。结果　数据显示B组透析充分性明显好于A组 ,透析初始月的残肾功能 (RRF)在两组中有显著差异 ,残肾功能较好 (RRF≥ 2ml/min)的患者其生存率明显高于较差组 (RRF <2ml/min)。A组中高转运特性患者的比例 ( 4 0 0 % )高于B组 ( 2 3 .5 % )。结论　透析开始时达较高的清除率水平似可维持较长时间的透析 ,而这与透析开始时所具有较好的残肾功能不无相关。当患者残肾功能逐步下降 ,日间不卧床腹膜透析无法保证透析充分性 ,尤其当水平衡难以维持时可行血液透析     

如何预防和纠正腹膜透析患者的营养不良

营养不良（蛋白质-能量营养不良）是腹膜透析（PD）患者常见的严重并发症，与患者的预后密切相关。PD患者营养不良的发生率随着透析时间的延长而升高，国外报道发生率在18％～56％之间，国内报道约为43．2％。尽管PD患者营养不良发生的原因十分复杂，但临床主要表现为机体蛋白储备下降（体重下降和低血清肌酐水平等）和内脏蛋白水平下降（低血清白蛋白和前白蛋白浓度等），这也使患者死亡风险显著增高。因此，有效防治PD营养不良对于提高患者生活质量、改善远期预后具有重要意义。本文就近年来国内外PD营养不良防治的进展作一综述。     

老年糖尿病终末期肾病血液透析和腹膜透析的比较

目的 比较老年糖尿病终末期肾病（DNESRD）血液透析（HD）和腹膜透析（PD）的疗效。方法 观察51例老年DNESRD（HD31例和PD20例）治疗前后血压、心功能、血脂、体重、尿量、超滤量、肾功能变化，分析透析充分性及临床转归。结果 两组治疗后体重、尿量、血压均下降，其中体重和尿量下降以HD组明显（P〈0．05）；治疗后两组心功能均明显改善，但组间比较无差异；治疗后两组BUN、Cr、K、P下降，以HD组BUN、Cr下降更明显（P〈0．05）；PD组治疗后血脂升高；两组治疗后RBC、Hb、TP、ALB上升，其中PD组RBC、Hb上升更明显（P〈0．05）；HD组透析充分性（KT／V）更佳，每周超滤量较PD组多，但残余肾功能下降更快；HD组存活时间较PD组长，但脑出血、心脏病发病率较PD组高。结论 HD和PD是治疗DNESRD的两种有效方法，两者各有优缺点，其中HD较PD治疗更充分，但对于有严重心脏病或脑出血的病人应首选PD。     

递增式腹膜透析的经验分享

<正>渐进式腹膜透析(PD)对于残余肾功能(RKF)较好的患者,起始采用低于标准的“全剂量”透析的剂量,结合适量的蛋白饮食及水盐限制,RKF和腹膜对溶质和液体达到总清除目标,随着RKF的变化,逐渐递增或递减剂量及超滤量,以保证总溶质清除及液体清除不变。与传统PD比较,更有利于延缓RKF减退,减少并发症,提高生活质量。目前对于这种治疗模式仍存在治疗时机、方法以及依从性和安全性等多个问题值得探讨。     

根据残余肾功能状态计算腹膜透析患者透析剂量的临床研究

目的:回顾性分析了腹膜透析(PD)患者不同透析效能状态下所使用透析液剂量(PDV)与残余肾功能(RRF)及体表面积(BSA)之间的相关性,探讨符合国人生理及病情特点的透析液剂量计算方法. 方法:414例患者中位透析时间为14.8个月(6～161个月)共进行1 650例次测定.按2006 NKF-K/DOQI标准分为充分、临界及不充分三组,观察各组患者之间尿素Kt/V、肌酐清除率(CCr)、蛋白质表现率(nPNA)和血浆白蛋白(Alb)、残余肾小球滤过率(rGFR)、PDV及单位BSA透析剂量(PDV/BSA)改变及彼此间相互关系. 结果:1 650检测中,透析不充分391例次,占23.7%.分析三组患者除尿素Kt/V、Ccr及nPNA有明显差异外,透析充分组无论是尿量(UV)及rGFR均明显高于其它两组,各组间亦有明显差异(P<0.01);以PDV/BSA为单位计算透析剂量,并以此判断与Kt/V、Ccr及nPNA之间相关性,较PDV更具有统计学意义(P<0.01);透析充分组患者rGFR明显高于其它组(P<0.01),而PDV/BSA明显少于其它各组(P<0.01);按rGFR分组观察同样显示不同RRF所需透析剂量差异有显著统计学意义(F=189.3,P<0.01);探讨rGFR与PV/BSA的相关性发现,两者间的相关系数可以用以下公式表达:PV/BSA=4277.0-123.7×rGFR(r=-0.58,P<0.01).由此得到PD患者个体化透析剂量的计算公式:PDV(L/d)=(4.4-0.15×rGFR)×BSA. 结论:所有PD患者应根据RRF及BSA状态来计算透析剂量.这种个体化透析方案不仅可以最大程度地发挥RRF在PD中的优势,还可以节约透析液用量,减少患者的经济开支.     

持续不卧床腹膜透析和日间不卧床腹膜透析临床效能的评判

腹膜透析(PD)因其便于保护残余肾功能(RRF)、血流动力学相对稳定、操作简便等优点,已日益成为终末期肾病(ESRD)患者的主要透析方法,但PD的方案在不同国家和地区有所不同.2006年,国际腹膜透析学会( ISPD)推荐ESRD患者最小PD剂量应使每周总尿素清除指数(Kt/V)(腹膜+ RRF)＞1.7,透析模式一般应予透析液24h留腹循环进行.     

简易营养评估法评估老年腹膜透析患者的营养状况

目的：采用简易营养评估法（mini nutritional assessment，MNA）对老年腹膜透析患者进行营养评估，并与传统的主观综合营养评估（subjective global assessment，SGA）方法进行比较。方法：采用横断面调查的方法，对我院腹膜透析中心的45例患者（60岁以上）进行问卷调查以及人体测量，分别用SGA与MNA两种方法，同时检测患者血液中白蛋白、前白蛋白水平、血常规，检测了与标化的蛋白质相当的总氮呈现率（nPNA），进行饮食调查。结果：（1）根据SGA，无营养不良22例（49％），轻至中度营养不良14例（31％），重度营养不良9例（20％）；根据MNA，无营养不良18例（40％），存在营养不良风险17例（38％），营养不良10例（22％）。（2）依据SGA与MNA评分，分别在不同营养状态的三组间进行以下指标的比较：平均每日每公斤体重能量与蛋白质摄入（DEI、DPI）、血白蛋白、nPNA、透析月龄、残余肾功能，透析充分性指标（Kt／V、Ccr）差异均有显著性统计学意义（P〈0．05）。但无营养不良组的DEI、DPI异常率在SGA评分时达到了64％，而MNA评分时降至28％（P〈0．05）；存在营养不良的两组患者，血白蛋白与前白蛋白的正常率，SGA评分时为43％与60％，MNA评分为44％与59％。存在明显营养不良时，两种评分的指标异常均明显升高。（3）无论采用SGA还是MNA方法，两种分类法的统计学结果是一致的。（4）在评估结果与各指标相关性研究中，发现SGA与MNA评分结果与一系列客观指标显著相关，MNA法较优。结论：（1）SGA与MNA皆是评价老年腹膜透析营养状况的简单有效方法，但还需结合其它的营养评估指标，如DEI、DPI、血白蛋白、前白蛋白、nPNA。（2）在某些方面，MNA评估法优于SGA评分。SGA对于评价已有的营养不良有效，而MNA更有利于早期发现需要营养干预的患者。MNA评估法简单易行，值得推广，需进一步研究。     

影响腹膜透析生存的因素及干预策略

腹膜透析(PD)是终末期肾脏疾病(ESRD)的主要替代治疗方法之一。心血管疾病(CVD)是PD患者死亡的主要原因。慢性肾脏病(CKD)患者存在非传统的、自身疾病特有的心血管危险因素,包括贫血、矿物质代谢紊乱、炎症和氧化应激状态及蛋白质能量消耗,这些都与CKD增加的全因死亡率和心血管疾病死亡率相关。提高PD患者长期生存率的策略包括纠正传统与非传统的心血管危险因素,如血压、血糖、血脂控制,戒烟,纠正贫血、钙磷代谢紊乱,纠正炎症和氧化应激及蛋白质能量消耗,同时必须高度重视PD患者存在的可纠正的影响生存的因素,如残余肾功能、腹膜完整性和PD中心规模。     

重视容量负荷因素对腹膜透析的影响

长期以来，腹膜透析（PD）被认为是改善终未期肾衰（ESRF）患者氮质血症，纠正液体平衡紊乱的重要措施之一。从理论上讲，PD过程中体内容量波动小，又由于其对残余肾功能（RRF）有较好的保护作用，因而，相比于血液透析（HD），PD能够更好地维持体内容量状态的稳定。但临床实践中发现，PD对维持ESRF患者的容量平衡作用并非如想象中的突出，具体体现在PD患者合并高血压非常普遍。     

尿毒症患者开始透析时的残肾功能和营养状况

为了解尿毒症患者开始透析时的残肾功能水平和营养状况及透析开始时的残肾尿素清除指数 (Kt/Vurea)和标准化蛋白等值的总氮呈现率 (nPNA)间的关系 ,早转诊肾科治疗是否会对透析前患者残肾功能和营养状况产生影响 ,本研究对 15 6例尿毒症患者进行回顾性研究。一、资料与方法1.对象与方法 :我院肾脏科 1998年 1月 1日至 2 0 0 1年10月 31日间开始透析 (包括血液透析和腹膜透析 )的终末期肾功能衰竭患者 15 6例 ,男 88例 ,女 6 8例 ,平均年龄 5 5 8岁。其中 113例为在透析前由其他科转诊本科进行治疗至少 4周 (A组 )的患者 ,另 4 3例为透析…     

水盐限制对腹膜透析患者血压的影响

目的研究水盐限制对腹膜透析患者血压的影响。方法选择我院肾内科门诊随访超过3个月的高血压腹膜透析患者42例,并对其进行限制水盐摄入治疗3个月,比较治疗前后体重、水肿状况、血压、血钠、白蛋白、血红蛋白水平、24小时尿钠定量、肾小球滤过率及降压药用量。结果水盐限制后,无浮肿的患者增加（P〈0．05）,轻中度浮肿患者减少（P〈0．01）,重度浮肿患者减少为0（P〈0．01）。患者体重明显减轻（P〈0．05）,24小时尿钠排出量降低（P〈0．05）,血压显著下降（P〈0．01）。透析液灌入量前后比较无显著性差异,总出量及超滤量减少,尿量增加（P〈0．05）,高渗透析液用量减少（P〈0．05）,白蛋白及血红蛋白明显升高（P〈0．05）,肾小球滤过率前后比较有显著性差异。降压药用量明显减少（P〈0．05）。结论对高血压腹膜透析患者进行严格水盐限制可明显减轻水肿、降低血压,减少高渗透析液及降压药用量。饮食指导增加了患者的依从性,患者营养状况改善。治疗后未观察到残。肾功能减退的现象。     

Prevention of malnutrition in peritoneal dialysis patients

Malnutrition is a frequent and serious problem for patients treated by peritoneal dialysis. Patients' survival depends on their nutritional status at the initiation of the dialysis treatment. Main malnutrition factors are inflammation, insufficient dialysis dose, peritoneal glucidic absorption and protein loss within the dialysate. These patients show a relationship between malnutrition, inflammation and cardiovascular diseases. To prevent malnutrition, it is necessary to reduce inflammation by improving dialysis solutions' biocompatibility and optimising the sodium regulation. The peritoneal membrane exposure to both glucose and its degradation products must also be reduced. In order to restrict protein losses, especially when peritoneal hyper permeability occurred, dialysis solutions containing amino acids can be used. Early dialysis treatment and a progressive increase of the dialysis dose corresponding to the decrease of the residual renal function can also be recommended.     

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.     

Continuous ambulatory peritoneal dialysis

The technique of continuous ambulatory peritoneal dialysis was evaluated in nine patients during 136 patient weeks. The major objectives were to see if continuous ambulatory peritoneal dialysis would provide [1] acceptable control of serum chemistries by usual criteria, [2] adequate removal of sodium and water, [3] tolerable protein losses, and [4] a low prevalence of peritonitis with episodes responsive to therapy with continuing continuous ambulatory peritoneal dialysis. Preliminary findings suggest continuous ambulatory peritoneal dialysis represents an effective ambulatory, portable, internal dialysis technique. Larger-solute clearances per week may approach values six times greater than with most hemodialysis techniques. Small-solute clearances approach dialysate flow rate (8.3 ml/min) and are comparable to other dialysis techniques on a weekly basis. Edema is readily controlled and protein losses should be tolerable with adequate protein intake. Peritonitus occurs on the average every 10 weeks but responds to therapy promptly with continuing continuous ambulatory peritoneal dialysis. If the prevalence of peritonitis can be reduced, continuous ambulatory peritoneal dialysis appears to represent a very attractive dialysis technique.     

Incremental peritoneal dialysis - yes

The incremental modality at the start of peritoneal dialysis (Incr-DP) is implicit in the definition of adequacy, which is expressed as the sum of dialysis clearance and renal clearance.Theoretically, it is possible to demonstrate that with a glomerular filtration rate at the start of dialysis of 6 mL/min, the minimum Kt/V target of 1.70 indicated by the current guidelines is easily exceeded with both 2-exchange of CAPD (incremental CAPD) and APD of 3 or 4 weekly sessions (Incr-APD), with a daytime icodextrin dwell. The GSDP (Peritoneal Dialysis Study Group) census data suggest that Incr-DP favors the choice of peritoneal dialysis. Although limited to a few studies with a relatively small number of patients, data show that Incr- CAPD is associated with a better quality of life, the achievement of Kt/V targets, and satisfactory ultrafiltration. The clearance of medium molecules is equivalent in Incr-DP and full-dose PD as it depends on the duration of the dwell and not on the number of exchanges. The maintenance of body weight, protein intake and peritoneal permeability may be explained by the lower glucose load with Incr-DP. The preservation of residual renal function is similar to that recorded with full-dose PD, while the peritonitis rate seems to be lower. The favorable results reported in the literature and the indications of the most recent guidelines about the importance of reducing the exposure to glucose to a minimum and safeguarding the patient's quality of life in our opinion further justify the use of Incr-DP.     

Epoetin responsiveness in peritoneal dialysis patients: a multi-center Slovenian study

The objective of our study was to assess the influence of residual renal function and other factors on epoetin requirements in chronic peritoneal dialysis patients. Fifty-one stable patients (mean age +/- SD: 52 +/- 13 years; 20 women) without recent bleeding, bone marrow disease or malignancy were recruited in four Slovenian centers. The target hemoglobin was above 110 g/L. The peritoneal equilibration test results and relevant clinical and laboratory parameters were recorded. The epoetin resistance index was expressed as a weekly epoetin dose/body weight/hemoglobin concentration. Twenty-four percent of the patients did not need epoetin treatment, the rest were treated with epoetin-beta in a dose of 70 +/- 56 U/kg per week s.c.; the hemoglobin concentration was 124 +/- 15 g/L. Ferritin >100 microg/L and transferrin saturation >20% fulfilled 63% of patients whose epoetin resistance index was not significantly lower (0.43 +/- 0.5 U/kg per week per g/L vs 0.6 +/- 0.72 U/kg per week per g/L, P = 0.502). No difference was found between diabetic and non-diabetic patients. Treatment with angiotensin system antagonists, but not with aluminum phosphate binders, was associated with increased epoetin resistance index (0.56 +/- 0.59 vs 0.3 +/- 0.4 U/kg per week per g/L, P = 0.038). No correlation between epoetin resistance index and residual glomerular filtration rate was found (r = -0.2, P = 0.173). A multiple linear regression analysis showed C-reactive protein, intact parathormone level, female sex and treatment with angiotensin system antagonists to be the independent predictors influencing epoetin resistance index. Our results show that systemic inflammation, secondary hyperparathyroidism and angiotensin system antagonist treatment are the most important modifiable parameters affecting epoetin requirements in stable peritoneal dialysis patients.     

Gastric emptying of solids in cirrhotic and peritoneal dialysis patients: influence of peritoneal volume load

INTRODUCTION: A delay in gastric emptying rate has been reported in peritoneal dialysis patients, often normalizing after evacuation of the dialysate. To evaluate the effect of the intraperitoneal volume, we compared this finding with a cirrhotic model in which gastric emptying was studied before and after a large-volume paracentesis. METHODS AND DESIGN: We used the 13C-octanoic acid breath test to measure gastric half-emptying time (T1/2) for solids in patients with alcoholic cirrhosis, non-diabetic peritoneal dialysis patients, and a control population (asymptomatic volunteers). Cirrhotic patients underwent the test on two consecutive mornings before and after an evacuating paracentesis. Peritoneal dialysis patients were studied twice on consecutive days: once with the dialysate present intra-abdominally ("full"), and once with an emptied abdomen ("empty"). Biochemical analysis was carried out on blood samples before the first test. All cirrhotics underwent a 13C-aminopyrine breath test to assess residual liver function. RESULTS: Gastric emptying in cirrhotics showed no difference before or after paracentesis (median T1/2 108.0 min v. 117.9 min), but it was delayed significantly versus normal in both tests. There was no correlation with biochemical parameters, Child-Pugh score, or 13C-aminopyrine breath test results. Gastric half-emptying times of "full" peritoneal dialysis patients (median T1/2 103.1 min) were significantly higher than those of "empty" peritoneal dialysis patients (median T1/2 68.9 min) and asymptomatic volunteers (median T1/2 60.1 min). "Empty" peritoneal dialysis patients showed no gastroparesis. CONCLUSION: In alcoholic cirrhotic patients with ascites, gastric emptying of solids is delayed, independently of the volume of ascites. In peritoneal dialysis patients, gastric emptying was delayed when "full" and normalized after drainage of the dialysate.