维持性腹膜透析患者甲状旁腺激素水平的影响因素及其对骨代谢的作用

目的 分析维持性腹膜透析（PD）患者甲状旁腺激素（PTH）水平的影响因素,并观察其对骨代谢的影响。方法 选择2020年1月1日~5月31日于东莞市人民医院肾内科腹膜透析中心进行规律透析治疗及随诊的PD患者167例作为研究对象,根据PTH值将患者分为PTH正常组（≤300 pg/ml）67例和PTH升高组（＞300 pg/ml）100例,比较两组一般临床资料及肾功能指标,并采用Spearman相关性分析PTH水平升高组各指标与PTH水平的关系,采用多因素Logistisc回归分析PTH水平升高的影响因素,并分析PTH水平对骨代谢的影响。结果 167例PD患者中PTH正常67例,PTH升高100例。两组性别、年龄、原发疾病、HGB、Alb、血脂系列[总胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白（HDL）、低密度脂蛋白（LDL）、脂蛋白α、同型半胱氨酸（Hcy）]比较,差异无统计学意义（P＞0.05）;而两组透析龄、淋巴细胞百分率、CO2CP、转氨酶、ALP、PTH、SCr、UREA、CysC水平比较,差异均有统计学意义（P＜0.05）。Spearman相关性分析显示,PTH水平与透析龄、UREA、SCr、CO2CP、CysC、淋巴细胞百分率、ALT、尿酸均有相关性（P＜0.05）。多因素Logistic回归分析显示,透析龄、CO2CP、ALT、尿酸是PTH水平升高的影响因素。PTH升高组磷和碱性磷酸酶高于PTH正常组,差异有统计学意义（P＜0.05）;两组钙水平比较,差异无统计学意义（P＞0.05）。结论 维持性腹膜透析患者PTH过高与透析龄、CO2CP、ALT、尿酸因素有关,对其进行分析研究并进行针对性治疗对改善患者预后及延长存活期具有重要意义。     

153例腹膜透析患者死亡及危险因素分析

目的分析腹膜透析患者死亡及其危险因素。方法对河北医科大学第三医院1997至2011年透龄6个月以上的153例CAPD患者进行回顾性分析,采用多变量Cox回归分析方法分析透析患者各临床指标对预后的影响。结果原发病病因中糖尿病肾病患者病死率最高（72．09％,31／43）,其次为缺血性肾病（60．00％,6／10）;死因中主要为心力衰竭（28．99％,20／69）,其次为脑血管意外（17．39％,12／69）。与存活组比较,死亡组血红蛋白（Hb）、血浆白蛋白（Alb）和总尿素清除指数（Kt/V）明显降低;年龄、脉压差、血磷及IyrH水平明显升高,差异均有统计学意义（均P〈0．05）。Cox回归分析结果显示患者年龄、总KdV、血磷、Hb、Alb水平对腹膜透析6个月以上死亡患者的相对危险度分别为1．188,0．798,2．308,2．102,O．898,均有统计学意义。结论透析初期患者年龄、Kt／V、血磷、Hb、Alb水平是CAPD死亡的独立危险因素。心脑血管疾病是CAPD患者的主要死因。     

腹膜透析患者血浆二甲基精氨酸水平与左心功能的相关性研究

目的研究腹膜透析患者血浆不对称二甲基精氨酸(ADMA)水平与左心功能的关系及腹膜透析对血浆ADMA水平的影响。方法选取内蒙古医科大学附属医院终末期肾脏病(ESRD,慢性肾功能不全尿毒症期)患者60例,同期健康志愿者30例(正常对照组),共计90例,其中男性54例,女性36例,平均年龄53.7岁。ESRD患者分持续性不卧床腹膜透析(CAPD,时间均大于3个月)治疗30例(CAPD治疗组)和保守治疗患者30例(保守治疗组)。3组年龄、性别相匹配。收集入组者的相关临床及实验室资料。使用酶联免疫吸附分析(ELISA)测定所有入组者血浆及CAPD治疗组患者腹膜透析液中ADMA含量;并对入组者行超声心动图检测,根据Devereux公式计算左心室质量(LVM)及左心室质量指数(LVMI)。统计学分析3组差异。结果 CAPD治疗组患者血浆ADMA水平为(0.125±0.076)μmol/L,保守治疗组血浆ADMA水平为(0.214±0.121)μmol/L,正常对照组血浆ADMA水平为(0.035±0.291)μmol/L,3组间差异有显著统计学意义(P=0.000)。CAPD治疗组血浆ADMA水平与左心室射血分数(LVEF)呈负相关(r=-0.562,P=0.001),且与LVMI、LVM、左心室舒张末期内径(LVDd)、左心房内径(LAD)呈正相关(P0.05)。保守治疗组比CAPD治疗组患者LVMI高(P=0.01),且有左心室肥厚(LVH)的保守治疗组患者比有LVH的CAPD治疗组患者血浆ADMA水平高(P0.05)。CAPD治疗组腹膜透析液ADMA水平为(0.146±0.077)μmol/L,CAPD治疗组腹膜透析液的ADMA水平与LVEF呈正相关(r=0.367,P=0.046),与LVMI呈负相关(r=-0.369,P=0.045)。结论 ESRD保守治疗组患者血浆ADMA水平与CAPD治疗组血浆ADMA水平均比正常对照组高,说明慢性ESRD存在ADMA的清除功能不全;CAPD治疗组血浆ADMA水平与LVH呈正相关,可以提示ADMA在CAPD患者左心室重构过程中可能起重要作用;保守治疗组比CAPD治疗组患者LVMI高,在腹膜透析液中检测到ADMA,说明腹膜透析可以在一定程度上清除血浆ADMA,腹膜透析对尿毒症患者心血管并发症的发生是一种保护性治疗。     

手工腹膜透析与自动化腹膜透析机在终末期肾病腹膜透析患者中的应用疗效比较

目的 比较手工腹膜透析与自动化腹膜透析机在终末期肾病腹膜透析患者中的应用疗效。方法 选取2019年12月-2021年12月于佳木斯市中心医院行腹膜透析治疗的60例终末期肾病患者,按照随机数字表法进行分组,其中手工腹膜透析组（30例）,自动化腹膜透析组（30例）。分别应用传统手工腹膜透析与自动化腹膜透析,比较两组矿物质代谢指标[钙（Ca）、磷（P）、全段甲状旁腺激素（iPTH）]、矿物质代谢达标率、肾功能指标[血清尿素氮（BUN）、血清肌酐（Scr）]、并发症情况及随访结局。结果 自动化腹膜透析组Ca、P、iPTH指标低于手工腹膜透析组,Ca、P、iPTH代谢达标率高于手工腹膜透析组,Scr、BUN水平低于手工腹膜透析组（P＜0.05）;自动化腹膜透析组并发症发生率低于对照组（P＜0.05）;两组继续腹膜透析率、肾移植率、死亡率比较,差异无统计学意义（P＞0.05）,但自动化腹膜透析组转血液透析率低于手工腹膜透析组（P＜0.05）。结论 相较于手工腹膜透析,自动化腹膜透析机在终末期肾病透析中的矿物质代谢效果更佳,可缓解肾功能损伤,且并发症少,血液透析中转率较低。     

腹膜透析患者的依从性与腹膜透析并发症的关系调查研究

目的：了解腹膜透析患者对腹膜透析相关培训的依从性,探讨患者依从性与腹膜透析相关并发症的关系,为降低腹膜透析的并发症,改善腹膜透析患者的预后性提供参考依据。方法采用自行设计的调查表对60例透析超过半年的腹膜透析患者进行调查,分析患者依从性与腹膜透析相关并发症的关系。结果通过系统的腹膜透析透析前培训,患者能配备透析相关设备,但操作过程存在不规范行为,尤其以年纪大、合并基础疾病患者明显。腹膜透析相关并发症与患者依从性存在负相关关系。结论腹膜透析患者依从性与其并发症的发生有关,提高患者对透析培训的依从性,有助改善患者透析预后。     

腹膜透析患者抗生素脑病危险因素分析

目的:分析腹膜透析患者使用抗生素出现抗生素脑病的危险因素。方法:回顾性分析本院2004-01—2018-01收治的64例维持性腹膜透析(CAPD)患者的临床资料,其中发生抗生素脑病患者10例,作为观察组,其余54例未发生抗生素脑病,从中随机选取15例作为对照组。比较两组间性别、年龄、平均CAPD时间、血液透析转为腹膜透析例数、血压(BP)、矫正钙、血磷、血浆白蛋白、标准蛋白分解率(nPCR)、血红蛋白(Hb)、血肌酐(Scr)、残存肾功能(GFR)、腹膜清除率、每周腹膜总肌酐清除率、每周腹膜总尿素清除指数、应用β-内酰胺类抗生素例数、抗生素使用时间等的分布差异,将差异有统计学意义的指标,经二分类Logistic回归分析引起抗生素脑病的可能因素。结果:抗生素脑病发生率为15.63%(10/64)。上述18个指标中年龄、平均CAPD时间、由血透转为腹透例数、收缩压、舒张压、GFR、每周总肌酐清除率、每周总尿素清除指数、应用β-内酰胺类抗生素例数、应用β抗生素时间3天等10个指标具有组间差异(P0.05或P0.01);将此10个指标纳入Logistic回归模型,分析发现除血压、每周腹膜总肌酐清除率和每周腹膜总尿素清除指数外其余各项指标均为腹膜透析患者发生抗生素脑病的独立危险因素(P0.05或P0.01)。结论:腹膜透析患者抗生素脑病发生率较高,影响因素较多,临床应重视管理,防范风险。     

腹膜透析技术的发展现状

由于本身的特点尤其是技术上的不断进步,腹膜透析技术在肾功能衰竭的治疗中得到更加广泛的应用。本文介绍了近年来腹膜透析的研究重点及其发展方向。     

心理护理干预对持续性非卧床腹膜透析慢性肾功能衰竭患者的影响

目的 分析心理护理干预对持续性非卧床腹膜透析慢性肾功能衰竭患者的影响.方法 回顾性分析2013年10月～2014年10月本院收治的102例行CAPD治疗的CRF患者的临床资料,按照随机数字表法分为观察组和对照组,每组51例.对照组予常规护理,观察组在其基础上加强心理护理干预,比较两组心理状态与生活质量.结果 观察组护理后SAS、SDS评分均低于对照组,且生活总体健康(77.53±12.89)分高于对照组的(64.57±10.11)分,差异均具统计学意义(P＜0.05).结论 心理护理干预对持续性非卧床腹膜透析慢性肾功能衰竭患者有积极影响.     

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。     

慢性肾衰血透患者骨代谢的评估

用ＩＲＭＡ、ＲＲＡ和ＲＩＡ等对２４例维持血透患者（ＭＨＤ）测定其血甲状旁腺激素、ＰＴＨ（１￣８４）、２５（ＯＨ）Ｄ３、１，２５（ＯＨ）２Ｄ３、ＢＧＰ、血钙和磷的变化，以探讨它们之间的关系和评估患者骨代谢的状况。ＭＨＤ患者ＰＴＨ和ＢＧＰ升高，透析后则降低；２５（ＯＨ）Ｄ３和１，２５（ＯＨ）２Ｄ３降低，透析对其无明显影响；ＰＴＨ与２５（ＯＨ）Ｄ３、１，２５（ＯＨ）２Ｄ３呈负相关，Ｐ分别小于０．０５和０     

Fungal Peritonitis in Patients on Continuous Ambulatory Peritoneal Dialysis

 The purpose of this study was to analyze the microbiological and clinical features of fungal peritonitis in patients with endstage renal failure treated with continuous ambulatory peritoneal dialysis (CAPD). The diagnosis of peritonitis was based on abdominal discomfort or pain, cloudy peritoneal effluent with an elevated leukocyte count and isolation of fungi from the peritoneal effluent. Amphotericin B, flucytosine, ketoconazole, miconazole and more recently fluconazole were used for antifungal therapy. From 1983 to 1997 13 patients experienced 14 episodes of fungal peritonitis, comprising 3.1% of all episodes of peritonitis in the dialysis centre. Isolates from the peritoneal effluent comprised Candida tropicalis in two cases, Candida parapsilosis in two cases, Candida albicans in one case, Candida lusitaniae in one case,Cephalosporium spp. in three cases, Aspergillus fumigatus in two cases, and an Aspergillus sp., a Trichoderma sp. and a yeast in one case each. In eight cases bacterial infection shortly before the episode of fungal peritonitis was documented. In 12 (86%) cases the peritoneal catheter had to be removed. Four patients died during the treatment, and one patient died 2 months after the end of treatment due to intra-abdominal bleeding from peritoneal adhesions. Only two patients continued CAPD later; the other patients were switched to hemodialysis. It is concluded that fungal peritonitis is a rare but serious complication in CAPD patients with high rates of morbidity, mortality and drop-out from the CAPD programme (85%). The most frequent isolates were Candida spp. A predisposing factor for fungal peritonitis could be a recent bacterial infection treated with antibiotics. Early peritoneal catheter removal is recommended.     

维生素D与骨代谢生化标志物的相关性研究

目的 调查北京市某社区春季中老年男性维生素D营养状态分布并初步探讨其与其他骨代谢生化标志物的相关性.方法 调查北京市某社区中老年男性人群502例,年龄40～ 70岁,于3～4月期间测定相关骨代谢生化标志物,根据血清25(OH)D3水平将患者分为维生素D严重缺乏组、缺乏组、不足组和充足组.进行统计分析比较各组间一般资料,分析维生素D与其他骨代谢生化指标的关系及骨转换标志物的影响因素.结果 该中老年男性人群春季25(OH)D3平均水平为18.80±7.66(5.0 ～44.50) ng/mL.维生素D缺乏与不足占89.93％,其中严重缺乏6.18％、缺乏62.01％,充足仅占10.07％.排除既往半年内服用维生素D制剂的人群50例后,25(OH) D3平均水平为16.99±5.53ng/mL,缺乏及不足人群占到97.42％.按维生素D水平分组的四组间比较,在校正年龄、BMI等混杂因素后,四组间iPTH随25 (OH)D3升高而降低,血Ca随25 (OH) D3升高而升高.Pearson相关分析显示25 (OH) D3与iPTH呈负相关(相关系数r=-0.229,P＜0.001),与Ca呈正相关(相关系数r=0.095,P=0.086).拟合曲线结果可见,维生素D与iPTH、血钙与iPTH之间有负相关趋势(P ＜0.001).BTMs多元线性回归分析显示OC与25(OH)D3、ALP呈正相关(分别β=0.102,P=0.041;β=0.142,P＜0.001),与BMI、HbA1c呈负相关(分别β=-0.348,P=0.030;β=-3.275,P=0.004);PINP与Pi、ALP呈正相关(分别β=0.742,0.013;P均＜0.001),与FBG呈负相关(β=-0.097,P=0.013);p-CTX与Cr、Pi、ALP呈正相关(分别β=0.009,P=0.045;β =0.938,P=0.002;β =0.009,P=0.045),与FBG呈负相关(β=-0.054,P=0.032).结论 北京春季中老年男性尤其是未补充维生素D制剂者维生素D缺乏现况严重.25 (OH) D3水平与iPTH呈负相关,与Ca呈正相关.BTMs与BMI、Cr、HbA1c、FBG、25 (OH) D3、ALP、Pi相关.     

甲亢患者骨密度及骨代谢生化指标的临床观察

测定甲亢患者的骨密度及骨代谢生化指标,探讨甲亢患者骨质疏松发生的机理.应用双能X线骨密度仪(DEXA),检查149例甲亢患者骨密度(BMD)变化,同时测定其中81例患者血清FT3、FT4、碱性磷酸酶(ALP)、骨钙素(BGP)、尿游离脱氧吡啶啉(D-pyd)的水平.结果显示甲亢时骨密度减低发生率30.2%,骨质疏松发生率24.1%.与对照组比较,甲亢患者各项骨代谢指标均明显升高.结论:甲亢时各项骨代谢指标均明显升高,呈高转换性骨质疏松.在治疗甲亢时应注意检测患者的骨密度,以便尽早发现骨质疏松.     

Two Cases of Peritonitis Caused by Kocuria marina in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Kocuria spp. are members of the Micrococcaceae family that are frequently found in the environment and on human skin. Few human infections have been reported. We describe what appear to be the first two cases of Kocuria marina peritonitis in patients undergoing continuous ambulatory peritoneal dialysis.     

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.     

Peritonitis Caused by Haemophilus parainfluenzae in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

We report a case of peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis. Haemophilus parainfluenzae biotype III was recovered in pure culture from dialysis fluid.     

血清BUN、Scr、PTH和核素骨扫描在肾性骨营养不良中的应用

目的 评价血清BUN、Scr、PTH和^99Tcm-MDP核素骨扫描在肾性骨营养不良中的临床应用价值.方法 75例慢性肾功能衰竭的患者在一周内接受血清BUN、Scr、PTH检测和^99Tcm标记的亚甲基二磷酸盐（^99Tcm-MDP）核素骨扫描,对核素骨扫描图像上可能出现的代谢性骨病显像特征的数量进行评价,并采用三级评分法对各代谢性骨病的图像特征进行半定量分析.结果 75例受检者血清BUN平均为20.31 ±7.95 mmol/L;血清Scr平均为730.2±275.4μmol/L;69例受检者的血清PTH平均为1477.4±781.9 pg/mL（13.7 ～ 3306 pg/mL）.核素骨扫描图像上,30例患者具备5个图像特征,具备4个、3个和2个图像特征的受检者数量分别为32例、11例和2例;半定量分析结果显示75例患者的合计评分范围为4 ～10分.结论 血清BUN,Scr、PTH结合99Tcm-MDP核素骨扫描有助于为肾性骨营养不良患者的诊断、鉴别诊断和疗效评价等方面提供有价值的信息.     

Erysipelothrix rhusiopathiae Peritonitis in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

Erysipelothrix rhusiopathiae is known as a pathogen of occupational diseases or a zoonosis. We report a case of E. rhusiopathiae peritonitis in a 50-yr-old male undergoing continuous ambulatory peritoneal dialysis (CAPD). He was suffered from mild abdominal pain with a distinctive erysipeloid skin lesion. E. rhusiopathiae was considered to be introduced through a lacerated wound on his hand when he was exposed to contaminated materials. He was treated successfully with a first generation cephalosporin. To our knowledge, CAPD peritonitis due to E. rhusiopathiae is very rare, and this is a report of the first case in Asia.     

Blockade of the renal tubular effects of vitamin D by cycloheximide in the rat

To further characterize the mechanisms by which 25(OH)vitamin D₃ (25(OH)D₃) and 1.25(OH)₂ vitamin D₃ (1,25(OH)₂D₃) suppress the phosphaturic action of parathyroid hormone (PTH) we have studied the effects of cycloheximide (cyclohex), a protein synthesis inhibitor, on the interaction between PTH and vitamin D metabolites in parathyroidectomized (PTX) rats, both in vivo and in vitro experiments. In clearance studies PTX PTH-infused rats were pretreated with cyclohex 2 h before the administration of vitamin D. In control, PTX PTH-infused rats not pretreated with cyclohex, the administration of 25(OH)D₃ and 1,25(OH)₂D₃ was associated with a fall in fractional excretion of phosphate (CP/CIN) from 0.30±0.05 to 0.16±0.02 and from 0.31±0.05 to 0.13±0.01 (P<0.005) respectively. Cyclohex-pretreated PTX PTH-infused rats failed to respond to both 25(OH)D₃ and 1,25(OH)₂D₃, and CP/CIN, which rose after PTH, remained 0.32±0.05 and 0.29±0.03 respectively. In vitro, both 25(OH)D₃ and 1,25(OH)₂D₃ inhibited the PTH-induced activation of adenylate cyclase in the renal isolated membrane fractions. Pretreatment with cyclohex abolished this effect of vitamin D metabolites. These results show that cyclohex blocks the antiphosphaturic effects of both 25(OH)D₃ and 1,25(OH)₂D₃ but does not alter the response to PTH. These findings are consistent with the possibility that the acute renal action of vitamin D depends on de novo synthesis of protein.An abstract of this work appeared in Clinical Research, 28 (2) A 387, 1980.