Barriers to utilization of chronic peritoneal dialysis in network #1, New England.

OBJECTIVE: The percentage of prevalent end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) therapy in the United States declined from 15% in 1991 to 8.1% in 2002. Previous studies indicate that nephrologists in the United States feel 32.6% of prevalent ESRD patients should be on CPD therapy. The present study was designed to better understand the reasons for the discrepancy in actual versus desired prevalence of CPD utilization. METHODS: The medical directors of all dialysis centers in New England were mailed a questionnaire about the nephrologists' opinions concerning the percentage of patients that should be maintained on CPD therapy, reasons that limited patients' selection of CPD as initial therapy, and concerns about the current status of CPD therapy. The nephrologists were also invited to free text any other comments or concerns. RESULTS: A total of 117 questionnaires were sent; 59 (50.4%) were returned. These medical directors cared for a median of 10 (range 1 - 100) patients on CPD therapy, meaning 15% of dialysis patients in New England are maintained on CPD therapy. The medical directors felt that 29% (range 10% - 50%) of prevalent ESRD patients should be maintained on CPD therapy. The most common reasons cited by the nephrologists as barriers to CPD therapy included patient preference (54%), contraindications to performing CPD therapy (32%), poor social support (31%), significant comorbid disease (20%), late referrals and acute hospital starts (19%), problems with education re chronic kidney disease (12%), and problems with the structure and organization of CPD facilities (12%). These same medical directors stated that concerns about technique failure (25%), long-term viability of CPD therapy (25%), and mortality rates of CPD patients (17%) impacted on their use of CPD therapy as renal replacement therapy for patients with ESRD. CONCLUSION: Nephrologists in New England felt that 29% of prevalent ESRD patients should be maintained on CPD therapy, yet the actual incidence of CPD utilization in New England is 15%. A variety of factors were cited by the nephrologists as important reasons limiting CPD utilization. These nephrologists were also concerned about technique failure and long-term viability of CPD therapy. It is necessary that we look closely at each domain cited by the nephrologists if CPD therapy is to remain a viable option for patients with ESRD in the United States.     

Patients' descriptions of specific factors leading to modality selection of chronic peritoneal dialysis or hemodialysis.

OBJECTIVES: There has been increasing interest in understanding how patients with chronic renal failure choose between chronic peritoneal dialysis (CPD) and hemodialysis (HD) for renal replacement therapy. The purpose of the present study was to examine the influences and specific factors that patients identify as significant in choosing a specific dialysis modality for treatment of their end-stage renal disease (ESRD). PATIENTS AND DESIGN: 40 patients (20 CPD, 20 HD) who had started dialysis within the preceding 6 months were randomly selected to participate in the study. A structured interview was conducted with the patients, discussing and exploring what factors patients thought were important in helping them decide their treatment modality. The format of the interview was open-ended. Based on patients' comments, a taxonomy of the specific factors that influenced the patients' decisions was developed. SETTING: The study was conducted in a freestanding CPD unit and two freestanding HD units. RESULTS: All 20 CPD patients reported choosing their treatment modality; only 8 of the 20 HD patients reported having a choice of treatment modality. 18 of the 22 patients who participated in predialysis educational programs opted for CPD. 83% of the patients reported that their physician was important in influencing their treatment choice; however, the CPD patients relied more on written material and the opinions of their spouse/significant other or other family members in making their decisions. Issues of autonomy and control were important for 95% of patients choosing CPD. Both CPD and HD patients cited a variety of treatment-specific factors. The three most frequently cited reasons for choosing CPD were (1) flexibility of schedule (19 patients), (2) convenience of performing CPD in their own home (19 patients), and (3) the option of doing dialysis at night while sleeping (8 patients). The 8 HD patients who selected their treatment modality cited the desirability of having a planned schedule (7 patients) and letting nurses or other take care of them (5 patients). CONCLUSIONS: The present study explored factors perceived by patients as being important in determining their choice of renal replacement therapy. A taxonomy of patient influences and concerns has been developed to provide caregivers with a framework to structure their educational strategies and assist patients with progressive renal failure in making an informed choice of therapeutic modality for their ESRD treatment.     

The John F. Maher Award Recipient Lecture 2006. The continuum of chronic kidney disease and end-stage renal disease: challenges and opportunities for chronic peritoneal dialysis in the United States.

End-stage renal disease (ESRD) patients undergoing renal replacement therapy have a high mortality rate and suffer from considerable morbidity. Degree of nutritional decline, disordered mineral metabolism, and vascular calcification are some of the abnormalities that predict an adverse outcome for ESRD patients. All these abnormalities begin early during the course of chronic kidney disease (CKD), long before the need for maintenance dialysis. Thus, CKD represents a continuum of metabolic and vascular abnormalities. Treatment of these abnormalities early during the course of CKD and a timely initiation of dialysis have the potential of improving patient outcomes. However, the thesis that successful management of these abnormalities will favorably modify the outcomes of dialysis patients remains untested. The proportion of incident USA ESRD patients starting chronic peritoneal dialysis (CPD) has historically been low. Limited physician training and inadequate predialysis patient education appear to underlie the low CPD take-on in the USA. Furthermore, two key changes have occurred in the USA: steep decline in CPD take-on and progressive increase in the use of automated peritoneal dialysis. The decline in CPD take-on has afflicted virtually every subgroup examined and has occurred, paradoxically, when the CPD outcomes in the country have improved. Understanding the reasons for historically low CPD take-on and recent steep declines in utilization may allow the development of plans to reverse these trends.     

上海市透析登记及其结果分析

目的通过上海市透析登记及其结果分析,反映上海市终末期肾病患者透析治疗的总体现状。方法上海市血液透析质量控制中心通过上海市"透析登记网络"系统,将2010年1月1日到2010年12月31日接受到的全市60家医院登记资料(其中开展血液透析共60所医院63家血液透析室,开展腹膜透析共38家医院),对所登记的资料进行统计分析。结果 2010年全年新增透析患者1621例(每百万人口发病率114.8pmp),较上一年度增加9.2%;其中血液透析占75.8%,腹膜透析占24.2%。2010年12月31日年末透析患者10508例(每百万人口点治疗率744.0pmp),较上一年度增加14.6%;其中血液透析占80.6%,腹膜透析占19.4%。透析患者主要原发病因仍然是慢性肾小球肾炎(46.2%),新增透析患者中,糖尿病占第2位(19.5%)。全年透析患者主要死亡原因依次为脑血管意外(22.4%)、感染(19.6%)和心血管事件(15.2%);年末透析患者中透析龄5年以上的占30.8%。患者透析充分性、贫血治疗状况、乙型肝炎和丙型肝炎病毒感染控制不断改善和提高。结论上海市终末期肾脏病(ESRD)透析患者逐年增加,主要原发病因为肾小球肾炎,新增患者中,糖尿病患者逐年增加,血液透析仍是目前上海市ESRD患者主要透析治疗模式。     

Adiponectin levels and atherosclerotic risk factors in pediatric chronic peritoneal dialysis patients.

BACKGROUND: Atherosclerotic vascular diseases are the major cause of mortality in patients with end-stage renal disease (ESRD) treated with chronic peritoneal dialysis (CPD), even in children. Adiponectin (ADPN) is a recently discovered adipocyte-derived plasma protein having anti-atherogenic properties. ADPN levels are elevated in ESRD but it has been reported that ESRD patients with low plasma ADPN levels have a high risk of cardiovascular death. OBJECTIVE: To clarify the atherosclerotic risk and especially the significance of ADPN levels in pediatric patients on CPD. DESIGN: Cross-sectional studyin the pediatric peritoneal dialysis unit of a university hospital. PATIENTS: 18 children, aged 12.6 +/- 5.6 years, being treated with CPD and 20 healthy age- and sex-matched control subjects were enrolled in this study. METHODS: Serum ADPN levels and other risk factors, including blood pressure, blood glucose, serum lipid/lipoprotein fractions, apolipoprotein B, C-reactive protein (CRP), lipoprotein(a), and homocysteine levels, were studied in CPD patients and compared to the controls. RESULTS: Serum ADPN levels were three times higher in the CPD group compared to the control subjects, as was previously reported. Apolipoprotein B and CRP levels were also high in the CPD group. No significant difference was found in other atherosclerotic parameters, including lipoprotein(a) and homocysteine levels. Interestingly, we found a negative correlation between log ADPN and creatinine levels among the CPD patients (r = -0.54, p < 0.05). There was no correlation between log ADPN and duration of CPD. Creatinine and low-density lipoprotein levels could account for 54% of the total variation in ADPN levels. CONCLUSION: Among pediatric CPD patients, serum levels of the anti-atherogenic protein, ADPN, were inversely associated with creatinine. ADPN level might be a novel marker to predict prognosis in pediatric CPD patients.     

高通量血液透析对终末期肾病患者透析充分性及细胞免疫功能的影响

目的观察高通量血液透析(HFHD)对终末期肾病(ESRD)患者透析充分性及细胞免疫功能的影响。方法选择本院2017年10月至2018年10月诊断为ESRD的患者96例为研究对象,按随机数字表法将其分为观察组与对照组,各48例。观察组采用HFHD治疗,对照组采用常规血液透析(HD)治疗。比较两组的透析充分性指标、治疗前、后细胞免疫功能指标。结果观察组的Kt/v、URR高于对照组,差异具有统计学意义(P<0.05)。治疗后,两组细胞免疫功能各指标水平均升高,且观察组高于对照组,差异具有统计学意义(P<0.05)。结论HFHD较HD能显著提高ESRD患者的透析充分性,改善细胞免疫功能,值得临床推广及应用。     

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.     

A psychiatric perspective of dialysis discontinuation

In the 1970s, the suicide rate of patients with end-stage renal disease (ESRD) was calculated by conflating deaths from obvious clinical suicide attempts with deaths caused by lethal noncompliance and deaths preceded by dialysis discontinuation. Three decades later, although society's view about cessation of life-support treatment has markedly changed, relatively little is known about the psychiatric aspects of dialysis discontinuation. This paper reviews the literature and suggests a number of findings that warrant further research investigation.     

Preservation of residual renal function in dialysis patients: effects of dialysis-technique-related factors.

OBJECTIVES: Residual renal function (RRF) is of paramount importance to dialysis adequacy, morbidity, and mortality, particularly for long-term continuous ambulatory peritoneal dialysis (CAPD) patients. Residual renal function seems to be better preserved in patients on CAPD than in hemodialysis (HD) patients. We analyzed RRF in 45 patients with end-stage renal disease (ESRD), commencing either CAPD or HD, to prospectively define the time course of the decline in RRF, and to evaluate dialysis-technique-related factors such as cardiovascular stability and bioincompatibility. STUDY DESIGN: Single-center prospective investigation in parallel design with matched pairs. MATERIALS: Fifteen patients starting CAPD and 15 matched pairs of patients commencing HD were matched according to cause of renal failure and RRF. Hemodialysis patients were assigned to two dialyzer membranes differing markedly in their potential to activate complement and cells (bioincompatibility). Fifteen patients were treated exclusively with the cuprophane membrane (bioincompatible) and the other 15 patients received HD with the high-flux polysulfone membrane (biocompatible). MEASUREMENTS: Residual renal function was determined at initiation of dialytic therapy and after 6, 12, and 24 months. Dry weight (by chest x ray and diameter of the vena cava) was closely recorded throughout the study, and the number of hypotensive episodes counted. RESULTS: Residual renal function declined in both CAPD and HD patients, although this decline was faster in HD patients (2.8 mL/minute after 6 months and 3.7 mL/min after 12 months) than in CAPD patients (0.6 mL/min and 1.4 mL/min after 6 and 12 months respectively). It declined faster in patients with bioincompatible than with biocompatible HD membranes (3.6 mL/min vs 1.9 mL/min after 6 months). Eleven percent of the HD sessions were complicated by clinically relevant blood pressure reductions, but there were no differences between the two dialyzer membrane groups. None of the CAPD patients had documented hypotensive episodes. None of the study patients suffered severe illness or received nephrotoxic antibiotics or radiocontrast media. CONCLUSIONS: The better preservation of RRF in stable CAPD patients corresponded with greater cardiovascular stability compared to HD patients, independently of the membrane used. Furthermore, there was a significantly higher preservation of RRF in HD patients on polysulfone versus cuprophane membranes, indicating an additional effect of biocompatibility, such as less generation of nephrotoxic substances by the membrane. Thus, starting ESRD patients on HD prior to elective CAPD should be avoided for better preservation of RRF.     

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.     

Recovery of renal function in Black South African patients with malignant hypertension: superiority of continuous ambulatory peritoneal dialysis over hemodialysis.

OBJECTIVE: To describe recovery of renal function (RC) in Black South African patients with primary malignant hypertension (MHT) and end-stage renal failure, according to the type of dialysis provided. DESIGN: A retrospective analysis of the records of 31 patients with MHT. SETTING: A university-based, large tertiary-care hospital and its community-based satellite continuous ambulatory peritoneal dialysis (CAPD) clinics. PATIENTS: Only patients with renal failure caused by MHT and who were on dialysis between January 1997 and June 2000. There were 11 patients on peritoneal dialysis (PD) that regained renal function; 11 patients on hemodialysis (HD), none of whom recovered renal function; and 9 patients on PD who did not recover renal function during the same time period. OUTCOME MEASURES: The groups were investigated for variables that might predict RC. RESULTS: Peritoneal dialysis compared with HD was highly significant as an indicator of RC (p < 0.0001), with 60% of patients on PD regaining renal function, versus 0% on HD. Median time to recovery was 300 (150 -365) days. There was no significant difference in decline of mean arterial pressure (MAP) between the groups; MAP declined significantly in all groups (p = 0.00002). All groups received similar drug therapy. In the RC group, initial MAP, kidney size, and urine output tended to be higher and creatinine lower (p = not significant). Dialysis adequacy was similar in the different groups. CONCLUSIONS:This retrospective study suggests there may be benefit from PD as the primary form of dialysis when patients have MHT as a cause of their renal failure. Possible predictors of RC include blood pressure control, initial MAP, initial serum creatinine, initial urine output, and kidney size. Time should be allowed for RC before transplantation is undertaken. Prospective studies are needed to confirm the benefit of CAPD in patients with MHT.     

Risk of Dementia in Peritoneal Dialysis Patients Compared with Hemodialysis Patients

♦ Background: Compared with similarly aged controls, patients with end-stage renal disease (ESRD) have a higher prevalence of cognitive impairment and more rapid cognitive decline, which is not explained by traditional risk factors alone. Since previous small studies suggest an association of cognitive impairment with dialysis modality, we compared incident dementia among patients initiating hemodialysis (HD) vs peritoneal dialysis (PD) in a large national cohort.♦ Methods: This is a retrospective cohort study of incident dialysis patients in the United States from 2006 to 2008 with no diagnosis of dementia prior to beginning dialysis. We evaluated the effect of initial dialysis modality on incidence of dementia, diagnosed by Medicare claims data, adjusted for baseline demographic and clinical data from the USRDS registry.♦ Results: Our analysis included 121,623 patients, of whom 8,663 initiated dialysis on PD. The mean age of our cohort was 69.2 years. Patients who initiated PD had a lower cumulative incidence of dementia than those who initiated HD (1.0% vs 2.7%, 2.5% vs 5.3%, and 3.9% vs 7.3% at 1, 2, and 3 years, respectively). The risk of dementia for patients who started on PD was lower compared with those who started on HD, with a hazard ratio (HR) = 0.46 [0.41, 0.53], in an unadjusted model and HR 0.74 [0.64, 0.86] in a matched model.♦ Conclusions: Dialysis modality is associated with incident dementia in a cohort of older ESRD patients. This finding warrants further investigation of the effect of dialysis modality on cognitive function and evaluation for possible mechanisms.     

Factors affecting peritoneal dialysis selection in Taiwanese patients with chronic kidney disease

LIANG C.‐H., YANG C.‐Y., LU K.‐C., CHU P., CHEN C.‐H., CHANG Y.‐S., O'BRIEN A.P., BLOOMER M. & CHOU K.‐R. (2011) Factors affecting peritoneal dialysis selection in Taiwanese patients with chronic kidney disease. International Nursing Review 58 , 463–469 Background: Taiwan has the highest incidence and prevalence of end‐stage renal disease (ESRD) in the world with 55 499 ESRD patients on long‐term dialysis. Nevertheless, 90.96% of these patients are managed on maintenance haemodialysis (HD), with only 9.03% enrolled in a peritoneal dialysis (PD) programme. Aim: The study aim was to identify the factors affecting Taiwanese patient's selection of PD in preference to HD for chronic kidney disease. Methods: A cross‐sectional research design was utilized with 130 chronic renal failure (CRF) patients purposively selected from outpatient nephrology clinics at four separate Taiwan hospitals. Logistic regression was used to identify the main factors affecting the patient's choice of dialysis type. Results: Single‐factor logistic regression found significant differences in opinion related to age, education level, occupation type, disease characteristics, lifestyle modifications, self‐care ability, know‐how of dialysis modality, security considerations and findings related to the decisions made by medical personnel (P < 0.05). Moreover, multinomial logistic regression after adjustment for interfering variables found that self‐care ability and dialysis modality know‐how were the two main factors affecting the person's selection of dialysis type. Conclusions: Self‐care ability and the person's knowledge of the different types of dialysis modality and how they function were the major determinants for selection of dialysis type in Taiwan based on the results from this study. The results indicate that the education of CRF patients about the types of dialysis available is essential to enable them to understand the benefits or limitations of both types of dialysis.     

终末期肾脏病患者透析方式选择的影响因素

目的回顾性调查终末期肾脏病（ESRD）患者透析前透析方式的选择情况，探讨终末期肾脏病患者透析方式选择的影响因素，为今后开展患者透析前宣传教育提供科学依据。方法采用方便取样法，选择规律透析治疗6～18月的患者（包括血液透析和腹膜透析）共60例，用自设问卷回顾性调查分析北京大学人民医院患者透析前的原发病及就诊情况、有无急诊透析及其透析原因、最终透析方式、透析方式决定者、透析知识了解情况等。结果①40例（66．7％）患者曾进行过急诊透析，而未进行过急诊透析患者的透析知识总分显著高于急诊透析组。②最终选择血液透析的患者中，急诊透析发生率显著高于最终选择腹膜透析的患者。③43．3％患者参与决定最终的透析方式，36．7％患者由医生决定透析方式，20．0％患者由家人和医生决定透析方式。本人参与决定透析方式的患者其信息获取主动性评分、透析知识总分和腹膜透析知识评分显著高于医生决定组。结论患者透析前对透析知识的掌握程度、患者获取信息的主动性、及是否有过急诊透析经历是影响患者选择最终透析方式的主要因素。     

Assessing recovery of renal function after tenofovir disoproxil fumarate discontinuation

Impaired renal function caused by tenofovir disoproxil fumarate (TDF) is considered reversible by discontinuing TDF administration, but there are occasional cases of incomplete recovery. We investigated the recovery of renal function after the discontinuation of TDF. Subjects comprised patients who had been started on TDF but in whom it was later discontinued because of impaired renal function. We investigated renal function until 96 weeks after the discontinuation of TDF, and the duration of TDF administration, up to May 2010. TDF was discontinued because of impaired renal function in 21 of 766 patients (2.7%). Following discontinuation, a significant recovery was seen in eGFR (p = 0.003). The median duration of administration was 28 days (6-941 days) in 9 patients whose eGFR recovered to pre-administration levels, 405 days (250-1,379) in 7 patients in whom mild recovery was seen, and 1,110 days (421-1,470) in 5 patients in whom eGFR was much lower than at the time of discontinuation. A significant correlation was seen between the eGFR recovery rate and the duration of TDF administration. TDF administration was discontinued because of renal impairment in 2.7% of patients. The duration of TDF administration was short in patients whose renal function recovered to pre-administration levels, but patients in whom sufficient recovery was not seen after discontinuation had received TDF over long periods and included many whose renal function gradually declined, even after discontinuation. Recovery of renal function after discontinuation of TDF is likely affected by the duration of TDF administration.     

腹膜透析治疗糖尿病肾病尿毒症患者的临床分析

目的　探讨影响糖尿病终末期肾病 (ESRD)患者腹膜透析生存率的因素。方法　对糖尿病ESRD患者 2年存活组与死亡组开始透析时的肾功能、营养状态及合并症情况进行对比分析。结果　糖尿病ES RD患者 2年死亡组开始透析时的尿素氮 (BUN)、血肌酐 (Scr)高于存活组 ,内生肌酐清除率低于存活组 ;与存活组相比 ,2年死亡组开始透析时的血红蛋白 (Hb)、血浆白蛋白 (Alb)明显较低 ;2年死亡组开始透析时的合并症数目多于存活组。结论　糖尿病ESRD患者的腹膜透析生存率与开始透析时的肾功能、营养状态及合并症情况密切相关 ,应根据患者透析前肾功能、营养状态及合并症情况综合考虑 ,选择适当的透析时机。     

Residual renal function in a large cohort of peritoneal dialysis patients: change over time, impact on mortality and nutrition.

OBJECTIVE: Residual renal function contributes importantly to total solute clearance in peritoneal dialysis (PD) patients. This study was designed to examine the progression of residual renal function over time and its impact on nutrition and mortality in PD patients in the six New England states (ME, NH, VT, CT, MA, RI) comprising End Stage Renal Disease (ESRD) Network 1. DESIGN: As part of the ESRD Clinical Indicators Project, data on 990 PD patients in Network 1 were abstracted from data supplied by dialysis units in the fourth quarter of 1997. This included demographic information; dose of PD in L/day; weekly renal, dialysis, and total Kt/V urea; weekly renal, dialysis, and total creatinine clearance (CCr); serum albumin level; and mortality and transplantation information. Data collection was repeated in the second and fourth quarters of 1998 and in the second quarter of 1999. PATIENTS: 990 PD patients in Network 1. OUTCOME MEASURES: The change in total and renal solute clearances over time, the relationship between renal clearance and mortality, and the relationship between renal clearance and nutritional status, as represented by serum albumin. RESULTS: Over the 2-year period, mean weekly renal Kt/V urea and weekly renal CCr dropped significantly. To examine the effect of residual renal function on mortality, patients were divided into high and low (above and below the median) weekly renal Kt/V urea and weekly renal CCr groups. Patients above the median levels of both weekly renal Kt/V urea and weekly renal CCr had a significantly decreased risk of dying during the observation period, after controlling for age, gender, serum albumin level, and diabetic status [OR for high vs low renal Kt/V urea 0.54 (CI 0.34 - 0.84), OR for high vs low renal CCr 0.61 (CI 0.40 - 0.94)]. The mean weekly renal Kt/V urea was significantly and directly correlated with the mean serum albumin level by Spearman rank correlation (R = 0.133, p < 0.001), as was the mean weekly renal CCr (R = 0.115, p < 0.001). CONCLUSIONS: Residual renal function is an important contributor to total solute clearance in PD patients. Even at low levels it is linked to decreased mortality and better nutritional status.     

Acute renal failure in critically ill patients: prognosis for recovery of kidney function after prolonged dialysis support

OBJECTIVE: To clarify the prognosis for eventual recovery of kidney function in patients who experience prolonged dialysis dependence after acute renal failure (ARF). DESIGN: Retrospective, chart review. SETTING: Inpatients of a large, referral-based hospital. PATIENTS: Twenty-six consecutive survivors of ARF who required greater than 4 wk of dialysis support. RESULTS: All 26 patients were critically ill and developed ARF during treatment in an ICU. The clinical course of these patients was characterized by multiple episodes of renal ischemia or nephrotoxin exposure during dialysis dependence. However, despite multiple renal insults and prolonged dialysis support (mean duration 8.4 +/- 0.7 wk), 23 (88%) of the 26 patients recovered sufficient kidney function to discontinue dialysis. Preexisting renal impairment was associated with a greater risk of irreversible renal failure, and, in patients able to discontinue dialysis, renal recovery was often incomplete. CONCLUSIONS: Despite some renal damage, most critically ill patients who survive ARF requiring prolonged dialysis support recover life-sustaining kidney function.     

实时三维斑点追踪成像技术评价不同透析方式终末期肾病患者的左心房容积及功能

目的:探讨实时三维斑点追踪成像(RT3D-STI)技术评价不同透析方式终末期肾病(ESRD)患者左心房容积及功能的价值。方法:选取2019年2-8月就诊于青岛大学附属医院的ESRD患者83例,分为未透析组(25例)、血液透析组(HD组,31例)及腹膜透析组(PD组,27例),另选30例健康志愿者为对照组,应用RT3D-STI技术获取左心房容积指数[左心房最大容积指数(LAVImax)、左心房最小容积指数(LAVImin)、左心房主动收缩前容积指数(LAVIpre)]、左心房功能参数[左心房射血分数(LAEF)、左心房被动射血分数(LApEF)、左心房主动射血分数(LAaEF)]及左心房心肌应变参数[整体纵向应变(GLS)、径向应变(GRS)、圆周应变(GCS)],比较各组间上述参数的差异,分析心肌应变参数与透析时间的相关性。结果:①未透析组、PD组及HD组LAVImax、LAVImin、LAVIpre较对照组增大,LAEF、LApEF、GLS、GRS、GCS较对照组减小(均P<0.05);PD组LAVImin及HD组LAVImax、LAVImin、LAVIpre较未透析组增大,PD组LAEF、LApEF、GLS、GCS及HD组LAEF、LApEF、GLS、GRS、GCS较未透析组减小(均P<0.05);HD组LAVImax、LAVImin、LAVIpre较PD组增大,LAEF、LApEF、GLS、GRS、GCS较PD组减小(均P<0.05)。②PD组GLS、GCS与透析时间呈负相关(r=-0.670,-0.596;均P<0.05),HD组GLS、GCS、GRS与透析时间呈负相关(r=-0.624,-0.631,-0.551;均P<0.05)。结论:RT3D-STI技术可对不同透析方式患者的左心房容积及功能作出有效评价,对评估患者预后、指导临床及时干预治疗有重要意义。