糖尿病肾病腹膜透析常见临床问题

近十年来,糖尿病肾病所导致的终末期肾病(ＥｎｄＳｔａｇｅＲｅｎａｌＤｉｅａｓｅ,ＥＳＲＤ)在我国呈明显增长趋势,其中绝大部分需要接受透析治疗,但这类患者究竟采用何种透析方式最为合适,以及透析方法对这类患者的远期预后有何影响一直未有定论。尽管从理论上讲,腹膜透析(ＰＤ)由于无需做动静脉瘘,故透析患者的心血管系统负荷较血透要小,而腹腔中注射胰岛素使血糖的控制更加简便和符合生理,还因为ＰＤ过程中机体内容量波动较小,多数患者的内环境相对稳定,更利于其耐受,所以临床上普遍认为糖尿病肾病患者应该更适用ＰＤ方式。但在临床实践…     

水盐限制对糖尿病腹膜透析患者容量负荷状况的影响

目的：探讨限制水盐摄入对糖尿病腹膜透析患者容量负荷状况的影响。方法：采用自身前后对照的方法调查所有接受连续性不卧床腹膜透析(CAPD)治疗至少6个月以上的糖尿病肾病患者，严格限制水、盐摄入。评估并检测水盐限制前及水盐限制1～3个月后容量负荷、体重、平均动脉压和超滤量等变化。结果：2002年5月～10月间20例糖尿病肾病CAPD患者，水盐限制前水肿程度、体重、平均动脉压、空腹血糖、透析液糖浓度、透析液糖总量、透析液总剂量和平均超滤量及总清除量均大于水盐控制后，差异均有显著性；水盐限制前后患者的尿量无明显变化。结论：单纯限制水盐摄入能明显改善糖尿病CAPD患者容量超负荷状况，并能降低血压、改善血糖控制。     

终末期糖尿病肾病的腹膜透析

终末期糖尿病肾病的腹膜透析唐政，俞雨生关键词糖尿病肾病，终末期，腹膜透析在西方国家，特别在美国，糖尿病肾病（ＤＮ）是终末期肾脏病（ＥＳＲＤ）最常见的病因。在过去的２０多年中，糖尿病ＥＳＲＤ的治疗有了很大的转变，腹膜透析（ＰＤ）成了血液净化治疗该病中的...     

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。     

糖尿病肾病腹膜透析38例临床分析

目的：观察腹膜透析（PD）及血液透析（HD）在糖尿病肾脏替代治疗中的利弊。方法：选取我院糖尿病肾病患者,其中行血液透析24例,腹膜透析38例;两组患者的性别,透析前的年龄及残余肾功能均相匹配;比较两组的生存率及血脂,血糖,白蛋白,血红蛋白等指。结果：两组前2年的生存率差异无显著性;腹膜透析组第3年的生存率大幅下降,明显低于血液透析组（P＜0．01）;PD组的空腹血糖,甘油三酯及低度脂蛋白均高于HD组,差异有显著性。PD组的血浆白蛋白水平显著低于HD组（P＜0．05）,而血红蛋白则高于HD组。结论：对于糖尿病肾病的肾脏替代治疗,腹膜透析相对于血液透析仍存在一些不完善的地方;是否以腹膜透析作为糖尿病肾病终末期的首选治疗方案,尚需大量的,严格的临床对照研究。     

腹膜透析患者开始透析治疗时的心血管状态及超声特点

目的了解持续不卧床腹膜透析（CAPD）治疗的终末期肾脏病（ESRD）患者透析开始时的心血管状态及超声心动图（UCG）特点。方法选择我院开始CAPD时行UCG检查的ESRD患者51例,收集入院时的血压、实验室检查结果及UCG报告。计算心血管合并症和UCG异常发生率,分析UCG异常及相关因素。结果CAPD患者开始透析时的心血管合并症缺血性心脏病为37．3％,心绞痛为27．5％,心肌梗死（MI）为9．8％,心律失常为5．9％,充血性心力衰竭为9,8％,周围血管病为2．0％。UCG检出左心室肥厚的发生率为为43．1％,相关因素有男性、收缩压增高、脉压增宽、低白蛋白血症和血脂异常;左心室舒张功能不全占77,1％,相关因素有老年、贫血和低白蛋白血症;左心室收缩功能不全占5,9％,相关因素有收缩压低、脉压小、左心室收缩末期内径增大和MI。结论接受CAPD治疗的ESRD患者开始透析时心血管合并症和UCG异常的发生率很高,UCG异常与老年、高血压、贫血、低白蛋白血症等有关。     

腹膜透析和血液透析病人生活质量的比较

生活质量是判断慢性疾病疗效的一个重要指标，也是决定终末期肾脏病患者透析方式的重要因素之一。生活质量受多种因素影响。我们尽可能在性别、年龄、原发病、文化程度、经济来源、并发症及婚姻状况等上进行配对，比较了１７例腹膜透析患者和１７例血液透析患者的生活质量。结果发现配对后，二组病人的生活质量无显著性差别。提示透析方式本身（血透和腹透）对患者生活质量的影响无显著性差别。因此，有必要在我国大力发展腹膜透析。     

腹膜透析导管置入术式及比较

<正>目前,终末期肾脏病(ESRD)的治疗方法主要有血液透析、腹膜透析和肾移植。腹膜透析(PD)因具有操作简便、减少血源性疾病传播、保护残存肾功能等特殊优点,越来越得到广大的医学工作者及患者的认可。有研究统计全世界已超过19万例ESRD患者选择PD~(〔1〕);在墨西哥和香港,80%以上的ESRD患者选择PD做为肾脏替代方式~(〔2〕)。传统的PD导管置入术主要有3种:盲穿法、解剖法和腹腔镜法。尽管传统术式是科学     

Comparison between the pathology of encapsulating sclerosis and simple sclerosis of the peritoneal membrane in chronic peritoneal dialysis

Reports analyzing the histopathological differences between encapsulating peritoneal sclerosis (EPS) and simple peritoneal sclerosis (non-EPS) and those comparing the pathology of early and late EPS are limited. We present pathological comparisons between EPS and non-EPS, also between the early and late EPS stages. We compared peritoneal membrane (PM) samples (Group B) of 12 EPS patients (Group A) and 23 non-EPS cases regarding; mesothelial loss, submesothelial compact zone degenerated layer and compact zone thicknesses, densities of total and diseased vessels, fibrin stain, new membrane formation and degenerative changes. Group A was subdivided into 7 early (group A1) and 8 late (group A2) EPS cases; we compared both subgroups in the same manner and finally compared groups A1, A2, and B. No differences were found between groups A and B in the incidences of mesothelial detachment, new membrane formation and compact zone degenerative changes between the two groups. Furthermore, there were no differences in compact zone thickness, and vascular densities in the compact zone of respective vascular grade. Whereas, fibrin deposition and thickness of the submesothelial degenerated layer were significantly higher in group A than group B (P = 0.01 and 0.05, respectively), and the thickness of the compact zone was less in group A1 than in group A2 (P = 0.03). Positive fibrin stains and thick degenerative compact zone layers are important pathological findings in EPS. Angiogenesis, vasculopathy, new membrane formation, fibrosis and degenerative changes of the compact zone are not unique characteristics for EPS. Larger size studies are recommended to verify this issue.     

两种不同腹膜透析导管拔除术在老年腹膜透析患者中的临床应用

目的分析两种腹膜透析导管拔除术在老年腹膜透析患者中的应用情况。方法采用回顾性队列研究的方法, 收集2010年8月至2020年5月于山西医科大学第二医院腹膜透析中心移除腹膜透析导管的107例老年腹透患者的临床资料, 分为外科开放式拔管组(外科组)和"pull"技术拔管组(pull组), 比较两组性别、年龄、原发病、透析龄、拔管原因及术前相关化验等指标, 观察两组手术时间、术后住院时间、手术疼痛程度及术后并发症等相关情况。结果外科组的手术时间[(71.2±13.4)min和(19.3±5.6)min, t=16.933, P<0.01]、术后住院时间[(9.5±1.8)d和(2.2±0.5)d, t=10.988, P<0.01]和术中疼痛评分[(4.4±1.6)分和(1.4±1.1)分, t=6.909, P<0.01]及术后24 h的疼痛评分[(3.7±1.4)分和(0.5±0.3)分, t=9.995, P<0.01]均高于pull组, 两组术后并发症发生率(6.8%和5.0%, χ2=0.037, P>0.05)差异无统计学意义。结论外科开放式手术法和...     

腹膜透析和血液透析患者与正常人群体液状况的比较

目的　比较并分析持续性非卧床腹膜透析 (CAPD)及血液透析 (HD)患者的体液状况。方法　通过无创性方法 (Xitron 42 0 0生物电阻抗分析仪 )分别测定 45例CAPD患者、44例HD患者和 46例正常人的细胞外液 (ECW )、细胞内液 (ICW )和总体液量 (TBW ) ,用标准体重 (身高 -10 5 )进行标准化后比较。结果　CAPD组标准化细胞外液 (nECW )比HD透析前、HD透析后及对照组均高。HD透析前组nECW比对照组高 ,但透析后组与其比较无显著性差异。HD透析前与透析后组的标准化细胞内液 (nICW )没有显著变化 ,但是与CAPD组及对照组比较均有显著性差异 ;而CAPD组与对照组间比较 ,无显著性差异。在体液分布 (ECW /TBW )上 ,各组间比较均有显著性差异。CAPD组与HD组患者间干体重比较无显著性差异 ;CAPD组患者体重与干体重之差为 ( 2 .6± 2 .4)kg ,与HD透析前组比较差异无显著性 ,而与HD透析后组 [( 0 .3± 2 .5 )kg ]比较 ,有显著性差异。结论　慢性腹膜透析患者普遍存在比血液透析患者更严重的容量超负荷。而腹透患者体液过多的原因可能与其过多水分摄入有关     

The effects of comorbid conditions on the outcomes of patients undergoing peritoneal dialysis

PURPOSE: Dialysis patients frequently have comorbid conditions. We examined the effects of age and comorbid conditions on technique failure (i.e., transfer to hemodialysis), death, hospital costs, and kidney transplantation in patients treated with peritoneal dialysis. METHODS: We studied 97 patients who began peritoneal dialysis from January 1, 1993, to December 31, 1998, at the University of Pittsburgh outpatient dialysis unit. Demographic characteristics, comorbid conditions, and outcomes were determined by reviewing the Medical Archival Retrieval System database and outpatient records. Because the comorbidity (Charlson) score was colinear with age, we used a modified version of the score without an age component. Low, moderate, and high comorbidity groups were defined based on the 33rd and 66th percentiles of the comorbidity score. RESULTS: In multivariate-adjusted models, each decade increase in age was associated with an increased risk of death (hazard ratio [HR] = 1.7; 95% confidence interval [CI]: 1.1 to 2.5) and technique failure (HR = 1.5; 95% CI: 1.0 to 2.3). High (versus low) comorbidity was associated with an increased risk of death or technique failure (HR = 3.5; 95% CI: 1.0 to 12) and significantly higher average inpatient costs. There were no differences in age or comorbidity score between patients who transferred to hemodialysis and those who died. CONCLUSION: Patients who are older and more ill have a greater risk of death and of transfer to hemodialysis from peritoneal dialysis.     

输尿管镜辅助下腹膜透析管置入技术的初步应用

目的探讨单通道输尿管镜辅助下腹膜透析管置入术的临床应用可行性和疗效。方法选择无腹腔手术史的慢性肾衰竭患者10例，局麻下采用经皮微创穿刺技术，使用输尿管镜进入腹腔内定位，通过一次性剥皮鞘将腹膜透析管放置到膀胱直肠窝或子宫直肠窝，近端建立皮下隧道并经左下腹戳洞引出。结果所有腹膜透析管均放置成功，平均手术时间26分钟，术中出血极少，术后3～7天出院。随访时间7～17个月，中位数10．8月，未见漂管、渗漏、堵管、出血、感染等并发症。结论单通道输尿管镜辅助下腹膜透析管置入术是一种定位精确、安全可靠、并发症少的置管新方法。     

腹膜清除效能与腹膜透析患者营养状况的关系

目的　回顾性分析腹膜清除效能与腹膜透析患者营养状况之间的关系。方法　选 取本院99例310例次行腹膜透析患者的随访资料,分别计算各例次的腹膜清除效能指标:腹膜尿 素Kt/v和腹膜Ccr。以蛋白呈现率(nPNA)、白蛋白、瘦体重百分比(%LBM)及主观综合评价法评 估营养状况;根据总尿素Kt/v分组,分析腹膜清除效能与营养状况间之的相关性。结果　A组 (Kt/v<1.7)的腹膜Kt/v、Ccr与白蛋白、%LBM、nPNA呈正相关;B组(1.7≤Kt/v≤2.0)腹膜Kt/ v、Ccr与白蛋白呈负相关;C组(Kt/v>2.0)腹膜Kt/v、Ccr与nPNA、%LMB呈正相关。结论　腹膜 清除效能与腹透患者营养状况之间在一定范围内呈负相关性,过高的腹膜清除对腹透患者的营养 状态并无益处。     

Outcome and survival in different peritoneal dialysis modalities

Peritoneal dialysis (PD) has been accepted as a treatment option for patients with end-stage renal disease, yet experience with PD in Arab countries is limited. This study was undertaken to evaluate the outcome and survival of different PD modalities. All patients managed at the Mubarak Al-Kabeer Hospital Kuwait between August 1982 and December 2003 using PD for three months or more were included in the study. Demographic features, outcome and survival of the patients were analyzed. Four hundred and fifteen patients with end-stage renal failure were admitted into the PD program. Their mean age was 52.06 +/- 16.43 years. Hospital-based intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), nightly intermittent peritoneal dialysis (NIPD) and continuous cycling peritoneal dialysis (CCPD) were preferred by 203 (48.9%), 176 (42.4%), 30 (7.2%) and 6 (1.4%) patients respectively. The mean duration of follow up was 12.7 +/- 11.7 months. Fifty-five (13.3%) patients were continuing on PD, 55 (13.3%) had shifted to hemodialysis, 73 (17.6%) underwent renal transplantation, 114 (27.5%) died, 34 (8.2%) returned to their native countries, 79 (19%) transferred to other centers and follow up was lost for 5 (1.45%) patients. Patient survival at two years was 56%, 72% and 87% in IPD, CAPD and NIPD respectively. Technique survival at two years was 60.6%, 75.4% and 100% in IPD, CAPD and NIPD respectively. Peritoneal dialysis modalities provide a feasible modality of renal replacement therapy. The overall outcome and patient and technique survival in home PD modalities were better than hospital-based PD.     

Abnormal iron status is associated with an increased risk of mortality in patients on peritoneal dialysis

Background and aimsIron deficiency is prevalent, but there is limited data about the relationship between iron status and poor outcomes in chronic kidney disease patients undergoing peritoneal dialysis (PD). We aimed to investigate the association between iron status and mortality in PD patients.Methods and resultsThis retrospective study was conducted on incident PD patients from January 2006 to December 2016 and followed up until December 2018. Patients were categorized into four groups according to baseline serum transferrin saturation (percent) and ferritin levels (ng/ml): reference (20–30%, 100–500 ng/ml), absolute iron deficiency (<20%, <100 ng/ml), function iron deficiency (FID) (<20%, >100 ng/ml), and high iron (>30%, >500 ng/ml). Among the 1173 patients, 77.5% had iron deficiency. During a median follow-up period of 43.7 months, compared with the reference group, the FID group was associated with increased risk for all-cause [adjusted hazard ratio (aHR) 1.87, 95% confidence interval (95% CI) 1.05–3.31, P = 0.032], but not cardiovascular (CV) mortality. Additionally, the high iron group had a more than four-fold increased risk of both all-cause and CV mortality [aHR 4.32 (95% CI 1.90–9.81), P < 0.001; aHR 4.41 (95% CI 1.47–13.27), P = 0.008; respectively].ConclusionFID and high iron predict worse prognosis of patients on PD.