持续性非卧床腹膜透析患者继发性甲状旁腺功能亢进相关因素分析

目的 探讨持续性非卧床腹膜透析(CAPD)患者继发性甲状旁腺功能亢进(SHPT)的患病率及相关因素.方法 分析2011年7月至2012年1月在本院腹膜透析中心规律随访的CAPD患者数据库资料.所有患者根据全段甲状旁腺激素(iPTH)分为甲状旁腺功能亢进组及甲状旁腺功能非亢进组.通过Logistic回归分析SHPT的相关影响因素.结果 共纳入639例患者,SHPT的患病率为46.95％.Logistic多因素回归分析结果显示,低血红蛋白、低血钙、高血磷、高碱性磷酸酶、高血肌酐、高标准化蛋白分解代谢率(nPCR)及低钙透析液是SHPT的独立影响因素.结论 CAPD患者中SHPT患病率较高,钙磷代谢异常、高蛋白饮食、肾性贫血及低钙透析液是影响SHPT发生的独立因素.     

继发性甲状旁腺功能亢进患者术后临床评估

目的探讨继发性甲状旁腺功能亢进患者行甲状旁腺全切除或次全切除术后的预后。方法选择2009年1月至2012年12月在深圳市人民医院行慢性肾替代治疗合并继发性甲状旁腺功能亢进症手术治疗后的88例患者进行1~4年随访观察。术中留取血液样本送检测全段甲状旁腺素(immunoreactive parathyroid hormone,iPTH)水平(电化学发光法),根据测定的iPTH水平,由外科医生决定手术方式为次全切除或全切除术。根据手术方法将88例患者分为次全切除组和全切除组。次全切除组64例,男35例,女29例;全切除组24例,男女各12例;比较2组患者术后的复发率及预后。另外根据术后随访及血清iPTH的检测,将88例患者复发分为复发组和未复发组。复发组11例,男6例,女5例;未复发组77例,男41例,女36例;应用Log-rank检验对复发情况进行分析,并对可能影响复发的因素进行分析。结果 88例患者进行了(21±11.3)个月的随访研究,复发患者术后第2天iPTH水平(111.20±81.4)ng/L高于未复发患者iPTH(24.4±35.8)ng/L,2组比较有统计学差异(t=-3.486,P0.01);随访期间次全切除组10人复发,全切除组1人复发,经Log-rank检验不同手术组的未复发率无统计学差异(χ~2=0.33,P=0.57)。全部88例患者术后第12、26、36个月累积未复发率分别为98.8%、91.3%及67.1%。结论维持性透析继发性甲状旁腺功能亢进患者行甲状旁腺全切除或次全切除术后的1~4年内复发率无显著差异,术后患者症状明显改善,术后第二天的iPTH水平可能与复发相关。     

腹膜透析并发甲状旁腺功能亢进患者的认知功能及其相关因素分析

目的探讨维持性腹膜透析并发甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)患者的认知功能及其影响因素。方法选择安徽医科大学第二附属医院透析时间超过3个月的维持性腹膜透析患者为研究对象并筛选出2组患者,A组21例患者的甲状旁腺激素(parathyroid hormone,PTH)630 ng/L合并骨痛、皮肤瘙痒等不适症状,B组45例患者的PTH630 ng/L未合并骨痛、皮肤瘙痒等不适症状。对每例患者详细询问病史并测定血常规、生化常规、电解质、甲状旁腺激素、25-羟维生素D_3[25(OH)D_3]等的检查,并在血液检查1周内采用智能评估量表(the modified mini-mental assessment amount,3MS)进行认知评分,分析2组患者临床指标间的差异及3MS得分的相关因素。结果 A组患者的血红蛋白(hemoglobin,Hb)、血肌酐(SCr)、血钙、25(OH)D_3及3MS得分等均高于B组,差别有统计学意义(均P0.05);A组患者的血磷、PTH水平等低于B组,差别有统计学意义(均P0.05)。相关性因素分析发现A组患者的3MS得分与年龄(r=-0.657,P=0.001)、有无脑血管疾病病史(r=-0.512,P=0.018)、PTH(r=-0.652,P=0.001)呈负相关,差别有统计学意义。B组患者的3MS得分男性高于女性,差别有统计学意义(r=-0.344,P=0.021)。3MS得分与Ca(r=0.958,P=0.000)、25(OH)D_3(r=0.983,P=0.000)呈正相关,与年龄(r=-0.804,P=0.000)、有无脑血管疾病病史(r=-0.425,P=0.000)、血磷(r=-0.965,P=0.000)、PTH(r=-0.941,P=0.000)呈负相关。多因素STEPWISE法回归分析发现,25(OH)D3(t=6.298,P=0.000)、血钙(t=3.233,P=0.002)、PTH(t=-2.632,P=0.012)是3MS得分的独立危险因素。结论维持性腹膜透析并发SHPT患者的整体认知水平与患者的性别、年龄、脑血管疾病史、血钙、血磷及25(OH)D_3水平及PTH等有关,改善维持性腹膜透析合并甲状旁腺功能亢进患者体内的钙磷代谢紊乱、降低血甲状旁腺激素水平也许是提高患者认知功能的重要手段。     

继发性甲状旁腺功能亢进甲状旁腺定位方法研究进展

正继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)已成为慢性肾病(CKD)的主要并发症之一,其发病原因主要是体内长期钙、磷代谢紊乱刺激甲状旁腺增生,大量甲状旁腺激素(PTH)释放入血,作用于运动、心血管系统等,轻者出现关节疼痛、周身瘙痒、四肢无力,重者出现骨质疏松、病理性骨折、异位钙化、心血管意外事件增加等~([1])。卞维静等~([2])对SHPT病人进行的流行病学调查显     

慢性肾衰继发性甲状旁腺功能亢进的治疗

<正>约40%的慢性肾衰透析患者存在继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT),其发病机制包括:1)磷潴留。这是慢性肾衰SHPT最重要的刺激因子。2)低钙血症。低血钙在数秒和数分钟内可增加PTH分泌,数小时内可上调PTH基因表达,数周或数月内刺激甲状旁腺细胞分裂增殖。3)活性维生素D(VD)代谢异常及抵抗。4)     

慢性肾脏病继发性甲状旁腺功能亢进的治疗进展

继发性甲状旁腺功能亢进是慢性肾功能衰竭时最常见的并发症之一,相关的矿物质代谢紊乱与患者高致残率、病死率相关.继发性甲状旁腺功能亢进的治疗是肾科医师面临的难题,需要探讨更好地治疗方法,现就目前的治疗方法及进展进行讨论.     

甲状旁腺切除治疗继发性甲状旁腺功能亢进

目的探讨甲状旁腺全切加自体移植及甲状旁腺次全切的2种手术治疗继发性甲状旁腺功能亢进（SHPT）的效果。方法根据19例SHPT患者甲状旁腺增生数目及腺体大小分为甲状旁腺全切加自体移植组及甲状旁腺次全切组,观察术后并发症,记录血清学指标,随访1年。结果腺体长径大于1cm病理改变且呈结节样增生。2组术后1个月钙、磷、碱性磷酸酶及甲状旁腺素水平变化无差异,术后1年碱性磷酸酶及甲状旁腺素变化存在显著统计差异。结论甲状旁腺切除治疗严重的SHPT效果确切,甲状旁腺全切加自体移植比甲状旁腺次全切复发率更小。     

甲状旁腺切除及无水酒精注射治疗继发性甲状旁腺功能亢进

目的：探讨甲状旁腺切除及腺体内无水酒精注射两种方式治疗继发性甲状旁腺功能亢进（SHPT）的疗效及安全性。方法：17例SHPT患者分为甲状旁腺切除组7例及甲状旁腺无水酒精注射组10例,术后腺体送检病理,观察药物注射前后腺体超声信号变化及术后并发症,记录血清学指标并随访1年。结果：腺体长径大于1.0cm病理改变呈结节样增生,无水酒精注射后腺体血流信号减少。两组术后钙、磷、碱性磷酸酶及甲状旁腺激素水平变化差异存在统计学意义（P〈0.01）,两组术后患者症状均有改善,并发症少,但手术组疗效优于注射组。结论：甲状旁腺切除治疗严重继发性甲状旁腺功能亢进效果确切,临床作为首选,甲状旁腺无水酒精注射治疗可作为单一腺体增生或甲状旁腺切除后的补充治疗。     

低钙透析液对腹膜透析患者钙磷代谢的影响

目的横断面研究腹膜透析患者使用低钙透析液的安全性及其影响因素。方法选择西安交通大学医学院第一附属医院肾脏内科腹膜透析超过6个月的患者共39例，其中男24例，女15例，年龄56．49±19．31岁，其中使用常规（ca 1．75mmol／L）透析液8例，低钙（ca 1．25mmol／L）透析液31例，比较两组血清钙、磷、甲状旁腺激素、血压以及使用碳酸钙的情况。结果两组血钙无明显差异；常规透析液组血磷和钙磷乘积高于低钙组，两组iPTH无明显差异。低钙组服用碳酸钙剂量明显高于常规透析液组。低钙组服用碳酸钙与未服用碳酸钙血钙无明显差异，服用碳酸钙组血磷控制较为理想、钙磷乘积更接近正常，未服用碳酸钙组血PTH明显升高。结论腹膜透析患者使用低钙透析液有利于控制血磷和血压，有效预防钙磷乘积升高。提高对碳酸钙的依从性是预防使用低钙透析液后引起继发性甲状旁腺功能亢进的关键。     

依折麦布联合阿托伐他汀钙治疗腹膜透析患者高脂血症的观察

目的 探讨依折麦布联合阿托伐他汀钙治疗腹膜透析患者高脂血症的疗效及安全性.方法 回顾性分析34例腹膜透析患者的临床资料,所有患者均行持续非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD),口服依折麦布(10 mg/d)联合阿托伐他汀钙(10mg/d)治疗12周,检测用药前、后患者血脂、肝功能、肌酸磷酸激酶(creatine phosphokinase,CPK)及超敏C反应蛋白(hypersensitive C-reactive protein,hs-CRP)的水平,并进行相关统计学分析.结果 ①在进行腹膜透析前,34例患者中有21例(占61.8％)存在高脂血症,其中高胆固醇血症6例(占17.6％),高三酰甘油(triacylglycerol,TG)血症5例(占14.7％),混合型高脂血症10例(占29.4％),而高胆固醇血症在原发病为糖尿病肾病患者中发病率较高,为14例(占41.2％);②经过12周联合治疗,与治疗前比较,治疗后患者的血清总胆固醇(total cholesterol,TC)、低密度脂蛋白胆固醇(low density lipoprotein cholesterin,LDL-C)、hs-CRP水平均有所降低,且差异均有统计学意义(P＜0.05).另外,虽然TG水平较前有所降低,高密度脂蛋白胆固醇(high density lipoprotein cholesterin,HDL-C)水平较前有所升高,但差异均无统计学意义(P＞0.05);丙氨酸氨基转移酶(alanine transaminase,ALT)、天冬氨酸氨基转移酶(aspartate transaminase,AST)、CPK水平较前并无明显变化;③34例患者经过12周联合治疗后,观察其治疗前、后的血清尿素氮(BUN)及肌酐(SCr)、尿量、腹膜透析超滤量、家庭自测血压的变化情况发现SCr有下降趋势,尿量有增加趋势,但差异并无统计学意义(P＞0.05),其余指标未见明显变化.结论 依折麦布联合阿托伐他汀钙能有效治疗CAPD患者高胆固醇血症,且能降低hs-CRP水平,发挥抗炎作用,同时对患者的腹膜透析治疗及血压无明显影响,具有良好的安全性.     

腹膜透析患者的营养管理

腹膜透析(PD)患者普遍存在营养不良,而营养不良是PD患者低生存率、高住院率、高死亡率的主要原因。PD患者营养不良的原因复杂,炎症、透析不充分、蛋白与热量摄入不足、透析过程中蛋白质丢失、腹膜高转运、残余肾功能下降、慢性酸中毒、高分解代谢、各种并发症等,都参与了营养不良的发生发展。营养不良的评估需要结合病史和检查的各项指标来综合判定,如主观全面营养状态评价(SGA)、生化指标、蛋白质相当的总氮呈现率(PNA)、双能X射线吸收法(DEXA)、生物电阻抗分析(BIA)等。改善PD患者的营养不良需要进行多方面综合管理,如管理膳食摄入、保持足够的透析剂量、保护残余肾功能、纠正酸中毒等,同时应注意积极预防和治疗腹膜炎、保持最佳的体液平衡、使用生物相容性好的透析液或使用药物治疗。     

Fatigue in chronic peritoneal dialysis patients

Fatigue is a common complaint in long termdialysis patients that may influence theirquality of life. The present study was carriedout in order to evaluate the prevalence andcourse of fatigue in a group of chronic PDpatients and to find the possible factor(s)related to its development. We retrospectivelyreviewed 100 charts of the patients previouslyon PD. The presence or absence of fatigue inthe 1st and last clinic visits and the 1st and2nd changes in fatigue state were studiedaccording to the monthly clinical records ofthe primary nurses. Data regarding dialysatevolume, urine volume, weekly erythropoietin(EPO) dose, hemoglobin, hematocrit, blood urea,serum creatinine, residual renal creatinine andurea clearances, dialysate to peritonealcreatinine ratio (D/P Cr), total weekly Kt/Vand total creatinine clearance/l.73 m² bodysurface area (TCrCl) were collected. Fifty-fivepatients were male and 45 female. The mean ageat the 1st clinic visit was 61.3 ± 16 years.At the 1st visit 55 patients had fatigue and 45did not. In 32 of the 55 patients fatiguedisappeared after a mean duration of 7.9 ± 8.4months and in 31 of the 45 patients fatigueappeared after a mean duration of 8 ± 6.8months. So at the last visit the frequency offatigue increased significantly from 55% to67% (p < 0.001). In patients with fatigue themean age and female percentage were higher(64.2 ± 14.1 vs 57.8 ± 17.6, p = 0.05 and 1.2vs 0.5, p < 0.05 respectively), mean hemoglobinconcentration was lower (104.4 ± 14.7 vs110.6 ± 14.2 g/L, p < 0.04) and mean EPO dosewas higher (6379.6 ± 7142 vs 3395.4 ± 4337.8units/week, p < 0.02) at the 1st clinic visit.EPO dose was also higher in patients withfatigue at the last visit (8253.7 ± 10317.3units/wk vs 4736.4 ± 5432.5, p < 0.03). Nocorrelation was found between dialysis adequacyaccording to either weekly Kt/V or TCrCl andnutritional state according to nPCR andfrequency of fatigue. We conclude that fatigueis a common symptom in PD patients and it'sprevalence increases over time. Anemia seemsto be the most important factor associated withfatigue. Dialysis adequacy and nutritionalstate did not show any correlation with thefrequency of fatigue in our study.     

黄芪改善腹透患者腹腔巨噬细胞功能的临床研究

目的：研究黄芪对尿毒症患腹腔巨噬细胞功能的影响。方法：对43例尿毒症初始行腹膜透析的患在腹透液中不加（对照组）和加入黄芪注射液（用药组）治疗1周,用ELISA法检测观察前后腹腔巨噬细胞分泌TNF－a能力和吞噬功能的变化。结果：黄芪用药组腹腔巨噬细胞吞菌率、吞噬指数、杀菌率和巨噬细胞分泌TNF－a水平和对照组相比均明显上升（P＜0．01）,巨噬细胞分泌TNF－a水平与用药前自身对比也显提高（P＜0．05）。结论：腹透液中加入黄芪注射液可提高腹透患腹腔巨噬细胞功能。     

Race and sex: predictors of the severity of hyperparathyroidism in peritoneal dialysis patients

BACKGROUND: Uraemic hyperparathyroidism remains a common clinical problem. Conversely, oversuppression of parathyroid hormone (PTH), particularly in diabetic patients on peritoneal dialysis, has been implicated in low bone turnover disease. Race may also be an important factor determining susceptibility to hyperparathyroidism and the different forms of renal osteodystrophy. These compounding factors that might influence the severity of hyperparathyroidism have been studied in US dialysis and predialysis populations. Dialysis-dependant Africans and Afro-Caribbeans (AC) are known to have higher circulating PTH concentrations than comparable Caucasians (C) but Indo-Asians (IA) living in temperate climates have not been studied. METHODS: We performed a cross-sectional study of all patients undergoing peritoneal dialysis at St Bartholomew's and The Royal London Hospital on 1 May 2000. The highest historical recorded PTH was recorded with concurrent biochemical and demographic details. Regression models were used for the analysis of covariance and separate manova was performed incorporating the factors that were shown on univariate analysis to be significant. RESULTS: The current study confirmed that in 50 AC patients on peritoneal dialysis, the mean (+/- SEM) peak PTH concentration (93.9 +/- 9.3 pmol/L) was higher than in 148 C (56.7 +/- 4.3 pmol/L) and 67 IA (60.2 +/- 5.7 pmol/L), P < 0.0001 and P < 0.002, respectively. This is despite there being no significant difference in serum calcium concentrations and AC having a lower serum phosphate concentration at the time of peak hyperparathyroidism. There was no significant difference in mean peak PTH concentration between C and IA. Females were also found to have higher peak PTH concentrations, but the presence of diabetes did not influence the peak PTH concentration in this study. CONCLUSION: Although we have demonstrated that patients of African (but not Asian) descent undergoing peritoneal dialysis have more severe hyperparathyroidism than Caucasians, other studies suggest that Afro-Americans develop low bone turnover at higher PTH. This would suggest that PTH values should be interpreted with care and that bone biopsies to determine histology remain important. It may emerge that there are different optimal PTH concentrations according to race.