儿童慢性腹膜透析相关腹膜炎危险因素的病例对照研究

目的 分析终末期肾病（ESRD）患儿慢性腹膜透析（CPD）相关腹膜炎(简称腹膜炎)发生的危险因素,为儿童腹膜炎防治提供依据。方法 回顾性收集复旦大学附属儿科医院（我院）开展ESRD患儿CPD 以来的全部病历,依据连续随访记录,以是否出现CPD分为腹膜炎组和非腹膜炎组,分析两组人口学指标、CPD指标和透析充分性指标。并行多因素分析探讨发生腹膜炎的危险因素。结果 2001年至2014年在我院接受CPD治疗的109例ESRD患儿进入本文分析,男60例（55%）、女49例。开始腹膜透析的中位年龄9.9岁,中位透析病程13.4月。连续性非卧床腹膜透析（CAPD）15例,自动腹膜透析（APD）94例（86.2％）。43例（39.4%）仍接受CPD治疗,50例（45.9%）成功行肾移植,7例（6.4%）转行血液透析治疗,6例（5.5%）死亡,3例（2.8%）失访。1、2、3和5年的生存率分别为97.1%、93.3%、90.1%和90.1%。33例发生57例次腹膜炎,平均腹膜炎发生率为1次/35.1病人月。单因素分析显示,开始透析时身高SDS（P=0.01）、透析病程（P<0.001）和白蛋白水平（P=0.01）腹膜炎组和非腹膜炎组差异有统计学意义。多因素Logistic回归分析显示,开始透析时身高SDS<-2.0（OR=12.746,95％CI：2.436~66.675,P=0.003）和透析病程>1年（OR=8.162,95%CI：2.514~26.500,P<0.001）是腹膜炎发生的独立危险因素。结论 开始透析时身高SDS<-2.0和透析病程>1年是儿童CPD相关腹膜炎发生的独立危险因素。     

腹膜透析在9例慢性肾功能衰竭患儿中的应用

目的分析和评价腹膜透析在终末期肾衰竭(ESRD)患儿中的应用情况。 方法对复旦大学儿科医院肾脏科2001-11—2005-04收治的9例(男7例,女2例)ESRD患儿腹膜透析前后尿毒症症状改善情况和营养、生长发育状况 进行回顾分析。 结果腹膜透析模式：持续性非卧床腹膜透析(CAPD)3例,持续性循环腹膜透析(CCPD)5例,夜间间歇性腹膜透析(NIPD)1例,透析时平均年龄 (11.6±3.0)岁,平均腹透(9.8±7.1)个月(2~36个月)。透析后,尿毒症症状均有改善,胃肠道症状消失,血尿素氮由透析前(31.4±7.4) mmol/L下降至透析后(19.6±3.4)mmol/L(P<0.01);平均血红蛋白及红细胞压积比由透析前的(77.1±19.9)g/L和(22±6)%上升至(98.4±40.2) g/L和(34±4)%;平均血压由透析前18.9/11.7kPa下降至透析后14.6/9.6kPa(P<0.01);透析前血钙(2.0±0.2)mmol/L,血磷(2.2±0.5)mmol/L ,甲状旁腺素(PTH)(602.7±332.2)pg/mL,透析后血钙2.5±0.2mmol/L,血磷(1.59±0.3)mmol/L,PTH(258.6±273.2)pg/mL,与透析前比较差 异均有显著性(P<0.05),钙磷代谢紊乱纠正,高PTH改善。透析后血白蛋白(41.0±3.2)g/L、Pre-A>400mg/L,Tf>2g/L,身高、体重增加,身高平 均增长(0.67±0.59)cm/月。腹膜炎发生率为1次/11.1病人月。 结论长期腹膜透析可以很好地改善ESRD患儿的尿毒症症状,纠正贫血、高血压、钙磷代谢紊乱,改善营养和生长发育状况,是ESRD患儿进行肾 替代治疗的有效手段。但腹膜透析也有一定的并发症,应引起重视。     

腹膜透析充分性对腹膜透析儿童营养状况的影响

目的前瞻性观察慢性腹膜透析(腹透)儿童的营养状况,探讨透析充分性对腹透儿童营养状况的影响。方法选择腹透时间超过3个月儿童,每3个月留取腹透液、尿液,抽血测BUN、Scr、清蛋白(Alb)、前清蛋白(PA)、转铁蛋白(Tf),计算尿素清除指数(Kt/V)、肌酐清除率(Ccr)、残余肾功能(RRF)、蛋白分解率(PCR),分析透析充分性与营养状况的关系。结果腹膜透析儿童10例(男6例,女4例)。平均年龄11.90岁(8.3～16.1岁);腹膜透析4～36个月,平均12.50个月。10例共进行32次检测,Scr为(830.31±156.48)μmol/L,BUN为(21.44±7.99)mmol/L,血浆Alb为(42.71±5.21)g/L,PA(419.68±118.0)mg/L,Tf(1.94±0.58)g/L,每周总Kt/V2.15±0.29,残余肾Kt/V0.57±0.45,每周总Ccr(49.13±15.25)L/1.73m2,残余肾Ccr(19.48±13.11)L/1.73m2,RRF(1.70±1.56)mL/min,PCR(1.17±0.18)g/(kg.d)。PCR与总Kt/V和总Ccr呈正相关(r=0.775,0.503Pa<0.01),与残肾Kt/V、残肾Ccr呈正相关(r=0.532,0.393Pa<0.05)。总Kt/V分别与Alb和PA呈正相关(r=0.496,0.541Pa<0.01),与Tf无关(r=0.226P>0.05)。RRF与总Ccr呈正相关(r=0.389P<0.05)。结论提高透析充分性有利于改善腹透儿童营养状况,制定合适透析处方以确保充分透析是预防腹透儿童营养不良的根本措施。     

慢性肾脏病及透析患儿的疫苗接种

慢性肾脏病患儿大多存在免疫紊乱及免疫功能缺陷.各种病原菌的感染率明显增高,尤其容易感染肺炎链球菌、HBV及流感病毒.在全球范围内,肺炎链球菌是细菌性肺炎和中耳炎的最常见病原,是细菌性脑膜炎的主要病原菌.血液透析的患儿更是HBV易感染的高危人群.流感是具有高度传染性及极其广泛的传播性疾病.美国免疫实践指南咨询委员会(ACIP)及改善全球肾脏病预后(KDIGO)特别推荐慢性肾脏病及慢性透析的患者接种的3种疫苗是HBV疫苗、灭活流感病毒疫苗及肺炎链球菌疫苗.接种疫苗是特异性的预防措施,可对慢性肾脏病及透析患者提供有效的预防保护.     

持续性腹膜透析儿童腹膜平衡试验及结果分析

目的通过腹膜平衡试验（PET）探讨我国慢性腹膜透析（PD）儿童腹膜转运特性特点。方法对6例持续性非卧床腹膜透析（CAPD）患儿（2—14岁）行10次儿童标准PET,参照Twardowski和儿科腹膜透析联盟（PPDSC）标准评价腹膜溶质转运类型。结果本组患儿首次PET于PD开始后平均（38．74±15．6）d进行。4h肌酐清除率（4h-D／P）和4h葡萄糖吸收率（4h-D／D0）分别为（0．85±0．24）、（0．34±0．19）。依Twardowski和PPDSC腹膜转运类型评价标准,本组腹膜溶质转运类型分别为高转运型6例（6／10）、高平均转运型1例（1／10）、低平均转运型3例（3／10）,无一例低转运型;两种标准分型的总符合率100％。本组腹膜葡萄糖转运类型分别为高转运型3例（3／10）、高平均转运型4例（4／10）、低平均转运型1例（1／10）,低转运型2例（2／10）;两种标准分型的总符合率90％。连续PET显示转运类型变化不一,腹膜炎后4h-D／P升高。结论本组CAPD儿童腹膜溶质和葡萄糖转运类型均以高转运和高平均转运为主（7／10）,呈偏态分布,提示儿童腹透溶质清除充分,但水超滤能力不足;标准儿童PET及其评价标准完全符合Twardowski标准PET要求。腹膜炎后溶质转运能力提高。     

腹膜透析治疗小儿肾功能衰竭临床分析

目的 探讨腹膜透析对儿童肾功能衰竭治疗的效果.方法 对2003年6月至2008年4月应用腹膜透析治疗的11例急慢性肾功能衰竭患儿临床资料及随访结果 进行分析.结果 11例患儿无一例死亡,急性肾功能衰竭平均在院透析时间15.5 d,慢性肾功能衰竭平均在院透析时间22.8 d.治疗前后血尿素氮、肌酐分别由(34.03±8.44) mmol/L和(710.09±167.54) μmol/L降至(15.94±4.93) mmol/L和(233.87±92.71) μmol/L,差异有非常显著性(P＜0.01).血钠由(130.91±9.15) mmol/L升至(139.46±3.98) mmol/L,差异有显著性(P＜0.05).血碳酸氢根由(14.56±2.07) mmol/L升至(22.47±3.29) mmol/L,差异有非常显著性(P＜0.01).随访时间1个月至5年不等.5例急性肾功能衰竭患儿肾功能和尿常规均正常.1例慢性肾功能衰竭患儿规律透析后行肾移植,3例仍于院外透析中.结论 经济、实用、有效的腹膜透析辅以综合治疗可成为儿童急慢性肾功能衰竭较好替代治疗方法 .     

胃炎患儿幽门螺杆菌感染危险因素的病例-病例对照研究

目的了解和探讨浙江省绍兴地区目前儿童幽门螺杆菌(H·pylori)感染率及临床状况,评价感染相关危险因素。方法2003—2005在浙江绍兴市人民医院用olympus GIF P30纤维胃镜对301例具有上消化道症状持续1个月以上的患儿进行胃镜检查,同时对患儿的年龄、性别、生活地区,环境因素(居住拥挤程度,卫生设施)、社会地位(母亲职业),经济条件(家庭收入),年幼时是否母乳喂养,患儿母亲受教育程度,密切接触患儿的监护人是否既往有胃部疾患史,患儿婴幼儿期是否有进食父母嚼后食物等因素进行调查分析。结果该地区儿童H·pylori的感染率为33·6%;消化性溃疡H·pylori的感染率为65·4%;年幼时进食父母嚼后食物会增加小儿H·pylori感染的风险,随母亲文化程度增高H·pylori感染风险降低;该地区儿童H·pylori感染与患儿年幼时是否母乳喂养,监护人是否有胃病史,母亲职业,家庭经济收入,生活地区等因素无统计意义上的关联。结论儿童H·pylori的感染率随年龄增大而增高;H·pylori感染与母亲文化程度,年幼时是否进食父母嚼后食物有关;儿童H·pylori感染易增加患溃疡的风险。     

65对4—6岁贫血儿童智商的病例对照研究

目的是探讨贫血对于学龄前儿童的智商影响。方法采用病例对照研究方法,对６５例４－６岁学龄前贫血儿童进行了调查测定,结果：贫血儿童的总智商和操作智商分别为９５．８５±１３．４２和９４．７１±１４．０８,而正常组儿童的总智商和操作智商分别为１００．８３±１４．９１和１００．３８±１５．０１。贫血组儿童的总智商和操作智商均低于正常组儿童,差异具统计学意义。而贫血组儿童的语言智商（９７．８８±１３．８７）与     

Subcutaneous recombinant human erythropoietin in children with renal anemia on continuous ambulatory peritoneal dialysis

Subcutaneous recombinant human erythropoietin (rHuEpo) treatment of renal anemia was performed in four boys and eight girls on CAPD, aged 0.8–12.5 (mean 7.4) years. In contrast to previous studies, our therapeutic goal was not set with a hematocrit of 30% but with full correction of anemia. Following a maximum weekly rHuEpo dosage of median 120 (range 100–240) IU/kg body weight, hcmatocrit increased in 10 children from 24 (14–29)%) within 12 (4–17) weeks to 40.1 (33.5–48.4)%. The weekly increase in hematocrit was 1.27 (0.5–3.1)%. The corrected reticulocyte count increased from I.3 (0.7–1.8)% to 2.3 (1.4–3.9)% within 4 (2–6) weeks. Eight childrcn fulfilled the protocol; six with an uncomplicated course were able to maintain a hematocrit of 37.1 (35.1–42.7)% with only one sc medication per week of approximately two-thirds of their highest weekly rHuEpo dosage. No serious adverse effect of rHuEpo therapy was observed.     

重组人生长激素在慢性腹膜透析儿童中的应用

目的研究重组人生长激素(rhGH)对慢性腹膜透析儿童身高增长的促进作用。方法回顾分析2例经rhGH治疗的慢性腹透患儿的相关临床资料。结果 2例女性患儿,分别于8岁8个月和9岁6个月时确诊尿毒症,并伴身材矮小。经过第1年腹透及纠正酸中毒、贫血和电解质紊乱,改善营养和治疗肾性骨病等,例1身高SDS由-1.9增至-1.4,例2身高SDS由-2.3减至-2.4。2例患儿分别在9岁9个月和12岁3个月时开始rhGH治疗,开始治疗时2例患儿青春发育均属于Tanner 1期。经过8个月的治疗,例1身高SDS由-1.3增加至-0.7,例2由-3.0增至-2.4;停止rhGH治疗8个月后,例1身高SDS继续由-0.7增至-0.4,例2由-2.4增至-2.2。例1于rhGH治疗8个月期间身高增长7.5cm,rhGH治疗停止8个月间身高增长减少为5.8 cm,例2身高增长则由9 cm降至4.5 cm。结论 rhGH可提高腹膜透析治疗尿毒症患儿的身高增长。     

Spectrum of renal osteodystrophy in children on continuous ambulatory peritoneal dialysis

BACKGROUND: The prevalence of different types of bone disease in chronic renal failure (CRF) has changed significantly during the last decade. The aim of the present study is to evaluate the spectrum of bone disease in children with CRF undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: Seventeen children with CRF on CAPD aged 7-20 years were evaluated. All patients had received regular vitamin D and calcium carbonate therapy during the 6 months preceding the bone biopsy. Serum calcium, phosphate, alkaline phosphatase and immunoreactive parathyroid hormone (iPTH) levels were measured and hand X-rays were performed. Transiliac bone biopsies were analyzed for histologic diagnosis. RESULTS: High turnover renal osteodystrophy (ROD) was the most common bone disease, present in eight patients (47%). Five patients (29%) had low turnover bone disease, and four (24%) had mixed ROD. The mean age of the high turnover ROD group was higher than that of the low turnover group (14 +/- 3 vs. 11 +/- 3 years, P < 0.05). Seven of the nine patients who had tubulo-interstitial nephritis were found to have high turnover bone disease. In contrast, none of the patients with glomerulonephritis exhibited high turnover bone lesions. Mean serum calcium levels were found to be significantly higher in the low turnover group compared with the patients with high turnover bone disease (P < 0.001). A serum iPTH level > 200 pg/mL was 100% sensitive and 66% specific in identifying patients with high turnover ROD. CONCLUSION: The spectrum of bone disease of the children with CRF undergoing CAPD seems to depend on the rate of CRF and primary disease. The risk of developing overt hyperparathyroid bone disease is high in children with slowly progressing forms of renal pathology and especially in those with tubulo-interstitial disease. In contrast, children with glomerular diseases who had a more rapidly progressive course may have a lesser risk of developing high turnover bone disease. The results of the present study indicate that even routinely prescribed regular vitamin D therapy early in the course of disease may lead to low turnover bone lesion in small children who have CRF due to rapidly progressive forms of renal pathology.     

乌鲁木齐市小学儿童睡眠障碍及影响因素分析

目的：乌鲁木齐市小学儿童睡眠障碍发生状况及影响因素。方法：2005年11~12月间在乌鲁木齐市三个行政区随机抽取2 034名6~14岁儿童,由专人负责对其家长进行儿童家庭环境、社会环境与睡眠健康问卷调查。结果：小学儿童睡眠障碍发生率为55%,依次为睡眠时辗转不安14.7%,梦呓4.8%,梦游1.5%,遗尿1.5%,睡眠时磨牙5.7%,睡眠时频繁打鼾12.9%,睡眠时呼吸暂停0.5%,憋醒1.9%。影响睡眠障碍发生的主要危险因素有曾长期或近期服用某些药物、常患感冒、家庭人均住房面积、家族中有人有睡眠障碍、与父母同睡等。结论：乌鲁木齐市小学儿童睡眠障碍的发生率较高,造成睡眠障碍的因素较多,应引起社会及家长的重视,对其防治还需进一步深入研究。［中国当代儿科杂志,2007,9（6）：543-545］     

IgG and IgG subclasses deficiency in children undergoing continuous ambulatory peritoneal dialysis and its provocative factors

BACKGROUND: Low levels of serum IgG or IgG subclasses may be responsible for the defective peritoneal defense and for peritonitis attacks in continuous ambulatory peritoneal dialysis (CAPD) children. Malnutrition, peritoneal loss or frequent peritonitis may lead to IgG or IgG subclasses deficiency. METHODS: Levels of IgG subclasses were determined in 12 children undergoing CAPD treatment. Radial immunodiffusion technique was used for determination. Patients were aged from 6 to 16 years (mean age 12.3 years) and had been on CAPD for 11-26 months (mean duration 19.4 months). We evaluated whether IgG and IgG subclasses deficiency are related to malnutrition, the peritonitis rate and the duration of CAPD using the SPSS program. RESULTS: Serum total IgG levels were found to be low in eight out of 12 patients. Eight patients showed low levels of IgG1, four patients IgG2, one patient IgG3 and three patients IgG4. Total IgG values were found to be positively correlated to malnutrition status, peritonitis rate and duration of CAPD. The IgG2 values were found to be related to the duration of CAPD. The IgG4 values were found to be correlated to the peritonitis rates. CONCLUSIONS: The IgG and IgG subclasses deficiency may develop in children while on CAPD treatment. Periodical determinations of either serum IgG or the subclasses may be useful in the follow-up of these patients.     

Successful resumption of peritoneal dialysis following living donor liver transplantation in children with end‐stage renal disease

Children with ESRD in need of RRT are commonly managed by PD due to difficulty with vascular access for HD and the relatively large extracorporeal blood volume required. Major abdominal surgery may result in injury to the peritoneum and consequent adhesion, thereby resulting in a reduction in the anatomical capacity and transport capability across the peritoneal membrane. Here, we report successful resumption of PD after LDLT in two pediatric patients. The causes of ESRD were PH1 and juvenile nephronophthisis, respectively. Both patients were managed by PD prior to LDLT. PD was converted to HD starting three days before LDLT and was continued postoperatively until resumption of PD on days 13 and 28, respectively. The PD weekly Kt/V urea was maintained before and after LDLT. The patients continued to do well on PD without complications. Meticulous intra‐operative techniques during LDLT allow postoperative PD resumption by preservation of peritoneal integrity with effective transport capability and without added risk of peritonitis.     

Bilateral laparoscopic nephrectomy with simultaneous peritoneal dialysis catheter implantation

Bilateral nephrectomy prior to transplantation is indicated in some patients with end-stage renal disease. The indications for bilateral nephrectomy include persistent heavy proteinuria, refractory hypertension, and urinary tract infections. We report an eight-month-old baby with male pseudohermaphroditism and renal failure secondary to diffuse mesangial sclerosis. While awaiting renal transplantation, dialysis became necessary and the child presented standard drug therapy-resistant hypertension. A bilateral nephrectomy was performed simultaneously to peritoneal dialysis catheter implantation by using laparoscopy. At the present time, the patient is doing well with ambulatory dialysis and all antihypertensive medication has been discontinued. We recommend this technique in children who require bilateral nephrectomy and peritoneal dialyisis. Not only is it somewhat less aggressive than traditional open surgery, but it also reduces post-operative pain, allows earlier initiation of peritoneal dialysis, and improves cosmetic appearance.