超纯透析液对慢性血液透析患者C反应蛋白及促红细胞生成素反应性的影响

目的 观察超纯透析液对慢性血液透析患者血清C反应蛋白及促红细胞生成素反应性的影响.方法 使用鲎细胞溶解物试验方法测定内毒素水平,用平板琼脂培养基37℃培养72 h并行菌落计数,观察超纯透析液及常规透析液内毒素水平及细菌菌落计数的差异.结果 50例透析患者应用超纯透析液前血清C反应蛋白为(9.58±6.35)mg/L,促红细胞生成素为(196±140)U·kg~(-1)·w~(-1);血红蛋白为(103.1±7.6)g/L,转铁蛋白饱和度为(29.9±7.6)%;应用超纯透析液6个月后血清C反应蛋白为(5.16±4.98)mg/L,促红细胞生成素为(179±136)U·kg~(-1)·w~(-1);血红蛋白为(105.3±6.3)g/L,转铁蛋白饱和度为(33.3±5.2)%,应用超纯透析液前、后患者血清C反应蛋白比较差异有统计学意义(P＜0.01).结论 多项研究结果提示,超纯透析可以减少维持性血液透析患者远期并发症、提高其生活质量.     

新乡地区维持性血液透析患者贫血现况调查及相关因素分析

目的 探讨维持性血液透析患者的贫血现况及相关影响因素.方法 收集2012年1月至3月新乡地区4家综合医院364例维持性血液透析3个月以上患者的临床资料.分析维持性血液透析患者贫血现况及其与促红细胞生成素、铁剂、营养不良、透析充分性、微炎症、甲状旁腺激素等因素的关系.结果 364例患者中促红细胞生成素治疗率为97％,铁剂治疗率为87％,贫血治疗达标率仅为30％,贫血治疗达标组患者的血白蛋白、转铁蛋白饱和度、透析龄、尿素清除指数、铁蛋白和转铁蛋白饱和度两者均达标率患者非达标组比较差异有统计学意义(P均＜0.05).而贫血治疗达标组患者的血红蛋白、透析频率、铁蛋白值、前白蛋白、铁蛋白和转铁蛋白饱和度达标率与非达标组比较差异有统计学意义(P均＜0.01),C反应蛋白值与非达标组比较差异有统计学意义(P＜0.01).贫血治疗达标组促红细胞生成素治疗量在与未达标组比较差异无统计学意义(P＞0.05),但其用量远低于肾脏病预后质量指南中推荐的量.多因素Logistic回归分析结果显示白蛋白、前白蛋白、尿素清除指数、透析频率是维持性透析贫血的独立影响因素.结论 新乡地区大部分维持性血液透析贫血患者均接受促红细胞生成素和铁剂治疗,但治疗仍不充分,达标率较低.营养不良、微炎症、透析不充分、性别也是贫血治疗达标率低的原因,但白蛋白、前白蛋白、尿素清除指数、透析频率是维持性血液透析贫血的独立影响因素.提示我们在采用充足的促红细胞生成素和铁剂治疗维持性血液透析贫血患者的同时,应加强其营养治疗和充分透析的宣传教育.     

促红细胞生成素对维持性血液透析非糖尿病患者胰岛素抵抗的影响

目的:探讨促红细胞生成素(erythropoietin,EPO)对维持性血液透析非糖尿病患者胰岛素抵抗的影响.方法:选取56例维持性血液透析非糖尿病患者,应用促红细胞生成素治疗,经过12周治疗后,观察两组患者治疗前后空腹血糖、胰岛素、铁蛋白、血红蛋白、红细胞压积、白细胞介素6、肿瘤坏死因子等变化,计算稳态模型胰岛素抵抗指数(HOMA-IR).结果:EPO治疗前后血红蛋白、红细胞压积、铁蛋白、空腹胰岛素、白细胞介素6、肿瘤坏死因子差异均有统计学意义(t=1.136～21.147,P<0.05).相关分析表明,铁蛋白、肿瘤坏死因子与HOMA-IR呈明显正相关(r分别为0.221、0.237、0.719,P均<0.05).结论:通过EPO治疗减少了炎症反应,从而改善了维持性血液透析非糖尿病患者的胰岛素抵抗状态.     

左卡尼汀联合重组人促红细胞生成素治疗肾性贫血的临床观察

目的:观察左卡尼汀联合重组人促红细胞生成素治疗肾性贫血的疗效.方法:将70例尿毒症维持性血液透析患者随机分成治疗组和对照组,两组患者均于血液透析后静脉注射重组人促红细胞生成素,同时治疗组每次血液透析后静脉注射左卡尼汀100mg/次,疗程3个月.结果:治疗组的血红蛋白(Hb)、血红细胞比容水平显著高于对照组(P＜0.01).治疗组于治疗后第3个月促红细胞生成素用量较治疗前明显减少,而对照组促红细胞生成素用量无明显改变.结论:左卡尼汀能减少促红细胞生成素的用量,提高其疗效,纠正肾性贫血.     

基于铁调素调节铁代谢机制观察蚕砂提取物对血液透析患者促红细胞生成素抵抗的影响

目的通过观察维持性血液透析(maintenance hemodialysis,MHD)患者体内铁调素对铁代谢的调节作用,探讨蚕砂提取物对促红细胞生成素(erythropoietin,EPO)抵抗的干预机制。方法将40例MHD患者随机分为对照组和治疗组各20例,均给予常规透析、EPO皮下注射等治疗,在此基础上,对照组口服多糖铁复合物胶囊,治疗组口服蚕砂提取物,连续观察12周;同时选取20例健康人群作为正常组。空腹取血,采用酶联免疫吸附法(ELISA)检测铁调素、白细胞介素6(interleukin-6,IL-6),免疫比浊法检测超敏C反应蛋白(high sensitive C reactive protein,hs-CRP),化学发光法检测铁蛋白(serum ferritsn,SF)和转铁蛋白饱和度(transferin saturation,TSAT);并检测血常规(血红蛋白、红细胞压积),记录体质量(body weight,BW),计算重组人促红细胞生成素(recombinant human erythropoietin,rHuEPO)用量与EPO抵抗指数(erythropoietin resistance index,ERI)。结果与正常组比较,对照组和治疗组MHD患者的血清铁调素、IL-6、hs-CRP、SF均显著升高,TSAT显著降低(P0.05)。治疗前后比较,治疗组治疗后的血清铁调素、IL-6、hs-CRP、SF、rHuEPO用量、ERI均较治疗前有显著降低,血红蛋白(hemoglobin,Hb)、红细胞压积(hematocrit value,Hct)较治疗前有显著升高(P0.05),而对照组变化不明显(P0.05)。治疗后组间比较,治疗组的血清铁调素、IL-6、hsCRP、SF、rHuEPO用量、ERI均显著低于同期对照组,Hb、Hct均显著高于同期对照组(P0.05)。结论 MHD患者的EPO抵抗与微炎症状态、铁调素升高、铁代谢紊乱具有相关性;蚕砂提取物可以通过抑制机体的微炎症反应及铁调素高表达,改善铁代谢,这可能是蚕砂提取物纠正MHD患者贫血、改善EPO抵抗的重要机制之一。     

血液透析患者炎症反应对rhu-EPO治疗剂量的影响

目的 观察尿毒症血液透析患者是否存在炎症反应及其对促红细胞生成素治疗效果的影响。方法 采用ELISA的方法测定43例维持性血液透析患者和60例健康对照血清IL-6和TNF-α水平．计算两组血红蛋白水平维持在100g/L时所需促红细胞生成素的剂量．研究影响促红细胞生成素治疗剂量的因素。结果 (1)血液透析患者的血清IL-6和TNF-α水平较正常对照组明显升高。(2)多元回归分析表明影响促红细胞生成素治疗剂量的因素是血清IL-6和TNF-α炎症介质。结论 血液透析患者存在炎症反应，其炎症介质水平的升高与促红细胞生成素治疗剂量的增加密切相关。     

黄芪注射液对血透患者重组人促红细胞生成素抵抗的影响

目的:观察黄芪注射液(AI)对维持性血液透析(MHD)患者重组人类促红细胞生成素(rHuEPO)抵抗的影响,探讨其治疗肾性贫血的机制。方法:58例存在rHuEPO抵抗的MHD患者随机分为治疗组和对照组各28例,分别采用AI静脉注射配合rHuEPO皮下注射和仅单用rHuEPO治疗,疗程均为12周,评价影响患者促红细胞生成素抵抗指数(ESARI)的相关因素;进行组间与组内前后比较两组患者的血红蛋白(Hb)、红细胞压积(Hct)、体质量(BW)、rHuEPO用量、ESARI、前白蛋白(PA)、血清白蛋白(Alb)、超敏C反应蛋白(hs-CRP)、白细胞介素-6(IL-6)、血清铁蛋白(SF)。结果:ESARI与hs-CRP、IL-6、SF呈显著正相关(P<0.05),与PA、Alb呈显著负相关(P<0.05);治疗组治疗后Hb、Hct、BW、PA、Alb均明显高于治疗前(P<0.05),hs-CRP、IL-6、SF、rHuEPO用量、ESARI均明显低于治疗前(P<0.05);且治疗组显著优于照组(P<0.05)。结论:AI通过抑制炎症反应,改善营养不良,从而减轻rHuEPO抵抗,显著提高rHuEPO治疗肾性贫血的疗效。     

血液透析患者C反应蛋白水平对网织红细胞血红蛋白含量的影响

目的：观察血液透析患者C反应蛋白（CRP）对网织红细胞血红蛋白含量（CHr）的影响。方法：将35例血透患者按CRP水平分为高CRP水平组（CRP〉10mg／L,19例）和低CRP水平组（CRP〈10mg／L,16例）,比较两组间CHr、转铁蛋白饱和度和促红细胞生成素反应指数,并观察CHr与CRP、转铁蛋白饱和度及促红细胞生成素反应指数的相关性。结果：高CRP水平组的CHr、促红细胞生成素反应指数和转铁蛋白饱和度明显低于低（、RP水平组[（27．47±2．56）Pg vs（31．94±1．91）pg,P〈0．01;0．26±0．03VS0．31±0．02,P〈0．05;（19．64±2．45）％vs（25．45±4．93）％,P〈0．01],CHr水平与CRP水平呈明显负相关（r=-0．73,P〈0.01）],CHr水平与转铁蛋白饱和度及促红细胞生成素反应指数明显正相关（r=0．52,P〈0．01;r=0．60,P〈0．01）。结论：低CHr水平可能与高CRP水平及促红细胞生成素低反应密切相关。     

血液透析红细胞生成素抵抗患者pro-hepcidin与炎性反应和铁代谢的关系

目的 研究维持性血液透析(MHD)红细胞生成素(EPO)抵抗患者pro-hepcidin与炎性反应和铁代谢的关系.方法 40例MHD患者为研究对象,其中20例EPO低反应和20例EPO正常反应.20例健康体检者为对照组.检测参试者的血红细胞计数(RBC)、血红蛋白(Hb)、网织红细胞计数(Ret)、红细胞比容(Hct)、血清铁蛋白(SF)、转铁蛋白(TF)、血清铁和总铁结合力、转铁蛋白饱和度(TSAT)(TSAT=血清铁/总铁结合力)、血清pro-hepcidin、血清超敏C反应蛋白(hs-CRP),并比较组间差异.Pearson相关法分析pro-hepcidin的影响因素.ROC曲线预测pro-hepcidin对EPO抵抗的价值.结果 MHD患者SF、血清pro-hepcidin、hs-CRP显著高于健康对照者(P＜0.01),TF显著低于健康对照者(P＜0.05).EPO抵抗患者血清铁蛋白、血清pro-hepcidin、hs-CRP明显高于反应正常的患者(P＜0.01).Pearson相关分析显示MHD EPO抵抗患者血清pro-hepcidin水平与血清铁蛋白(r=0.843,P=0.000)和hs-CRP(r=0.695,P=0.001)呈正相关.预测EPO抵抗的ROC曲线显示,pro-hepcidin、SF、hs-CRP曲线下面积分别为0.713、0.769和0.958.结论 EPO抵抗与炎性反应和铁代谢相关.血清pro-hepcidin、SF、hs-CRP有可能成为EPO抵抗的标志.     

维生素C和左旋肉碱联合促红细胞生成素治疗维持性血液透析患者肾性贫血的临床观察

目的观察维生素C和左旋肉碱在维持性血液透析合并肾陛贫血患者治疗中的作用。方法将75例维持性血液透析患者随机分成A组、B组、C组,3组患者均皮下注射促红细胞生成素6000U,每周2次;除此之外,A组每次血液透析结束时静脉注射左旋肉碱2g,每周2次;B组每日口服维生素C300mg（分3次口服）;C组联合使用左旋肉碱和维生素C0观察时间为3个月。结果C组患者血细胞比容、血红蛋白上升幅度明显高于A组和B组（P〈0．05或P〈0．01）,而C组血C反应蛋白水平明显低于A组和B组（P〈0．01）。结论对于维持性血液透析患者联合使用维生素C和左旋肉碱可减轻体内微炎症反应,改善对促红细胞生成素的敏感性,减少其用量,提高其疗效,安全性较好。     

Ultrapure dialysate improves iron utilization and erythropoietin response in chronic hemodialysis patients - a prospective cross-over study

BACKGROUND: The impact of ultrapure dialysis on dialysate-related chronic inflammatory status and anemia in uremic patients on maintenance hemodialysis (HD) remains uncertain. We evaluated ultrapure dialysate effects on erythropoietin (EPO) response and inflammatory status in a prospective, randomized, cross-over study. METHODS: Thirty-four HD patients were divided into two groups. One group was treated with conventional dialysate and the other group with ultrapure dialysate for 6 months and crossed over for another 6 months. Bacteria growth and dialysate endotoxin were examined. Parameters including C-reactive protein (CRP), recombinant human erythropoietin (rHuEPO) dose, ferritin, iron saturation and serum albumin were measured at the start, and at 6 and 12 months. RESULTS: The endotoxin levels reduced significantly in the ultrapure dialysate by adding a dialysate ultrafilter. After a 6-month treatment with ultrapure dialysate, there were statistically significant differences in the systemic inflammation markers between both groups. Changing from conventional to ultrapure dialysis fluid significantly reduced CRP (7.01 +/- 5.059 to 4.461 +/- 3.754 mg/L, p<0.05), and resulted in reduced rHuEPO doses (12500 +/- 7060 to 10440 +/- 7050 U/month, p<0.05). Continuous conventional dialysate use was not associated with significant alternations in CRP (from 5.849 +/- 7.744 to 6.187 +/- 7.997 mg/L, p=0.456) and rHuEPO dose (14060 +/- 6210 to 15060 +/- 7250U/month, p>0.05). The ferritin level reduced significantly (422 +/- 183 to 272 +/- 162 mcg/L, p<0.05) in the ultrapure dialysate group. After another 6-month cross-over, the study parameters were reversed among the two groups indicating the beneficial effect of ultrapure dialysis. CONCLUSIONS: Through endotoxin reduction in conventional dialysate, ultrapure dialysis in dialysis patients manifested a reduced inflammatory parameter, reduced rHuEPO dose and improved iron utilization; and therefore, could be beneficial in anemia treatment.     

Ultrapure dialysate and inflammatory response in haemodialysis evaluated by darbepoetin requirements--a randomized study.

BACKGROUND: Dialysate quality has been suggested to influence inflammation status in patients subject to haemodialysis (HD). The aim of this study was to compare ultrapure dialysate (UPD) vs conventional dialysate (CD) with respect to darbepoetin requirements and other inflammation markers. METHODS: A controlled prospective randomized study was carried out on 78 patients from two HD units who were treated with low-flux polyamide dialysers. Patients were assigned to two groups by using different sized blocks per unit and dialysis session. One group received CD treatment while the other was treated with UPD over 12 months. From the groups, 37 patients started treatment with CD and 41 with UPD while 31 patients ended with CD and 30 with UPD. The main variables analysed were haemoglobin (Hb) and darbepoetin dose; other variables studied were C-reactive protein (CRP), albumin, interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1Ra). RESULTS: No significant differences were observed between the two groups for the variables analysed. At the beginning of the study the following values of CD and UPD were assessed: Hb 11.3 and 11.3 (g/dl); darbepoetin dose: 0.49 and 0.44 (microg/kg/week); CRP: 13 and 24 (mg/l); albumin: 3.8 and 3.7 (g/dl); IL-6: 5.94 and 4.18; and IL-1Ra: 345 and 420 (ng/l), respectively. At the end of the study the values of CD and UPD were: Hb 12 and 11.9 (g/dl); darbepoetin dose: 0.47 and 0.48 (microg/kg/week); CRP: 14 and 14 (mg/l); albumin: 3.8 and 3.7 (g/dl); IL-6: 14.03 and 12.93 and IL-1Ra: 322 and 340 (ng/l). CONCLUSIONS: UPD does not improve the inflammatory status evaluated by darbepoetin requirements in conventional HD patients treated with low-flux polyamide dialyser. Further controlled studies are required to evaluate the clinical influence of UPD in HD with other low- and high-flux membranes.     

Factors related to erythropoietin hypo-responsiveness in patients on chronic peritoneal dialysis

Background The present study was aimed at investigating the factors related to hypo-responsiveness to erythropoietin in patients on chronic peritoneal dialysis (PD). Methods We studied 44 patients with end-stage renal disease who had been on PD for more than 6 months and on erythropoietin (EPO) ≥6,000 U/week for more than 3 months. We expressed EPO resistance index (ERI) as weekly EPO dose per hematocrit (Hct) per body weight. The dose of EPO was titrated to maintain a target Hct level between 33% and 36%. Patients were divided into two groups according to weekly EPO dose. We compared the various factors in those two groups and, by using correlation and linear regression analysis, investigated factors that might predict EPO resistance. Results There were 13 patients in the EPO <150 U/kg per week group and 31 patients in the EPO ≥150 U/kg per week group. Among those 31 patients, there were five patients on EPO ≥300 U/kg per week. Compared to the EPO <150 U/kg per week group, the EPO ≥150 U/kg per week group had a lower normalized protein catabolic rate (nPCR), lower level of serum albumin and higher C-reactive protein (CRP). Correlation analysis showed that the ERI had a statistically significant correlation with CRP (r = 0.303, P < 0.05), serum albumin (r = −0.26, P < 0.05), parathyroid hormone (PTH) (r = −0.307, P < 0.05) and nPCR (r = −0.259, P < 0.05). These results show that CRP, serum albumin, PTH and nPCR are factors related to hypo-responsiveness. Multiple stepwise linear regression analysis showed that CRP was the most important independent predictor of EPO hypo-responsiveness. Conclusion CRP, serum albumin, nPCR and PTH are factors related to hypo-responsiveness. Inflammation contributes significantly to EPO hypo-responsiveness.     

腹膜透析患者红细胞生成素低反应的影响因素及其预测价值

目的 分析影响腹膜透析患者红细胞生成素（EPO）治疗反应的因素，并建立回归模型。 方法 114例腹膜透析患者根据每周EPO剂量分为低反应组、正常反应组和高反应组。收集患者临床资料，检测营养及炎性反应指标，进行直线相关和Ordinal等级回归分析。 结果 与高反应组及正常反应组比较， EPO低反应组血红蛋白[（78.11±13.42）比（106.28±23.83）、（96.31±12.33） g/L]、血清白蛋白[（33.98±4.78）比（39.72±4.26）、（35.76±4.88） g/L]水平下降，C反应蛋白（CRP）[（26.08±21.66） 比（5.46±1.75）、（11.82±5.63） mg/L]、血清铁蛋白[（371.08±89.38）比（289.39±76.84）、（323.07±62.46） μg/L]水平升高，差异均有统计学意义 (均P < 0.01)。相关回归分析显示，CRP、血清白蛋白及铁蛋白是EPO治疗反应的显著影响因素(P < 0.05)。根据这些因素建立数学模型，血清白蛋白<30 g/L对EPO治疗低反应的影响最大，高血清铁蛋白、高CRP的影响次之。 结论 血清白蛋白、CRP和铁蛋白水平与EPO治疗反应相关。炎性反应状态和营养不良是导致EPO低反应的主要原因。     

Nutritional-inflammation status and resistance to erythropoietin therapy in haemodialysis patients.

BACKGROUND: Chronic kidney disease patients who are resistant to erythropoietin (EPO) treatment may suffer from malnutrition and/or inflammation. METHODS: In a cross-sectional study of haemodialysis patients, we investigated the relationship between the natural logarithm of the weekly EPO dose normalized for post-dialysis body weight and outcome measures of nutrition and/or inflammation [BMI, albumin and C reactive protein (CRP)] by means of multiple linear regression analysis. On the basis of the decile distribution of weekly EPO doses, we also evaluated four groups of patients: untreated, hyper-responders, normo-responders and hypo-responders. RESULTS: Six hundred and seventy-seven adult haemodialysis patients were recruited from five Italian centres. BMI and albumin were lower in the hypo-responders than in the other groups (21.3+/-3.8 vs 24.4+/-4.7 kg/m(2), P<0.001; and 3.8+/-0.6 vs 4.1+/-0.4 g/dl, P<0.001), whereas the median CRP level was higher (1.9 vs 0.8 mg/dl, P = 0.004). The median weekly EPO dose ranged from 30 IU/kg/week in the hyper-responsive group to 263 IU/kg/week in the hypo-responsive group. Transferrin saturation linearly decreased from the hyper- to hypo-responsive group (37+/-15 to 25+/-10%, P = 0.003), without any differences in transferrin levels. Ferritin levels were lower in the hypo-responsive than in the other patients (median 318 vs 445 ng/ml, P = 0.01). At multiple linear regression analysis, haemoglobin, BMI, albumin, CRP and serum iron levels were independently associated with the natural logarithm of the weekly EPO dose (R(2) = 0.22). CONCLUSIONS: Our findings support a clear association between EPO responsiveness and nutritional and inflammation variables in haemodialysis patients; iron deficiency is still a major cause of hypo-responsiveness.     

重组人类红细胞生成素纠正心脏直视手术后贫血的可行性研究

目的了解手术失血对病人自体促红细胞生成素的影响,通过动物实验证实生理条件下应用基因重组人类促红细胞生成素(rhEPO)的作用及对血液粘稠度的影响,将重组人类促红细胞生成素应用于心脏手术后早期纠正贫血,促进病人迅速恢复。方法术前无贫血、术中中等量失血、术后未输血择期外科手术病人10例(EPO组),测定其术前、术后1、2、4、6、8天EPO及Hct变化。健康家兔6只,用rhEPO300IU共2周,监测给药前、给药后3、6、12、13、21天Hb、Hct、RBC变化及监测血清ALT、血清K+、血浆粘度和全血粘度变化。心脏手术后贫血(Hb＜100g/L)病人6例(给药组),应用rhEPO300IU连续两周,观察给药前后Hb、Hct变化。结果EPO组术后血清EPO立即上升,术后第1～2天达到高峰后下降,但与术前比较仍呈显著性升高。Hct术后下降,至术后8天无明显上升。家兔用药后第12天Hb、Hct、RBC明显升高,血清ALT、血清K+无显著改变,血浆粘度和全血粘度无明显升高。术后给药组患者Hb、Hct升高,给药后第14天Hb升高与术前无显著性差异,而Hct增加与给药前比较有显著差异P＜0．05。结论应用rhEPO纠正心脏术后贫血安全有效,可避免异体输血和因贫血造成组织供氧降低而产生的并发症。     

Comparison of the therapeutic efficacy of epoetin beta and epoetin alfa in maintenance phase hemodialysis patients

In May 2009 for financial reasons, the epoetin product used for hemoglobin (Hb) maintenance in our renal dialysis unit was changed from epoetin beta to epoetin alfa. Although widely believed that the dosage requirements are the same, we undertook a retrospective analysis to investigate whether the dosage requirements in chronic renal failure patients were comparable for both preparations. We studied 128 stable end-stage renal failure patients on hemodialysis (three times per week) receiving erythropoietin therapy to maintain their Hb at 11-12.5 g/dL. Patients were excluded if within the study period they developed signs of infection, bleeding, required blood transfusion, were under-dialyzed, or required hospital admission. Regular monthly Hb concentrations and hematocrit (Hct) levels were measured for each patient. The weekly EPO index (defined as weekly epoetin dose/mean monthly Hct) was derived for each patient, before and after regime change. Of the 128 patients in end-stage renal failure, 79 were included in the study. There was no significant difference between the two preparations in terms of Hct level achieved (p = 0.15). However, the median weekly epoetin dose requirement increased from 6733 (range 750-30,000) IU/week to 9000 (250-30,667) IU/week (p < 0.001). EPO index similarly increased from 20,465 (2500-130,846) IU/week/% to 27,073 (729-98,937) IU/week/% (p < 0.001). Our study showed that a higher dose of epoetin alfa was needed to maintain target Hb concentration.     

维持性血液透析患者血红蛋白波动的临床研究

目的了解维持性血液透析患者血红蛋白(Hb)波动情况,初步探讨Hb波动的影响因素。 方法选取复旦大学附属中山医院血液透析中心透析龄超过12个月的患者。以Hb110～120 g/L为靶目标值,根据前后两个月的Hb变化值是否达到10 g/L分为波动组和非波动组。应用多因素Logistic回归分析Hb波动的影响因素。 结果共163例患者,基线Hb值为(107.52±15.47)g/L,随访期平均Hb值为(106.57±15.22)g/L。基线及随访期Hb达标情况大致相似,46.6%～56.4%患者Hb未达标(Hb<110 g/L)。随访期中仅有1.2%患者Hb始终达标。患者平均Hb波动值为8.15±5.01 g/L,Hb波动率为27.0%,短期波动在大多数血液透析患者中较常见,少数患者Hb长期处于不稳定状态。非波动组患者的透析龄和基础Hb值显著高于波动组(t＝－5.602, P＝0.048; t＝－1.731, P＝0.010),促红细胞生成素(EPO)剂量显著低于波动组(t＝6.218, P<0.001)。多因素Logistic回归分析显示,经过透析龄<24个月、基础Hb<100 g/L等因素校正后,EPO剂量≥200 U/(kg·w)与Hb波动显著独立相关(OR＝4.7,95%CI 3.2～9.3,P＝0.030)。 结论Hb波动在维持性血液透析患者中普遍存在,少数患者Hb长期处于不稳定状态。Hb波动较大的维持性血液透析患者EPO剂量应用也较大。     

Relationship between responsiveness to erythropoiesis-stimulating agent and long-term outcomes in chronic hemodialysis patients: a single-center cohort study

Background

Responsiveness to erythropoietin-stimulating agent (ESA) may be associated with mortality risk in hemodialysis (HD) patients. The aim of the present study was to assess the relationship between responsiveness to ESA and long-term outcome in chronic HD patients.

Methods

Patients on HD therapy for more than 6 months were enrolled in this cohort study. The first year was used to assess the longitudinal dialysis status of patients; the subsequent years were used to assess the time-dependent risk of all-cause mortality. Hazard ratios were estimated using a Cox proportional model for the association between ESA dose and hemoglobin (Hb) level and mortality, adjusting for potential confounders. The ESA resistance index (ERI) was determined as the weekly weight-adjusted dose of ESA divided by Hb concentration. Patients were divided into three groups by tertiles of ERI.

Results

Of the 320 subjects enrolled, 105 died during the follow-up period of 70.4 ± 29.0 months. When subjects were stratified by epoetin dose and Hb level into four groups, those who had low Hb despite a high dose of epoetin were associated with the highest risk of mortality among the four groups (adjusted hazard ratio 1.86; 95 % confidence interval 1.25–2.75). These highest risk subjects had older age, lower body mass index, and lower serum levels of albumin, triglyceride, and transferring saturation. The impact of serum albumin and serum ferritin on mortality risk in an adjusted Cox proportional hazards model was in accordance with low Hb and higher ESA. There was no significant difference between the mortality risk and tertile of ERI.

Conclusions

High ESA dose and low Hb level were associated with an increased risk of all-cause mortality. However, the responsiveness to ESA estimated by ERI was not related to mortality risk. These findings suggest that the responsiveness to ESA should be evaluated by different methods in HD patients.     

We Use Impure Water to Make Dialysate for Hemodialysis

Patients receiving hemodialysis are exposed to a large volume of water, used to prepare dialysate for each treatment session. Technological advancements now make it possible to generate ultrapure dialysate that has substantially lower bacterial and endotoxin counts than the standard dialysate used in the United States. Low‐level water contamination is thought to propagate a state of chronic inflammation seen in hemodialysis patients, and a number of studies demonstrate that the use of ultrapure dialysate has a favorable effect on laboratory parameters of inflammation, nutrition, erythropoietin responsiveness, dialysis‐associated amyloidosis, and atherosclerosis. Few studies even suggest a direct clinical benefit of adopting ultrapure dialysate. As there is no proven harm with use of ultrapure dialysate and the economic implication appears to be minimal when using modern dialysis machines, it is imperative for regulatory agencies and the dialysis community to ensure that our vulnerable patients are no longer exposed to impure water during their hemodialysis treatments.