帕立骨化醇与骨化三醇治疗尿毒症血透患者继发性甲状旁腺功能亢进症的疗效比较

目的 探讨帕立骨化醇和骨化三醇治疗尿毒症血透患者继发性甲状旁腺功能亢进症的治疗效果。方法 随机选取2019 年1 月～2020 年1 月于我院就诊的尿毒症血透患者继发甲旁亢64 例,其中将应用骨化三醇治疗的34 例患者设为对照组,应用帕立骨化醇治疗的30 例患者设为研究组,对比两组患者治疗后的效果及安全性。结果 研究组患者用药后iPTH 含量为（216.02±25.56）pmol/L、血清磷为（1.36±0.28）mmol/L、血清钙为（2.51±0.38）mmol/L 和碱性磷酸酶含量为（72.39±3.61）mmol/L,结果均优于对照组,差异均有统计学意义（P<0.05）;研究组患者用药后不良反应总发生率明显低于对照组,差异有统计学意义（P<0.05）。结论 应用帕立骨化醇能够有效降低继发性甲旁亢患者iPTH 的含量,且高钙血症和高磷血症的发生率较低,不良反应总发生率较低,相较于骨化三醇其效果更佳,安全性更好。     

尿毒症血液透析患者行甲状腺全切术围手术期护理要点研究进展

尿毒症血液透析患者合并继发性甲状旁腺功能亢进在临床上是极为常见的,长期血液透析患者常出现甲状旁腺功能亢进,表现为血甲状旁腺激素明显升高,血钙持续升高,骨质脱钙和血管及软组织的异位钙化。出现甲旁亢,可采取的治疗方法有药物治疗和外科手术。药物治疗对轻型甲旁亢有效,中重度甲旁亢常需要外科手术治疗。当出现:(1)明显临床症状,如骨关节痛、肌无力、皮肤搔痒等;(2)持续性高钙血症、高磷血症或钙磷乘积大于70;(3) i PTH大于800 pg/m L,并且对活性维生素D药物治疗抵抗;(4)颈部彩色超声显示:至少一个甲状旁腺增大,直径大于1 cm并且有丰富的血流是需要外科手术。甲状腺全切术在此病治疗中较为常用,围手术期精心、完善、正确的护理模式对患者术后的康复以及并发症的发生等具有重大的意义。     

Gut bacterial translocation contributes to microinflammationin experimental uremia

ObjectiveTo investigate whether gut microbiome dysbiosis and translocation occurred in experimental uremia, and whether they consequently contribute to microinflammation.MethodsHealth male SD rats were randomly divided into uremic group and sham group. Uremic group were operated for 5/6 nephrectomy to establish uremic models, while sham group were only operated for nephrocapsulotomy. Postoperative blood, livers, spleens, and mesenteric lymph nodes (MLNs) were subjected to bacterial 16S ribosomal DNA amplification to determine if bacteria were present. Bacterial genomic DNA samples from the MLNs and colon were amplified with specific primers designed by the 16SrRNA sequence of the species obtained from blood, livers and spleens. Pyrosequencing was used to analyze the ileum and colonic microbiome of each subject. Intestinal permeability to 99mTc-DTPA, plasma hs-CRP, and IL-6 were measured. ResultsBacterial DNA in extraintestinal sites and altered colonic microbiomes at the phylum, family, and genus levels were detected in some rats in the uremic group. Bacterial genomic DNA in MLNs and colon were obtained by primers specific for bacterial species observed from blood, livers, and spleens of identical individuals. Intestinal permeability, plasma hs-CRP, and IL-6 levels were statistically higher in the uremic group compared with that in sham group(all P＜0.05). ConclusionGut microbiome dysbiosis occurs and presumably bacteria translocate to the systemic and lymph circulation, thereby contributing to microinflammation in experimental uremia.     

Strategies for the Treatment of Acute Renal Failure in Intensive Care Units: The Aspect of Dosing

Despite all the medical progress, the mortality rate in intensive care units for patients with acute renal failure (ARF) remains high, among specific patient populations, up to 88% [Letourneau I, Dorval M, Belanger R, Legare M, Fortier L, Leblanc M. Acute renal failure in bone marrow transplant patients admitted to the intensive care unit. Nephron Apr 2002; 90(4), 408–12.]. Recent trial results indicate that patient survival may be improved by adequate renal replacement therapy. In particular, the dose of intermittent and continuous renal replacement therapies has proved to be a significant factor affecting patient survival. Daily intermittent hemodialysis, e.g., is superior to alternate‐day intermittent hemodialysis, and with continuous therapies, survival is related to the filtration rate. Further relevant factors include early initiation of renal replacement therapy, choice of biocompatible membranes and the application of bicarbonate‐buffered replacement solutions for defined patient groups. The advantages offered by continuous techniques could be demonstrated for individual patient groups; in meta‐analyses, advantages were shown for the total population of patients with ARF. Other than for patients with chronic renal failure (NKF—DOQI. Clinical practice guidelines for hemodialysis adequacy. Am J Kid Dis 1997; Vol. 30, 515–566.), there are no current clinical guidelines for a standard treatment of intensive care patients with ARF. Therefore, such a treatment standard still needs to be determined.     

Structural Causes of Cardiac Dysfunction in Uremia

While coronary heart disease is undoubtedly a major cause of cardiac morbidity and mortality in uremia, important noncoronary problems contribute to the common presence of cardiac problems. Based on clinical and experimental studies, we could show: (i) Left ventricular hypertrophy (LVH) can be dissociated, at least in part, from elevation of blood pressure, (ii) In uremia, PTH-dependent intermyo-cardiocytic fibrosis occurs; it may account, at least in part, for disturbed LV compliance and contribute to the arrhythmogenic potential. (iii) Blood pressure-independent abnormalities of intracardiac arterioles and reduced myocardial capillary supply are observed.     

Acute Sodium Chlorite Poisoning Associated with Renal Failure

Background and Objectives: Different techniques of continuous renal replacement therapy (CRRT) might have different effects on azotemic control. Accordingly, we tested whether continuous veno-venous hemodiafiltration (CVVHDF) or continuous veno-venous hemofiltration (CVVH) would achieve better control of serum creatinine and plasma urea levels. Design: Retrospective controlled study. Setting: Two tertiary Intensive Care Units. Patients: Critically ill patients with acute renal failure (ARF) treated with CVVHDF (n = 49) or CVVH (n = 50). Interventions: Retrieval of daily morning urea and creatinine values before and after the initiation of CRRT for up to 2 weeks of treatment. Measurements and Results: Before treatment, serum urea and creatinine concentrations were significantly lower in the CVVH group than in CVVHDF group (urea: 31.0 ± 15.0 mmol/L for CVVHDF and 24.7 ± 16.1 mmol/L for CVVH, p = 0.01, creatinine: 547 ± 308 µmol/L vs. 326 ± 250 µmol/L, p < 0.0001). These differences were still significant after 48 h of treatment (urea: 20.1 ± 8.3 mmol/L vs. 14.1 ± 6.1 mmol/L; p = 0.0003, creatinine: 360 ± 189 µmol/L vs. 215 ± 118 µmol/L; p < 0.0001). Throughout the duration of therapy, mean urea levels (22.3 ± 9.0 mmol/L for CVVHDF vs. 16.7 ± 7.8 mmol/L for CVVH, p < 0.0001) and mean creatinine levels (302 ± 167 vs. 211 ± 103 µmol/L, p < 0.0001) were better controlled in the CVVH group. Conclusions: CRRT strategies based on different techniques might have a significantly different impact on azotemic control.     

维持性血液透析患者炎症状态与血清热休克蛋白70的关系

目的探讨维持性血液透析（MHD）患者热休克蛋白70（HSP70）检测与炎症状态的关系。方法将MHD患者92例根据超敏C反应蛋白（hs-CRP）水平分为2组：非炎症组（hs-CRP〈3mg／L）58例;炎症组（hs-CRP≥3mg／L）34例。检测2组患者血清前白蛋白（PA）、血白蛋白（Alb）、hs-CRP、血红蛋白（Hb）、HSP70、铁蛋白、肿瘤坏死因子α（TNF-α）、白细胞介素6（IL-6）等。结果尿毒症患者血清HSP70与hs-CRP、IL-6、TNF-α、铁蛋白等炎症指标无明显相关性;与Hb、Alb、总胆固醇等营养指标也无相关性。非炎症组透析前HSP70水平较低,透析后迅速升高（P=0．013）;而炎症组透析前后的HSP70水平差异无统计学意义（P=0．871）。结论炎症状态可能是导致炎症组HSP70升高的原因;但HSP70不能反映MHD患者是否存在慢性炎症状况,也不能反映其蛋白质营养状态。透析前、后HSP70水平检测可反映机体抗应激反应能力。     

高通量血液透析联合左卡尼汀对尿毒症心肌病的临床研究

目的 高通量血液透析联合左卡尼汀对尿毒症心肌病的影响.方法 选取81例于本院门诊和住院部透析的患者,随机分成两组:实验组41例,对照组40例,所有患者均每周3次血液透析,每次4h,实验组自2012年10月开始接受高通量血液透析联合左卡尼汀治疗,对照组进行单纯的高通量血液透析治疗,两组患者都观察8个月.治疗前后检测血红蛋白、血细胞比容,做常规超声心动图,观察左心室舒张期末内径(LVIDd)、左心室收缩末期内径(LVIDs)、室间隔舒张期末期厚度(IVSd)、左室心肌质量(LVM)、左室心肌质量指数(LVMI)、左室后壁厚度(PWTH)、射血分数(EF)、左心室的舒张功能(EPSS)等.结果 治疗8个月后,实验组患者的血红蛋白、血细胞比容与对照组比较明显升高(P＜0.05),超声心动图EF值明显升高,LVIDd、LVIDs、IVSd、PWTH、LVM、LVMI明显降低,差异均有统计学意义(P＜0.05).结论 高通量血液透析联合左卡尼汀在改善尿毒症心肌病患者心肌重构及心功能方面有较好的疗效.     

高通量血液透析联合罗盖全对尿毒症患者钙磷代谢紊乱及微炎症状态的影响

目的：探讨高通量血液透析联合罗盖全对尿毒症患者钙磷代谢紊乱及微炎症状态的影响。方法选择2012年04月至2014年10月于南京医科大学附属江宁医院行规律血液透析的尿毒症患者70例。将70例尿毒症患者按随机数表法分为观察组35例(高通量血液透析联合罗盖全)和对照组35例(常规血液透析联合罗盖全),随访12个月,观察两组患者治疗前和治疗12个月后的血钙、血磷、甲状旁腺素(PTH)、β2微球蛋白(β2-MG)及炎症因子[超敏C反应蛋白(hs-CRP)、白介素(IL-6)、肿瘤坏死因子(TNF)-α、脂蛋白Lp(a)]的变化,比较两组患者心脏瓣膜钙化的患病率。结果治疗12个月后,观察组脱失5例,完成30例,对照组脱失4例,完成31例。观察组患者治疗12个月后的血磷[(1.60±0.15) mmol/L vs (1.23±0.17) mmol/L]、PTH [(68.9±4.73) nmol/L vs (30.26±3.10) nmol/L]、β2-MG水平[(24.26±7.14) mg/L vs (10.40±3.65) mg/L ]均显著低于对照组,差异均有显著统计学意义(P<0.01),而两组患者的血钙水平比较差异无统计学意义(P>0.05);观察组患者的炎症因子hs-CRP [(15.48±5.86) mg/L vs (5.17±2.63) mg/L]、IL-6[(151.97±48.16) ng/L vs (82.42±27.40) ng/L]、TNF-α[(1.65±0.92) ng/L vs (0.86±0.24) ng/L]、Lp(a)[(486.75±380.42) mg/L vs (237.38±157.42) mg/L]水平均显著低于对照组,差异均有显著统计学意义(P<0.01);观察组患者的心脏瓣膜钙化患病率为26.67%,显著低于对照组的54.83%,差异有显著统计学意义(P<0.01)。结论高通量血液透析联合罗盖全能够更有效的清除血磷、PTH、β2-MG及炎症因子,降低心脏瓣膜钙化患病率,其疗效优于普通血液透析联合罗盖全治疗。     

Exercise activities are impaired in maintenance dialysis patients and its correlative factors

Objective To investigate the exercise performance in maintenance dialysis patients, and analyze its correlative factors. Methods Maintenance dialysis patients admitted in Tongji Hospital of Shanghai from December 2014 to March 2015 were enrolled, with their baseline data and biochemical measurement being collected. The anthropometric indexes including arm circumference, triceps skinfold, waist circumference and hip circumference were detected. The exercise activity was assessed by hand grip test, timed up and go test (3mTUG) and five times sit-to-stand test (FTSST). Patients were divided into fast group (3mTUG≤12 s) and slow group (3mTUG＞12 s). Univariate and multivariable analyses were used to evaluate the factors influencing exercise performance in maintenance dialysis. Results There were 121 patients enrolled: 62 on peritoneal dialysis and 59 on hemodialysis, 76 men and 45 women. Patients' average age was (61.6±13.0) years and median dialysis age was 31.7(12.3, 69.0) months. There was no statistical difference between fast group (n=80) and slow group (n=41) in gender, dialysis method, dialysis age, body mass index (BMI), arm muscle area (AMA), waist-hip ratio (WHR), hemoglobin (Hb) and total cholesterol (TC). Patients in fast group were younger, had higher serum albumin, prealbumin, serum phosphate and iPTH, and less prevalence of diabetes than those in slow group. In exercise activity, patients in fast group had better performance in handgrip, 3mTUG and FTSST (all P＜0.05). Univariate analysis showed that, handgrip was correlated with sex (male), AMA, BMI, age, diabetes, serum phosphorus and TC; scores in FTSST was correlated with age, BMI, diabetes, WHR, dialysis method, dialysis age, prealbumin and serum phosphorus; scores in 3mTUG was correlated with age, diabetes, WHR, dialysis method and dialysis age, prealbumin, serum phosphorus and iPTH (all P＜0.05). Multiple stepwise regression analysis showed that sex (male), age, AMA and diabetes were independently correlated with handgrip in dialysis patients (all P＜0.05); age, dialysis method, BMI and diabetes were independently correlated with scores in FTSST (all P＜0.05); age, dialysis method, diabetes and WHR were independently correlated with scores in 3mTUG (all P＜0.05). Conclusions The exercise performances of patients on maintenance dialysis are impaired. Age and diabetes are independent factor associated with the exercise performances of patients on maintenance dialysis. AMA is independently associated with upper limb movement, and dialysis method, BMI and WHR are independent factors associated with lower limb movement in dialysis patients.