前列地尔注射液在尿毒症患者动静脉内瘘成形术后的应用

目的 通过观察前列地尔注射液对预防动静脉内瘘成形术后血栓形成及血管内皮细胞（vascular endothelial cell,VEC）功能的影响.方法 84例维持性血液透析患者,拟行动静脉内瘘成形术前采用随机数字表分为治疗组44例和对照组40例.对照组在动静脉内瘘成形术后常规给予抗血小板聚集治疗,口服拜阿司匹林100 mg,治疗组在动静脉内瘘成形术后予以前列地尔注射液20 μg,加入0.9％生理盐水注射液100 ml中静脉滴注,每日1次,连用7d.分别于治疗前后检测全血黏度、血浆黏度、红细胞聚集指数、纤维蛋白原（fibrinogen,Fib）、凝血酶原时间（prothrombin time,PT）、血浆内皮素（plasma endothelin,ET）及一氧化氮（nitric oxide,NO）水平.术后观察内瘘杂音和震颤及有无出血征象,术后4周用多普勒超声测定内瘘头静脉内径、壁厚、每分钟血流量、内瘘成熟后血管进行初次透析使用的时间及透析时血流量.结果 前列地尔治疗后内瘘成熟率（90％）明显优于对照组（72％）,全血黏度[（4.92±0.42） mPa,s比（5.04±0.58） mPa,s、血浆黏度[（1.82±0.12） mPa,s比（2.12±0.14） mPa·s]、红细胞聚集指数[（2.74±0.57）比（2.92±0.46）、Fib[（3.14±0.14） g/L比（3.28±0.16） g/L]等血液流变学指标的变化均比治疗前有所降低,疗效优于对照组.且前列地尔组在ET[（48.15±16.19） ng/L比（52.34±17.35） ng/L]、NO[（37.31±3.10） μmol/L比（34.26±2.18） μmol/L]水平的改善方面也优于对照组,术后4周,治疗组内瘘成熟率高于对照组（90％o比72％）、头静脉内径[（6.18±0.20） mm比（5.50±0.25） mm]、壁厚[（0.72±0.05） mm比（0.63±0.04） mm、血流量[（815.50±65.68） ml/min比（610.62±75.82） ml/min]均优于对照组,透析时血流量明显大于对照组[（254.71±24.44） ml/min比（204.58±32.25） ml/min,并且其初次血透使用时间缩短[（25.42±5.26）d比（36.26±8.28）d].结论 ?     

The use of multi-detector computed tomography venography and three dimensional reconstruction image in evaluating the central venous occlusive disease of hemodialysis patients

Objective To evaluate the feasibility and value of multi-detector computed tomography venography (MDCTV) and three dimensional reconstruction image in the assessment of central venous occlusive disease in hemodialysis patients, and in the value of guiding interventional treatments. Methods Sixty hemodialysis patients with swelling of upper limbs were scanned by Toshiba 128-multislice spiral computed tomography (128-MSCT) and totally 80-100 ml non-ionic contrast media was injected into each of the patients via the peripheral veins of the contralateral limb with the rate of 4 ml/s. MSCT scanning was taken by the technique of intelligent triggering after setting scanning triggering threshold, with the monitoring?point?set in the development of the lumen of inferior vena cava, to detect the position and degree of vascular stenosis. The images were reformed as maximum intensity projection (MIP), volume rendering (VR), curved planar reformation and three-dimensional image reconstruction technique. Results MDCTV clearly demonstrated the lesion location in all cases enrolled. Seventy-five occlusive lesions were detected in the total of 60 hemodialysis patients with swelling of upper limbs by MDCTV, of which the lesions of brachiocephalic vein was 47, superior vena cava 15 and subclavian vein 13. Among the 75 stenosis lesions, the number of complete occlusive, severe, moderate and mild stenosis was 31, 24, 19 and only 1, respectively. MDCTV provided information coincident with that of digital?subtraction?angiography (DSA), which the correlation index was 0.401, while DSA showed that number of complete occlusive, severe, moderate and mild stenosis was 49, 7, 14 and 5, respectively. Percutaneous transluminal angioplasty was performed in 53 patients, and stent placement was done in 40 patients. After interventional treatments, swelling of upper limbs were obviously relieved and vascular accesses got functional recovery to?the?extent?that?they could meet the requirement of hemodialysis. Conclusions MDCTV is the first choice to evaluate the condition of central?venous?occlusive diseases of hemodialysis patients with advantages of non-invasion, high definition and three-dimensional?reconstruction. It can provide accurate evaluations of the conditions of occlusive lesions, which can be of great clinical significance to subsequent interventional therapy.     

血液透析对慢性肾衰患者肺功能的影响

目的了解血液透析对慢性肾衰患者肺功能的影响。方法入选尿毒症患者38例，分为血液透析组23例与非透析组（对照组）15例。均行肺功能检查，血液透析患者于透析前及透析结束后2h分别进行肺功能检测，比较2组肺功能水平的差异及透析组透析前后肺功能的变化。结果透析组与非透析组FVC／预计值（％）、FEV，／预计值（％）、FEV1／1．1VC（％）、PEF／预计值（％）、MMEF／预计值（％）、DLCO／预计值（％）等参数均明显降低，以非透析组尤为明显（P〈0．01）；透析组透析后FVC／预计值（％）、FEV1／预计值（％）、FEV1／FVC（％）、PEF／预计值（％）、MMEF／预计值（％）、DLEO／预计值（％）等参数均明显改善（P〈0.01）。结论尿毒症患者肺通气功能和弥散功能均明显下降，血液透析可有效改善肺功能。     

血液透析联合腹水回输治疗顽固性腹水的临床观察

目的探讨血液透析并腹水静脉回输在尿毒症顽固性腹水患者中的临床疗效。方法回顾性研究2010年10月至2013年9月在我科接受血液透析并腹水静脉浓缩回输治疗的尿毒症患者,11例,41例次,通过分析比较治疗前后体重、腹围、血压、血浆白蛋白、尿素氮、肌酐等各项指标的变化,探讨血液透析并腹水静脉回输在尿毒症顽固性腹水患者中的临床疗效。结果 1例行2次治疗后腹水消失,1例行7次治疗后胸腔积液及腹水均消失,水肿消退,11例患者治疗后均有明显效果,表现为腹胀、活动受限等腹水压迫症状明显改善,浮肿消失,夜间阵发性呼吸困难、睡眠明显好转,食欲增加,腹围、体重明显减少（P〈0.05）,血浆尿素氮、肌酐明显下降（P〈0.01）,血浆白蛋白明显升高（P〈0.01）。结论血液透析并腹水静脉回输能显著改善尿毒症并顽固性腹水患者的临床症状,提高其生存质量,延长生存时间,临床疗效确切。     

鼻烟窝动静脉内瘘制作及临床应用研究

目的：研究鼻烟窝动静脉内瘘在长期血液透析患者中的临床应用价值。方法对51例尿毒症患者实施显微镜下鼻烟窝桡动脉远心端与头静脉近心端血管吻合术制作动静脉内瘘。结果49例内瘘手术一次性成功,手术成功率为96.08%,内瘘4周、1年、2年、3年、5年通畅率分别为93.88%、78.57%、75%、50%及23.08%。内瘘初次使用时吻合口平均血流量为（612±104）ml/min,透析平均血流量253 ml/min。结论鼻烟窝动静脉内瘘可作为血管条件较好的长期血液透析患者最优先选择的血管通路。     

血液灌流治疗血透患者难治性高血压的研究

目的观察血液灌流对维持性血液透析患者血压和致高血压物质的影响。方法将60例符合难治性高血压的维持性血压透析患者随机分为灌流组及对照组,分别在血液透析基础上进行血液灌流和透析滤过治疗。观察两组治疗前后血压、降压药使用、血肾素活性（PRA）、内皮素（ET）、血管紧张素Ⅱ（ATⅡ）、甲状旁腺素（PTH）、醛固酮（Ald）等致高血压物质及血肌酐（Bcr）、磷（P）的变化。结果伴难治性高血压血透患者存在高水平的PRA、ET、ATⅡ、PTH、Ald、β2-MG;16周后,两组Bcr、P、β2-MG、Ald较治疗前明显降低,差异有统计学意义（P〈0．05）;灌流组AT Ⅱ、ET较治疗前明显降低,差异有统计学意义（P〈0．05）,而对照组无明显变化;两组PTH均有明显下降,灌流组P〈0．01,对照组P〈0．05;两组PRA治疗前后无明显变化。灌流组血压下降,降压药种类使用减少,治疗前后差异有统计学差异。对照组血压及降压药使用种类有下降趋势,但治疗前后差异无统计学意义。结论灌流组对致高血压物质的清除优于对照组,有明显降低血压的作用。     

Oxidant Stress in Hemodialysis Patients: What Are the Determining Factors?

Oxidant stress contributes to morbidity in hemodialysis patients. Three possible causes of oxidant stress have been suggested: the uremic state, the dialyzer membrane, and bacterial contaminants from the dialysate. Oxidant stress occurs in uremia before dialysis therapy is initiated, as evidenced by increased production of reactive oxygen species, increased levels of oxidized plasma proteins and lipids, and decreased antioxidant defenses. It has been proposed that increased production of reactive oxygen species during hemodialysis is also an important contributor to oxidant stress. Hemodialysis is associated with a transient increase in production of reactive oxygen species, particularly with cellulose membranes. In addition, surveys have shown widespread contamination of dialysate by endotoxin, which may cross membranes and prime production of reactive oxygen species by phagocytic cells. Recent studies, however, show a decrease in protein oxidation from pre- to post-dialysis and a normalization of neutrophil reactive oxygen species production. Taken together, these data suggest that uremia, per se, is the most important cause of oxidant stress in hemodialysis patients. Dialysate quality may also contribute to oxidant stress, but evidence that the dialyzer membrane plays a role is weak.     

尿毒症继发甲状旁腺功能亢进的手术治疗进展

继发性甲状旁腺功能亢进是尿毒症患者常见的严重并发症之一.手术治疗是有效的治疗方法.甲状旁腺全切除加前臂移植术因其疗效确切,易于监测,较为常用.术前应进行充分的准备,特别是术前甲状旁腺定位至关重要.各种手术方法均有一定的复发率.     

血液透析配合血液灌流治疗尿毒症顽固性高血压疗效观察

目的：探讨血液透析配合血液灌流治疗尿毒症顽固性高血压的疗效。方法64例尿毒症顽固性高血压患者根据治疗方法不同分成观察组和对照组两组。对照组采用单纯血液透析治疗,每周3次,观察组采用血液透析联合血液灌流治疗,每周1次。比较两组治疗后的降压效果。结果观察组的总有效率显著高于对照组（90.6% vs 71.9%,P ＜0.05）。观察组和对照组患者治疗后的 SBP、DBP 均较治疗前明显降低,且观察组患者的 SBP、DBP 较对照组降低更显著（P ＜0.05）。结论血液透析配合血液灌流治疗尿毒症顽固性高血压疗效确切,值得推广和应用。     

中西医结合治疗对尿毒症心肌病患者左室功能和结构的影响--附66例临床观察分析

目的考察并比较中西医结合治疗与单用中医治疗、西医治疗尿毒症心肌病的疗效.方法中西医结合治疗组23例,采用中医辨证论治、西医基础治疗及心室逆转治疗;与单纯西医治疗组23例及中医治疗组20例进行比较.三组疗程均为9个月.结果中西医结合治疗组23例,治疗前后患者左室功能及左室结构指标大多均有所改善(P＜0.05、P＜0.01、P＜0.001),疗效优于西医治疗组、中医治疗组.结论以痰瘀为主的中医辨证论治、结合西医降压等对症治疗,可在一定时期内改善尿毒症心肌病,且优于单纯中医或西医治疗.