Intensive Home Hemodialysis: An Eye at the Past Looking for the Hemodialysis of the Future

Multiple observational studies along with a limited number of randomized clinical trials suggest that intensive hemodialysis (IHD) not only improves outcomes for uremic patients undergoing chronic dialysis but does so with a more favorable cost/benefit ratio compared with conventional hemodialysis. As a result of this, there has been a rapid increase in the interest in home hemodialysis (HHD) as HHD represents the easiest means of implementing IHD. While HHD has generated increased interest given its association with better outcomes/reduced hospitalizations, there are very few randomized controlled trials comparing HHD with other hemodialysis methods. Reported HHD‐associated increased survival benefits compared with in‐center hemodialysis are from uncontrolled studies, which raise patient selection bias as underlying the differences found. Thus, while HHD draws increasing attention, studies that pay careful attention to the psychosocial, demographic, and clinical factors associated with patients selected to undergo HHD will be needed to ultimately demonstrate its benefits, clarify the clinical applications, and determine the limits of IHD use in dialysis patients.     

XStrainTM技术评价尿毒症患者左心室局部与整体收缩功能

目的 探讨XStrain^TM技术测定尿毒症心肌病患者左心室局部与整体收缩功能的可行性。方法 将28例尿毒症患者分两组,A组左心室非肥厚12例,B组左心室肥厚16例;C组为正常对照16名。经胸超声心动图采集并存储3个心动周期心尖四腔心、两腔心及三腔心切面二维灰阶图像。采用XStrain^TM定量软件进行脱机分析,获得收缩期左心室壁16节段纵向/横向应变及应变率,对16节段应变参数取平均值获得整体纵向/横向应变数据,并对以上参数进行统计学分析。结果 16节段心肌收缩期纵向应变及应变率(除中间段后间隔外)、横向应变(除中间段前间壁和后间壁外)、横向应变率为C组>A组>B组(P均<0.05)。尿毒症患者左心室收缩期整体纵向及横向应变较C组明显减低(P<0.05)。结论 XStrain^TM技术可清晰显示左心室心肌,评估左心室收缩功能,可用于定量评估尿毒症心肌病患者左心室局部与整体收缩功能。     

尿毒症患者炎症反应与血脂的关系

目的　通过分析尿毒症患者慢性炎症指标与血脂的关系 ,探讨尿毒症的炎症反应影响心血管系统的途径。方法　测定 67例尿毒症患者慢性炎症指标血C 反应蛋白 (CRP)、白细胞介素 6(IL 6)、肿瘤坏死因子 α(TNF α)及血脂 ,并分析它们之间的关系。结果　 2 6.87%的尿毒症患者CRP超过正常参考值 ( 5mg/L) ,CRP升高组血清甘油三酯 (TG)、低密度脂蛋白胆固醇 (LDL C)、载脂蛋白B(ApoB)、载脂蛋白A1/载脂蛋白B(ApoA1/ApoB)、脂蛋白 (a) [Lp(a) ]高于CRP正常组 (P值均 <0 .0 5 ) ;血CRP与总胆固醇 (TC) (P <0 .0 5 )、TG、LDL C、ApoB、Lp(a)、血清肌酐 (Scr)、血尿素氮(BUN)呈正相关 (P值均 <0 .0 1) ,Logistic回归分析显示 ,CRP与TG、Lp(a)关系更为显著。结论　尿毒症患者存在慢性炎症状态 ,慢性炎症与脂代谢紊乱密切相关。     

尿毒症患者血浆脑钠肽水平变化及与心功能的关系研究

目的观察尿毒症患者血浆脑钠肽水平变化,探讨其与心功能的关系。方法收集徐州医学院附属连云港医院肾内科2012年6月—2013年12月收治的新发尿毒症患者72例,根据纽约心脏病协会(NYHA)心功能分级分为Ⅱ级组27例,Ⅲ级组25例,Ⅳ级组20例,比较3组患者血浆脑钠肽水平、射血分数、血肌酐水平。所有患者进行透析治疗,比较透析前、透析3次后次日、透析4周后次日血浆脑钠肽水平、射血分数、血肌酐水平。结果 3组患者血肌酐水平比较,差异无统计学意义(P0.05);Ⅲ级组、Ⅳ级组患者血浆脑钠肽水平高于Ⅱ级组、射血分数低于Ⅱ级组,Ⅳ级组患者血浆脑钠肽水平高于Ⅲ级组、射血分数低于Ⅲ级组(P0.05)。所有患者透析3次后次日、透析4周后次日血浆脑钠肽水平、血肌酐水平低于透析前,射血分数高于透析前,透析4周后次日血浆脑钠肽水平低于透析3次后次日,射血分数高于透析3次后次日(P0.05)。结论尿毒症患者心功能越差,血浆脑钠肽水平越高,透析治疗可明显改善尿毒症患者心功能,降低血浆脑钠肽水平。     

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.