围手术期应用重组人促红细胞生成素21例的经验

目的　观察围手术期患者使用重组人促红细胞生成素 (rHuEPO)在纠正贫血和减少异体输血的临床效果。方法　 2 1例腹部择期手术患者 (术前贫血或预计出血量约 4 0 0～ 6 0 0ml或预计需输血 2～ 3U)分成治疗组和对照组 ,治疗组术前每周给予rHuEPO 30 0IU/kg ,分 3次皮下注射 ,同时口服速力菲 30 0mg/d ,共 2周。对照组术前 2周口服速力菲 30 0mg/d。观察术前贫血纠正、术中减少异体输血、术后恢复的效果。结果　治疗组用药后RBC、Hgb、Hct较术前基础值分别升高 0 36×10 12 /L、13 3g/L和 3 8% ,术中异体输血量少于对照组 (P <0 0 5 ) ,术后恢复改善 ;对照组无明显变化 ,甚至下降。结论　中等量失血的围手术期患者使用rHuEPO在纠正贫血和减少异体输血是有效的方法     

Improving the nurse‐patient relationship: a multi‐faceted approach

Aim: A Corporate Education Session was held to provide concrete strategies for overcoming several specific barriers in the daily nurse‐patient relationship that negatively affect the patient, nurse, or both, and to provide the latest information about best practice as it affects nurses in renal care. Methodology: The session was led by a moderator who presented three video case studies to the audience. Communication strategies for recognising and overcoming nurse‐patient communication barriers were presented. The audience expressed their views about each case study using voting pads, and a panel of experts addressed the comments of the audience and discussed guidelines for best practice in renal care. The panel comprised three experienced renal nurses, a senior nephrologist, and an expert in social interaction. Conclusions: Optimal treatment of patients with renal disease should include early treatment of anaemia, adequate levels of dialysis, and a multidisciplinary approach, responding to both the medical and the social needs of the patient.     

Effects of different treatment methods on renal anemia in maintenance hemodialysis patients with hyperparathyroidism secondary to uremia

Objective To observe the effects of three treatment methods on renal anemia in maintenance hemodialysis patients with hyperparathyroidism secondary to uremia and analyze the influencing factors of erythropoietin (EPO) dosage. Methods A total of 55 maintenance hemodialysis patients with secondary hyperparathyroidism at the hemodialysis center of Huashan Hospital affiliated to Fudan University from January 2015 to December 2016 were retrospectively divided into three groups according to different treatment methods, parathyroidectomy +forearm transplantation group (surgery group, n=16), cinacalcet treatment group (n=6), and calcitriol treatment group (n=33), respectively. The hemoglobin level and erythropoietin dosage were measured before treatment and in the 3rd month, the 6th month and the 12th month after treatment. The changes of hemoglobin and erythropoietin dosage in the three groups before and after treatment were observed, and the mixed effect model was used to analyze the difference of the change of hemoglobin and erythropoietin dosage among three groups. Multiple linear regression analysis was used to analyze the influencing factors of EPO dosage after one year. Results The levels of intact parathyroid hormone (iPTH) in the surgery group and the cinacalcet group before treatment were significantly higher than that in the calcitriol group (both P＜0.05). In the 12th month after treatment, the levels of iPTH decreased significantly in the patients of surgery group and the cinacalcet group compared with those before treatment (both P＜0.05). The levels of serum alkaline phosphatase, serum calcium and serum phosphorus in the surgery group also decreased significantly compared with those before treatment (all P＜0.05). The mixed effect model analysis showed that the hemoglobin level of surgery group was on an upward trend after the treatment, and the overall level was significantly higher than cinacalcet and calcitriol treatment group (P=0.007). There was no significant difference in the dosage change of erythropoietin (EPO) in the three groups over time. However, the intra-group comparison of the mixed effect model showed that the dosage of EPO in the 12th month was significantly lower than that of before the treatment in surgery group (P=0.007). Multiple linear regression analysis showed that dialysis vintage (B=-0.064, P=0.012) and ferritin ≥ 500 μg/L (B=0.645, P=0.032) were independent influencing factors of EPO dosage. The longer the dialysis vintage, the less EPO dosage, and more EPO dosage were observed in patients with ferritin ≥ 500 μg/L. Conclusions Parathyroidectomy and forearm transplantation is more effective in reducing EPO dosage and improving renal anemia in maintenance hemodialysis patients with secondary hyperparathyroidism. Dialysis vintage and ferritin are independent influencing factors for the dosage of EPO.     

肿瘤坏死因子α和干扰素γ对癌性贫血患者红细胞生成素生成和红系增生的影响

目的探讨癌性贫血患者EPO生成及红系增生的变化，以及TNF、IFN等负调控细胞因子对EPO生成及红系增生的影响。方法对50例癌性贫血患者、15例癌症无贫血患者及对照组采用放射免疫法检测血清EPO水平，ELISA方法检测血清可溶性转铁蛋白受体（sTfR）、TNF-α、IFN-γ水平，用直线回归方法及相关分析定量分析体内EPO生成、红系增生情况及其与TNF-α、IFN-γ的关系。结果癌性贫血患者血清EPO水平为（23．11±10．00）IU／L，明显低于同等程度贫血的缺铁性贫血患者的（43．00±22．00）IU／L（P〈0．01）；实测值／预估值（O／P）EPO为0．88（0．54～1．10），明显低于对照组及癌症无贫血患者，后二者之间的O／PEPO差异无统计学意义。癌性贫血患者的血清sTfR水平（30．8±16．95）nmol／L，高于健康对照组的（17．82±6．76）nmol／L，而低于溶血性贫血患者的（65．75±29．12）nmol／L，差异均有统计学意义（P〈0．05）；O／PsTfR为0．89（0．57～1．22），明显低于对照组及癌症无贫血患者，后二者之间O／PsTfR差异无统计学意义。正常情况下存在于log（EPO）与血红蛋白浓度之间以及log（sTfR）与血红蛋白浓度之间的反比关系消失。癌性贫血患者血清TNF-α、IFN-γ水平分别为（25．75±26．71）ng／L、（50．49±42．12）ng／L，均显著高于正常对照组及癌症无贫血组。TNF-α、IFN-γ水平与血红蛋白浓度之间呈负相关关系。TNF-α与O／PEPO、O／PsTfR之间呈负相关。血清IFN-γ水平与O／PEPO之间无相关关系，与O／PsTfR呈负相关。结论TNF-α、IFN-γ等负调控因子的作用下，内源性EPO对贫血的反馈性增生相对不足，以及骨髓红系对EPO的反应性增生相对不足参与癌性贫血的发病机制。     

护理干预对促红细胞生成素两种注射方式转变的影响

目的:利用护理干预的方法观察人类重组红细胞生成素(rhu-EPO)由静脉注射方式转变为皮下注射方式的疗效。方法:采用健康教育、实际操作等护理干预实现两种不同途径的转变。结果:两组患者红细胞、血红蛋白、红细胞比容均有明显上升,6周后两组之间比较差别有显著性(P<0.05),90%患者由静脉注射转变为皮下注射。结论:合理的护理干预可有效地改变患者的从医行为,选择更有效的治疗方式。     

慢性肾衰竭大鼠肾移植后骨髓红细胞生成素受体的变化

目的通过观察慢性肾衰竭大鼠肾移植前后骨髓红系祖细胞的红细胞生成素受体(EPOR)的变化及与肾功能和贫血的关系,探讨红细胞生成素受体(EPOR)抑制在肾性贫血中的作用。方法以慢性肾衰竭(CRF)大鼠作为受者行同种异体肾移植术模拟人类肾移植。模型建立后RT-PCR法测定假手术组、CRF组和肾移植后不同时间大鼠骨髓红系祖细胞EPORmRNA表达的变化,WesternBlot分析EPOR蛋白质含量变化趋势,同时作EPORmRNA、EPOR蛋白质含量、Scr、Hb之间的相关性分析。结果CRF模型在5／6肾切除后90d时成功,接受肾移植后其血清肌酐和尿素氮迅速下降。CRF时EPORmRNA的表达和EPOR蛋白质含量较正常对照组明显降低,肾移植术后第7d开始二者明显升高,14d时恢复正常。相关性分析显示,EPORmRNA、EPOR蛋白含量、血红蛋白(Hb)均与血清肌酐呈显著性负相关,而EPORmRNA、EPOR蛋白含量与Hb呈显著性正相关。结论大鼠接受肾移植,尿毒症毒素完全清除后EPORmRNA及EPOR蛋白质含量显著增加至正常水平,提示EPOR抑制是引起肾性贫血的重要机理之一。     

骨髓间充质干细胞缺氧后促红细胞生成素信号通路的改变

目的研究骨髓间充质干细胞缺氧后细胞死亡情况及促红细胞生成素信号通路成分的表达改变。方法从Wistar大鼠股骨提取骨髓分离培养骨髓间充质干细胞并在体外扩增。取第4至6代接近融合的骨髓间充质干细胞置于氧浓度为0．5％的缺氧箱内培养24、48、72、96h后行台盼蓝染色计数阳性细胞并提取蛋白行Western blot检测促红细胞生成素、促红细胞生成素受体、HIF-1α、ERK、磷酸化ERK表达改变，另取0．5％缺氧培养48h的细胞免疫荧光染色观察EPO表达改变，Hoechst 33342染细胞核。结果常氧浓度培养对照组骨髓间充质细胞组台盼蓝染色阳性率为3．5％±0．4％，缺氧培养24、48、72、96h组分别为3．9％±0．2％、5．0％±0．4％、5．9％±0．5％、7．1％±0．5％。Western blot和免疫荧光染色发现EPO表达在缺氧48h后开始明显上调。F20R表达在缺氧后24h即开始显著上调且倍数更高。总ERK在对照组和不同缺氧时间组表达改变不明显，但HIF-1α和磷酸化ERK缺氧24h后即上调，72h达高峰。结论骨髓间充质干细胞对单纯缺氧损害较耐受，缺氧后促红细胞生成素信号通路的主要成分均显著上调，提示促红细胞生成素信号通路在骨髓间充质干细胞耐缺氧和旁分泌保护能力中起着重要作用。     

Erythropoietin and uremic platelet aggregation in vivo and in vitro

Erythropoietin treatment is known to correct anemia and to improve hemostasis. Since platelets may contribute to thromboembolic complications, we assessed platelet aggregation in whole blood and platelet-rich plasma from chronically hemodialyzed patients treated with erythropoietin and evaluated in vitro effects of this drug on aggregatory responses of uremic and normal platelets. Recombinant human erythropoietin was given to uremic patients at a dose of 2.000 IU subcutaneously three times a week. Platelet aggregation in whole blood and platelet-rich plasma was induced by collagen, ADP, arachidonic acid, and ristocetin. In uremic patients, erythropoietin therapy resulted in an enhancement of platelet sensitivity to various agonists, particularly in platelet-rich plasma, reaching values comparable to those of healthy volunteers. In vitro studies we were unable to show any direct effect of erythropoietin, used at concentrations that occurred post intravenous administration, on platelet aggregation both in whole blood and in platelet-rich plasma.     

The use of erythropoiesis-stimulating agents in patients with non-myeloid hematological malignancies: a systematic review

The effectiveness of erythropoiesis-stimulating agents (ESAs) for the treatment of anemia in patients with non-myeloid hematological malignancies needs to be assessed as the response to their administration is not uniform and their cost is high. We conducted a systematic review (SR) of the literature to identify reports of the effect of ESAs on survival, quality of life (QOL), transfusion requirements, and anemia. The entries to MEDLINE, EMBASE, and the Cochrane Library databases, and abstracts published in the proceedings of the annual meetings of the American Society of Clinical Oncology and the American Society of Hematology were searched. Seventeen reports and five abstracts of randomized trials fulfilled prospective criteria for inclusion. Five trials reported on survival; three failed to detect differences between groups and two demonstrated inferior survival in patients allocated to an ESA. Seven trials and three abstracts reported on QOL with four articles and three abstracts describing improvements in patients allocated to erythropoietin. However, important methodologic limitations were identified in these reports. Seven randomized controlled trials reported a reduction in the proportion of patients transfused. The absolute risk reduction in transfusions ranged from 15% to 24%. This is the only SR that assesses the use of erythropoiesis-stimulating agents specifically in patients with hematological malignancies. We conclude that available data evaluating ESAs in patients with hematologic malignancies demonstrate that these agents reduce transfusion requirements. Limitations of these data preclude conclusions that these agents improve QOL. More data are required to confirm the inferior survival associated with ESAs.     

Epoetin responsiveness in peritoneal dialysis patients: a multi-center Slovenian study

The objective of our study was to assess the influence of residual renal function and other factors on epoetin requirements in chronic peritoneal dialysis patients. Fifty-one stable patients (mean age +/- SD: 52 +/- 13 years; 20 women) without recent bleeding, bone marrow disease or malignancy were recruited in four Slovenian centers. The target hemoglobin was above 110 g/L. The peritoneal equilibration test results and relevant clinical and laboratory parameters were recorded. The epoetin resistance index was expressed as a weekly epoetin dose/body weight/hemoglobin concentration. Twenty-four percent of the patients did not need epoetin treatment, the rest were treated with epoetin-beta in a dose of 70 +/- 56 U/kg per week s.c.; the hemoglobin concentration was 124 +/- 15 g/L. Ferritin >100 microg/L and transferrin saturation >20% fulfilled 63% of patients whose epoetin resistance index was not significantly lower (0.43 +/- 0.5 U/kg per week per g/L vs 0.6 +/- 0.72 U/kg per week per g/L, P = 0.502). No difference was found between diabetic and non-diabetic patients. Treatment with angiotensin system antagonists, but not with aluminum phosphate binders, was associated with increased epoetin resistance index (0.56 +/- 0.59 vs 0.3 +/- 0.4 U/kg per week per g/L, P = 0.038). No correlation between epoetin resistance index and residual glomerular filtration rate was found (r = -0.2, P = 0.173). A multiple linear regression analysis showed C-reactive protein, intact parathormone level, female sex and treatment with angiotensin system antagonists to be the independent predictors influencing epoetin resistance index. Our results show that systemic inflammation, secondary hyperparathyroidism and angiotensin system antagonist treatment are the most important modifiable parameters affecting epoetin requirements in stable peritoneal dialysis patients.