小儿血液透析267例次临床分析

报道我院自１９７８年１０月￣１９９４年１１月为３７例肾功能衰竭患儿进行２６７例次血液透析,占同期我院血液透析中心总数１９４８４例次的１．３％,结果：痊愈１４例,好转１６例,死亡７例,主要并发症为失衡综合征（１９．１％）,低血压（１８．０％）和心力衰竭及肺水肿（１．９％）,通过血液透析,降低了小儿明功能衰竭的死亡率。根据临床实践及有关实验研究,提出有关小儿血液透析必须遵循的特点及做法。     

Red blood cell lifespan in long-term hemodialysis patients treated with roxadustat or recombinant human erythropoietin

IntroductionA significant decrease in red blood cell (RBC) survival has been observed in patients with renal failure, which is supposed to contribute to renal anemia. The aim of this observational study was to determine RBC survival in hemodialysis (HD) patients treated with roxadustat or recombinant human erythropoietin (rhuEPO) compared with healthy persons.MethodsRBC lifespan was measured by Levitt’s CO breath test with newly developed automatic instrument ELS Tester.ResultsA total of 102 patients receiving long-term HD from two independent dialysis centers enrolled in the study, of whom 62 were treated with rhuEPO and 40 were on roxadustat therapy. A total of 25 healthy participants were recruited to match HD participants according to age and sex. Median RBC survival times in rhuEPO, roxadustat, and control groups were 65.0 (25th–75th percentile, 49.5–77.3), 75.5 (25th–75th percentile, 57.3–99.3), and 108.0 (25th–75th percentile, 89.0–141.5) d, respectively. Patients treated with roxadustat had significantly longer RBC survival time than patients treated with rhuEPO (p < .05). In multivariate analysis of factors affecting RBC lifespan in the whole HD patients, anemia treatment drugs (rhuEPO/roxadustat) and levels of hemoglobin were the significantly independent factors. RBC survival was not found to correlate with either weekly rhuEPO dosage (r = –0.087, p = .500) or weekly roxadustat dosage (r = −0.267, p = .110) in our cohort.ConclusionsHD patients treated with roxadustat had significantly longer RBC survival time than patients treated with rhuEPO, large prospective studies with long-term follow-up are warranted to verify the results in future. Abbreviations RBC: red blood cell; HD: hemodialysis; rhu EPO: recombinant human erythropoietin; ESRD: end-stage renal disease; EPO: erythropoietin; ROS: reactive oxygen species; CKD: chronic kideny disease; ESAs: erythropoiesis-stimulating agents; HIF-PHD: hypoxia-inducible factor prolyl hydroxylase; CO: carbon monoxide; Hb: hemoglobin     

维持性血液透析患者输血传播性病毒感染状况及其基因分析

目的研究维持性血液透析患者输血传播性病毒(TTV)感染状况,及进行其部分基因序列分析.方法设计TTVORF1部分基因引物,巢式PCR检测80例血液透析患者及12例血液透析工作人员血清标本,将PCR产物克隆、测序分析.结果血液透析患者TTV感染率为35%(28/80),12名工作人员中有1例呈TTV阳性(8.3%).与日本株相比较,本实验分离株TTVORF1部分基因同源性为96.7%.TTV合并HBV感染者8例(8%),合并HCV感染者5例(6%);TTV与HBV、HCV同时感染者2例(2%).TTV阳性患者中,有输血史者占57%.结论血液透析患者中存在严重的TTV感染,血液透析工作人员亦存在TTV感染.TTV可以与HBV、HCV重叠感染,TTV感染者可能与输血有关,但TTV的非血液传播同样应引起重视.     

铁超负荷对尿毒症患者心脏结构和功能的影响

目的研究铁超负荷对尿毒症维持性血液透析患者心脏结构与功能的影响.方法19例维持性血液透析患者按血清铁蛋白水平分为A、B二组,A组患者血清铁蛋白＜200 μg/L,B组患者血清铁蛋白400～600μg/L,两组患者在性别、年龄、透析年限、血压、血红蛋白、甲状旁腺素、平均超滤量、透析充分性、内瘘流量等方面差异不明显(P＞0.05).比较两组患者心动超声下心脏结构与功能的差异.结果A组的室间隔厚度、左室后壁厚度、左室心肌重量指数均明显低于B组(0.93±0.13vs 1.30±0.18cm,0.93±0.09 vs1.27±0.21cm,109.8±29.2vs166.9±44.4g/m2,P＜0.01);A、B两组患者心室舒张功能障碍发生率分别为27.3%、73.2%,B组明显高于A组(P＜0.01);A、B两组患者的射血分数、心脏指数差异不显著(P＞0.05);但A组患者平均每单位心肌的射血分数、心脏指数均明显高于B组(0.59±0.17vs0.39±0.16,0.039±0.008vs0.021±0.004,P＜0.01).结论铁超负荷是影响尿毒症血透患者左室肥厚、降低左室收缩与舒张功能的重要因素.     

Prostate cancer with multiple lung metastases in a hemodialysis patient

In hemodialysis patients, few cases of prostate cancer have been reported until recently. We present a case of prostate cancer with multiple lung metastases in a chronic hemodialysis patient. A 65-year-old Japanese man who had maintained hemodialysis for 5 years was referred to our hospital with multiple metastatic lung tumors. Serum prostate tumor markers were highly elevated although his plasma testosterone level was within the normal range. A transrectal needle prostate biopsy confirmed a histologic diagnosis of moderately differentiated adenocarcinoma. Androgen blockade therapy was very effective as evidenced by a quick decrease of serum tumor markers. The follow-up computed tomography scan of the chest performed 3 months later showed a complete disappearance of the coin lesions. The early detection of prostate cancer in hemodialysis patients is difficult because of a lack of urologic symptoms, which indicate the importance of periodic screening by serum tumor markers. Combined androgen blockade is effective even in hemodialysis patients. However, close follow up is necessary because long-term results and prognoses are still unknown.     

血液透析对硫嘌呤甲基转移酶活性的影响

目的　探讨慢性尿毒症患者红细胞内硫嘌呤甲基转移酶 (thiopurinemethyltransferase ,TPMT)的活性及血液透析对它的影响。方法　 3 0例慢性尿毒症患者血液透析前和血液透析后 4小时及 5 0名健康志愿者各取 5毫升静脉血采用高效液相色谱法 (high perfor manceliquidchromatographic ,HPLC)测定红细胞的TPMT活性。结果　健康志愿者活性的平均值为 ( 17.1± 4.6)U/mLpRBCs ,慢性尿毒症患者血液透析前红细胞内TPMT活性平均为 ( 2 2 .3± 6.7)U/mLpRBCs ,而血液透析后 4小时TPMT活性平均为 ( 17.5± 4.0 )U/mLpRBCs。结论　除了遗传因素可以影响TPMT活性外 ,尿毒症患者可因肾功能不全诱导TPMT活性上调 ,而血液透析后诱导因素去除 ,TPMT活性又接近正常     

维生素E对血液透析病人氧化应激的干预效果

目的　研究抗氧化剂维生素E对血液透析病人氧化应激状态的干预效果。方法　处于稳定状态的血液透析病人 5 6例 (不服用任何抗氧化药)采用自身对照的方法 ,观察 1个月后 ,随机均分为两个实验组 ,A组口服维生素E 2 0 0mg/d ,B组口服维生素E 4 0 0mg/d,服药 1个月 ;两组分别在观察期和服用维生素E干预期前后检测循环晚期氧化蛋白产物(AOPP)、丙二醛 (MDA)和谷胱甘肽过氧化物酶(GSHPx)水平以及血清维生素E浓度。另选 5 6例健康者作为正常对照组。结果　实验组血清AOPP、MDA水平明显高于同龄正常对照组(n =5 6 ,P <0 0 1) ,GSHPx、维生素E浓度明显低于正常人(P <0 0 1) ;透析病人在未服抗氧化药的 1个月观察期前后AOPP、MDA、GSHPx及维生素E浓度无明显变化 (P均 >0 0 5 ) ;A组治疗后 ,血清维生素E水平较治疗前明显增高 (P <0 0 1) ,但AOPP、MDA和GSHPx水平与治疗前相比无明显差异 ;B组治疗后血清维生素E、GSHPx水平较治疗前增高 (P <0 0 1,P <0 0 5 ) ,AOPP较治疗前明显降低 (P <0 0 1) ,但MDA水平无明显变化。结论　口服大剂量维生素E(4 0 0mg/d)可以改善血透病人的氧化应激状态 ;血透病人短期服用大剂量维生素E未见明显副作用。     

Prevalence of antibodies to hepatitis E virus among hemodialysis patients in Sweden

In order to study the prevalence of antibody to hepatitis E virus (HEV) among hemodialysis patients and to evaluate whether chronic hemodialysis is associated with an increased risk of exposure to HEV in developed countries, the IgG anti-HEV was determined in serum samples obtained from 182 patients on chronic hemodialysis and 349 statistically selected, healthy Swedish control subjects. Serum specimens from 11 of the 182 (6.0%) hemodialysis patients and from 18 of the 349 (5.2%) control subjects were repeatedly positive for HEV antibodies (the difference was not significant: P= .67). Analysis of serial serum samples obtained at the initiation of hemodialysis and consecutively during follow-up periods of several years demonstrated no IgG anti-HEV seroconversion during chronic hemodialysis. The seroprevalence of anti-HEV antibody in the adult Swedish population was associated significantly with age. In persons younger than 40 years, the percentage of seropositive individuals was 2.5%, whereas the seroprevalence rate of anti-HEV was 7.4% in subjects older than 40 years (P< .05). This study indicates that nosocomial transmission of HEV to patients on maintenance hemodialysis was non-existent in three dialysis centers in Sweden (a developed country) and that chronic hemodialysis is not associated with an increased risk of exposure to HEV infection in this region. J. Med. Virol. 54:38–43, 1998. © 1998 Wiley-Liss,Inc.     

维持性血液透析对患者内皮功能及凝血纤溶的影响

目的探讨维持性血液透析(MHD)患者内皮细胞功能、凝血纤溶系统变化及血液透析对其的影响。方法采用发色底物法、酶联免疫吸附法测定76例MHD患者透析前后凝血酶调节蛋白(TM)、纤溶酶原激活物抑制物-1(PAI-1)、凝血酶-抗凝血酶复合物(TAT)及纤溶酶抗纤溶酶复合物(PAP)水平,并与正常对照组进行比较。结果MHD患者透析前TM、PAI-1、TAT和PAP水平较正常对照组明显升高,分别为(13.2±4.0)μg/Lvs(3.9±1.4)μg/L,(67.8±31.5)μg/Lvs(37.0±5.9)μg/L,(15.8±6.2)μg/Lvs(5.0±2.7)μg/L,(145.2±90.3)μg/Lvs(62.7±13.8)μg/L(P<0.001);一次透析后MHD患者PAI-1水平较透前明显下降,(67.8±31.5)μg/Lvs(38.5±25.2)μg/L,TAT、PAP水平较透前明显升高,(15.8±6.2)μg/Lvs(28.9±15.1)μg/L,(145.2±90.3)μg/Lvs(185.2±110.0)μg/L(均P<0.001);TM、PAI-1水平与维持性血液透析年限成正相关(r分别为0.464、0.435,均P<0.001)。结论MHD患者存在血管内皮细胞功能损伤、高凝状态和纤溶亢进;血液透析过程中凝血、纤溶系统均被激活。体外血液净化过程对MHD患者血管内皮细胞功能、凝血纤溶存在不利影响。     

血液透析治疗难治性充血性心力衰竭的体会

目的：了解血液透析治疗难治性充血性心力衰竭的可行性、治疗效果及安全性。方法：回顾性分析了经内科治疗无效或恶化而改用血液透析、超滤、脱水治疗的12例难治性充血性心力衰竭患者的情况。结果：12例患者均能耐受3h血透治疗;11例心衰得到纠正,抢救成功率91．7％;死亡1例,住院病死率8．3％;死因为心源性休克,未见血液透析急性并发症。结论：常规内科治疗无效的难治性充血性心力衰竭,合并肝、肾功能恶化,水、电解质、酸碱平衡紊乱的患者,行血液透析、超滤、脱水治疗是一种安全、有效的救治措施,成功率较高。