系统性营养管理在门诊CAPD患者中应用的效果评价

目的对门诊持续非卧床性腹膜透析(CAPD)患者进行系统性营养管理,改善其营养状况。方法对59例门诊CAPD患者开展持续8个月系统性营养管理,进行主观综合性营养评估(SGA),测量血液生化、直接人体测量等指标,对营养管理前后情况进行分析评价。结果门诊CAPD患者管理前后的SGA比较有显著性差异(P<0.05),管理后各项营养生化指标显著增高(P<0.05)。结论对门诊CAPD患者进行系统性营养管理能显著改善患者的营养状况,可应用于临床。     

Environmental Transmission of Hepatitis B and Hepatitis C Viruses Within the Hemodialysis Unit

Abstract: The hepatitis B virus (HBV) can be transmitted in the dialysis setting through blood transfusions and environmental surfaces. Transfusion related hepatitis C virus (HCV) infection is very well known, but only recently the environmental transmission of this virus was postulated. In order to study the prevalence, mechanisms of transmission, and the ALT patterns of HBV and HCV infections in hemodialysis and CAPD patients before the implementation of HBV vaccination and HCV screening in the blood bank, we conducted a study from January 1987 to January 1990. Sera from 185 hemodialysis and 124 CAPD patients were stored in this period and later analyzed for HBsAg, anti-HBc, anti-HBs, and anti-HCV (second generation ELISA). The prevalence of any HBV marker was 55.7% (103/185) for hemodialysis patients and 31.5% (39/124) for CAPD patients (hemodialysis vs. CAPD, p < 0.001). The prevalence of positive anti-HCV was 35.1% (65/185) for hemodialysis and 33.9% (42/124) for CAPD patients (not significant). There was a significant association between HBV markers positivity and anti-HCV positivity. The multivariate analysis of risk factors revealed an association of the positivity of each virus with the duration of renal replacement therapy (RRT), number of previous blood transfusions, and past history of hemodialysis treatment. Thus, besides the transfusion-related transmission, hemodialysis environmental transmission may also occur for both viruses. The findings of a high prevalence of both viruses and evidence for environmental transmission in the dialysis setting are of major importance for the planning of future preventive measures.     

Functional Deterioration of the Peritoneum: Does It Occur in the Absence of Peritonitis?

Peritoneal function in relation to the occurrence of peritonitisand the osmolarity of the dialysate was studied in 72 CAPD patientswith a mean duration of treatment of 16.5±9.0 months(group 1). Data from 24 of these patients, who were on CAPDfor longer than 2 years (average 28.6±4.9), were subjectedto further detailed analysis (group 2). Each group consistedof two subgroups, one of patients who had experienced peritonitisand one of patients who had had no episodes of peritonitis. Results from group 1 revealed that the use of hyperosmolar bagsincreased in parallel with the duration of CAPD treatment evenin the non-peritonitis subgroup, and that peritonitis enhancedthe tendency to use hyper osmolar dialysate solutions. Thisphenomenon was also observed in the peritonitis subgroup ofgroup 2, but was not apparent in the non-peritonitis subgroupof group 2 when examined as a whole: however, individual analysisrevealed that some of them had a similar tendency to use hyperosmolardialysate, as was seen in the peritonitis subgroup. These results comfirm that the peritonitis impairs the ultrafiltrationcapability of the peritoneum. The results also suggest thatthe long-term use of hyperosmolar dialysate may be associatedwith decreased ultrafiltration, hence emphasis should be placedupon the use of hyposmolar dialysate solutions for long-termCAPD.     

Protein nitrogen appearance in CAPD patients: what is the best formula?

BACKGROUND.: The protein equivalent of nitrogen appearance is an indirectindex commonly used to assess dietary protein intake in patientson CAPD. Moreover it has been suggested that the ratio betweennitrogen appearance and dietary nitrogen intake (fractionalurea synthesis) can predict nitrogen balance in uraemic patients.Several formulae to directly calculate the protein equivalentof nitrogen appearance have been published. It has not beenestablished, however, what formulae give the most appropriateestimate of protein intake and nitrogen appearance. STUDY DESIGN.: Nitrogen balance studies were carried out in seven stable patientson CAPD. All of the patients were receiving a diet whose proteincontent (1.2 g/kg/body wt/day) and calorie content (35 kcal/kg/bodywt/day) were rigorously controlled. Six formulae for calculatingprotein equivalent of nitrogen appearance and nitrogen appearancewere tested and the agreement of the estimating formulae wasevaluated by means of the Bland and Altman method. RESULTS.: Net nitrogen balance was 1.68±0.9 g/N day, protein intake(g/day) 81±19, protein intake (g/kg) 1.05±0.17.Differences in protein equivalent of nitrogen appearance ofup to about 20% were found. The smallest differences betweenprotein equivalent of nitrogen appearance and protein intakewere obtained by the formulae of Bergstrom (1±7 g, limitsof agreement –12 and +15 g) and Blumenkrantz (–2±5g, limits of agreement –11 and +7 g). The formula of Bergstrommost closely estimated nitrogen appearance (–0.35±0.89g). Using such formula, the fractional urea synthesis was 54±12%,giving evidence of positive nitrogen balances. CONCLUSION.: For the routine monitoring of protein equivalent of nitrogenappearance in CAPD patients, we recommend Bergstrom's formulawith the determination of dialysate protein losses.     

The impact of topical mupirocin on peritoneal dialysis infection in Singapore General Hospital.

BACKGROUND: Peritonitis and exit-site infections (ESI) are major causes of morbidity in peritoneal dialysis (PD) patients. The application of topical mupirocin to exit sites reduces such complications, and prolongs life in PD. Since the year 2000, this topical treatment has been used in our hospital on new PD patients. We analysed the results of this protocol, and studied the effects of comorbidities on the incidence of peritonitis. METHODS: We studied 740 incident PD patients, who were divided into two groups based on year of entry into PD (Group 1 from January 1998 to December 1999 inclusive, topical mupirocin not used, and Group 2 from January 2000 to March 2004 inclusive, topical mupirocin used). The variables we studied included gender, age, diabetic status, ischaemic heart disease, peripheral vascular disease, cerebrovascular disease and serum albumin. RESULTS: The application of topical mupirocin at the exit site led to a significant reduction in the rate of peritonitis (0.443 vs 0.339 episodes per patient-year; P<0.0005) and in ESI (0.168 vs 0.156 episodes per patient-year; P<0.005), results attributed primarily by the significant (P<0.005) reduction in Staphylococcus aureus infection. There was also an unexpected lowering of Pseudomonas aeruginosa peritonitis in the mupirocin group (P<0.005). Stepwise multiple logistic regression analysis revealed that only the application of mupirocin and serum albumin levels were significant predictors of peritonitis. CONCLUSIONS: Our study, although retrospective, has demonstrated that the topical use of mupirocin was associated with a significant reduction in ESI and peritonitis and, unexpectedly, with findings of fewer incidences of Pseudomonas peritonitis. Serum albumin level before the initiation of PD was a strong predictor of subsequent peritonitis. Mupirocin, with its low toxicity, ease of application and demonstrable beneficial effect in reducing ESI and peritonitis is now used on all of our incident PD patients.     

Differing prognostic significance of reinfection and relapse in CAPD peritonitis

All episodes of recurrent infection in a CAPD unit over a 26-monthperiod have been analysed to discover whether relapse and reinfectionhave different prognostic importance. Relapse and reinfectionwere distinguished by detailed microbiological investigation.Prognosis was expressed in terms of outcome of treatment andthe fate of the Tenckhoff catheter. Twenty-nine patients suffered recurrent infections (i.e. morethan one infection during a 12-month period). Nine (6 male,3 female, age range 42–73 years) had relapses, and 20(16 male, 4 female, age range 42–74 years) reinfections.The characteristics of the two groups of patients were indistinguishable. Relapse was of graver prognostic consequence: patients who relapsedwere significantly less likely to respond to antibiotic treatment(78% versus 20%) and have to have their catheters removed (78%versus 10%) than those with reinfections. Thus it is importantto differentiate relapse from reinfection in CAPD peritonitis.In addition to being helpful for the management of individualpatients, this is essential if results of therapeutic trialsare to be interpreted correctly.     

Potassium supplementation via the dialysate in continuous ambulatory peritoneal dialysis

A small percentage of patients treated with continuous ambulatory peritoneal dialysis (CAPD) may become hypokalemic. Since both the intravenous and oral routes for potassium repletion have disadvantages, we studied the feasibility, effectiveness, and safety of acute potassium loading via the dialysate in patients on CAPD. Five patients were studied during an exchange containing 20 mEq/L of potassium. This was well tolerated and led to a gradual increase in the plasma potassium concentration (.44 +/- .11 mEq/L) as about three-fourths of the intraperitoneal load was absorbed, most of it by two hours. The greatest increase in the plasma potassium concentration was .63 mEq/L. A separate patient developed intense abdominal pain during an exchange containing 40 mEq/L of potassium. We conclude that the dialysate is a safe and effective route for acute potassium repletion during CAPD when the dialysate potassium concentration does not exceed 20 mEq/L.     

Serum and dialysate concentrations of cephalexin following repeated dosing in CAPD patients

Oral cephalexin, 1 to 2 g daily for 3 days, was given to six stable, noninfected patients receiving maintenance continuous ambulatory peritoneal dialysis (CAPD). The peak serum concentration after a 2 g initial dose was between 73 and 123 mg/L. On the second and third day in five patients who received a 2 g daily oral dose, the serum concentrations were between 35 and 118 mg/L in serum obtained 1 to 1.5 hours after the dosing. Similar serum concentrations were seen in one patient who only received a 1 g oral dose on the second and third day. Cephalexin concentrations in the peritoneal dialysate reached a peak on the first day between 4 to 14 hours after the dose and were between 31 to 78 mg/L. During the second and third day, the highest cephalexin concentration was 118 mg/L and the lowest was 12 mg/L. The data are consistent with the feasibility of oral cephalexin for treatment of CAPD-associated peritonitis with microorganisms that are sensitive to these levels of cephalexin.     

Pharmacokinetic study of antimicrobial agents in patients undergoing continuous ambulatory peritoneal dialysis

A pharmacokinetic study was done in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) to establish an appropriate treatment for bacterial peritonitis. Twenty-nine CAPD patients were randomized to receive either oral ofloxacin (OFLX) 300 mg, followed by 200 mg once a day; intraperitoneal vancomycin (VCM) 30 mg/kg once a week; or intravenous imipenem/cilastatin (IPM/CS) 1000 mg once a day. Pharmacokinetic simulation models were determined according to changes of doses and duration. The time to reach the maximum plasma concentration (t _max), the maximum plasma concentration (C _max), the plasma elimination half-life (t _1/2), and area under the curve (AUC) were, respectively, 5.2 hours, 4.7 μg/mL, 20.4 hours and 80.5 μg/mL/h (AUC_0–24) for OFLX, 7.0 h, 26.4 μg/mL, 92.0 hours, and 1641 μg/mL/h (AUC_0–120) for VCM, 1.1 hour, 62.3 μg/ml, 3.76 hours, and 229.3 μg/mL/h (AUC₀₋₁) for IPM/CS. Twenty-three of 27 (85%) strains of clinical isolates were gram-positive cocci; 20 strains (74%) consisted of staphylococci or streptococci. The MIC₉₀ of OFLX, VCM, and IPM was 3.13, 1.56, and 0.78 μg/mL, respectively. When the minimum concentration in the dialysate during the initial 5 days was higher than the MIC, all the isolates (7 out of 7) were eradicated, when it was lower, only half of the isolates (3 out of 6) were eradicated. The simulation study suggested a significant drug accumulation in response to shortening the dosing duration.