透析液钙离子浓度对肾功能衰竭血液透析患者血清钙离子水平及血压的影响

目的 观察不同钙离子浓度的透析液对血液透析患者透析后血清钙离子水平及血压变化的影响，为肾功能衰竭血液透析患者的高钙血症及高血压的防治提供依据。方法 选择不同钙离子浓度的透析液，将维持性血液透析患者分为高钙组（1．75mmol／L）和低钙组（1．25mmol／L），比较患者每次透析前后脉搏、血压，同时抽查患者透析前后血钙及血肌酐浓度的变化。结果透析后两组患者血肌酐浓度均显著下降，透析前后差异均具有统计学意义（P〈0．01）；高钙组患者透析后血钙较透析前升高，差异具有统计学意义（P〈0．01），而低钙组患者血钙比透析前略降低，差异无统计学意义（P〉0．05）。高钙组患者透析后较透析前收缩压、舒张压及平均动脉压都升高，差异均具有统计学意义（P〈0．05），而低钙组患者透析后较透析前收缩压、舒张压及平均动脉压都降低，差异均具有统计学意义（P〈0．05）。透析后两组血钙比较差异具有统计学意义（P〈0．01）；透析后低钙组较高钙组患者的收缩压、舒张压及平均动脉压都降低，三者差异均具有统计学意义（P〈0．01）。结论透析液钙离子浓度与血液透析患者血清钙离子水平及血压呈正相关，低钙透析液透析有助于维持性血液透析患者高血压的控制。     

Oxidative stress induced by iron released from transferrin in low pH peritoneal dialysis solution

Background. Transferrin binds extracellular iron and protectstissues from iron-induced oxidative stress. The binding of ironand transferrin is pH dependent and conventional peritonealdialysis (PD) solutions have unphysiologically low pH values.Herein, we investigated whether conventional PD solution releasesiron from transferrin and if the released iron causes oxidativestress. Methods. Effects of PD solutions on iron binding to transferrinwere examined with purified human transferrin and transferrinin dialysates drained from PD patients. Oxidative stress inducedby iron released from transferrin was evaluated in terms ofthe formation of thiobarbituric acid reactive substance (TBARS)and protein carbonylation in the human red blood cell (RBC)membrane. The iron deposition in peritoneal tissue from PD patientswas evaluated by Perls' staining with diaminobenzidine intensification. Results. Low pH PD solution released iron from transferrin.This iron release occurred within 1 min. Iron release was notobserved in neutralized PD solution. Iron released from transferrinin low pH PD solution increased TBARS formation and proteincarbonylation in the human RBC membrane. Iron deposition, whichis prominent in the fibrotic area facing the peritoneal cavity,was observed in the peritoneum of PD patients. Conclusions. Iron released from transferrin in low pH PD solutioncan produce oxidative stress in the peritoneum of a PD patient.Neutralizing PD solution can avoid this problem. Iron depositionin the peritoneum may participate in the pathogenesis of peritonealfibrosis in PD patients.     

Endotoxin transfer through dialysis membranes: small- versus large-pore membranes.

In this in-vivo study, dialysate and serum endotoxin was evaluated before and after haemodialysis with small-pore (PS400) and large-pore (PS600) polysulphone dialysers, and before and after haemodiafiltration with the PS600 filter. The source of the endotoxin was the presence in dialysate of Pseudomonads at a concentration of 10(3)-10(4) CFU/ml. Endotoxin was measured by a modified chromogenic limulus amoebocyte lysate (LAL) assay. In spite of dialysate endotoxin concentrations greater than 100 pg/ml, no changes in pre- versus posttreatment LAL reactivity were observed in PS400 dialysis and PS600 haemodiafiltration. In contrast, PS600 haemodialysis was related to an increase in serum LAL reactivity from 1.3 +/- 1.5 to 3.8 +/- 2.0 pg/ml (n = 15, P less than 0.01), and five patients (33.3%) showed a post-dialysis value in excess of 5 pg/ml. Our data are consistent with the absence of in-vivo endotoxin transfer during haemodialysis with small-pore dialyser membranes, and during haemodiafiltration with membranes with larger pores. An increase in LAL reactivity during haemodialysis with membranes with larger pores is, however, present, presumably due to the occurrence of backdiffusion/filtration with that specific strategy.     

滤膜法与涂抹法检测血液透析相关用水微生物的效果

目的 探讨滤膜法和涂抹法检测血液透析相关用水微生物的效果,为选择合适的检测方法提供依据。方法 回顾性收集某三级甲等综合性医院2018年1-12月同时采用滤膜法和涂抹法检测血液透析相关用水微生物的结果,对比分析滤膜法和涂抹法检测细菌检出率、单位菌落数、超干预值检出率和微生物合格率。结果 共收集274份血液透析相关用水微生物检测结果,其中透析液131份,反渗水39份,B浓缩液（下简称B液）14份,置换液34份,其他透析用水56份。滤膜法细菌检出率均高于涂抹法,其中透析液、反渗水、置换液、其他透析用水标本使用两种方法的细菌检出率比较,差异有统计学意义（均P<0.05）。透析液、B液、其他透析用水标本单位菌落数滤膜法数值上低于涂抹法,但仅其他透析用水标本使用两种方法检测结果单位菌落数差异有统计学意义（t=-3.011,P=0.004）。超干预值检出率其他透析用水滤膜法低于涂抹法,差异有统计学意义（χ²=6.596,P=0.010）。置换液、反渗水标本微生物合格率滤膜法数值上低于涂抹法,但仅置换液标本微生物合格率差异有统计学意义（χ²=18.987,P<0.001）。结论 滤膜法检出细菌的能力高于涂抹法,但其在血液透析相关用水微生物检测中存在一定局限性,除用于置换液比较适合外,应用在其余血液透析相关用水微生物的检测效果并不优于涂抹法。     

Clearing the clouds: Case‐report and review of the literature

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non‐infectious causes must be considered. A 46‐year‐old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic‐range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.     

KT/V and protein catabolic rate determination from serial urea measurement in the dialysate effluent stream

A bloodless technique of evaluating protein catabolic rate (PCR) and KT/V (K, clearance; T, dialysis time; V, urea distribution volume) in hemodialysis patients is presented based on serial measurement of urea in the dialysate effluent stream. PCR follows from equating urea generation and urea removal over a 7 day cycle, changes in body stores being comparatively negligible: PCR = 0.026 [U1 + U2 + U3]/BWdry + 0.17, where U1 is the amount of urea in mmol appearing in the dialysate for each session in the 7 day period. KT/V is obtained from the slope of the natural logarithm of spent dialysate urea concentration-time plot: KT/V = [- slope.T + 3.delta BW/BWdry]/[1 - 0.01786.T(hr], where delta BW = amount ultrafiltered in liters. The dialysate-based approach was validated and compared with conventional urea kinetic modeling (UKM) for 17 patients studied for three consecutive dialyses. The dialysate-based and UKM values of PCR agreed well when in vivo clearance values based on total dialysate collection were used for UKM. KT/V values agreed poorly on a session-by-session basis but were nearly equivalent when averaged for the three dialyses of the week. These findings lay the foundation for UKM automation with a urea sensor in the effluent dialysate stream.     

透析液中氯化钾含量测定方法的改进

目的：改进透析液中氯化钾含量测定方法提高回收率。方法：将原方法中四苯硼钠的浓度增加到0．02mol／l。结果：测得的回收率从原来的94．79％增加以100．15％。结论：改进后的方法准确、可靠。     

Water-Soluble Vitamins and Trace Elements Losses during On-Line Hemodiafiltration

Maintenance hemodialysis induces water-soluble vitamins and trace elements losses, which is why recommendations regarding potential supplementation were provided, but mainly based on conventional hemodialysis. This study′s aim was to measure the water–soluble vitamins and trace element losses during one on-line post-dilution hemodiafiltration (HDF) session. Thirty-nine patients under maintenance HDF were enrolled. We used the Theraflux^® sampler (Theradial Corp., Orvault, France) to analyze the full session dialysate mass transfer. Blood and dialysate samples were collected before and after one HDF session to measure B1, B2, B6, B9, B12, C vitamins, zinc, and selenium concentrations. Values significantly decreased for B1 (20.2%), B2 (13%), B6 (25.4%), B9 (32.6%), C (66.6%) and selenium (6.7%). No significant differences were found for vitamin B12 and zinc. The dialysate losses per session were 1.12 ± 0.88 mg for vitamin B1, 0.28 ± 0.30 mg for B2, 0.33 ± 0.09 mg for B6, 0.3 ± 0.18 mg for B9, 147.5 ± 145.50 mg for C and 25.75 ± 6.91 mg for zinc. Vitamin B12 and selenium were under detection values. In conclusion, during a standard 4hr-HDF session, we found important losses for vitamin B1, B6, B9, C and zinc, suggesting the need for regular monitoring of plasma levels and systematic supplementation of these compounds.     

血液透析患者出现热原反应原因调查

为探寻血液透析患者出现热原反应的原因,进行了微生物污染与消毒剂浓度调查。结果,消毒透析器所用过氧乙酸浓度低至０．０５％～０．１６％,贮罐中自来水、反渗水及透析器入口处透析液的细菌总数分别高达 １１ ２００ｃｆｕ／ｍｌ、 １５８０ｃｆｕ／ｍｌ与 １２５０ｃｆｕ／ｍｌ,透析液、反渗水细菌内毒素阳性率均为 １００％（ ２０／ ２０）。经确保过氧乙酸浓度≥０．３％,缩短消毒周期,改善液体过滤除菌设备,液体微生物检测均达标,未再出现热原反应。     

高糖透析液对大鼠腹膜结缔组织生长因子表达的作用

目的探讨腹膜透析液对大鼠腹膜结缔组织生长因子（CTGF）的表达及细胞外基质（ECM）合成的影响。方法将中南大学湘雅二医院动物实验中心提供的SD大鼠随机分为4组：正常对照组（Con）、生理盐水组（NS）、低糖透析液组（LG）、高糖透析液组（HG）。4周后,评价腹膜的功能。VG染色镜下测量腹膜胶原组织厚度。免疫组织化学方法检测CTGF、TGF-β1及纤连蛋白（FN）蛋白质的表达。采用RT-PCR检测大鼠腹膜组织中CTGF和TGF-β1mRNA的表达。结果LG、HG组与Con、NS组相比较,超滤量均显著下降（P〈0.05）;HG组与LG组比较,其超滤量明显减少（P〈0.05）。D/Pcr的比较：HG组比Con、NS组升高（P〈0.05）;D/DO的比较：HG组比Con、NS组明显下降（P〈0.05）,LG组比Con组低（P〈0.05）。HG组腹膜胶原厚度比与其余各组均增厚（P〈0.05）;LG组比Con组增厚（P〈0.05）;HG组CTGF、TGF-β1、FN蛋白表达水平显著高于其他各组（P〈0.05）;LG组显著高于Con、NS组（P〈0.05）。在Con及NS组中,TGF-β1、CTGFmRNA呈低水平表达,TGF-β1、CTGFmRNA在HG组中表达最高（P〈0.05）。结论腹膜透析液尤其是高糖腹膜透析液,能明显诱导大鼠腹膜CTGF的表达增强,并促使腹膜纤维化发生。