慢性肾衰，选择血透还是腹透

随着我国医疗体系构建的不断完善,人们越来越重视自己的身体状态,与此同时,现代繁杂的城市生活一方面致使很多人生活作息不规律,同时生活压力过大,种种原因导致近几年慢性肾衰的患者越来越多。就这一部分患者而言,他们的肾脏结构与肾脏功能出现了一定的障碍,并且已经严重地影响患者健康。对于慢性肾衰患者而言,在临床环节是能够通过一定的诊疗方式进行缓解的,目前比较常见的就是通过透析的方式维持患者生命,从而保证患者工作、生活不受病症影响,就目前来看,透析是肾脏治疗过程中最主要的方式。就目前来说,我们在肾病透析环节,常见的透析种类又分为血透和腹透,那么针对不同慢性肾衰患者,该选择什么样的透析方式,来最大程度上降低透析对患者身体的损伤呢?下面,本文将针对这一问题探究肾病透析究竟是怎么一回事儿。     

Paraoxonase activity and antibodies to oxidized-LDL in chronic renal failure patients on renal replacement therapy

Serum paraoxonase (PON1) and antibodies to oxidized-LDL (anti ox-LDL) were measured in chronic renal failure subjects on renal replacement therapy such as hemodialysis (HD) peritoneal dialysis (PD) and transplantation (Txp). Paraoxonase activity was significantly lower in HD and PD group (P<0.001) than in control subjects. In transplant patients, paraoxonase activity was not significantly different from that of controls. Antibodies to ox-LDL was significantly higher in HD, PD and Transplant patients (P<0.0001) compared to control subjects. High titers of antibodies were observed in the HD group compared to the PD and Transplant subjects. A decrease in paraoxonase activity and high titers of Antibodies to ox-LDL in the dialysis group suggest a decreased cardio protective effect of HDL and enhanced risk of premature cardiovascular complications. Whereas in case of transplant subjects, there seems to be restoration of PON1 activity, but elevated levels of anti-oxLDL could still be a potential atherogenic factor. Hence, we propose that estimation of these two parameters can be used as a useful index to measure the cardiac risk in the above patient category     

The Assessment of Oxidative Stress on Patients with Chronic Renal Failure at Different Stages and on Dialysis Patients Receiving Different Hypertensive Treatment

The aim of this study is to evaluate the oxidative stress in predialysis, hemodialysis (HD) and peritoneal dialysis patients and to test the effects of antihypertensive drugs and volume control on oxidative stress parameters. The study was composed of five groups as follows: control group (n = 30), predialysis group (n = 30), peritoneal dialysis group (n = 30), hemodialysis group, (normotensive with strict volume control, n = 30), hemodialysis group (normotensive with medication, n = 30). Plasma malondialdehyde (MDA), erythrocyte superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSHPx) and routine biochemical parameters were studied in all patients. Hemodialysis patients with strict volume control (HD_vc) had lower levels of MDA than other patient groups (p < 0.001), and CAT, SOD values had highest level other patient groups (p < 0.001). The treatment of hypertension with strict volume control in chronic renal failure patients causes less damage to the antioxidant capacity.     

Bardet–Biedl Syndrome: A Rare Cause of Chronic Kidney Disease

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive condition characterized by retinitis pigmentosa, postaxial polydactyly, central obesity, and renal involvement. Renal failure is the commonest cause of death. We report a case of BBS with chronic kidney disease (CKD) at younger age (17 year) from India. This diagnosis should be considered in patients with renal disease and the characteristic phenotype of retinitis pigmentosa, postaxial polydactyly and central obesity. These patients should undergo regular monitoring of renal function test to early diagnosis and treatment of CKD to prevent morbidity and mortality. Renal transplantation is a viable option of renal replacement therapy in these patients. These findings are valuable for comparing phenotype of BBS patients with CKD from various national and international centers.     

Malnutrition-inflammation-atherosclerosis syndrome in Chronic Kidney disease

Chronic kidney disease is becoming a major health problem globally and in India an alarming number of about 8 million people are suffering from this disease. Patients undergoing hemodialysis have a high prevalence of protein-energy malnutrition and inflammation. As these two conditions often occur concomitantly in hemodialysis patients, they have been referred together as ‘malnutrition-inflammation-atherosclerosis syndrome’ to emphasize the important association with atherosclerotic cardiovascular disease. The three factors related to the pathophysiology in these patients are dialysis related nutrient loss, increased protein catabolism and hypoalbuminemia. Inflammation in Chronic Kidney disease is the most important factor in the genesis of several complications in renal disease. Pro-inflammatory cytokines like IL-1 and TNF-alpha play a major role in the onset of metabolic alterations in Chronic Kidney disease patients. Atherosclerosis is a very frequent complication in uremia due to the coexistence of hypertension, hyperhomocysteinemia, inflammation, malnutrition and increased oxidative stress, generation of advanced glycation end products, advanced oxidation protein products, hyperlipidemia and altered structural and functional ability of HDL. LDL-cholesterol, apolipoprotein (A), apolipoprotein (B), and Lp(a) are also associated with atherosclerosis. Studies have now provided enormous data to enable the evaluation of the severity of malnutrition-inflammation-atherosclerosis syndrome as well as effective monitoring of these patients.     

Effect of vitamin E supplementation on oxidative stress in hemodialysis patients

Hemodialysis represents a chronic stress status for its recipients. Many hypotheses state that this may be associated with oxidative stress. Thus, there may be deficiency of antioxidants like erythrocytic superoxide dismutase, catalase, vitamin E or increased generation of free radicals like superoxide anions. A study was carried out to investigate oxidant and antioxidant status in chronic renal failure patients undergoing hemodialysis and effect of vitamin E supplementation on these two status. Blood samples were collected from patients before and after hemodialysis and from controls. The samples were analyzed for quantitation of MDA as index of lipid peroxide, nitric oxide, vitamin E, vitamin C and enzymatic antioxidants namely erythrocyte SOD and catalase. As compared to controls, the levels of serum MDA were significantly increased and activities of erythrocyte SOD and catalase, levels of serum nitric oxide, serum vitamin E and plasma vitamin C were significantly decreased both before and after hemodialysis. The efficiency of vitamin E therapy in hemodialysis patients was assessed by re-evaluating oxidant and antioxidant status of same patients after supplementation of vitamin E. Vitamin E supplementation caused decrease in serum MDA and increase in levels of serum nitric oxide, vitamin E, vitamin C and activities of erythrocytic SOD and catalase. Our results suggest the presence of oxidative stress and the possible preventive role of vitamin E therapy in hemodialysis patients.     

Analysis of protein posttranslational modifications by mass spectrometry: With special reference to haemoglobin

Mass spectrometry provides a convenient platform for the study of different protein post translational modifications from clinical specimen. Analysis of different post translational modifications of hemoglobin like glycation and glutathionylation can provide useful information on the disease progression and the possible outcome of therapies. In the present study, we have addressed post translational modifications of hemoglobin like glutathionylation and glycation in relation to diabetes and chronic renal failure. We found that both alpha and beta chains of human hemoglobin are glycated irrespective of the extent of glycemia as evidenced by a mass increment of 162 Da. The phenomenon of glutathionylation was observed with only the beta globin chain of hemoglobin probably due to the presence of an accessible cysteine residue indicated by a mass increment of 305 Da. Also, the extent of gltuathionylation observed in the CRF patients could correlate with the severity of the oxidative stress owing to renal replacement therapies like dialysis and transplantation.     

Drug-induced renal Fanconi syndrome: A case report

The renal Fanconi syndrome which results from renal tubular dysfunction can be either associated with various inbom errors of metabolism or acquired from various etiology. We report a case of gentamycin-induced Fanconi syndrome in a 4-month old infant who presented with aminoaciduria, glucosuria, phosphaturia and compensated metabolic acidosis.     

Effect of hemodialysis on circulating cystatin c levels in patients with end stage renal disease

Plasma cystatin C is an emerging parameter to assess kidney function. Its utility in assessing the adequacy of hemodialysis in patients with end-stage-renal disease has however not been established with certainty. This study was therefore carried out to assess the usefulness of serum cystatin C estimation in patients undergoing low flux membrane hemodialysis. Serum creatinine and cystatin C were estimated in 20 patients before and after undergoing hemodialysis. The mean serum creatinine decreased from a pre-dialysis value of 7.72 mg/dL to a post-dialysis value of 2.90 mg/dL. On the contrary, the mean serum cystatin C levels were found to increase from a pre-dialysis value of 5.97 mg/L to a post-dialysis value of 8.25 mg/L. Therefore, serum cystatin C cannot be used to monitor dialysis adequacy. It however, serves as a surrogate marker of the inadequacy of low flux membrane bicarbonate hemodialysis in clearing low molecular weight proteins from the circulation.     

Edidence for oxidant injury in patients with postdiarrhoeal acute renal failure

Oxygen free radicals have been implicated in the pathogenesis of ischaemic acute renal failure (ARF). The evidence for this is mainly drawn from studies on experimental models. There are no such studies in postdiarrhoeal ARF, which is common in India and forms an ideal human model of ischaemia-reperfusion injury to the kidney, to confirm the observations made, in experimental models. 12 patients with postdiarrhoeal ARF and 15 healthy volunteers were included in the study. In patients with ARF, plasma lipid peroxides (LPO), superoxide dismutase (SOD), plasma iron and plasma ferritin were significantly increased when compared to controls. Plasma glutathione peroxidase levels were significantly lower in the patients with postdiarrhoeal ARF. All these changes persisted at the end of one week. The results of the study strongly suggest the role of reactive oxygen species in the production of postdiarrhoeal acute renal failure as a result of ischaemia-reperfusion injury that occurs in patients with diarrhoeal illness on fluid replacement therapy. This study helps in providing the markers to monitor antioxidant therapy as a preventive as well as therapeutic measure in cases of postdiarrhoeal acute renal failure.     

Loss of proteinase binding capacity of plasma alpha2 macroglobulin in some disease conditions

Alpha₂-macroglobulin (MG) levels in terms of proteinase binding capacity in fresh plasma of diabetics (males 183.9±60.3 mg MG/dl, females 173.8±49.7) and viral hepatitis patients (195.2±41.4) were comparable to normal sujbects (males 180.0±28.6, females 213.0±59.6) whereas in renal failure the values were decreased (144.0±30.0) and was found to be increased in nephrotic syndrome (331.5±47.9). MG activity was stable in normals and nephrotic patients in plasma on standing for 12 hr. at 37°C. In other conditions, the proteinase binding capacity was considerably reduced (mean decrease: 51.2% in diabetes, 64.0% in renal failure and 52.6% in viral hepatitis). Concentration of MG determined by immunoelectrophoresis did not however change in diabetic plasma on 12 hr. incubation. It is proposed that proteinases are continously generated in plasma in some disease conditions which bind to MG causing reduction in measured proteinase binding capacity.     

Uric acid as one of the important factors in multifactorial disorders--facts and controversies

With considering serum concentration of the uric acid in humans we are observing hyperuricemia and possible gout development. Many epidemiological studies have shown the relationship between the uric acid and different disorders such are obesity, metabolic syndrome, hypertension and coronary artery disease. Clinicians and investigators recognized serum uric acid concentration as very important diagnostic and prognostic factor of many multifactorial disorders. This review presented few clinical conditions which are not directly related to uric acid, but the concentrations of uric acid might have a great impact in observing, monitoring, prognosis and therapy of such disorders. Uric acid is recognized as a marker of oxidative stress. Production of the uric acid includes enzyme xanthine oxidase which is involved in producing of radical-oxigen species (ROS). As by-products ROS have a significant role in the increased vascular oxidative stress and might be involved in atherogenesis. Uric acid may inhibit endothelial function by inhibition of nitric oxide-function under conditions of oxidative stress. Down regulation of nitric oxide and induction of endothelial dysfunction might also be involved in pathogenesis of hypertension. The most important and well evidenced is possible predictive role of uric acid in predicting short-term outcome (mortality) in acute myocardial infarction (AMI) patients and stroke. Nephrolithiasis of uric acid origin is significantly more common among patients with the metabolic syndrome and obesity. On contrary to this, uric acid also acts is an "antioxidant", a free radical scavenger and a chelator of transitional metal ions which are converted to poorly reactive forms.     

Improvement in electrolyte imbalance in critically ill patient after magnesium supplementation — A case report

Hypomagnesaemia is common finding in current medical practice mainly in critically ill, post-operative patients and patients admitted to ICU in tertiary cancer cases. Magnesium has been directly implicated in hypokalemia, hypocalcaemia and dysrrthymias. We report a case of 60 year old patient, suffering from rectal carcinoma for a period of one year with confirmed hypokalemia, hypocalcaemia and hyponatremia. Magnesium supplementation corrected the underlying multiple electrolyte disturbances in the patient thus, establishing a positive correlation of magnesium with sodium, potassium and calcium.     

Evaluation of urinary abnormalities in nephrolithiasis patients from Marathwada region

Urinary abnormalities were evaluated in 100 renal stone patients with first episode of renal stone having age 22 to 45 years from both sex and compared to 100 normal healthy control group having same age group from both sex. Twenty-four hours urinary oxalate, calcium, uric acid, sodium, magnesium, phosphorus and citrate were estimated. The urinary pH was also determined. In stone formers urinary oxalate, calcium, sodium and uric acid excretions were significantly higher when compared with control group. Whereas citrate, phosphate and magnesium excretion were significantly lower in stone formers when compared with control. The pH of urine in stone formers was lower than the controls. High dietary intake of purine rich diet causes elevated excretion of uric acid, which leads to calcium oxalate crystal formation and precipitation. Other risk factors such as urinary oxalate, calcium also related to formation of renal calculi. Hypocitraturia is the main cause of renal calculi along with hypomagnesiuria and hypophosphaturia in the patient of Marathwada region. On the basis of urinary abnormalities further stone formation in the patient can be prevented by dietary modifications.     

Association of Prooxidant–Antioxidant Balance with Clinical and Laboratory Parameters and Its Relation to Different Drug Regimens in Polycystic Ovary Syndrome Women with Normal BMI

Polycystic ovarian syndrome is one of the most common hormonally leading cause infertility disorders. The effect of oxidant-antioxidant imbalance on disease progression has been studied in many disorders. The present study was aimed to evaluate prooxidant–antioxidant balance (PAB) in patients with polycystic ovarian syndrome compared to healthy subjects. We also studied the possible effect of treatment with available drugs on serum PAB. In this case–control study 100 polycystic ovary syndrome (PCOS) patients and 100 healthy individuals were enrolled in the study. The laboratory features of patients and controls like as serum LH and FSH concentration and hematological examinations were collected. PAB was evaluated by a colorimetric method. Serum PAB value was significantly higher before treatment compared to after treatment and healthy subjects. PAB values were also higher in subjects with irregular menstrual cycle compared to normal subjects. Our results represented that serum PAB values has an indirect significant correlation with serum LH concentration. We also found that drugs regimen containing spironolactone effectively reduced the serum PAB values. Our results showed that PCOS patients had increased level of PAB and treatment with spironolactone mainly decreases the level of serum PAB. Our results indicate that the measurements of PAB may be used as a potential laboratory marker for assessment of PCOS patients.     

超声医学在慢性肾衰竭患者心脏损害方面的作用

目的：为了解慢性肾衰竭（ CRF）患者的心脏损害情况,并探讨这种心脏损害的影响因素。方法：选择2012年一月至2013年1月收治的慢性肾衰竭30例患者作为观察组,另选同一时间段未患慢性肾衰竭30例患者作为对照组。将超声心动图检查两组患者的LAD,LAPWs,LAPWd,IVSTd,IVSTs, SV,EF等数据进行评价,分析慢性肾衰竭后患者心功能受损的情况。结果：检查后的两组数据显示,肾衰竭组LAD,LAPWs,LAPWd,IVSTd,IVSTs较对照组显著增加,具有患者心脏彩超异常者占93.3%（28/30）,具有统计学意义（p〈0.05）,观察组SV,EF,A,E较对照组明显增高,异常者为96.6%（29/30）。对照组心脏超声主要表为左室扩大、左室肥厚、左房扩大、瓣膜反流及心功能不全,尤以左室舒张功能损害为主。这些心脏损害的主要影响因素有尿毒症毒素、高血压、贫血。尽早透析,积极控制高血压,纠正贫血是预防和治疗CRF患者心脏并发症的主要手段。结论：对于肾衰竭患者而言,心脏彩超是一种无创性的较准确地反心脏形态和心功能受损的辅助检查方法。     

Effect of Hemodialysis on Plasma Myeloperoxidase Activity in End Stage Renal Disease Patients

End stage renal disease (ESRD) patients on hemodialysis (HD) have an increased oxidative stress, with a high risk of atherosclerosis and other co-morbid conditions. Recent studies have suggested that myeloperoxidase (MPO)—mediated oxidative stress may play a role in the pathogenesis of cardiovascular complications in dialysis patients. Furthermore, dialysis treatment ‘per se’ can aggravate oxidative stress. Hence this study was designed to determine whether HD leads to an alteration in the plasma levels of MPO and malondialdehyde (MDA), a marker of oxidative stress in ESRD patients on maintenance HD. To study the effect of HD, plasma MPO and MDA were determined before and after HD in forty ESRD patients (24 men and 16 women, age between 8 and 71 years, median being 40.5 years) on maintenance HD. Plasma MPO and MDA were assayed by spectrophotometric methods. Haematological and other biochemical parameters were obtained from patients’ case records. Plasma MPO and MDA levels were significantly higher after HD when compared with pre-dialysis levels (p < 0.05). There was no correlation between MPO and MDA (r = 0.184, p = 0.10) and other biochemical parameters (p > 0.05). However, there was a significant correlation between MPO and MDA with haemodialysis vintage (p < 0.05). In univariate regression analysis duration of HD (β = 1.470, p = 0.045, β = 0.388, p = 0.013), was independently associated with MPO and MDA. Although HD is indispensable for survival of patients with ESRD, it is fraught with undesirable side-effects, such as an increase in the plasma MPO and MDA levels. The elevated levels of MPO contribute to the increased oxidative stress as free radicals are produced by the reaction catalyzed by it.     

Determinants of bone mineral density in patients on haemodialysis or peritoneal dialysis – a cross-sectional,longitudinal study

Introduction:

The aim of the study was to identify biomarkers of alteration in bone mineral density (BMD) in patients on haemodialysis (HD) and peritoneal dialysis (PD).

Materials and methods:

In a cross-sectional, longitudinal study dual-energy X-ray absorptiometry scans were performed in 146 HD-patients and 28 PD-patients. Follow-up after 14 months (mean) was conducted in 73 patients. As potential biomarkers we investigated parathyroid hormone (PTH), 25-hydroxy vitamin-D, ionised calcium, albumin, phosphate, and total alkaline phosphatases (t-ALP).

Results:

Both groups of dialysis patients had lower BMD in the femoral neck (BMD_neck) (P < 0.001) and forearm (BMD_forearm) (P < 0.001) compared to healthy controls, but comparable BMD in the lumbar spine (BMD_spine). BMD did not differ between dialysis types, but patients ever-treated with glucocorticoids had significantly lower BMD, while patients with polycystic kidney disease had higher BMD. BMD correlated with body weight, actual age, age at initiation of dialysis, duration of dialysis and levels of PTH and t-ALP. However, t-ALP only remained associated with low BMD_spine after adjusting for other factors (P = 0.001). In the follow-up study all patients had decreased BMD in all three locations, but only for the lumbar spine there was a significant association between BMD and the bone markers t-ALP (P = 0.009) and PTH (P = 0.013).

Conclusions:

Both HD and PD patients have low BMD, and increased concentrations of t-ALP is associated BMD_spine after adjustment, while PTH and t-ALP is associated with decrease in BMD_spine over time. This substantiates the use of these biomarkers in both types of dialysis patients.     

Alcohol induced effects on kidney

After administration ethanol and its metabolites go through kidneys and are excreted into urine, and its content in the urine is higher than that of the blood and the liver. Chronic ethanol administration decreases the renal tubular reabsorption and reduces renal function. Multiple functional abnormalities of renal tubules may be associated with ethanol-induced changes in membrane composition and lipid peroxidation. The vulnerability of the kidney to oxidative damage has been partly attributed to its high content of long-chain polyunsaturated fatty acids. Renal ultra structural abnormalities due to ethanol exposure may be important in the genesis of functional disturbances. Increased oxidative stress and endothelial dysfunction with their complex interrelationships are relevant aspects of atherogenesis in chronic renal failure. Antioxidants, particularly polyphenols are expected to decrease the vulnerability of the kidney to oxidative challenges.     

Spontaneous Tumor Lysis Syndrome in an Infant: A Case Report

Tumor lysis syndrome has been observed in patients with malignancies with high cellular burden and high cell turnover, tumor sensitive to therapy, especially after initiating medical treatment. It very rarely occurs spontaneously. The case described here is of 6 months male infant who presented with fever since 1 month and loose stools associated with blood since 15 days. The laboratory investigations showed lactate dehydrogenase (LDH) of 6,192 IU/L and serum uric acid 18.2 mg/dl along with pancytopenia. The infant presented with electrolyte abnormalities and renal failure.