Chinese Journal of Blood Purification

12 June 2016, Volume 15 Issue 06 Previous Issue    Next Issue

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The mechanism of neointimal hyperplasia in autologous internal arteriovenous fistula in maintenance hemodialysis patients 2016, 15 (06):  330-334.  doi: 10.3969/j.issn.1671-4091.2016.06.004 Abstract ( 326 )   HTML ( 0 )   PDF (2513KB) ( 529 )   Objective To evaluate the influence and mechanism of hypertensive nephropathy and diabetic nephropathy on neointimal hyperplasia in autologous internal arteriovenous fistula (AVF) in maintenance hemodialysis (MHD) patients. Methods Cephalic veins were collected during the surgery of AVF angioplasty or reconstruction for MHD patients. The samples were divided into chronic glomerulonephritis group, hypertensive nephropathy group and diabetic nephropathy group based on primary disease of the patients. Histological changes were examined and the thickness of intima and media was measured after H-E staining of the sample. Immunohistochemistry was used to detect the expression of several growth factors in vascular tissue. The correlation between α-SMA and growth factors was then analyzed. Results Intima thickness increased more in hypertensive nephropathy and diabetic nephropathy groups than in chronic glomerulonephritis group. Immunohistochemical staining showed that α-SMA, bFGF, IGF-1 and MMP-9 increased significantly after the surgery for 12-18 months in hypertensive nephropathy and diabetic nephropathy groups. In contrast, VEGF reduced significantly, and MMP-2 had no changes. Univariate regression analysis revealed that α-SMA level was positively correlated with the levels of bFGF, IGF-1 and MMP-9, and negatively correlated with the level of VEGF in vascular tissue. Conclusions Proliferation of vascular smooth muscle cells (VSMCs) was the leading cause of intima hyperplasia in MHD patients. The up- regulation of bFGF, IGF- 1 and MMP-9 and down-regulation of VEGF in vascular tissue may relate to the VSMCs proliferation. Hypertension and diabetes can accelerate the processes of intima hyperplasia and shorten the life of fistula, especially in MHD patients with diabetes. Metrics

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Clinical application of internal arteriovenous fistula at higher site in hemodialysis patients with the dysfunction of forearm standard arteriovenous fistula 2016, 15 (06):  335-337.  doi: 10.3969/j.issn.1671-4091.2016.06.005 Abstract ( 279 )   HTML ( 0 )   PDF (327KB) ( 357 )   Objective To evaluate the effect and advantage of arteriovenous internal fistula at higher site in hemodialysis patients with dysfunction of standard arteriovenous fistula in forearm. Methods Arteriovenous internal fistula at higher site was made in 40 uremia patients whose vascular condition in forearm was inadequate for successful construction of an internal arteriovenous fistula. We then analyzed the advantages and complications of the internal fistulas at higher site. Results The operation was successfully performed in 39 cases and was failed in one case because of the bad vascularity condition; long-term deep vein catheterization was then used in this case. The internal fistulas were used for hemodialysis after 4～8 weeks, and the blood flow can reach 230～300 ml/min. Blockage of the internal fistulas due to thrombosis was found in 4 cases. Swelling of distal limbs was detected in 5 cases, not affecting physical activity and blood access in hemodialysis. Conclusions Arteriovenous internal fistula at higher site can be successfully used in patients with poor vascularity condition in forearm. This operation can also protect patient's blood vessels for the preparation of vascular graft. Metrics

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Pathological changes in the cephalic vein before and after stripping of venous neointimal hyperplasia in hemodialysis patients with stenosis of arteriovenous fistula 2016, 15 (06):  338-340.  doi: 10.3969/j.issn.1671-4091.2016.06.006 Abstract ( 345 )   HTML ( 0 )   PDF (1536KB) ( 293 )   Objectives Dysfunction of vascular access in hemodialysis is a major cause of morbidity and mortality in hemodialysis patients. The most common cause of vascular access dysfunction is venous stenosis resulting from venous neointimal hyperplasia (VNH) within the peri-anastomotic region of AV fistula. Failed fistula can be restored by VNH stripping. This study investigated the pathological changes of cephalic vein before and after VNH stripping. Methods Vein samples were collected before and after VNH stripping near the site of AV anastomosis. Histological and immunohistochemical studies were performed on these vein samples. Results The majority of the cells in neointima were myofibroblasts (SMA positive). The vascular endothelial cell marker CD34 still existed after VNH stripping. Conclusion Vascular endothelial cell marker CD34 still existed after VNH stripping. Metrics

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Observation of regularly urokinase combined heparin sealed tube to the long-term hemodialysis catheter tube in prevention of infection 2016, 15 (06):  341-343.  doi: 10.3969/j.issn.1671-4091.2016.06.007 Abstract ( 287 )   HTML ( 1 )   PDF (371KB) ( 313 )   Objective To research the influence of regularly urokinase and heparin sealed tube to the long-term hemodialysis catheter tube in prevention of infection, so as to find out the clinical significance of regular application of urokinase and heparin seal tube. Methods We selected 60 patients using right internal jugular vein long-term indwelling catheter with cuff as vascular access line maintenance hemodialysis during April 2014-March 2015 in our hospital dialysis centers, and randomly divided them into two groups (the experimental group and control group, each group of 30 patients). The experimental group with a catheter-locking regimen of urokinase and heparin once weekly ,with heparin used in the other sessions.; The control group only with a catheter-locking regimen of heparin. Results The experimental group can obviously reduce the incidence rate of catheter infection (3.3% vs. 25%；χ2=4.043，P=0.044); In the experimental group before and after treatment ,there were no significant changes in PT[(13.93±1.82)s vs. 13.89±1.92)s，t=3.129，P=0.894]、PLT[(190.59±49.65)×109/L vs. (193.91±39.68)×109/L，t=0.393，P=0.617]、INR [(1.2±0.20 )s vs. (1.21± 0.15)s，t=0.619，P=0.751]、APTT [(33.85±6.51)s vs. (33.99±7.12)s，t=0.297，P=0.814]、FIB [(2.98±0.78)g/L vs. (3.06±0.76)g/L，t=0.706，P=0.483]and TT [(11.37±1.59)s vs. (11.91±1.54)s，t=0.587，P=0.523]. Conclusion Regularly urokinase and heparin sealed tube to the long-term hemodialysis catheter tube can reduced the incidence of infection , It is safe and effective to prevention of catheter-related bacteremia. Metrics

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Vascular access at the initiation of hemodialysis and its related factors in Shanghai 2016, 15 (06):  344-347.  doi: 10.3969/j.issn.1671-4091.2016.06.008 Abstract ( 258 )   HTML ( 0 )   PDF (391KB) ( 385 )   Objective To investigate the vascular access modalities at the initiation of hemodialysis in maintenance hemodialysis (MHD) patients, and to analyze the factors affecting the selection of vascular access modalities. Methods A total of 125 MHD patients were recruited from Shanghai Huashan Hospital during the period from Oct. 1, 2015 to Jan. 1, 2016. The vascular access modalities at the initiation of hemodialysis were described, and the factors relating to the selection of vascular access modalities were analyzed. Results Arteriovenous fistula was used at the initiation of hemodialysis in 53.6% MHD patients. There were significant differences in hypertension (24 vs. 43, χ2=6.042, P=0.014), time from diagnosis of renal disease to the initiation of hemodialysis [1.085(0.000～42.280) vs. 4.170 (0.170～40.112) years, Z=2.314, P=0.021], referral to nephrologists before the initiation of hemodialysis (23 vs. 53, χ2=19.496, P＜0.001), and period from suggestion of arteriovenous fistula operation by nephrologists to the initiation of hemodialysis [0.000 (- 36.505～13.201) vs. 4.100 (1.000～75.072) months, Z=7.748, P＜0.001] between the patients using central venous catheter and those using arteriovenous fistula. Conclusions The proportion of arteriovenous fistula for blood access at the initiation of hemodialysis was higher in this Blood Purification Center, but needs to be increased further. The selection of blood access modality at the initiation of hemodialysis was related to hypertension, time from diagnosis of renal disease to the initiation of hemodialysis, referral to nephrologists before the initiation of hemodialysis, and period from suggestion of arteriovenous fistula operation by nephrologists to the initiation of hemodialysis. Metrics

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Impact of Prealbumin Levels on Mortality in Patients With Acute tubular necrosis: An Observational Cohort Study 2016, 15 (06):  348-352.  doi: 10.3969/j.issn.1671-4091.2016.06.009 Abstract ( 242 )   HTML ( 0 )   PDF (478KB) ( 250 )   Objective To evaluated the prognostic value of prealbumin levels in patients with acute kidney injury (AKI)，which reason for causing AKI is acute tubular necrosis. Methods This was a prospective cohort study. Hospital- acquired AKI patients in the Ninth People’s Hospital from February 2012 to June 2014. laboratory measurements and clinical data were recorded. Cox proportional hazards models was uesd to estimate the risk of the ninety days mortality associated with serum prealbumin level at the beginning of the nephrology consultation. Results Three hundreds and forty-eight hospital-acquired AKI patients matched at least one of the Risk, Injury, Failure, Loss, End Stage (RIFLE) criteria for increased serum creatinine, and had requested a nephrology consultation. Clinicopathologic variables were compared between patients with a serum prealbumin level, ＜13.6 mg/dL (the exposed group; cutoff point, median) and patients with a serum prealbumin level≥13.6 mg/dL (the control group). In-hospital mortality rates associated with prealbumin levels were 48.3% for ＜13.6 mg/dL, and 21.4% for≥13.6mg/dL (χ2=13.622, P＜0.001). After adjusted analysis age, sex, hemoglobin, serum albumin, C-reactive protein, Liano score and serum total cholesterol, the presence of a serum prealbumin level, ＜13.6mg/dL was significantly associated with increased the ninety days mortality (HR 1.784，95% confidence interval 1.059～3.006, P = 0.029). In addition, each increment of 5 mg/dL of serum prealbumin was associated with an adjusted 24% decrease of the ninety days mortality (HR 0.754，95% confidence interval 0.606～0.938，P=0.011). Conclusions Low levels of serum prealbumin was an independent risk factor of death in hospital-acquired AKI patients Metrics

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Body composition analyses for the evaluation of nutritional status in maintenance hemodialysis patients 2016, 15 (06):  353-356.  doi: 10.3969/j.issn.1671-4091.2016.06.010 Abstract ( 266 )   HTML ( 1 )   PDF (451KB) ( 324 )   Objective To assess the nutritional status by body composition monitor (BCM) in maintenance hemodialysis (MHD) patients. Method A total of 57 MHD patients were enrolled in this study. Their body composition and laboratory data were measured and collected. Patients were divided into 2 groups according to the mean value of BMI. Fat and muscle content per body surface unit and laboratory data were then compared between the 2 groups. Result Fat content per body surface unit was higher in the high BMI group (BMI ≥21.68 kg/m2) than in the BMI low group (BMI ＜21.68 kg/m2) (t=4.327, P＜0.001); univariate regression analysis found that BMI value was positively correlated with fat content per body surface unit (r=0.588, P＜0.001). The difference in muscle content per body surface unit between high BMI group and low BMI group was statistical insignificant (t=0.892, P=0.376), and BMI value had no linear correlation with muscle content per body surface unit (r=-0.109, P=0.419). Cholesterol (t=2.882, P=0.006), triglyceride (t=2.040, P= 0.047) and hemoglobin (t=3.857, P＜0.001) were higher in the high fat content per body surface unit (≥12.29 kg/m2) group than in the low fat content per body surface unit (＜12.29 kg/m2); fat content per body surface unit was positively correlated with cholesterol (r=0.370, P=0.010), triglyceride (t=0.403, P=0.005) and hemoglobin (r=0.405, P=0.002) levels. Serum creatinine (t=2.515, P=0.015) and albumin (t=2.189, P=0.033) were higher in the high muscle content per body surface unit group (≥22.80 kg/m2) than in the low muscle content per body surface unit group (＜22.80 kg/m2); muscle content per body surface unit was positively correlated with serum creatinine (r=0.416, P=0.001) and albumin (r=0.315, P=0.018). Conclusion The nutritional status in MHD patients could be conveniently and accurately assessed by BCM. Metrics

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Effect of hemoglobin variability at patient-level and facility-level on mortality in maintenance hemodialysis patients 2016, 15 (06):  357-361.  doi: 10.3969/j.issn.1671-4091.2016.06.011 Abstract ( 270 )   HTML ( 0 )   PDF (374KB) ( 211 )   Objective Results describing the relationship between hemoglobin variability (Hb-Var) of patient-level and mortality were ambiguous in hemodialysis (HD) patients. However, clinical anemia management pattern has important effects on patients’hemoglobin condition as well as on Hb-Var of patient- level (PL Hb-Var) and Hb-Var of facility-level (FL Hb-Var). This study aimed to analyze the effect of PL Hb-Var and FL Hb-Var on mortality in HD patients. Methods This retrospective cohort analysis used the data in Beijing Hemodialysis Quality Control and Improvement Center (BJHDQCIC) database. Patients on stable HD (＞3 month) before Jan. 1st, 2010 in this database were included. Patients should survive the baseline phase (Jan.-Jun., 2010) and had at least 3 Hb measurements during the baseline phase. Study subjects were followed up until Dec. 31st, 2011. Dialysis facilities with 10 or more eligible patients were included in this study. For every patient, demographics, primary cause of end stage renal disease, date of first HD, date of censoring and reason for censoring, date of death, cause of death, and 3 Hb measurements were extracted. The primary outcome was all-cause mortality. Patients were divided into 3 groups according to the FL Hb-Var. Two Cox regression models were established to analyze the relationship between mortality and PL Hb-Var and FL Hb-Var. The possible effective factors were also analyzed. Results This study included 2,013 subjects from 91 facilities. There were 276 death and 66 patients censored during follow-up period. Compared with the lowest PL Hb-Var group (＜4.4 g/L), mortality in the highest PL Hb-Var group (＞8.8 g/L) increased by 47.5% (HR= 1.475, 95% CI 1.105～1.968, P=0.008). Compared with the patients ＜40 years old, the crude hazard ratio of death for patients＞65 years old was 6.764 (95% CI 2.983～15.339, P＜0.001). The hazard ratio of death for males was 1.280 (95% CI 1.007～1.627, P=0.044). Outcomes for patients with diabetes (HR=1.000) and hypertension (HR=0.700, 95% CI 0.458～1.070, P=0.100) as the primary ESRD causes were relatively worse. While outcome for patients with glomerulonephritis was better (HR=0.521, 0.458～1.070, P=0.004). After adjustments, the mortality risk increased by 42.2% in the highest FL Hb-Var group compared with the lowest group (HR=1.422, 95% CI 1.056～1.914, P=0.020). Conclusions Moderate fluctuation of PL Hb-Var did not affect mortality. However, greater fluctuation (＞8.8g/L) increased death risk. Patients with age ＞65 years old, male gender, and diabetes and hypertension as the primary ESRD causes had higher mortality risk. Patients in facilities in the highest FL Hb-Var group had higher mortality risk. Effort aiming to improve anemia management pattern in facilities will reduce the mortality. Metrics

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The clinical characteristics and short- term prognosis of hospital- acquired AKI in elderly patients 2016, 15 (06):  362-366.  doi: 10.3969/j.issn.1671-4091.2016.06.012 Abstract ( 232 )   HTML ( 0 )   PDF (534KB) ( 268 )   Objective To investigate the clinical characteristics and short-term prognosis of hospital-acquired acute kidney injury (AKI) in the elderly. Methods The clinical data of hospital-acquired AKI patients admitted in the Ninth People’s Hospital from January 2013 to September 2014 were collected, and the elderly patients with AKI were then identified. Their clinical characteristics and risk factors for mortality within 90 days were analyzed. Results A total of 368 hospital-acquired AKI patients were identified. Of all the elderly patients (n=201), the mortality within 90 days was 34.8%. Among the non-elderly patients, the mortality within 90 days was 33.5%. The main causes of death for elderly patients were ischemia and infection. Multivariate analysis performed by Cox model showed that platelet (HR=0.996, 95% CI 0.993～0.999, P=0.005), C-reactive protein (HR=1.011, 95% CI 1.006～1.015, P＜0.001), mean arterial blood pressure (HR=0.981, 95% CI 0.967～0.996, P=0.001), APACHE II score (HR=1.053, 95% CI 1.023～1.084, P＜0.001), AKI complication (HR=2.406, 95% CI 1.220～4.745, P=0.011) were the independent variables predicting survival within 90 days in elderly AKI patients. Conclusions Lower platelet, higher C- reactive protein, lower mean arterial blood pressure, higher APACHE II score, and AKI complications were the independent risk factors for shortterm prognosis in elderly AKI patients. Metrics

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The quality of life and its related factors in peritoneal dialysis patients 2016, 15 (06):  367-370.  doi: 10.3969/j.issn.1671-4091.2016.06.013 Abstract ( 278 )   HTML ( 0 )   PDF (369KB) ( 239 )   Objective To analyze the factors relating to the quality of life in peritoneal dialysis (PD) patients treated in Peking University Third Hospital. Methods SF-36TM survival quality assessment scale was used in this cross-sectional study. Quality of life was assessed and compared among different patient groups. Dialysis adequacy, Charlson comorbidity index (CCI) and biochemical parameters were analyzed to assess their relevance to quality of life in PD patients. Results In the 93 PD patients, physical components score (PCS) was 59.4 (43.4～74.8), and mental components score (MCS) was 68.2 (51.9～78.8). Patients with different gender, marriage situation, medical reimbursement ratio, live condition, and educational level had no significant differences in quality of life, while patients who live on themselves and those who must rely on others were different in PCS and MCS. Dialysis condition parameters had no relevance to quality of life in PD patients. CCI and serum albumin were the independent risk factors for quality of life in PD patients. Conclusion CCI and serum albumin were the independent risk factors for quality of life in PD patients. These results suggest that improvement of self-management skills and treatment of comorbidities may have a positive effect on quality of life in PD patients. Metrics

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Polymorphism in MDR1 gene may affect gingival hyperplasia induced by calcium channel blockers in end-stage renal disease patients 2016, 15 (06):  371-374.  doi: 10.3969/j.issn.1671-4091.2016.06.014 Abstract ( 212 )   HTML ( 0 )   PDF (389KB) ( 236 )   Objective To investigate whether polymorphism in MDR1 gene is associated with gingival hyperplasia induced by calcium channel blockers in end-stage renal disease (ESRD) patients. Methods We studied 183 ESRD patients with hypertension from the Haikou Xiangya Hospital of Central South University. Patients were classified into 3 groups based on calcium channel blocker (CCB) agent used. The patients were genotyped for C3435T polymorphism in MDR1 gene. Results The distribution of C3435T genotype in MDR1 gene was in Hardy-Weinberg equilibrium (CC=28.3%, CT=50.7% and TT=21%; χ2=0.032, P=0.985). No statistically significant difference was found in the ratio of CCB-induced gingival hyperplasia among the 3 genotypes (χ2=3.690, P=0.158). Conclusions MDR1 C3435T polymorphism was not associated with the CCB- induced gingival hyperplasia in ESRD patients with hypertension. Further study with larger samples may be required. Metrics

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Current status of hemodialysis in Xinjiang 2016, 15 (06):  375-377.  doi: 10.3969/j.issn.1671-4091.2016.06.015 Abstract ( 282 )   HTML ( 1 )   PDF (591KB) ( 274 )   Objective To introduce the current status of hemodialysis in Xinjiang in order to provide an objective basis for the improvement of hemodialysis treatment. Methods We investigated all of the hospitals providing hemodialysis treatment in Xinjiang by using field survey method. We collected the data about dialysis equipments, medical staffs and number of hemodialysis patients, summarized the information about online registered hemodialysis patients during 2013～2014, and then performed an integrated analysis. Results There are totally 82 medical institutions providing hemodialysis treatment, covering all state cities and 63% of county-level hospitals. These medical institutes can meet the demand of hemodialysis for 80% population in Xinjiang. 90% of counties with >100,000 residences provide hemodialysis treatment. By May 2015, there are 3,202 MHD patients, of whom 70% receive hemodialysis in state hospitals or county hospitals. The hemodialysis ratio in Xinjiang is 158/1,000,000 population, but the ratio is ＜100/1,000,000 population in Kashi, Hotan, Aksu, Hami and Tacheng districts. In hemodialysis patients, the infections of hepatitis B, hepatitis C, syphilis, HIV/AIDS are 7.3%, 6.8%, 1.9% and 0.3% respectively. A total of 192 physicians are working for hemodialysis, and 94 of them have got the professional training certificate. A total of 498 nurses engage in hemodialysis, and 276 of them have got the professional training certificate. A total of 58 engineers are working for hemodialysis, and 22 of them have got the professional training certificate. Conclusions A hemodialysis treatment system has been established in Xinjiang Uygur Autonomous Region. This system can meet the demand of 80% patients that need hemodialysis. The quality of hardware for hemodialysis in the hospitals also meets the national standards. However, the ratio of medial workers being trained and educated with the professional of hemodialysis is still lower, suggesting great demands for continuing training and education. Metrics

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The two- way referral system to promote peritoneal dialysis in primary health care institutions 2016, 15 (06):  378-381.  doi: 10.3969/j.issn.1671-4091.2016.06.016 Abstract ( 238 )   HTML ( 0 )   PDF (465KB) ( 285 )   Objective To promote peritoneal dialysis (PD) in primary health care institutions by using the two-way referral system in order to improve the survival rate and quality of life in patients with end-stage renal disease (ESRD). Methods We have established a mutual referral system with six community hospitals since 2012. We then set down our responsibilities, shared clinical data and therapeutic effects, organized a PD patient club, and collected feedbacks from patients and their family members with these community hospitals. Results ① A total of 276 new PD patients (141 males and 135 females) were treated from 2009 to 2014. The age at the beginning of PD was 52.75±13.31 years old, and the average PD age was 23.23±14.18 months. Chronic glomerulonephritis was the main cause of ESRD, followed by nephropathies due to diabetes mellitus and hypertension. After the implementation of mutual referral system, 226 new PD patients were treated in our center from Jan. 2012 to Dec. 2014. The treatment time, drop rate and mortality rate were 27.37 months, 29.41%, and 23.21% respectively during 2009 to 2011, and reduced to 19.95 months, 24.76%, and 19.08% respectively during 2012 to 2014. ②PD patients felt more convenient and less expense. Medical expenses were 8.5% lower for PD patients than for hemodialysis patients. ③Eighteen doctors/nurses from the six community hospitals were trained for PD knowledge and skills in our center to improved their PD professional abilities. Conclusions The two-way referral system to promote PD in primary health care institutions achieved favorable social and economic benefits and can therefore be used widely. Metrics