Chinese Journal of Blood Purification

12 July 2018, Volume 17 Issue 07 Previous Issue    Next Issue

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Clinical manifestations and diagnostic methods of calcification in the medial layer of arteries in hemodialysis patients 2018, 17 (07):  433-437.  doi: 10.3969/j.issn.1671-4091.2018.07.001 Abstract ( 611 )   PDF (879KB) ( 628 )   【Abstract】With the progression of renal dysfunction in chronic kidney disease (CKD) patients, cardiovascular disease (CVD) becomes one of the main causes of death. Vascular calcification is one of the most common pathological changes in these patients. Vascular calcification accounted for about 30% of the total mortality in end-stage renal disease patients. Vascular calcification is prevalent in CKD patients with or without dialysis due to the existence of a variety of risk factors. Vascular calcification can be found in intimal and/ or medial layers, but calcification in medial layer is the characteristic manifestation of CKD. Medial calcification is manifested by the deposition of calcium hydroxyapatite crystal throughout the medial layer and spreading to all arterial layers. This is an active process of vascular smooth muscle cells to attract calcium and phosphorus. Clinical manifestations of vascular calcification are mainly the symptoms of organ involvement, including aortic arch calcification, blood access vessel calcification, simple vascular calcification score, abdominal aortic calcification, cardiac valve calcification, coronary artery calcification, etc. Intimal calcification is associated with ischemic heart disease, and medial layer calcification causes arterial stiffness, systolic hypertension and left ventricular hypertrophy. The two types of calcification can induce cardiovascular events in different ways. The diagnosis of vascular calcification relies on imaging examination, including X-ray, CT, MRI and ultrasound examinations. Every method has its unique advantages. X-ray examination is cheaper and displays opaque foreign substances. CT clearly shows blood vessels, vascular lesions and 3-D imaging. MRI can be used for hemorrhagic lesions. Color Doppler ultrasound becomes more important for the diagnosis of vascular diseases. Metrics

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Anemia and left ventricular hypertrophy in patients with chronic kidney disease Xin-Ju ZHAO 2018, 17 (07):  438-441.  doi: 10.3969/j.issn.1671-4091.2018.07.002 Abstract ( 392 )   PDF (292KB) ( 591 )   【Abstract】Anemia is common in patients with chronic kidney disease (CKD) and its prevalence and severity increases with the decrease of glomerular filtration rate. Anemia causes many symptoms related to renal dysfunction, and results into increasing the risk of cardiovascular disease, hospitalization rate and mortality in these patients. Cardiovascular disease is a major cause of mortality in patients with CKD. Left ventricular hypertrophy (LVH) plays a vital role in cardiovascular disease development. Anemia is an important independent risk factor for the development and progression of LVH in CKD patients. Anemia improvement in CKD patients can reverse LVH and reduce the incidence and mortality of cardiovascular complications. Metrics

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The causes of the renal anemia hyporesponsive to therapy 2018, 17 (07):  442-445.  doi: 10.3969/j.issn.1671-4091.2018.07.003 Abstract ( 444 )   PDF (367KB) ( 659 )   【Abstract】Anemia is prevalent in chronic kidney disease (CKD) patients, but the control rate of anemia is unsatisfactory in Chinese CKD patients. The causes of poor effectiveness to renal anemia therapy are variable. The common causes of hyporesponsiveness to erythropoietin stimulating agents (ESA) are easily correctable, such as absolute iron deficiency, folate or vitamin B12 deficiency, hypothyroidism, ACEI/ARB drugs and less compliance to therapy. Several factors are potentially correctable, such as infection/inflammation, underdialysis, hemolysis, hemorrhages, hyperparathyroidism, pure red cell aplastic anemia, malignancy and malnutrition. Several factors are impossible to be corrected, such as hemoglobinopathies and bone marrow diseases. When hyporesponsiveness to ESA occurs, we should carefully search for causes and treat correctable factors. For patients remaining to be hyporesponsive to ESA after correction of treatable factors, individualized therapy according to the relative risk degree and benefit should be adopted. Metrics

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The clinical significance of neutrophil- to- lymphocyte ratio in peritoneal dialysis related infection 2018, 17 (07):  446-449.  doi: 10.3969/j.issn.1671-4091.2018.07.004 Abstract ( 360 )   PDF (385KB) ( 605 )   【Abstract】Purpose To observe the clinical significance of neutrophil- to- lymphocyte ratio (NLR) in peritoneal dialysis (PD) related infection. Methods A total of 119 hospitalized patients with PD-related infection treated in the Second Hospital of Anhui Medical University between Jan. 2012 and Dec. 2016 were compared with the 92 hospitalized PD patients without infection during the same period. Age, gender, diabetes history, hemoglobin, serum albumin, serum potassium, serum magnesium, corrected serum calcium, serum phosphorus, triglycerides, total cholesterol, hs-CRP and NLR were collected and compared between the two groups of patients. Results A total of 211 cases were recruited in this study. There were no statistical differences in age (52.66±14.53 vs. 52.35±15.07 years, t=0.150, P=0.881), gender (54 males vs. 51 females, χ2=2.099, P=0.147), diabetes history (12 vs. 12, χ2=0.451, P=0.502), hemoglobin level (91.05±20.04 vs. 93.77±18.25 g/L, t=-1.017, P=0.311), serum potassium (3.59±0.75 vs. 3.77±0.72 mmol/L, t=-1.696, P=0.091), triglycerides [1.21 (0.82, 1.58) vs. 1.19 (0.81, 1.66) mmol/L, Z=-0.179, P=0.919] and total cholesterol (4.44±1.09 vs. 4.67±1.06 mmol/L, t=0.158, P=0.784) between the two groups. Compared to the non-infection group, NLR [6.29 (3.85, 10.35) vs. 2.71 (2.70, 3.78), Z=- 8.321, P＜0.001], corrected serum calcium [2.43 (2.28, 2.61) vs. 2.34(2.18,2.44) mmol/L, Z=-3.164, P=0.002] and hs-CRP (66.67±64.53 vs. 6.57±10.86 mg/L, t=8.833, P＜0.001) were significantly higher in the infection group, while serum albumin (26.38 ± 6.79 vs. 29.59±5.30 g/L, t=-3.742, P＜0.001), serum magnesium [(0.72±0.17) vs. (0.79±0.16) mmol/L, t=-3.167, P=0.002] and serum phosphorus [1.26 (0.98, 1.50) vs. 1.31 (1.13, 1.64) mmol/L, Z=-2.040, P=0.041] were significantly lower in the infection group. Spearman multivariate correlation analysis indicated that PD-related infection was positively correlated to NLR (r=0.574, P=0.000), corrected serum calcium (r=0.218, P=0.001) and hs-CRP (r=0.188, P=0.006), and negatively correlated to serum albumin (r=-0.224, P=0.001), serum magnesium (r=-0.224, P=0.001) and serum phosphorus (r=-0.141, P=0.041). Logistic regression analysis suggested that higher NLR and lower serum albumin were closely associated with PD-related infection. Conclusion NLR, corrected serum calcium and hs-CRP were elevated, while serum albumin, serum magnesium and serum phosphorus were lower in PD-related infection patients. Higher NLR and lower serum albumin were the risk factors for PD-related infection. Metrics

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Evaluation of hemodialysis adequacy using body composition monitor combined with online clearance monitoring 2018, 17 (07):  450-455.  doi: 10.3969/j.issn.1671-4091.2018.07.005 Abstract ( 358 )   PDF (822KB) ( 535 )   【Abstract】Objective To evaluate hemodialysis adequacy using body composition monitor (BCM) and online clearance monitoring (OCM). Methods A total of 138 patients were recruited in this prospective clinical trial. Three methods determining dialysis dose were simultaneously applied: Kt/VDau (conventional method with Daugirdas formula), Kt/VOcm (OCM with urea distribution volume V based on anthropometric estimate), and Kt/VBcm (urea distribution volume V by BCM, and Kt value by OCM). Using the difference value of 0.25 between Kt/VBcm and Kt/VOcm as the boundary, we divided the patients into two groups: Kt /VBcm-Kt/VOcm <0.25 group and Kt/VBcm-Kt/VOcm≥0.25 group. Clinical indices were compared between the two groups. Linear regression was applied to analyze the potential impact factors for the difference between Kt/V values calculated by the two methods. Results A total of 138 MHD patients with an average age of 54.934±12.705 years old were enrolled, and 55.934% of them were males. The dialysis dose was measured as Kt/VDau 1.432(1.235,1.718), Kt/VBcm 1.434(1.244, 1.642) and Kt/VOcm 1.177(1.076,1.355). There was no difference between Kt/VDau and Kt/VBcm (Z=- 0.224, P=0.823). Kt/VDau was incidentally prone to falsely high or low values due to operative errors, whereas OCM-based measurement Kt/VBcm and Kt/VOcm delivered realistic values. An excellent correlation was observed between Kt/VDau and Kt/VBcm, the mean difference was 0.07 [95% CI (0.020, 0.204), r=0.842 (0.821~0.862)]. The difference between Kt/VBcm and Kt/VOcm was due to the difference between anthropometric estimated Vwatson and measured VBCM (t=25.400, P<0.001). A higher mean Kt/VBcm-Kt/VOcm value was correlated to older age (t=-3.748, P<0.001), female (c2=5.163, P=0.023), lower lean tissue index (t=11.345, P<0.001), lower total body water (t=7.988, P<0.001), lower extracellular water (t=8.564, P<0.001), lower intracellular water (t=5.878, P<0.001), and higher fat tissue index (t=-4.242, P<0.001). Excellent correlations were observed between lean tissue index (LTI) or LTI difference to reference and the mean Kt/VBcm - Kt/VOcm value (g=-0.781, P<0.001; g=-0.728, P<0.001). Conclusion BCM can give more accurate parameter of urea distribution volume, thus modifying the result of Kt/V. It is very useful not only to monitor adequacy of dialysis but also to evaluate nutritional status. Metrics

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Effects of Pilates exercise on fatigue and sleep quality in maintenance hemodialysis patients 2018, 17 (07):  456-460.  doi: 10.3969/j.issn.1671-4091.2018.07.006 Abstract ( 339 )   PDF (445KB) ( 531 )   【Abstract】Objective To investigate the effects of Pilates exercise on fatigue and sleep quality in maintenance hemodialysis (MHD) patients. Methods A total of 58 MHD patients were recruited from the Hemodialysis Center, the Fourth Affiliated Hospital of Nanchang University and treated in the period from Aug. 2015 to Aug. 2017. Patients with the dialysis time on Monday, Wednesday and Friday were assigned as group A, and those with the dialysis time on Tuesday, Thursday and Saturday were assigned as group B. The two groups were randomly determined to be intervention group and control group, respectively. Patients in control group were treated with routine care, and those in intervention group were treated with Pilates exercise in addition to the routine care. Fatigue and sleep quality were evaluated by the modified Piper fatigue scale (RPFS) and the Pittsburgh sleep quality index (PSQI) before and after the intervention for 6 months. Results After the intervention for 6 months, the score of fatigue (t=-4.588, P＜0.001) reduced significantly and the score of sleep quality increased significantly in intervention group as compared with those in control group. In intervention group after the intervention for 6 months, the fatigue status score (t=2.136, P=0.034) reduced significantly and the sleep quality score (t=11.132, P＜0.001) increased significantly as compared with those before the intervention. Conclusion The Pilates exercise can effectively improve fatigue condition and sleep quality in MHD patients, and thus can improve the quality of life. This intervention method is useful in clinical practice. Metrics

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Clinical application of the two-stage calcium supplement model in continuous venous-venous hemofiltration under regional citrate anticoagulation (RCA-CVVH) 2018, 17 (07):  461-465.  doi: 10.3969/j.issn.1671-4091.2018.07.007 Abstract ( 378 )   PDF (600KB) ( 575 )   【Abstract】Objective To establish the calcium supplement equation based on the two-stage calcium supplement model in order to promote the local citrate anticoagulation method simply and effectively used in clinical practice. Methods Fifty patients with renal replacement therapy were recruited in this study. They were effectively treated with continuous venous-venous hemofiltration under regional citrate anticoagulation (RCACVVH) for a total of 156 times. The CVVH adopted pre-dilution mode using the low-base and calcium-free replacement solution with the speed of 4L/h and lasted 6-8 hours. The anticoagulant citrate dextrose solution-a (ACD-a) was infused in arterial end, and the citrate was fed at 4.0～4.5 mmol/L plasma flow. The venous end was supplemented with 5% calcium chloride, and the calcium supplement rate was calculated by the "twostage calcium supplement model". The degree of coagulation in filter was observed during CVVH treatment. The calcium ion level at the arterial end and before the filter was measured by the iState biochemical analyzer every 2～3 hours, and the total calcium level was measured at the arterial end. The ratio of total calcium/ion calcium was then calculated. Results In the 156 times of CVVH, the percentage of effective anticoagulation using RCA was 96.79% (151/156), which is the ideal result. The calcium ion concentration of 0.2～0.4 mmol/L in ore-filter was found in 90.4% CVVH sessions, which approaches the target range. The calcium ion concentration of 1～1.2 mmol/L in arterial port was found in 90.5% CVVH sessions. The ratio of total calcium/ion calcium in the body was <2.5, without citrate accumulation. Skilled application of the two-stage calcium supplement equation can significantly reduce the frequency of calcium ion monitoring, and save the manpower, material and financial resources. Conclusions The two-stage calcium supplement model is effective, safe and simple. It is useful in hemodialysis. Metrics

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progress of anticongulation treatment of atrial fibrillation in patients with kindeny failture 2018, 17 (07):  472-475.  doi: 10.3969/j.issn.1671-4091.2018.07.010 Abstract ( 230 )   PDF (278KB) ( 801 )   Metrics

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Treatment of central venous stenosis in hemodialysis patients and the effect of reimbursement on the selection of treatment mothod 2018, 17 (07):  476-480.  doi: 10.3969/j.issn.1671-4091.2018.07.011 Abstract ( 668 )   PDF (550KB) ( 545 )   【Abstract】Objective We investigated the clinical effect, medical expenses and protection of vascular resources in the treatment of central venous stenosis in maintenance hemodialysis (MHD) patients. We also explored the effect of reimbursement ratio by medical insurance on the choice of treatment methods. Method The MHD patients with central venous stenosis first diagnosed in the period from Jan. 2013 to Oct. 2016 were recruited in this study. The lesion side was accompanied by an arteriovenous fistula. They were treated with percutaneous transluminal angioplasty (PTA), percutaneous transluminal stenting (PTS) or pathway reconstruction. They were followed up for 3, 6 and 12 months. Hospitalization duration, total expenses, the payment part by patients, treatment methods, and the use of blood vessel resources were recorded. Results A to-tal of 27 patients (12 males and 15 females) were enrolled in this study. A history of central venous catheterization was found in 96.30% of patients. PTA, PTS and pathway reconstruction were adopted in 12, 4 and 11 patients, respectively. (a) After PTA for 3, 6 and 12 months, the primary patency rates were 91.67%, 58.33% and 41.67%, respectively, and the secondary patency rates were 100%, 83.33% and 58.33%, respectively. After PTS for 3, 6 and 12 months, the primary patency rates were 100.00%, 75.00% and 50.00%, respectively, and the secondary patency rates were 100.00%, 100.00% and 75.00%, respectively. PTA, PTS or pathway reconstruction had to be conducted after central venous catheterization for 6.36±2.69 months, 9.00±4.24 months and 1.73±0.26 months, respectively. Patients treated with pathway reconstruction were hospitalized after removal of the catheters. (b) Hospitalization duration was shorter in patients with PTA and PTS (for PTA, 6.58±0.67 vs. 11.45±1.75 days, t=-8.657, P＜0.001; for PTS, 9.00±0.82 vs. 11.45±1.75 days, t=-3.675, P=0.003). However, the medical expenses for PT and PTS were higher than those of pathway reconstruction (compared to PTA, 21788.16±1246.29 vs. 12966.36±902.44 Yuan, t=19.557, P＜0.001; compared to PTS, 33853.50±1524.99 vs. 12966.36±902.44 Yuan; t=25.800, P＜0.001). The payment part by patients was similar in patients treated with PTA and those with pathway reconstruction 5056.36±1795.27 vs. 4510.09±916.26 Yuan, t=0.930, P=0.366). (c) PTA and PTS had the advantage of vascular resource preservation and protection, and only one blood vessel was used for PTA and PTS. In contrast, 4 blood vessels had to be used for pathway reconstruction. (d) Patients with higher payment ratio by medical insurance tended to choose PTA or PTS (72.73%,100.00% vs. 33.33%), while those with lower payment ratio by medical insurance chose pathway reconstruction. Conclusions Endovascular treatment had the advantages of better effects, lower expenses and preservation of blood vessel resources, especially the endovascular treatment of PTA. The payment ratio by medical insurance affected the treatment method. With the increase of reimbursement ratio by medical insurance, endovascular treatment is the first choice for the treatment of central venous stenosis. Metrics

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The 5S management of water treatment system in hemodialysis center 2018, 17 (07):  484-487.  doi: 10.3969/j.issn.1671-4091.2018.07.013 Abstract ( 363 )   PDF (688KB) ( 567 )   【Abstract】Objective To ensure the quality and continuous supply of dialysis water in hemodialysis center. Methods The 5S management idea was applied to the management of water treatment system in hemodialysis center. We also tried to transform and upgrade our water treatment system and to standardize the management, according to the actual situation of water treatment system in our hospital. Results The 5S management can effectively improve the dialysis water supply and quality. Conclusion Scientific management is essential to ensure quality of medical equipment for clinical use. Metrics

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The clinical significance of transmembrane pressure monitoring in hemodialysis 2018, 17 (07):  490-493.  doi: 10.3969/j.issn.1671-4091.2018.07.015 Abstract ( 552 )   PDF (396KB) ( 1111 )   【Abstract】This paper analyzes the causes of transmembrane pressure change and its unfavorable effects. We focuse on the principle of transmembrane pressure monitoring in dialysis machine. We particularly emphasize the training for medical staffs about the importance of transmembrane pressure monitoring and the manipulation of relevant preventive measures to achieve safe and efficient use of dialysis. Metrics

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Application of PDCA cycle in the management of hyperphosphatemia for patients on maintenance hemodialysis 2018, 17 (07):  494-496.  doi: 10.3969/j.issn.1671-4091.2018.07.016 Abstract ( 267 )   PDF (344KB) ( 599 )   【Abstract】Aim To explore the clinical implication of PDCA cycle (P, plan; D, do; C, check; A, action) in the management of hyperphosphatemia for maintenance hemodialysis patients. Methods This was a single group and self-control study. A total of 136 patients were enrolled. All participants received regular health education on phosphorus restriction, and were additionally provided with one-to-one education on dietary phosphorus restriction based on self-developed health education tool by designated nurses for three months. The whole quality improvement process was managed by PDCA cycle, including investigation, root cause finding, target identification, intervention development and implementation, feedback and action. Participatory health education was adopted to guide the development of health education tool and reinforce the control of dietary phosphorus intake. The percentage of patients with hyperphosphatemia and patient satisfaction were evaluated. Results All participants completed the study. The percentage of patients with a serum phosphorus level equal to or above 1.78mmol/L was decreased significantly, from 57% to 44% (χ2＝4.250, P=0.039). Patients satisfaction on phosphorus management was achieved after the implementation of PDCA cycle (χ2＝9.285, P=0.002). Conclusions The implementation of PDCA cycle can reduce the ratio of patients with hyperphosphatemia, improve patient satisfaction, and help nurses gain a sense of personal and professional achievements. Metrics