Objective To explore the influencing factors for the risk of autologous arteriovenous fistula (AVF) nonfunction in patients on hemodialysis (HD) for >10 years. Methods A total of 50 patients on HD >10 years were assigned into two groups of nonfunction (n=26) and function (n=24) according to the presence or absence of AVF nonfunction. General profiles and laboratory parameters were compared between two groups for evaluating the effects of various indicators on AVF nonfunction. ResultsInitial cannulation time for AVF was significantly earlier in nonfunction group than that in function group. The levels of cholesterol and retinol-binding protein were significantly higher than those in function group. Inter-group differences also existed in the proportions of different cannulation techniques and blood flow distribution (P<0.05). Multivariate Cox regression analysis indicated that advanced age at an initial hemodialysis, upper arm AVF, area puncture cannulation technique and initial cannulation time were the significant influencing factors for AVF nonfunction. Conclusions Patients with forearm AVF and a longer initial cannulation time are more prone to AVF while advanced age and area puncture cannulation technique may elevate the risks of AVF nonfunction.

2020年初始,我国出现新型冠状病毒( 2019 novel coro-navirus,2019-nCoV)感染流行.国家卫生健康委于2020年1月20日,将新型冠状病毒肺炎( coronavirus disease 2019, COVID-19)纳入法定传染病乙类管理,采取甲类传染病的预防、控制措施.慢性肾脏病( chronic kidney disease,CKD)患者免疫力低下,属于 COVID-19易感人群[1].血液透析室是2019-nCoV暴露风险极高的医疗场所[2].在患者病情危急、没有转运条件的情况下,如何对疑似 COVID-19的多器官功能衰竭患者进行就地抢救,是对基层医院及医护人员的较大挑战.2020年4月,南京市栖霞区医院血液透析室成功救治1例疑似 COVID-19的危重心肾综合征患者,现报道如下.

老年维持性血液透析患者常合并心血管基础疾病,如心肌肥厚、心肌病、冠心病、心力衰竭等,透析过程易发生心律失常[1] ,表现为心房颤动、房性早搏、房室传导阻滞、室性心律失常[2] ,若室性心动过速持续存在,易进展为室颤,病情危重,若处理不当或不及时,死亡率极高. 近期,我科发现1例血透中并发室性心动过速伴低血压,经胺碘酮静脉注射、心脏同步电复律后抢救成功的病例,现报告如下.

Objectives To Observe the four different methods of cuffed central venous catheter and clinical analysis.Methods All 132 patients underwent cuffed central venous catheterization,who were divided into group A (36 cases) of the avulsed sheath placement cuffed central venous catheter,group B (36 cases) of external jugular vein placed catheter,group C (32 cases) of placement catheter directly by direction of wire and after expansion layer by layer and group D (28 cases) of internal jugular vein incision.Results There were no significant differences in creatinine,urea nitrogen level before and after dialysis of four groups and urea clearance index were both standard.There were no the significant differences in blood flow,blood return venous pressure,urea clearance index and catheter retention time of three groups(group A、B、D).There were no significant differences in above index of group A、C.There were no bleeding and infection related complications in four groups after operation,but one case of catheter ectopic occurrence in group B and group C.Conclusions Classic avulsion sheath catheter method is as the preferred for cuffed catheter central venous catheter insert method,and it is a safe and high successful method with less complications.The second method is the internal jugular vein catheter incision,through the guide wire and expansion layer by layer placed catheter,it is suitable for patients with loose subcutaneous tissue,less fat layer.The internal jugular vein incision method in the cuffed central venous catheter is the remedy method for clinical puncture failure without ultrasonic guide,but this method is needed higher technology with high operation risk,not as the clinical first choice.

Objectives To observe the improvement of warfarin for cuffed central venous catheter dysfunction due to thrombus and fibrin sheath and to carry on the clinical analysis.Methods 59 patients with cuffed central venous catheter were divided into group A (28 cases) and control group B (31 cases),patients in the group A were given warfarin 1.5 ～3mg/d,and patients in the control group B were given aspirin 100mg/d.The heparin was used to sealed tube in two groups.Catheter hemodialysis blood flow,blood return venous pressure in hemodialysis and the blood urea nitrogen and creatinine,ultrafiltration before and after dialysis,urea clearance index (Kt/V) and the effect of dialysis were recorded and evaluated.Non dialysis state international normalized ratio(INR) was regularly detected.Catheter retention time and median retention time,bleeding,catheter related blood stream infection and other complications were compared between the two groups in a year.Results There were statistical differences in level of creatinine and urea nitrogen between group A and B before and after dialysis.Urea clearance index of group A was standard.There were statistical differences in blood flow and vein blood pressure in dialysis between two groups.There were also statistical differences in level of creatinine and urea nitrogen,urea clearance index and INR after dialysis between group A and group B.And there was also statistical difference in retention time of the two groups.Bleeding,complications of catheter related blood stream infection were not found in group A and B.Conclusions After cuffed central venous catheter placement,taking moderate dose warfarin with heparin sealed tube is better than aspirin,which would improve catheter dysfunctiondue due to thrombus and fibrin sheath and prolong catheter retention time with few complications.But the study is fairly small,and the observation time is short.It should be further studied in clinic to confirm clinical safety and efficacy of warfarin after cuffed central venous catheter placement.

Objective To observe N-terminal brain natriuretic peptide(NT-proBNP) used for evaluation of dry weight in maintenance hemodialysis(MHD) patients and analyze the clinical significance.Methods Forty-eight patients undergoing MHD were divided into dry weight group(n=24)and capacity overload group(n=24).The age,mean arterial pressure(MAP),cardiothoracic ratio,left ventricular ejection fraction(LVEF),left ventricular volume(LV),N-terminal brain natriuretic peptide,serum creatinine,urea nitrogen,and estimated glomerular filtration rate(eGFR) were compared between the two groups before treatment NT-proBNP,serum creatinine and urea nitrogen were detected before and after routine dialysis in the two groups and the urea clearance index(Kt/V)was calculated,and NT-proBNP,serum creatinine and urea nitrogen were detected before the next dialysis.Results There were no significant differences in age,LVEF,LV and serum creatinine,urea nitrogen,eGFR before dialysis between two groups.MAP[(88.10±10.16)mm Hg vs.(93.92±8.03)mm Hg],cardiothoracic ratio[(48.80±6.11)%vs.(53.25±2.72)%]and NT-proBNP[(3827.67±712.12)ng/L vs.(5793.58±945.20)ng/L]in dry weight group were significantly reduced as compared with capacity overload group(P<0.05 or P<0.01).There were statistically significant differences in the changes of NT-proBNP[(1 847.77 ± 802.54) ng/L vs.(3 023.58 ±876.56) ng/L]and serum creatinine[(287.26 ± 62.86) μmol/L vs.(298.86 ± 74.57) μmol/L]between the two groups after dialysis(P<0.01).There was no statistically significant difference in the NT-proBNP and serum creatinine detected before the next dialysis from the previous dialysis(P>0.05).The median of NT-proBNP values in the two groups was significantly higher than the normal value range.Conclusions The NT-proBNP increased,indicating capacity overload was ubiquitous in MHD patients with no dominant edema.NT-proBNP could be used to evaluate the no dominant edema capacity load of MHD patients,but there were limitations.Physical examination and multiple detection comprehensive evaluation are used to determinate dry weight of MHD patients.

患者,男,54岁。因尿毒症行维持性血液透析9年,于2个月前感胸闷,伴右背部疼痛,无恶心、呕吐,入院前1天常规血液透析时突感右背部疼痛加剧,难以忍受,遂收治入院。入院查体,示体温36.5℃,脉搏80次/min,呼吸20次/min,血压150/80 mn Hg,神志清,痛苦面容,两肺呼吸音粗,右下肺呼吸音低,可闻及湿性啰音,心率80次/min,律齐,腹部查体无特殊。实验室检查:血红蛋白122 g/L,血尿素29.27 mmol/L,血肌酐1138.9μmol/L,血钾5.78 mmol/L,C反应蛋白96.9 mg/L;查胸部CT示右肺感染,右侧胸腔积

目的 探讨颈外静脉切开置入带涤纶套中央静脉导管在特殊患者中的临床应用效果及评估其安全性.方法 将42慢性肾脏病(chronic kidney disease,CDK)5期并欲行带涤纶套中央静脉导管置入术的患者设为A组,以颈外静脉切开方法置管;同期选取36例已行右颈内静脉置入术的患者设为B组,置管方法为经皮穿刺右颈内静脉经撕脱鞘置入带涤纶套中央静脉导.观察术中、术后并发症.记录透析前后血肌酐、尿素氮变化以及透析中血流量、回血静脉压指标,计算尿素清除指数(Kt/V)值并比较.A组42例患者行颈外静脉切开置管患者根据原发病:糖尿病肾脏疾病、Ⅱ型心肾综合征进展至终末期肾脏疾病(end stage renal disease,ESRD)、慢性肾小球肾炎、强直性脊柱炎肾损害进展至终末期肾脏疾病、急性肾损伤,比较导管留存时间、导管中位留存时间.结果 2组患者Kt/V值均达标,血流量、回血静脉压无统计学差异(P＞0.05),且透析前后血肌酐、尿素氮水平变化存在统计学差异(P＜0.05).2组手术后未出现出血、血流量不佳导管相关性血流感染等并发症.A组中心肾综合征及急性肾损伤(acute kidney injury,AKI)患者导管留存时间与糖尿病肾脏疾病相比存在统计学差异(P＜0.05).结论 尽管带涤纶套中央静脉导管置入方法推荐首选经典撕脱鞘置管,该方法安全成功率高,术后并发症少,但是经颈外静脉切开置入带涤纶套中央静脉导管术式在特殊患者中的临床应用中手术安全,能够保证透析充分性,并发症少,临床值得推荐.

近年来,有不少学者报道不同导管置入法,笔者现报道8例颈内静脉穿刺失败在无超声学指引下改行颈内静脉切开置管及1例临时导管滑落至右心房而行颈内静脉切开拔管并置入涤纶套中央静脉导管.