终末期肾病患者的钙化异常与心血管疾病

终末期肾病患者较正常人有很高的患病率和病死率，其中心血管疾病占死亡原因的首位，而心血管系统的普遍钙化是高死亡率的重要因素。本文就钙化异常在ESRD患者心血管疾病中的作用作一综述。     

腹膜透析的糖尿病肾病患者的健康教育

糖尿病(DM)是导致终末期肾病(ESRD)的主要原因之一,近年来相关资料显示我国在进入肾透析治疗的患者中,糖尿病导致终末期肾病患者仅次于继发肾脏病的患者.     

铁与终末期肾病患者心血管并发症的关系

终末期肾病(ESRD)患者发生心血管疾病(CVD)的风险明显高于同龄一般人群。除了传统的CVD危险因素(糖尿病、高血压、高脂血症、吸烟)以外,许多尿毒症患者的常见并发症也成为CVD危险因素,如：贫血、高半胱胺酸血症、高磷血症、血管钙化以及炎症、氧化应激等。有些学者认为,铁可能也是一个危险因素。     

1233例维持性血液透析患者高脂血症的危险因素分析

目的探讨多中心维持性血液透析(maintenance hemodialysis,MHD)患者发生高脂血症的危险因素。方法选取2018年1月至2018年4月在广东地区10个血液净化中心行MHD治疗3个月以上患者为研究对象做横断面研究。收集所有患者一般情况、透析相关资料、透析期间并发症等数据。结果 1 233例MHD患者入组,其中男性719例(58. 8%),年龄56(46,67)岁,身高163 (156,169) cm。行血液透析滤过(hemodialysis filtration,HDF) 480例(38. 9%),血液灌流(hemoperfusion,HP) 101例(8. 2%)。在基础肾脏病方面,原发性肾小球疾病630例(51. 3%),糖尿病肾病281例(22. 9%),高血压肾损伤71例(5. 8%),慢性肾小管间质性疾病17例(1. 4%),梗阻性肾病88例(7. 2%),狼疮性肾炎7例(0. 6%),多囊肾51例(4. 2%),痛风性肾病15例(1. 2%),乙肝相关性肾病15例(1. 2%),其他60例(4. 9%)。多因素Logistic回归分析结果表明性别、血钙与MHD患者发生高脂血症密切相关,而HP则是MHD患者发生高脂血症的一个重要保护因素(P 0. 05)。结论高脂血症是MHD患者常见的主要并发症之一,女性及高血钙水平是MHD患者发生高脂血症的独立危险因素,HP透析模式可能对预防MHD患者高脂血症有效。     

脑卒中患者血清Hcy、VitB12和FA水平变化的研究

自Mccully1969年提出高同型半胱氨酸（Hcy）血症可能与动脉粥样硬化（AS）有关的观点以来，血浆Hcy水平增高是导致动脉粥样硬化（AS）和冠心病的一种独立危险因素已得到一致认同。近来国外研究表明高Hcy血症与脑卒中的发生和发展关系十分密切。由此．本研究拟观察脑卒中病例中血清Hcy、维生素B12（VitB12）和叶酸（FA）水平变化。从而说明脑卒中与高Hcy血症的关系。     

维持性血液透析患者合并肺部感染的危险因素分析

肺部感染是维持性血液透析患者常见的并发症，严重影响透析患者的生活质量，甚至导致死亡。很多资料显示感染是导致终末期肾衰竭透析患者死亡的第二位病因（约占25％），仅次于心血管疾病（约占50％）^[1]；而肺部感染又是感染的主要原因。为了解肺部感染发生的原因，及早作出正确的诊断，从而有效的控制肺部感染，     

面对慢性肾病患者心血管病的严重挑战--"新"危险因素与防治对策

慢性肾病(CKD)流行病学的最新资料表明,心血管疾病(CVD)是CKD患者最主要的并发症,而且其患病率大大高于普通人群;CVD也是导致CKD患者死亡的头号杀手,至今死亡率仍居高不下.因此,CKD患者CVD问题已引起国内外学者的高度关注.     

胰岛素抵抗及其对糖尿病肾病作用的新认识

糖尿病肾病(DN)是糖尿病最重要和最常见的并发症之一,1型和2型糖尿病患者中DN的发生率约为35%[1].同时DN也是终末期肾脏疾病(ESRD)的重要原因,虽然我国大陆DN仅占ESRD的5%,但在生活水平较高的地区如日本却高达28%[2].随着我国经济水平的提高,糖尿病发病率逐年上升,DN可能会成为导致ESRD的主要原因.人类对胰岛素抵抗(IR)的认识始于半个多世纪前对糖尿病的研究,2型糖尿病普遍存在IR早已定论.IR是多种疾病,特别是糖尿病及心血管疾病的共同危险因素,进一步认识DN与IR的关系,有效防治DN及其并发的心血管疾病是当前糖尿病和肾脏病领域共同面临的重要课题.     

维持性血液透析患者肌少症危险因素的Meta分析

目的 系统评价维持性血液透析患者肌少症的危险因素,为针对性干预提供参考。 方法 计算机检索PubMed、Web of Science、CINAHL、中国生物医学文献数据库、中国期刊全文数据库、万方数据知识服务平台等中外文主要数据库,采用RevMan5.4软件进行Meta分析。 结果 共纳入18篇文献3 109例患者。男性、高龄、低体重指数、体力活动不足、营养不良、超敏C反应蛋白水平升高、高血磷、认知功能障碍、经济困难、高细胞外水分比率、高体脂率是维持性血液透析患者肌少症的危险因素（均P＜0.05）;握力水平较好为保护因素（P＜0.05）。 结论 维持性血液透析患者肌少症影响因素较多,应进行针对性、个体化干预,防止肌少症的发生或加重,以提高患者生活质量。     

终末期肾病透析患者营养不良的机制及评估进展

蛋白质能量营养不良（PEM）是指由于蛋白质能量的摄入与需求不平衡导致的代谢改变、功能损害及体重下降。PEM是终末期肾病（ESRD）透析患者常见的疾病,是血透患者死亡的独立危险因素。PEM的血透患者的年死亡率在25％～30％。透析患者开始透析前后定期进行营养状况的评估,尽早发现PEM及其病因,给予合理的治疗,有助于防止病情恶化及其并发症的发生。本文对近年来终末期肾病透析患者中营养评估的进展作一综述。     

Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients

Conventional risk factors of cardiovascular disease and mortality in the general population such as body mass, serum cholesterol, and blood pressure are also found to relate to outcome in maintenance dialysis patients, but often in an opposite direction. Obesity, hypercholesterolemia, and hypertension appear to be protective features that are associated with a greater survival among dialysis patients. A similar protective role has been described for high serum creatinine and possibly homocysteine levels in end-stage renal disease (ESRD) patients. These findings are in contrast to the well-known association between over-nutrition and poor outcome in the general population. The association between under-nutrition and adverse cardiovascular outcome in dialysis patients, which stands in contrast to that seen in non-ESRD individuals, has been referred to as "reverse epidemiology." Publication bias may have handicapped or delayed additional reports with such paradoxical findings in ESRD patients. The etiology of this inverse association between conventional risk factors and clinical outcome in dialysis patients is not clear. Several possible causes are hypothesized. First, survival bias may play a role since only a small number of patients with chronic kidney disease (CKD) survive long enough to reach ESRD. Hence, the dialysis patients are probably a distinctively selected population out of CKD patients and may not represent the risk factor constellations of their CKD predecessors. Second, the time discrepancy between competitive risk factors may play a role. For example, the survival disadvantages of under-nutrition, which is frequently present in dialysis patients, may have a major impact on mortality in a shorter period of time, and this overwhelms the long-term negative effects of over-nutrition on survival. Third, the presence of the "malnutrition-inflammation complex syndrome" (MICS) in dialysis patients may also explain the existence of reverse epidemiology in dialysis patients. Both protein-energy malnutrition and inflammation or the combination of the two are much more common in dialysis patients than in the general population and many elements of MICS, such as low weight-for-height, hypocholesterolemia, or hypocreatininemia, are known risk factors of poor outcome in dialysis patients. The existence of reverse epidemiology may have a bearing on the management of dialysis patients. It is possible that new standards or goals for such traditional risk factors as body mass, serum cholesterol, and blood pressure should be considered for these individuals.     

Inadequate treatment of cardiovascular disease and cardiovascular disease risk factors in dialysis patients: a commentary

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Despite its significant impact on health outcomes, which would imply a need for aggressive intervention, both CVD and CVD risk factors are inadequately treated in this patient population. The reasons for this inadequate treatment are unclear. This article reviews the contribution of traditional risk factors to the burden of CVD in ESRD patients, outlines the evidence regarding undertreatment of CVD and traditional CVD risk factors, and identifies potential factors that may be responsible for inadequate cardiovascular care in ESRD patients.     

Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study

Although atherosclerotic cardiovascular disease (ASCVD) risk in end-stage renal disease (ESRD) is 5 to 30 times that of the general population, few data exist comparing ASCVD risk factors among new dialysis patients to the general population. This cross-sectional study of 1041 dialysis patients describes the prevalence of ASCVD risk factors at the beginning of ESRD compared with estimates of ASCVD risk factors in the adult US population derived from the Third National Health and Nutrition Examination (NHANES III). CHOICE Study participants had a high prevalence of diabetes (54%), hypertension (96%), left ventricular hypertrophy by electrocardiogram (EKG) criteria (22%), low physical activity (80%), hypertriglyceridemia (36%), and low HDL cholesterol (33%). CHOICE participants were more likely to be older, black, and male than NHANES III participants. After adjustment for age, race, gender, and ASCVD (defined as myocardial infarction, revascularization procedure, stroke, carotid endarterectomy, and amputation in CHOICE; and as myocardial infarction and stroke in NHANES III), the prevalence of diabetes, hypertension, left ventricular hypertrophy by EKG, low physical activity, low HDL cholesterol, and hypertriglyceridemia were still more common in CHOICE participants. Smoking, obesity, hypercholesterolemia, and high LDL cholesterol, however, were less common in CHOICE than NHANES III participants. The projected 5-yr ASCVD risk based on the Framingham Risk Equation among those older than 40 yr without ASCVD was higher in CHOICE Study participants (13%) than in the NHANES III participants (6%). In summary, many ASCVD risk factors are more prevalent in ESRD than in the general population and may explain some, but probably not all, of the increased ASCVD risk in ESRD.     

Clinical epidemiology of cardiovascular disease in chronic kidney disease prior to dialysis

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Both in dialysis and in transplant patients, CVD remains the leading cause of death. There is accumulating evidence that the increase in CVD burden is present in patients prior to dialysis, due to both conventional risk factors as well as those specific to kidney disease. Of importance is that even in patients with mild kidney disease, the risk of cardiovascular events and death is increased relative to patients without evidence of kidney disease. The new classification system proposed by the National Kidney Foundation as part of the Dialysis Outcomes Quality Initiative (DOQI) process describes the five stages of kidney disease, as well as those complications associated with chronic kidney disease (CKD), in particular cardiovascular risk factors and disease. Patients with kidney disease are deemed to be at highest cardiovascular risk. CVD, defined as the presence of either congestive heart failure (CHF), ischemic heart disease (IHD), or left ventricular hypertrophy (LVH), is prevalent in cohorts with established CKD (8-40%). The prevalence of hypertension, a major risk factor for coronary artery disease (CAD) and LVH is high in patients with CKD (87-90%). At least 35% of patients with CKD have evidence of an ischemic event (myocardial infarction or angina) at the time of presentation to a nephrologist. The prevalence of LVH increases at each stage of CKD, reaching 75% at the time of dialysis initiation, and the modifiable risk factors for LVH include anemia and systolic blood pressure, which are also worse at each stage of kidney disease. Even under the care of nephrologists, a change in cardiac status (worsening of heart failure or anginal symptoms) occurs in 20% of patients. The presence of CVD predicts a faster decline of kidney function and the need for dialysis, after controlling for all other factors including glomerular filtration rate (GFR), age, and the presence of LVH. This article describes the new classification system for staging of CKD, defines and describes CVD in CKD, and reviews the evidence and its limitations with respect to the current understanding of CKD and CVD. Specifically, methodologic issues related to survival and referral bias limit our current understanding of the complex interaction of conventional and nonconventional kidney disease-specific risk factors. We identify the importance of well-conducted studies of patient groups with and without CVD, with and without CKD, in order to better understand the complex physiology so that treatment strategies can be appropriately applied.     

Sympathetic overactivity--the Cinderella of cardiovascular risk factors in dialysis patients

Cardiovascular morbidity and mortality is exceedingly high in patients with chronic renal failure. Sympathetic overactivity is an important pathomechanism contributing to progression of renal disease as well as cardiovascular complications. For more than 30 years it has been known that plasma levels of norepinephrine are elevated in chronic renal failure pointing to increased sympathetic nerve activity. The kidneys are richly innervated by efferent sympathetic and afferent sensory nerves. They participate in many reflex adjustments of renal function. Initially, this finding had not been attributed to increased efferent sympathetic drive, but rather to reduced renal clearance and defective neuronal reuptake of norepinephrine.
At this time, however, the evidence for increased sympathetic drive is solid. Interventions to reduce sympathetic overactivity will provide new therapeutic approaches. The available experimental and clinical evidence to suggest such a pathophysiological role of sympathetic overactivity is summarized in this current review.     

Reverse epidemiology in patients with chronic kidney disease who are not yet on dialysis

Many traditional risk factors show a seemingly paradoxical, inverse association with mortality in patients on dialysis. In spite of their larger numbers, patients with chronic kidney disease (CKD) who are not yet on dialysis are less well studied. Preliminary studies indicate that "reverse epidemiology" is also present in patients with CKD who are not yet on dialysis. Studying patients with CKD offers hope to further our understanding of this phenomenon.     

Risk factors for cardiovascular disease in children on maintenance dialysis

Cardiovascular disease mortality is high in children on maintenance dialysis, accounting for about 25% of patient deaths. Cardiovascular-related mortality rates for children on dialysis are higher than for children with successful kidney transplants. Data on the long-term consequences of risk factors for cardiovascular disease are lacking for pediatric end-stage renal disease patients. This article reviews pediatric data pertaining to the following risk factors: anemia, hypertension, hyperlipidemia, left ventricular hypertrophy, abnormal calcium-phosphorus metabolism, and hyperhomocysteinemia. The potential relationship of end-stage renal disease to the etiology of several functional disorders of the cardiovascular system is discussed. Clinical studies are needed to assess the prevalence of cardiovascular disease and of cardiovascular disease risk factors in the pediatric end-stage renal disease population. Possible preventive and therapeutic guidelines need to be developed for at-risk children on maintenance dialysis.     

Novel cardiovascular risk factors in end-stage renal disease

Traditional risk factors only in part explain the risk differential between the general population and the population of patients with chronic nephropathies. Uncontrolled hyperphosphatemia and high calcium phosphate product constitute risk factors for cardiovascular calcifications, cardiac ischemia, and adverse cardiovascular outcomes, yet inflammation may be an even more important trigger of vascular calcification than these metabolic derangements. Homocysteine predicts cardiovascular events in ESRD, but evidence that this sulfur amino acid is directly implicated in the high cardiovascular mortality of uremic patients is still lacking. It seems unlikely that Chlamydia pneumoniae is a major risk factor in dialysis patients because the association between anti-Chlamydia antibodies and incident cardiovascular events seems to depend largely on the confounding effect of some traditional risk factors. Oxidative stress and raised plasma concentration of asymmetric dimethylarginine (ADMA) are pervasive in ESRD, and high ADMA in these patients may be at least in part the expression of the high rate of generation of oxidants. ADMA per se seems responsible for a 52% increase in the risk of death and for a 34% increase in the risk of cardiovascular events in dialysis patients.