| IntrodutionChronic Renal Failure(CRF) is a severe disease that damages the function of systemic organs. Hemodialysis(HD) is an effective replacement therapy for CRF. Hemodialysis can eliminate uremic toxins and excess water accumulated in the body; rectify electrolyte and acid-base imbalance; improve the pathogenetic condition; make the patients with CRF survive on hemodialysis; recover the normal abilities of life and work.Maintenance hemodialysis patients are exposured toabout 360 liter water every week, while healthy people only drink 14 liter water. There are only semipermeable membranes between blood and dialysis fluid during hemodialysis. Semipermeable membranes lack good selectivity, therefore high purity of water and dialysis solutions are required. Otherwise, toxins in water can easily penetrate the membranes into human body, cause damage to patients and generate all kinds of acute and chronic complications.Lots of clinical investigations suggested that uremia is a symptom of chronic inflammation. The status of mild inflammation exists extensively in maintenance hemodialysis patients with uremia. Long term use of normal dialysis fluid with relative high concentration of endotoxin may aggravate inflammatory reaction and cause reduction of immune function, such as amyloidosis, atherosclerosis, cardiovascular disease and erythropoietin resistance. However, replacement with super-pure dialysis solutions can avoid pyrogen permeation, minimize influence with inflammatory factors, effectively interfere inflammatory responses, significantly decrease the levels of C-reactive protein (CRP), interleukin 6 (IL-6) and reduce the occurrence of inflammation.A novel water management system was introduced in our hospital since October 2003. This was a heat sterilized, anti-osmotic water system without dead space and used heat treated bicarbonate dialysis solutions. The system supplied super-pure water for hemodialysis therapy. Class II,class I .anti-osmotic water and even ionized water are still employed to maintain hemodialysis treatment in most other dialysis centers.We examined the levels of hs-CRP, IL-6, TNF- α , ALB and PAB in patients from different dialysis centers using different water treatment systems; compare the differences of inflammation and nutritional status between groups; and investigated the influence of dialysis fluid with different purity on mild inflammatory responses and nutritional status in maintenance hemodialysis patients.Subjects and MethodsSubjects and grouping method1. Questionnaire about the water management systems were performed in the dialysis centers of 6 hospitals in Hangzhou. We collected information of the following aspects: information about the machines producing anti-osmotic water in different centers; time of first use; sterilization methods of anti-osmotic membranes and time between two sterilization; sterilization methods of supplying channels and time between two sterilization; methods of supplying concentrated fluid; sterilization methods of hemodialysis machines and so on.2. Inclusion and exclusion standard: Patients with end-stage renal failure were eligible for this study if they were older than 18 years; hadmaintained hemodialysis for more than 6 months; had no obvious infection or liver disfunction or angina pectoris attacks within one month. Patients were excluded from the study if they had tumor or took immunosuppressant.3. Patients were divided into two groups, one with normal dialysis fluid and the other with super-pure dialysis fluid.Group with normal dialysis fluid: Normal dialysis fluid should meet the American AAMI standards about dialysis solutions. Fourty-one patients receiving hemodialysis therapy in two dialysis centers and meeting the inclusion and exclusion standard were enrolled. Group with super-pure dialysis fluid: Super-pure dialysis fluid should meet the European standards about dialysis water. Fourty-five patients receiving hemodialysis with super-pure dialysis fluid and meeting the inclusion and exclusion standard were enrolled.Methods1. Collect water samples from the proximal, middle, distal end of the anti-osmotic water, concentrated B solution and the entrance of dialysis fluid with 20ml sterile syringes under sterile conditions in different water management systems. Bacteria and endotoxin were examined.2. Collect 5ml venous blood per subject before hemodialysis. The bloodsamples were non-anticoagulated, centrifuged and the supernatant fluid were stored in -80℃.3. Detect the levels of endotoxin with ALA method.4. Examine hs-CRP, PAB with velocity scattering turbidimetry.5. Determine IL-6, TNF-α with ELISA.6. Statistical analysisAll the data were analyzed with SPSS10.0 software package and were presented with x ±S. t-Test was employed to compare group differences and p< 0.05 was indicative of statistical significance.Results1. No bacteria were detected and all the concentration of endotoxin was less than 0.25EU/L in all the anti-osmotic water and dialysis solutions in super-pure dialysis fluid , supplied by the heat sterilized, anti-osmotic water system without dead space and used heat treated bicarbonate dialysis solutions; bacteria were detected in distal end of anti-osmotic water and dialysis solutions , the concentration of endotoxin was more than 2.0EU/L in normal water management system.2. The levels of hs-CRP in the patients with super-pure dialysis fluid (8.52±11.54mg/L) were much lower than that with normal dialysisfluid( 11.16± 14.52mg/L) and there was a significance between groups (p<0.05) . The levels of IL-6 and TNF-α in the patients with super-pure dialysis fluid (11.69 ± 9.52pg/L; 61.44 ± 61.21pg/L) were lower than that with normal dialysis fluid(13.15 ± 13.39pg/L; 77.44 ± 59.69pg/L ), but there was no significance between groups (both p>0.05)3. The levels of serum ALB and PAB in the patients with (38.71 ± 5.51g/L; 32.11 ±10.38g/L) were much higher than that with normal dialysis fluid(32.93 ± 2.42g/L; 30.89 ± 8.65g/L) and there was a significance between groups (both p<0.05) .Conclusions1. A heat sterilized, anti-osmotic water system without dead space and used heat treated bicarbonate dialysis solutions. The system supplied super-pure water for hemodialysis therapy.2. Super-pure dialysis fluid could lower the level of serum hs-CRP and reduce the inflammatory reaction in patients.Super-pure dialysis fluid increased the level of ALB and improved the nutritional status in patients. |
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