| Dialysis adequacy is the treatment goal of uremia patients receving maintenance dialysis.This should meet the two basic conditions:accurate and objectively evaluation of the adequacy, accurate features of the clear of uremia toxins and related clinical factors.Currently, there is academic controversy on the evaluation of dialysis adequacy. Urea clearance index (Kt/Vurea) and creatinine clearance rate(Ccr) are main indexes to evaluate dialysis adequacy. K-DOQI guideline regarded Kt/Vurea 1.7 as the main goals of dialysis. However, many studies have questioned on this:1. Cardio-and cerebro-vascular diseases and infection are the main causes of death of patients receiving maintenance dialysis. There is no clear evidence that urea is directly related to these causes of death. Uremic toxins should include water、electrolytes and metabolites of different molecular. Urea and creatinine are small molecular water-soluble nitrogen metabolites. They are very different with other uremic toxins in the metabolism and clearance characteristics. So, their clearance could not represent the clearance of other uremic toxins.3. It was ignored that the impacts of the patients’s own physiology, metabolism and lifestyle characteristics on dialysis.4. Single or a few indicators are still not enough. It ignores the effects of symptoms, quality of life, social regression and other aspects on dialysis adequacy.5. This evaluation is carried out by a doctor or several ones, their own clinical experiences would have inevitably effect. Therefore, it is a research direction to find more reasonable, more representative indicator and more scientific evaluation methods to make a comprehensive, objective, scientific evaluation. Uremic toxins include many types of different categories. Sodium and potassium are important electrolyte of human, Sodium retention is an important risk factor of cardiac and cerebro-vascular diseases in patients receving maintenance dialysis. Potassium disorder is common complications of peritoneal dialysis patients, it can cause serious consequence.P-cresol sulfate often is regarded as the represent of uremic toxins that binding to proteins.It is significantly associated with uremia symptoms and cardiovascular complications of patients receiving maintenance dialysis, and it is a powerful predictor of death.This several substances have important clinical significance and are representative. To reveal their clear characteristics and relevant clinical factors in peritoneal dialysis patients can provide valuable reference for fix and adjust clinical treatment.Which indices should be used to evaluate dialysis adequacy? How much are these indices’ weight? Let’s see the opinions of national dialysis experts.Charpter 1 International survey on the weight of indices for evaluation of dialysis adequacyObjective To explore the importance of indices for evaluation of dialysis adequacyMethods Questionnaire surveys were performed to experts attending the international conference. Results were dealed with the entropy approach.Results There were 1765 survey questionnaires, and a total of 323 were recovered, of which 277 were valid. The respondents come from 17 countries and regions of Asia-Pacific region, Europe and America. The results showed that 98.19% respondents believe that multiple indicators to evaluate the dialysis adequacy should be adopted.87.73% of them approved the index system in the questionnaire. In first class indices, the volume balance is the most important, its weight is 8.79. Followed is the toxin clearance,8.6. The last one is the complications,7.18. In the secondary indexs, the most important is edema, its weight is 8.64. Followed is potassium concentration in plusma,8.635. Peritoneal and residual renal function Kt/Vurea and Ccr, which represent toxin clearance, listed at the 9th and 11th.Conclusion Multi-indices system should be used to evaluate the dialysis adequacy. Edema should be emphasized. Serum potassium should be carefully monitored and corrected.The widely questionnaire surveys explored the weight of indices for evaluation of dialysis adequacy and difined that Multi-indices system should be used to evaluate the dialysis adequacy. But how should the dialysis adequacy be evaluated?Charpter 2 A mathematics model to evaluate dialysis adequacy with comprehensive system of multi-indices.Objective To estabolish a mathematics model to evaluate dialysis adequacy with comprehensive system of multi-indices.Methods and results To establish multi-index evaluation system of dialysis adequacy with level analysis method. It is divided into one class index and secondary index. Toxin clearance, volume balance, nutrition, electrolyte acid-base, complication evaluation, the quality of life are including in one class index. Several secondary indicators are including in each one level indicators, such as uremic toxin removal, including symptoms, serum creatinine concentration, blood concentration ofβ2 microglobulin, peritoneal Kt/Vurea and Ccr, renal Kt/Vurea and Ccr. A total of 29 indicators were included. We also studied the questionnaires from specialists of dialysis in a limit extent, we introduced entropy theory to analysis the findings and determined the weights of each index in the system which also indicated the effect of each index on the assessment. with entropy theory analysis of the survey results of dialys experts suggested the value of each index—every indicators on the influence of the results of evaluation. We fuzzily processed the clinical data of each index according to scoring system and unified quantified clinical data of different measurement. The scoring system consisted of three or five ranks, the optimal value was nine and the inferior value was one. The quantitative clinical data were included in evaluation model, you can get a score within 1-99 points, the higher score indicated more adequate dialysis.Conclusion Using information processing method, such as entropy, fuzzed can minimize the subjective impact of the evaluators and reduce the one-side evaluation. And the evaluation of dialysis adequacy could be objective and comprehensive.Dialysis adequacy is made up of peritoneal clearance and residual renal function. The peritoneal clearance is the major to most PD patients. It is puzzled that residual renal function can predict the prognosis but peritoneal clearance can’t. How to explain the contradiction?Chapter 3 Residual renal function is more efficient than peritoneal clearance on fluid or sodium removal per 0.1 Kt/Vurea:a possible explanation of their different effection on PD patients’ prognosis.Objective To compare the efficiency between peritoneal and renal removal of fluid and sodium when the same Kt/V reached, so as to explain different effects of the RRF and peritoneal clearance on the prognosis of patients.Methods A cross-sectional study was performed in patients receiving dialysis more than 3 months, the average daily urine volume>100ml during the study period. The information of peritoneal, residual renal and total weekly Kt/V、daily clearance of water and sodium were calculated, also, the clearance of water and sodium of RRF and peritoneal membrane per 0.1 Kt/V were calculated. With the independent sample t-test comparing the patients’clearance efficiency of water and sodium of RRF and peritoneal with pearson correlation test, the relationship of the residual kidney, peritoneum and the total clearance of water and sodium with Kt/V were analyzed.Results 205 patients receiving maintenance dialysis were included. The renal clearance of water and sodium is more than peritoneal. But there was no statistically significant.(water:p=0.169, sodium:p=0.073); residual renal Kt/V is significantly lower than peritoneal(p=0.003) the clearance efficiency per 0.1Kt/V of remnant renal is significantly higher than peritoneum,147.88±83.72 vs 46.54±39.11(ml), p=0.000, 11.40±6.08 vs 4.47±4.79 (mmol), p=0.000, repectively; the water and sodium clearance of RRF is best correlated with Kt/V. (water:p=0.000, sodium:p=0.000), the following is peritoneum(water:p=0.011, sodium:p=0.026), both are statistically significant; total clearance of water and sodium is not related with Kv/V(water: p=0.097, sodium:p=0.135).Conclusion The residual renal clearance efficiency of water and sodium of is far higher than peritoneum,and this may the reason that residual renal could predict the prognosis of patients, and the peritoneum cannot. when residual renal function declines, the adjustment of dialysis programs should take into account of both Kt/V and removal of water and sodium. Sodium removal is important content of dialysis adequacy. To explore the effecting clinical factors is undoubtedly helpful to increase sodium removal and this is one of key elements to maintain sodium balance in body.Chaper 4 Clinical factors associated with sodium removal in peritoneal dialysis patientsBackground Sodium retention is an important risk factor of cardiac and cerebrovascular diseases in peritoneal dialysis (PD) patients. Clarifying the factors that contribute to sodium removal is very important in preventing and treating sodium overload.Methods A cross-sectional study was performed from 1 January 2008 to 1 October 2010 in 156 clinical stable patients on PD. Serum biochemical parameters, peritoneal function by the modified Peritoneal Equilibration Test (PET) and dialysis adequacy were analysed with multivariate linear regression analysis in relation to sodium removal.Results One hundred and fifty-six patients were included in the study. Factors affecting peritoneal removal of sodium included infuse volume(β=0.104, p<0.001) and ultrafiltration volume ((3=1.023, p<0.001) per 24 hours, sodium dip during modified PET (β=-0.422, p<0.001), and sodium difference between serum and fresh dialysate(β=0.354, p<0.001). Factors affecting total removal of sodium inclued ultrafiltration (β=0.908, p<0.001) and urine volume (β=0.799, p<0.001) per 24 hours, sodium dip (β=-0.438, p<0.001), and sodium difference (β=0.368, p<0.001).Conclusions An adequate volume of fluid removal is necessary for enough sodium removal when a traditional dialysate is used. Low-sodium dialysate may be an effective way to solve the problem of sodium retention. Sodium removal should be included in the evaluation of dialysis adequacy.The survey in 1st chapter explored that serum potassium was regarded an important indice for evaluation of dialysis adequacy. It is a pity that serum potassium disorder has been common complication. How to prevent and correct it?Chapter 5 Kinetics character of transport and metabolism of potassium in peritoneal dialysis patientsObjective To explore the kinetics character of transport and metabolism of potassium in peritoneal dialysis patients and to provide quantitative evidence of correcting the disorder of potassium.Methods Mathematic model of trans-peritoneum transport and metabolism of potassium was established according to the three-pore model and metabolism dynamics.Results The concentration and mass removal curves of potassium in dialysate are like inverse parabola during single dwell. They increased rapidly in the first 2 hours and then slowed down at about the 3rd hour and finally became flat after the 5th hours. Mass removal of potassium is positively correlated with dialysis dose. Serum concentration of potassium would change if dialysis dose had changed. New banlance of serum potassium at different levels would be achieved according to different treatments after potassium disorder happened. Appropriate supplement dose is quantitative related to the initial serum concentration and dialysis dose but not the body weight when hypokalemia happens. Dialysis scheme of 2L/2hours dwell will make the serum concentration decrease more than 0.3mmol/L/hour when hyperkalemia happens.Conclusions The first 2 hours is the most efficient dwell time for peritoneal dialysis to remove intrabody potassium. Supplement dose can be given according to the initial serum concentration and dialysis dose when hypokalemia is corrected. Peritoneal dialysis can correct hyperkalemia rapidly and efficiently, and the economic and efficient scheme is 2L/2hours dwell. The period to reach new balance of serum potassium is about 15 days no matter what kind of treatment be given if all the causes of potassium disorder were removed. During the period, the frequency of serum potassium test is about once every day in the former 3 days and one after 5 days.p-cresol sulfate is significantly correlated with uremia syndrome and cardio-vascular diseases in maintained dialysis patients. It is also a powerful predictive factor of mortality. To increase PCS removal is key element of dialysis adequacy. The premise is to understand the characteristics of PCS removal through peritoneum and its effecting clinical factors.Chapter 6 Study on the characteristics of PCS removal and its effecting clinical factors in peritoneal dialysis patientsObjective To explore the characteristics of PCS removal and its effecting clinical factors in peritoneal dialysis patientsMethods A prospective design, cross-sectional, clinical study was performed from 1 January 2008 to 1 October 2010 in clinical stable patients on PD. Serum biochemical parameters, peritoneal function by the modified Peritoneal Equilibration Test (PET) and dialysis adequacy were recorded. high-performance liquid chromatography tandem mass spectrometry was used to detect PCS in plasma, drainage dialysate and urine. multivariate linear regression analysis was used for analysis of peritoneal and total PCS removal. Partial correlation analysis was used for analysis the correlation between peritoneal PCS removal and peritoneal permeability and dialysis mode. Paired t test was used to compared the difference between renal and peritoneal removal of PCS. Dependent sample t test was used to compare the difference of urea and PCS removal between CAPD and IPD.Results 72 patients were included in the study. Among them 44 patients were on CPAD. Plusma PCS concentration in plusma was 14.72±12.59ug/L. Daily dialysis dose was 7.45±1.5L and urine volume 1.00±0.61L, residual renal function 2.76±3.01ml/min, peritoneal Kt/V 1.33±0.48, total Kt/V 2.24±1.48, peritoneal PCS clearance 3.10±1.91L/week, total PCS clearance 10.79±8.78L/week. Multivariate linear regression analysis used, total PCS clearance was significantly correlated with RRF according to, p=0.000; peritoneal PCS clearance was significantly correlated with dialysis dose, p=0.010. Partial correlation analysis used, peritoneal PCS clearance was significantly correlated with dialysis mode but not D/Pcr, p=0.007. Paired t test used, there were significant difference between peritoneal and renal PCS removal and PCS removal per 0.1Kt/V, p was all less than 0.001. Renal Kt/V was significantly lower than peritoneal, p=0.021. Dependent sample t test used, there were significant difference of dialysis dose, peritoneal PCS clearance, peritoneal Kt/V between CAPD and IPD, p=0.000,0.002,0.003, respectively.Conclusions One reason to preserve residual renal function is that it can decrease PCS retention. CAPD can remove more PCS than IPD. Renal efficiency of PCS removal is far higher than peritoneal when the same Kt/V reached, and this may be one reason to explain that renal can predict patients’ prognosis but peritoneal can’t. PCS removal should also be considered together with Kt/V as to evaluate dialysis adequacy and modify dialysis regimen.SummaryOur research focused on dialysis adequacy, carried out the investigation of evaluation index weights, and established the mathematic model to assess dialysis adequacy by a multi-index system. In the two studies, we introduced the information-processing and decision-making ideas and methods such as entropy theory, analytic hierarchy process and fuzzy process. Sodium, potassium and p-cresol sulfate are clinical significant and representative uremic toxins. Chapter three to chapter six of the search studied the characteristics of renal clearance of the three substances respectively, and highlighted the relative clinical influential factors. The research is of great value for clinical evaluation of dialysis adequacy, developing a reasonable program to ensure dialysis adequacy and improving the prognosis of patients. |
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