终末期肾病糖尿病患者的尿毒症治疗方案

Polenaković Momir H

Department of Nephrology, Clinical Centre, Vodnjanska 17, Skopje, Republic of Macedonia.

Prilozi. 2004;25(1-2):27-51.

In many countries, diabetic renal disease has become, or will soon become, the single most common cause of end-stage renal disease (ESRD). End-stage renal failure (ESRF) in type-2 diabetic patients is increasing worldwide. Incidence of ESRF caused by diabetic nephropathy (DN) in 1996 in the USA was 41.7% and prevalence was 32.4%. ESRD and ESRF caused by DN was 10%, 5-15% in different haemodialysis centres in adults in the year 2000 in the Republic of Macedonia. In this review article we discuss options in uraemia therapy for diabetics with ESRD. Assessment and treatment of a diabetic with ESRD must be highly individualized. Haemodialysis (HD) has emerged as the most common treatment for all forms of renal failure including diabetic nephropathy. In diabetics patients with ESRD, dialysis is started early at creatinine clearance as high as 15-20 ml/min, at serum creatinin levels as low as 3-5 mg/dl. The first choice of HD access in diabetics is an autologous a-v fistula of the Cimino-Brescia type. The A-V fistula should be created several months before starting HD when creatinine clearance is above 20-25 ml/min. When peritoneal dialysis (PD) is selected, advance planning should ensure that a suitable peritoneal catheter is in situ 2-4 weeks before starting dialysis. HD procedures should be with low ultrafiltration rates and prolonged duration of dialysis sessions. The ultrafiltration in diabetics should not exceed more than 500-600 ml/h on HD. This means dialysis sessions of more than 4h and, in larger patients, of more than 5h HD three times per week. Renal transplantation (RT) is a safe and effective treatment modality for diabetic subjects with ESRD. Cardiovascular disease and serious infections are the major causes of death in haemodialysed and transplanted diabetics. Despite recent improvement, rehabilitation of HD diabetics continues to be inferior to that of non-diabetics. Improvement of survival is a matter of reduction of cardiovascular death and infection.

在许多国家，糖尿病肾病已成为或即将成为终末期肾病（ESRD）的最常见单一病因。2型糖尿病患者的终末期肾衰竭（ESRF）在全球范围内呈上升趋势。1996年美国由糖尿病肾病（DN）导致的ESRF发病率为41.7%，患病率为32.4%。2000年在马其顿共和国，不同血液透析中心成人中由DN导致的ESRD和ESRF分别为10%、5 - 15%。在这篇综述文章中，我们讨论了ESRD糖尿病患者尿毒症治疗的选择。对ESRD糖尿病患者的评估和治疗必须高度个体化。血液透析（HD）已成为包括糖尿病肾病在内的所有形式肾衰竭的最常见治疗方法。对于ESRD糖尿病患者，当肌酐清除率高达15 - 20 ml/min、血清肌酐水平低至3 - 5 mg/dl时就尽早开始透析。糖尿病患者HD通路的首选是Cimino - Brescia型自体动静脉内瘘。当肌酐清除率高于20 - 25 ml/min时，应在开始HD前几个月建立动静脉内瘘。选择腹膜透析（PD）时，应提前规划以确保在开始透析前2 - 4周合适的腹膜导管已就位。HD程序应采用低超滤率和延长透析时间。糖尿病患者HD时超滤量不应超过500 - 600 ml/h。这意味着透析时间超过4小时，对于体型较大的患者，每周进行3次HD，每次超过5小时。肾移植（RT）是ESRD糖尿病患者安全有效的治疗方式。心血管疾病和严重感染是血液透析和肾移植糖尿病患者的主要死亡原因。尽管最近有所改善，但HD糖尿病患者的康复情况仍逊于非糖尿病患者。提高生存率在于降低心血管死亡和感染。