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Objective:To investigate the impacts of hierarchical management based on medical alliance on the patency of arteriovenous graft (AVG),and provide a basis for further exploration of optimal AVG management.Methods:In this retrospective cohort study, clinical and follow-up data of patients with AVG established in the First Affiliated Hospital of Zhengzhou University from January 1, 2018 to December 31, 2021 were analyzed. Patients were divided into medical alliance group and non-medical alliance group according to whether they were under hierarchical management model, and the patency rate of AVGs and the incidence of clinical events were compared between the two groups.Results:A total of 328 AVGs were included in this study, which were from 151 hemodialysis centers, including 189 AVGs (57.6%) from 72 centers in medical alliance group, and 139 AVGs (42.4%) from 79 centers in non-medical alliance group. The age of the patients was (55.57±11.80) years, among whom 130 (39.6%) were males and 126 (38.4%) were diabetic. The follow-up time of AVGs in this cohort was 15.5 (9.5, 26.2) months, with 15.4 (9.8, 25.2) months in medical alliance group and 15.5 (9.2, 27.3) months in non-medical alliance group. The incidence of thrombosis or occlusion (0.328 times/patient-year), graft dissection (0.007 times/patient-year), graft infection (0.030 times/patient-year), and catheter utilization (0.043 times/patient-year) in the medical alliance group were lower than those in the non-medical alliance group (0.589 times/patient-year, 0.040 times/patient-year, 0.054 times/patient-year and 0.147 times/patient-year, respectively), and there was no significant difference in clinic follow-up rates between the two group (1.91 times/patient-year vs. 1.94 times/patient-year). The median primary patency time was 17.4 (95% CI 11.3-23.5) months, the median primary assisted patency time was 32.6 (95% CI 25.0-40.2) months, and the median secondary patency time was 47.9 (95% CI 40.0-55.8) months in the medical alliance group, compared with 12.3 (95% CI 9.4-15.2) months, 19.4 (95% CI 14.3-24.5) months, and 34.6 (95% CI 29.3-39.9) months in the non-medical alliance group, respectively. Primary patency were significantly higher in the medical alliance group (77.4%, 62.2%, 39.9%, and 26.6%) than those in the non-medical alliance group (71.1%, 50.1%, 30.6%, and 13.4%) at 6, 12, 24, and 36 months (Log-rank test, χ2=4.504, P=0.034). Primary assisted patency were significantly higher in the medical alliance group (90.9%, 84.3%, 67.1%, and 46.1%) than those in the non-medical alliance group (89.2%, 75.7%, 42.0%, and 16.6%) at 6, 12, 24, and 36 months (Log-rank test, χ2=10.655, P=0.001). Secondary patency were significantly higher in the medical alliance group (96.8%, 91.8%, 84.2%, and 74.0%) than those in the non-medical alliance group (89.9%, 85.8%, 69.3%, and 47.5%) at 6, 12, 24, and 36 months (Log-rank test, χ2=11.634, P=0.001). Multivariate Cox regression analysis showed that it was a protective factor for primary patency ( HR=0.708, 95% CI 0.512-0.980, P=0.037), primary assisted patency ( HR=0.506, 95% CI 0.342-0.749, P=0.001) and secondary patency ( HR=0.432, 95% CI 0.261-0.716, P=0.001) under the medical alliance model. Conclusion:The hierarchical management based on medical alliances can improve the patency of AVGs and reduce the incidence of clinical events.
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Objective:To investigate the clinical outcomes of hemodialysis (HD) patients with stent grafts for arteriovenous access complications in real-world.Methods:It was a retrospective cohort study. Clinical data of HD patients treated with stent grafts for arteriovenous access complications from August 1, 2018 to December 31, 2021 in the First Affiliated Hospital of Zhengzhou University was collected to analyze target lesion primary patency (TLPP), target lesion primary assisted patency (TLPAP), and access circuit primary patency (ACPP) using the Kaplan-Meier survival analysis and Log-rank test, and to compare TLPP and mean annual intervention times between pre-stent grafts and post-stent grafts placement.Results:A total of 77 stent grafts in 71 patients were included according to the inclusion criteria, of which 46 (59.7%) were arteriovenous fistula (AVF) and 31 (40.3%) were arteriovenous graft (AVG), with a median follow-up time of 22.4 months. At 6, 12, 24, and 36 months after stent grafts deployment, TLPP was 89.3%, 66.5%, 48.3% and 42.5%, respectively. TLPAP was 94.8%, 90.4%, 78.7% and 75.4%, respectively. And ACPP was 77.2%, 54.3%, 35.2% and 29.0%, respectively. At subgroup analysis, there was no difference in TLPP at the three different sites of central vein, cephalic arch, and AVG venous anastomosis or outflow tract ( χ2=0.086, P=0.808). TLPP was better in the stenosis group than thrombosis or occlusion group, but was not statistically significant ( χ2=2.551, P=0.110). Compared with pre-stent grafts, TLPP improved significantly ( χ2=7.484, P=0.006), the median patency time increased from 16.6 months to 23.2 months, and the mean annual intervention times decreased from 0.99 (0.10, 1.83) to 0.50 (0, 1.45) ( Z=-2.841, P=0.004) after stent grafts placement Conclusion:The TLPP of HD patients with stent grafts for arteriovenous access complications improves significantly, and the mean annual intervention times reduce significantly.
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Objective:To investigate the risk factors for catheter-related bloodstream infection (CRBSI) in hemodialysis (HD) patients with tunnel-cuffed catheter (TCC) and construct a risk prediction model for the prevention and treatment of catheter infection.Methods:It was a retrospective study. Patients who had their TCC removed in Hemodialysis Access Center of the First Affiliated Hospital of Zhengzhou University from July to December 2020 were randomly divided into a training set (for model building) and a validation set (for model validation) in the ratio of 7∶3. The training set was divided into CRBSI group and non-CRBSI group with reference to the 2019 Kidney Disease Outcomes Quality Initiative clinical practice guidelines for vascular access, and the risk factors for the occurrence of CRBSI were analyzed. The odds ratio ( OR) values of the variables in the multivariate logistic regression analysis were applied to construct a risk prediction model, and the assessment ability of the model was validated in the validation set. Results:A total of 254 HD patients were included. The training set consisted of 179 patients with male-to-female ratio of 1.36∶1, age of (55.81±15.95) years old, median dialysis age of 18(8, 27) months, median TCC retention time of 15(5, 24) months, and 40 patients with confirmed CRBSI. Logistic regression analysis showed that, combined diabetes ( OR=2.711, 95% CI 1.174-6.258, P=0.019), history of catheter-related infection within 3 months ( OR=3.674, 95% CI 1.541-8.760, P=0.003), more than 4 times nursing interventions within 1 month ( OR=3.128, 95% CI 1.343-7.283, P=0.008), and central venous disease ( OR=2.572, 95% CI 1.130-5.854, P=0.024) were the independent influencing factors for CRBSI occurrence in HD patients with TCC. The OR values of the variables in the multivariate logistic regression were rounded to the assigned scores of the risk prediction model. The corresponding scores of each factor were summed in the training set to obtain the risk score. The receiver operating characteristic (ROC) curve was plotted, with area under the curve ( AUC) of 0.761(0.683-0.839) and maximum Youden index of 0.461, at which time the corresponding cut-off value was 6, with sensitivity of 90.0% and specificity of 56.1%. The model was validated in the validation set with AUC of 0.794(0.674-0.914) and cut-off value of 6, with sensitivity of 61.6% and specificity of 82.5%. Conclusions:Combined diabetes, history of catheter-related infection within 3 months, more than 4 times nursing interventions within 1 month, and central venous disease are the independent risk factors for CRBSI, and the prediction model based on the above factors has good efficacy in predicting the risk of CRBSI and can provide guidance for the prevention and treatment of CRBSI in HD patients.
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Objective:To investigate the patency rates and risk factors of arteriovenous graft (AVG), and provide a clinical guidance for further optimization of vascular access selection and improvement of dialysis quality.Methods:This was a retrospective study. The clinical and follow-up data of patients who received AVG in the Blood Purification Center, First Affiliated Hospital of Zhengzhou University from January 1, 2017 to December 31, 2021 were selected. Kaplan-Meier curve and Cox regression model were used to analyze the patency rates and risk factors of AVG.Results:A total of 381 cases with AVG were included, with 154 cases (40.4%) of males, age of (55.5±11.8) years old, and 140 cases (36.7%) of diabetes. The median time of primary patency was 377.00(95% CI 314.26-439.74) days, and the primary patency rates at 1, 2, and 3 years were 51.0%, 30.7%, and 15.4%, respectively. The median time of primary assisted patency was 839.00(95% CI 668.89-1 009.11) days, and the primary assisted patency rates at 1, 2, and 3 years were 78.3%, 56.4%, and 39.1%, respectively. The secondary patency rates at 1, 2, and 3 years were 96.7%, 90.1%, and 78.5%, respectively. Multivariate Cox regression analysis results showed that anastomotic vein types of basilic vein and cephalic vein (median cubital vein as a reference, HR=1.869, 95% CI 1.124-3.107, P=0.016; HR=2.110, 95% CI 1.176-3.786, P=0.012) and the diameter of anastomotic vein<3.5 mm ( HR=1.411, 95% CI 1.020-1.952, P=0.037) were the independent influencing factors for abnormal primary patency of AVG. Males ( HR=1.680, 95% CI 1.127-2.503, P=0.011), mean arterial pressure<70 mmHg ( HR=3.228, 95% CI 1.109-9.394, P=0.032), Acuseal graft type (Intering as a reference, HR=1.884, 95% CI 1.185-2.994, P=0.007), anastomotic vein type of cephalic vein (median cubital vein as a reference, HR=2.817, 95% CI 1.328-5.977, P=0.007), the diameter of anastomotic vein<3.5 mm ( HR=1.555, 95% CI 1.048-2.306, P=0.028), serum phosphorus ≤1.78 mmol/L (1.13-1.78 mmol/L />1.78 mmol/L, HR=1.737, 95% CI 1.111-2.716, P=0.015;<1.13 mmol/L />1.78 mmol/L, HR=2.162, 95% CI 1.072- 4.362, P=0.031), and ferritin<200 μg/L ( HR=1.850, 95% CI 1.231-2.780, P=0.003) were the independent influencing factors for abnormal primary assisted patency of AVG. Serum albumin<40 g/L ( HR=2.165, 95% CI 1.096-4.275, P=0.026) was an independent influencing factor for abnormal secondary patency of AVG. Conclusions:The primary patency rates of AVG at 1, 2, and 3 years were 51.0%, 30.7%, and 15.4%, respectively. The secondary patency rates of AVG at 1, 2, and 3 years were 96.7%, 90.1%, and 78.5%, respectively. Anastomotic vein types of cephalic vein and basilic vein, and internal diameter<3.5 mm are the independent risk factors for abnormal primary patency of AVG. Anastomotic vein type of cephalic vein and internal diameter<3.5 mm are the independent risk factors for abnormal assisted primary patency of AVG. Serum albumin<40 g/L is an independent risk factor for abnormal secondary patency of AVG. It is suggested that systematic preoperative evaluation and good nutritional status of patients are important to maintain long-term patency of the AVG.
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Objective To explore the effects of BSA on hypoxia inducible factor/hypoxia response element (HIF/HRE) transcription activity in rat tubular epithelial cells (NRK-52E) with HRE-Luc reporter plasmid.Methods Luciferin activity of NRK-52E cells incubated by a medium contained BSA in varying concentration (0,5,10,20 mg/ml) and stimulus duration (24,48,72 h) was detected by dual luciferase detecting system based on HRE-Luc reporter plasmid and HIF-1 α expression was detected by Western blotting.Results HIF/HRE transcription activity of NRK-52E cells was increased in BSA incubation group (10 mg/ml,48 h) compared with blank control (BSA 0 mg/ml,48 h) [(2.59±0.35)vs (1.03±0.09),P=0.000].HIF-1α expression of NRK-52E cells was increased in BSA incubation group (20 mg/ml,48 h) compared with blank control (BSA 0 mg/ml,24 h) [(0.052±0.010) vs (0.014±0.003),P=0.000].Conclusion Albumin can increase HIF/HRE transcription activity of TEC.
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objective To investigate the value of NT-proBNP in assessing the volume status in maintenance hemodialysis patients with non-dominant edema.Methods One hundred and forty-five patients were recruited.Bioimpedance measurements were performed for overhydration (OH).NT-proBNP was detected by colloidal gold method.Patients were divided into three groups by levels of OH variability (△ OH,equal to OH minus weight increase) as group H (hypervolemia,n=90); group N (normovolemia,n=36) and group L (hypovolemia,n=19).Hemoglobin,albumin,blood urea nitrogen and serum creatinine were assayed,blood pressure and body mass increase were recorded.Dry weight of patients in Group H were adjusted in 3 months,the relationship between NT-proBNP and volume change were assessed.Results (1) At baseline,overall plasma NT-proBNP levels were higher than normal range.The median NT-proBNP levels in group H and group N were [1318.50(IQR 717.00,3154.25) pg/ml] and [703.50 (IQR 873.00,450.50) pg/ml],respectively.NT-proBNP was positively correlated with △OH value (r=0.801,P ＜ 0.001).(2) After 3 months,NT-proBNP levels in group H was significantly lower than baseline.Forty-one patients reached normal volume range (group H1),49 patients were resistant hypervolemia (group H2).The median NT-proBNP levels in group H1 and group H2 were [685.00 (IQR 422.50,988.50) pg/ml] and [1569.00 (IQR 982.50,2500.50) pg/ml],△ OH in group H1 and group H2 were [(0.63±0.23)L] and [(1.75±0.71)L],respectively.NT-proBNP and △ OH value in two groups had significant difference (P ＜ 0.05).NT-proBNP was positively correlated with △ OH value (r=0.684,P ＜ 0.001).(3) The area under ROC curve for NT-proBNP was 0.818,95％CI (0.733～ 0.904),P ＜ 0.001,since the absolute value of normovolemia was defined as ≤ 1.The cut off value of plasma NT-proBNP was set at 962.50 pg/ml in MHD patients with non-dominant edema,the diagnostic specificity and sensitivity were 79.6％ and 73.2％.Conclusion NT-proBNP could be used to assess volume status in MHD patients with non dominant edema.
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Objective To explore the effects of ethyl-3,4 dihydroxybenzoate(EDHB), a prolyl hydroxylase inhibitor, pretreatment on the tubular epithelial cells apoptosis induced by albumin and hypoxia. Methods To investigate the effects of albumin and hypoxia on cells, rat tubular epithelial cells(NRK-52E)were incubated for 24 h in:(1)normoxia(5%CO2);(2)hypoxia(1% O2);(3)albumin(30 g/L)under normoxia;(4)albumin(30 g/L)under hypoxia. To investigate the effects of EDHB pretreatment on cells apoptosis, NRK-52E were incubated in hypoxia for 24 h in:(1)normoxia;(2)hypoxia;(3)hypoxia+albumin(30 g/L);(4)hypoxia+EDHB(500 μmol/L);(5)EDHB pretreatment(albumin 30 min after EDHB). Apoptosis was measured by flow cytometry(AnnexinV-FITC-PI). bcl-2, bax and vascular epithelial growth factor(VEGF)mRNA expression were detected by RT-PCR. VEGF protein expression was detected by Western blotting. Results NRK-52E apoptosis was not significantly different between hypoxia and norraoxia groups(P>0.05), but increased significantly in albumin(30 g/L)under hypoxia group compared with albumin(30 g/L)under normoxia group(37.36%?.95% vs 25.59%?.32%, P< 0.05). There was an increase in bax mRNA expression and a decrease in bcl-2 mRNA expression in albumin(30 g/L)under hypoxia group compared with albumin(30 g/L)under normoxia group(P< 0.05). EDHB pretreatment improved these impairments of albumin(30 g/L)under hypoxia on NRK-52E(P< 0.05). VEGF expression elevated in hypoxia compared with normoxia(P<0.05), decreased in albumin(30 g/L)under hypoxia groups compared with that without albumin groups(P<0.05).EDHB pretreatment significantly improved VEGF expression compared with albumin(30 g/L)under hypoxia group(P <0.05). Conclusion NRK-52E cells apoptosis induced by albumin is accelerated by hypoxia, however partially improved by EDHB pretreatment, probably through the up-regulation of VEGF expression.
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Objective To study the effect of recombinant human edostatin on peritoneal angiogenesis in uremic peritoneal dialysis(PD) rats. Methods Forty male SD rats were randomly divided into 5 groups: normal control rats (group 1), renal failure without PD rats (group 2), rats dialyzed with 4.25% PD solution (group 3), rats dialyzed with 4.25% PD solution and received subcutaneous injection of recombinant human endostatin 10 mg/kg (group 4), rats dialyzed with 4.25% PD solution and received subcutaneous injection of recombinant human endostatin 40 mg/kg (group 5). Recombinant human endostatin was given every other day during peritoneal dialysis period, total 14 times. After regular PD for 28 days, tissue immunohistochemical staining and RT-PCR were used to detect the mRNA and protein expressions of VEGF and bFGF in peritoneal tissues of each group rats. Microvessel density (MVD) of peritoneum was detected and quantified with anti-CD34 immunohistochemical staining. Results The mRNA and protein of VEGF and bFGF were expressed in each group. Compared to group 1, the mRNA and protein expression of VEGF and bFGF were significantly up-regulated in group 2 and group 3 (all P＜0.05). Compared with group 3, the mRNA and protein expression of VEGF and bFGF were significantly downregulated in group 4 and group 5 (all P＜0.05). Compared with group 4, the mRNA and protein expression of VEGF and bFGF were significantly down-regulated in group 5 (all P＜0.05). The new microvascular vessels in group 1 showed little or none. Compared with group 1, MVD was significantly increased in group 2 and group 3 (P＜0.05). Compared with group 3, MVD was significantly decreased in group 4 and group 5 (all P＜0.05). Conclusions Recombinant human endostatin can effectively inhibit rat peritoneal neoangiogensis. Down-regulated expression of VEGF and bFGF in peritoneum may be one of the mechanisms of recombinant human endostatin inhibiting peritoneal angiogenesis.
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Objective To investigate the expression of endostatin (ES) in rat peritoneum and its association with peritoneal neoangiogensis. Methods Thirty-two male SD rats were randomly divided into 4 groups: normal control rats (C group), renal failure without PD rats (non-PD group), rats dialyzed with 1.5% PD solution (1.5% PD group) and 4.25% PD solution (4.25% PD group). After regular PD for 28 days, mRNA and protein expression of ES in peritoneal tissues of each group were detected by RT-PCR and immunohistochemistry respectively. Microvessel density (MVD) of peritoneal tissue was assessed using immunohistochemistry with CD34 monoclonal antibody. Results ES mRNA was expressed in each group, 0.47±0.05 in C group, 0.45±0.04 in non-PD group, 0.46±0.04 in 1.5%PD group, 0.47±0.03 in 4.25%PD group, and no significant differences were found among groups. Score of ES protein expression was O in C group, 2 in non-PD group, 4 in 1.5%PD group, and 9 in 4.25%PD group. MVD was 3.13±1.13 in C group, 5.13±1.14 in non-PD group, 9.00±1.51 in 1.5%PD group, 10.75±1.83 in 4.25%PD group, and significant differences were found among groups. Conclusion Uremia circumstance and non-physiological compatibility peritoneal dialysate can increase ES protein expression and MVD, which may participate in and have effects on the course of peritoneal neoangiogensis.
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Objective To study the combination effects of telmisartan and pioglitazone on the expression of heparanases (HPA) and podocin in the kidney of diabetic nephropathy (DN) rats and its possible mechanism. Methods DN model rats were established by intraperitoneal injection with STZ for 12 weeks. All the DN rats were randomly divided into telmisartan group (T group), pioglitazone group (P group), combination of telmisartan and pioglitazone group (L group), and DN group (D group). Healthy rats were chosen as healthy control group(N group). After garage with drugs for 12 weeks, 24-h urinary protein and serum biochemical indicators were examined. RT-PCR and immunohistochemistry methods were applied to detect the mRNA and protein expression of HPA and podocin. Results Compared with T group and P group, 24-h urinary protein of L group was markedly decreased(P<0.05). Compared with the N group, the level of fasting blood glucose, relative renal weight, BUN and Scr in other 4 groups were markedly increased (P<0.05). Compared with T group and P group, the Scr level and the expression of HPA mRNA and protein in L group was markedly decreased (P<0.05), and the protein and mRNA expression of podoein in L group was markedly increased (P<0.05). Conclusion Combination of telmisartan and pioglitazone can down-regulate the mRNA and protein expression of HPA of glomerular basement membrane and up-regulate the protein expression of podocin of podocyte in DN rats, which may ameliorate the proteinuria.