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Many studies have reported long-term hemodialysis patients with dialysis-related causes (DRP) is to increase mortality in patients with end-stage renal disease and the prevalence of the most common reasons. Cardiovascular disease (CVD) is the main clinical manifestations DRP is the cause of end-stage renal disease leading cause of death, and most CVD are derived from atherosclerosis (AS) complications. Oxidative stress and chronic micro-inflammatory state is a major factor in DRP. Dialysis systems biological incompatibility especially microbial contamination and heat dialysate composition and oxidative stress and chronic micro-inflammatory response are closely related. Oxidative stress in hemodialysis patients with oxidizing substances produced enhanced and increased oxygen radical scavenging system damage, thus forming oxidation and antioxidant imbalance. Contaminated dialysate to promote the generation of reactive oxygen species, accelerated oxidative stress, manifested as lipids, nucleic acids, proteins, macromolecules damage, such as lipid peroxidation product malondialdehyde (MDA), advanced oxidation protein products ( AOPP), myeloperoxidase (MPO) levels increased, while antioxidant enzyme glutathione peroxidase (GSH-Px), superoxide dismutase (SOD) activity decreased. Dialysate bacterial derivatives can stimulate monocyte-macrophage cell synthesis and release of pro-inflammatory cytokines, such as: interleukin -1 (IL-1), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), which are long-term hemodialysis treatment of acute or chronic inflammatory disease of the key media. Which, IL-6 can promote the liver to produce acute phase proteins (C-reactive protein (CRP), serum amylase A) and reduced plasma albumin (Alb) synthesis. Himmelfarb, who believe that in patients with urea in vivo, oxidative stress and inflammation by myeloperoxidase (MPO) linked. Stimulated neutrophils and monocytes produce peroxide and hydrogen peroxide disproportionation product, and can generate both MPO. The MPO is the only body capable machine chloride and hydrogen peroxide into the role of hypochlorous acid enzymes. In vitro, purified human plasma or serum albumin may generate hypochlorous stimulation AOPP, AOPP The concentration of hypochlorous acid with increasing concentration dependence was measured. For hemodialysis patients, the water in contact with the body only through a non-selective semipermeable membrane to achieve, if exposed to contaminated water for dialysis patients may increase oxidative stress and chronic inflammation of the level of progress, so the dialysis water very high purity requirements. American Association for Advancement of Medical Instrumentation (AAMI) recommended ultrapure water standards: Bacterial colonies lt; 0.1CFU/ml, endotoxin levels lt; 0.03EU/ml. Studies show that the use of ultra-pure water can reduce the production of proinflammatory cytokines, reducing non-enzymatic pathway of oxidative stress, raise levels of nutrition, improve anemia; But for monocyte activation, antioxidant enzyme systems, monitoring of specific indicators still not reported. Objective: This study aimed to investigate the dialysis water before and after improvement in maintenance hemodialysis patients the level of oxidative stress and inflammatory effects, and to further explore the relationship between oxidative stress and inflammation, especially inflammation in the body caused by stimulating the release of MPO generated between AOPP problems, and their associated factors. Method: 1. Case selection: maintenance hemodialysis in 36 patients (24 males, 12 females), stable disease, dialysis duration ≥ 3 months, has been ruled out acute infection, vasculitis, and other active disease. The average age was 56.25 ± 11.85 (30-75) years, dialysis median age was 19.50 (3-192) months. 2-3 times a week dialysis patient, every four hours, the application of unfractionated heparin or low molecular weight heparin. 2. Experimental Design: Keep the other treatments the same premise, select the three time points, instead AquabossEcoRO Ⅱ in the water treatment plant and no dead space loop dialysis water circulation line before the switch after the first six months, after switching the first 12 months, respectively, and water samples taken from patients with blood. The serum samples were centrifuged rear -70 ℃ low temperature storage, the indicators as soon as the line is detected. 3. Bacteria, endotoxin Monitoring and oxidative stress, inflammatory markers detection: At the entrance to the dialysis machine dialysis water taken for bacterial culture, endotoxin detection (dynamic turbidity method); oxidation index measured by fluorescence spectrophotometry AOPP, MDA detection thiobarbituric acid (TBA) reaction, GSH-Px activity was detected using 5 ', 5'-dithio-bis-2 - nitrobenzoic acid (DTNB) assay, MPO activity was measured by colorimetry . Inflammatory markers neopterin, TNF-α and IL-6 by ELISA, CRP, and Alb by the hospital laboratory routine determination were used Immunoturbidimetry and bromocresol green method. 4. Statistical analysis: Data were expressed as mean ± standard deviation ((?) ± s) representation; various indicators of repeated measurements using repeated measures analysis of variance, multiple comparisons between groups using LSD test; Mauchly test of sphericity results if P ≤ 0.05, then for freedom for Greenhouse-Geisserε corrected. Any correlation between the two parameters partial correlation coefficients indicate selection. All data were analyzed using SPSS11.5 statistical software processing. Results: 1. Before dialysis water treatment system to improve the number of colonies of bacterial culture (85.05 ± 13.35) CFU / ml, the modified 6 months, 12 months, there was no bacterial growth (F = 121.722, P = 0. 008). Before endotoxin levels in improving the improved 6 months, 12 months, respectively 0.30EU/ml, lt; 0.02 EU / ml, lt; 0.02 EU / ml. 2. Indicators of oxidative stress in patients with AOPP, MDA, GSH-Px, MPO levels in the test three time points was significant difference between (P = 0.034, P = 0.006, P = 0.049, P = 0 .001). Compared with the use of ultra-pure water before 6 months AOPP, MDA, GSH-Px, MPO levels were improved (P = 0.01, P = 0.015, P = 0.027, P = 0.001 ); 12 months further decline in MDA levels (P = 0.009). 3. Patients with inflammatory markers Alb, CRP, neopterin, TNF-α, IL-6 levels at different points in time there was significant difference between (P = 0.003, P = 0.044, P = 0.044, P = 0.036, P = 0.033). Compared with the use of ultra-pure water before six months had elevated levels of Alb (P = 0.015), CRP, neopterin, TNF-α levels were lower (P = 0.005, P = 0.044 , P = 0.033); 12 months of the indicators have improved, the difference was statistically significant (P = 0.002, P = 0.034, P = 0.032, P = 0.039, P = 0.017). 4. Using partial correlation analysis to eliminate the remaining variables. The results showed: ultrapure water before use, CRP and TNF-α with a positive correlation (r = 0.5591, P = 0.002), but negatively correlated with Alb (r = -0.5175, P = 0. 004); IL-6 and TNF-α levels and a positive correlation (r = 0.7712, P lt; 0.001), but negatively correlated with Alb (r = -0.4474, P = 0.015); Replace ultrapure water at 6 months, AOPP and TNF-α levels were positively correlated (r = 0.3881, P = 0.037); replace ultrapure water 12 months, serum AOPP and CRP levels were positively correlated (r = 0.5028, P = 0.005), CRP was positively correlated with MPO levels (r = 0.4089, P = 0.028), MDA and neopterin levels were positively correlated (r = 0.4572, P = 0. 013). Conclusions: 1, when the dialysis water bacteria and endotoxin were significantly decreased when the oxidative stress and inflammation in the detection of indicators in six months significantly improved, and this state can be maintained within 1 year, or further improved. 2, MPO involved in oxidative stress and inflammation, it may also suggest the level of oxidative stress and inflammation indicators. 3, neopterin is closely related with the MDA, indicating that monocyte activation may also cause lipid peroxidation, both of which affect the mutual promotion and common occurrence of atherosclerosis and development. 4, ultrapure water level gradually improved Alb important reason may be related to improvements in inflammatory state.
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