Ⅳ型心肾综合征中医证候分布及相关因素分析

目的:探讨Ⅳ型心肾综合征(CRS)中医证候分布特点及规律,尝试临床理化指标与中医辨证理论相结合,探索两者之间是否存在内在联系,为Ⅳ型CRS中医辨证论治提供理论依据。方法:本研究选取2011年01月~2016年12月在北京中医药大学东直门医院肾病科及心血管科住院符合纳入标准的Ⅳ型CRS患者154例,分为正虚和邪实各5个证型。归纳Ⅳ型CRS中医证候分布规律及与临床指标之间的相关性。结果:Ⅳ型CRS在正虚证候中:气虚证在CKD2期、心功能Ⅱ级多见,阳虚证在CKD5期、心功能Ⅲ级多见,气阴两虚证在CKD3期、心功能Ⅳ级多见,阴阳两虚在CKD5期、心功能Ⅳ级多见;在标实证候中:湿浊证、水气证、血瘀证、痰饮证在CKD5期、心功能Ⅳ多见,湿热证在CKD3期、心功能Ⅱ级多见。正虚证积分与心、肾功能相关性分析表明:阳虚证积分与e GFR(P=0.002<0.05)呈负相关,气阴两虚证积分、阴阳两虚证积分与BNP(P=0.000<0.05)呈正相关。标实证积分与心、肾功能相关性分析表明:湿浊证积分、水气证积分、血瘀证积分均与e GFR呈负相关(P<0.05),水气证积分、血瘀证积分与BNP呈正相关,与射血分数呈负相关(P<0.05)。结论:气虚证是心肾综合征患者早期发病的主要证候表现,晚期以阳虚证及阴阳两虚证为主要证候表现,湿浊、水气、血瘀互结是造成病情恶化主要病因;CRS患者以肾功能加重为主时,阳虚证表现明显,以心功能加重为主时,气阴两虚证及阴阳两虚证表现明显;水气证、血瘀证候贯穿疾病各个阶段,加速心、肾功能恶化。     

维持性血液透析患者后腹腔镜肾癌根治术的安全性

目的探讨后腹腔镜根治性肾切除术治疗维持性血液透析合并肾癌患者的安全性。方法回顾性分析我院2013年1月~2019年3月9例终末期肾病(维持性血液透析)合并肾癌患者的临床资料。肿瘤最大径平均3.7 cm(1.2~5.4 cm),临床分期T 1N 0M 0。维持性血液透析时间19~62个月,平均50个月。均行后腹腔镜根治性肾切除术。术前改善全身一般状况并加强血液透析,围手术期予普通血液透析和无肝素血液透析相结合的方法行肾脏替代治疗,术中、术后限制性补液。结果9例手术均顺利完成,无中转开放、术中输血及死亡。手术时间67~160 min,平均102.9 min。术中出血量40~120 ml,平均73.3 ml。术后第1天即行无肝素血液透析,恢复普通血液透析时间6~7 d。术后急性左心衰竭1例,皮下气肿1例,均对症治愈。术后住院时间7~12 d,平均8.1 d。术后随访5~70个月,平均35个月,均存活,未见肿瘤复发及远处转移,继续血液透析。结论只要术前准备充分,围手术期周密管理,加之个体化补液和及时血液透析,维持性血液透析患者并发肾癌行后腹腔镜手术安全有效。     

结石CT值测定联合输尿管软镜治疗大负荷肾结石

目的探讨输尿管软镜下单次碎石治疗CT值≤800 HU、直径≥2 cm的肾结石的有效性、安全性和可行性。方法2016年1月~2018年12月我科对30例CT值≤800 HU、直径≥2 cm的肾结石行输尿管软镜下碎石。术前常规放置输尿管支架管2周。全麻后放置输尿管软镜鞘,沿鞘置入F 9.8 Olympus电子输尿管软镜,插入200μm或365μm(结石位于肾盂者)钬激光光纤,钬激光碎石能量设置为1.0 J,频率20~30 Hz,逐步粉碎结石。粉碎后较大结石碎片套石网篮取出。术后留置输尿管支架管1根。结果30例均顺利放置镜鞘并置入输尿管软镜,一次进镜成功率100%。手术时间50~90 min,平均75 min。均无二次手术。28例手术成功,2例术后有残余结石(直径分别为8、10 mm),行体外冲击波碎石术后2~3周排出。5例术后发热,经加强抗炎输液对症处理后,体温降至正常。无输尿管穿孔、出血等并发症。术后住院2~4 d,平均2.4 d。术后随访1年,2例复发,3例发现肾结晶,无特殊处理。结论CT值≤800 HU的大负荷肾结石行输尿管软镜下碎石安全、有效、可行。     

腔镜不停跳术对左心瓣膜置换术后远期三尖瓣重度反流疗效分析

目的 总结左侧心脏瓣膜置换术后远期出现孤立性重度三尖瓣关闭不全患者的腔镜辅助不停跳三尖瓣手术治疗经验。方法 11例心脏瓣膜疾病患者行左心瓣置换术后远期发生重度三尖瓣关闭不全并右心衰竭,8例出现心脏恶病质综合征及肝肾功能不全,予行再次三尖瓣手术,包括人工瓣环成形术2例,行三尖瓣置换术9例,其中置换生物瓣5例,双在叶机械瓣4例;在腔镜辅助下行心脏不停跳再次手术5例,常规再次心脏停搏手术6例。结果 2例围术期死亡,均为停跳组瓣膜置换病人。术后心包引流液量心脏不停跳组明显少于停跳组（P<0.05）。停跳组术后严重低心排血量综合征4例,不停跳组1例。两组术后1月复查超声心动图,右心房、室均明显缩小,三尖瓣无或少量反流,两组间无明显差异。获长期随访5例、随访时间25~86月、心功能Ⅱ级3例、Ⅲ级2例。结论 左心瓣膜置换术后远期孤立性重度三尖瓣关闭不全合并右心衰的再次手术死亡率高、合理掌握手术指征、手术时机、积极开展微创不停跳手术和良好的围术期治疗是手术成功的关键。对于终末期病例,手术死亡率高,应积极开展针对右心系统的心脏超声及磁共振检测指标,综合评估手术风险,常规换瓣手术指征需慎重,必要时可考虑微创经皮导管瓣膜植入术。     

Impact of serum uric acid on renal function after bariatric surgery: a retrospective study

BackgroundDespite a known negative association between serum uric acid level (SUA) and renal function, this correlation in patients after bariatric surgery remains unknown.ObjectiveTo assess correlation between postoperative SUA and estimated glomerular filtration rate (eGFR) at 12 months after bariatric surgery.SettingA single tertiary referral center.MethodsA total of 252 patients (age = 40.5 ± 11.2; body mass index = 39.0 ± 5.5 kg/m²) undergoing bariatric surgery divided into 2 groups (i.e., normal renal function [90 ≤ eGFR < 125 mL/min/1.73 m², n = 176] versus renal function impairment [eGFR < 90 mL/min/1.73 m², n = 76]) were assessed for relationships between SUA and eGFR in both groups (primary endpoint) and associations of percentage weight loss with changes in SUA (△SUA) and eGFR (△eGFR) for all patients (secondary endpoint) at 12 months.ResultsOverall, prevalence of hyperuricemia was 40.4% and 22.2% (baseline and postoperative 12 mo, respectively). Reverse relationship was observed between SUA and eGFR (r = −.152, P = .007) for all patients with no association noted between baseline SUA and eGFR in each group as well as between SUA and eGFR at 12 months in the normal group (r = −.076, P = .437). The reverse relationship was found (r = −.417, P = .005) in renal function impairment group for whom SUA was identified as a predictor of eGFR at 12 months. There was no association of percentage weight loss with △SUA (r = .089, P = .601) and △eGFR (r = −.046, P = .785).ConclusionThe results demonstrated a negative relationship between postoperative SUA and renal function in patients with preexisting renal dysfunction undergoing bariatric surgery. Clinical significance of our findings warrants further investigation.     

Tripolar Articulations as a “High Stability Bearing” for Revision Total Hip Arthroplasty: Success Rates and Risk Factors for Failure

BackgroundUnconstrained tripolar articulations have been theorized to increase hip stability. The purpose of this study is to report the performance of tripolar articulations in revision THA and identify factors associated with success and failure.MethodsBetween 1994 and 2016, 67 revision THAs were performed with an unconstrained tripolar articulation. Mean follow-up was 5.4 years. Patient charts were retrospectively reviewed emphasizing factors associated with risk of instability. There were 21 patients with neither a history of instability (HI) nor abductor insufficiency (AI), 20 patients with HI alone, 13 with AI alone, and 13 had both HI and AI.ResultsTwelve THAs sustained at least one postrevision dislocation at an average of 2.1 years. One bipolar dissociation occurred early (1.2 y). Nine hips had a re-revision to address these complications. Survival free from dislocation at 2, 5, and 10 years was 88%, 85%, and 74%, respectively. Survival free from re-revision at 2, 5, and 10 years was 91%, 84%, and 65%, respectively. Patients with combined AI and HI had the worst survivorship free from dislocation at 2, 5, and 10 years (77%, 68%, and 55%), respectively. In contrast, patients with neither HI nor AI experienced zero dislocations. There were no failures associated with bearing wear.ConclusionOff-the-shelf tripolar articulations were associated with reasonable survival at midterm follow-up. In patients with both AI and HI, the risks and benefits of alternative options such as dual mobility or constrained liners should be explored as the risk of dislocation at 10 years approached 50%.     

Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation

BackgroundSeveral reports have indicated that suprarenal (SR) fixation may impair renal function after endovascular abdominal aortic aneurysm repair (EVAR). However, most were short-term or at most, 1-year observational studies; therefore, the midterm effects on renal function remain unclear. This study aimed to identify predictors of midterm renal dysfunction after EVAR and compare renal outcomes in patients after EVAR with SR and infrarenal (IR) fixation.MethodsA total of 467 patients who underwent EVAR of nonruptured IR abdominal aortic aneurysm between 2007 and 2014 were reviewed in a prospectively collected database. Patients on hemodialysis at baseline were excluded. Among the remaining patients, those with 3-year laboratory testing were included in this study. Patients who developed acute kidney injury were excluded from the late renal function estimation. Predictors of 3-year renal function decline were estimated using logistic regression analysis. In addition, patients undergoing EVAR with IR (IR group) and SR fixation devices (SR group) were propensity matched by age, sex, baseline renal function, baseline aneurysm diameter, comorbidities, smoking habits, and regular use of medicines that may act on kidney function. Changes in renal function after surgery were compared between the IR group and the SR group.ResultsDuring the study period, 237 patients (102 IRs and 135 SRs) were followed up with laboratory testing 3 years after surgery. Logistic regression analysis revealed that the use of a SR fixation device was independently predictive of a more than 20% decrease in the estimated glomerular filtration rate at 3 years after EVAR (odds ratio, 2.06; 95% confidence interval, 1.18-3.58; P = .011). Eleven patients who developed acute kidney injury (1 IR and 10 SRs) were excluded from the subsequent analysis. After propensity score matching, 87 pairs were selected (mean age, 77.2 ± 6.3 years; 151 males [86.8%]). The mean follow-up duration was 5.5 ± 1.8 years. In the SR group, estimated glomerular filtration rate at 3 years after surgery decreased significantly more than that in the IR group (mean of 17.8% vs 11.6%, respectively; P = .034).ConclusionsThis study suggests that, compared with EVAR with IR endograft fixation, EVAR with SR endograft fixation is associated with worse outcomes for midterm renal function.