鹿角状肾结石开放取石的术式选择

目的:探讨鹿角状肾结石开放取石的术式选择、预防术中意外切肾和术后失肾的措施。方法:术中根据结石形态与肾脏解剖关系选择术式。对23例鹿角状肾结石患者行开放取石术治疗,左肾鹿角状结石9例,右肾10例,双肾4例。手术前后加强防治感染,术后充分引流,以预防术后失肾。结果:手术均顺利完成,结石均于术中取尽。术中无一例意外切肾。术后1个月随访全部患者的术侧肾脏功能恢复良好。结论:对鹿角结石,根据结石的形态、分布、肾盂类型、肾积水状态和肾实质厚度等因素综合判断,选择合理的术式,能保障手术安全、干净取石。     

影响终末期肾衰竭患者心脏扩大的因素

目的了解成都铁路分局医院血液进化中心终末期肾衰竭并维持性血液透析患者心脏扩大的影响因素,以便提高患者的血液透析质量和生存率。方法回顾本血液净化中心收治的216例终末期肾衰竭并维持性血液透析2月以上患者,根据心脏彩色多普勒检查,分为心脏扩大与心脏未扩大2组,对可能影响心脏扩大的因素:年龄、血液透析病程、每周血液透析时间、高血压、容量超负荷、血红蛋白水平、低蛋白血症等用SPSS10.0软件作Logistic回归分析。结果终末期肾衰竭并维持性血液透析患者216例,心脏扩大者183例,未扩大者33例,心脏扩大的发生率为84.72%。心脏扩大与容量超负荷呈显著正相关,P=0.002,OR值42.619;心脏扩大与高血压呈正相关,P=0.026,OR值15.353;心脏扩大与血红蛋白水平呈负相关,P=0.043,OR值0.934。心脏扩大与年龄、血液透析病程、每周血液透析时间和低蛋白血症无相关关系。结论终未期肾衰竭并维持性血液透析患者心脏扩大发生率高,而容量超负荷、高血压、血红蛋白水平是影响它的关键,高血压及容量超负荷是促进心脏扩大的独立危险因素,血红蛋白水平下降亦是促进心脏扩大的独立危险因素。     

939例慢性肾衰竭患者中医证候临床调查研究

通过对939例慢性肾衰竭患者临床调查,总结分析慢性肾衰竭的辨证分型规律,归纳出慢性肾衰竭的主要证型为脾肾气虚,兼湿热瘀血。     

Individualized Mycophenolate Mofetil Dosing Based on Drug Exposure Significantly Improves Patient Outcomes After Renal Transplantation

Efficacy and safety of mycophenolate mofetil (MMF) may be optimized with individualized doses based on therapeutic monitoring of its active metabolite, mycophenolic acid (MPA). In this 12-month study, 137 renal allograft recipients from 11 French centers receiving basiliximab, cyclosporine A, MMF and corticosteroids were randomized to receive either concentration-controlled doses or fixed-dose MMF. A novel Bayesian estimator of MPA AUC based on three-point sampling was used to individualize doses on posttransplant days 7 and 14 and months 1, 3 and 6. The primary endpoint was treatment failure (death, graft loss, acute rejection and MMF discontinuation). Data from 65 patients/group were analyzed. At month 12, the concentration-controlled group had fewer treatment failures (p = 0.03) and acute rejection episodes (p = 0.01) with no differences in adverse event frequency. The MMF dose was higher in the concentration-controlled group at day 14 (p < 0.0001), month 1 (p < 0.0001) and month 3 (p < 0.01), as were median AUCs on day 14 (33.7 vs. 27.1 mg*h/L; p = 0.0001) and at month 1 (45.0 vs. 30.9 mg*h/L; p < 0.0001). Therapeutic MPA monitoring using a limited sampling strategy can reduce the risk of treatment failure and acute rejection in renal allograft recipients 12 months posttransplant with no increase in adverse events.     

Heart insufficiency in traumatic arteriovenous fistulas

Objective: To analyse the incidence, clinical presentation, and outcome of heart insufficiency in patients with chronic arteriovenous fistulas (AVF). Methodology: From 1991 to 2000 we treated 49 patients with traumatic AVF. The present study included 19 patients with AVF present for 6 months or longer, as it was presumed that these AVF will have an impact on cardiac overload. There were 16 male and three female patients with a mean age of 36 years (17–59). The time from injury to admission varied from 6 months to 33 years. Cardiological examination checked for dyspnoea and palpitation. ECG, chest X‐ray and ECHO‐cardiography were also performed. All AVF were deleted, magistral vessels reconstructed, non‐magistral obliterated, either surgically or by percutaneous embolization. Results: Mean follow up was 44.2 months (3–93). Serious heart insufficiency was seen in two patients only, with AVF in the subclavial vessels. Both suffered from serious heart disease prior to the therapeutic procedures that resulted in iatrogenic AVF, so it was difficult to connect heart insufficiency to the AVF alone. Despite surgical closure of AVF and intensive medical treatment, signs of heart insufficiency remained in both patients. Signs of cardiac overload were seen in six patients with long‐standing AVF in major vessels. Except for one patient who refused surgical closure of femoral AVF, the remaining five were symptom free for cardiac overload during the follow‐up period. Conclusion: In our series, heart insufficiency was an infrequent complication in long‐standing AVF, even when major vessels were involved.     

Thrombotic Micro‐Angiopathy with Sirolimus‐Based Immunosuppression: Potentiation of Calcineurin‐Inhibitor‐Induced Endothelial Damage?

Thrombotic microangiopathy is a rare but important finding in the context of organ transplantation. Acute renal insufficiency in the setting of hemolysis and thrombocytopenia, a triad that constitutes 'hemolytic uremic syndrome', can be associated with, or triggered by, conditions such as verocytotoxin-producing Escherichia coli, viral infections, malignant hypertension, scleroderma, allograft rejection, lupus erythematosus, pregnancy, and medications including mitomycin C, calcineurin inhibitors, and oral contraceptives. After renal transplantation, it can occur, as either a de novo episode, or recurrent disease. Calcineurin inhibitors have long been associated with post-transplantation thrombotic microangiopathy. Sirolimus has been used as a primary immunosuppressant in patients transplanted with a history of earlier hemolytic-uremic syndrome, and also as rescue therapy in patients with calcineurin-inhibitor-associated thrombotic microangiopathy. We describe four cases where there was significant thrombotic microangiopathy in the context of contemporaneous or contiguous calcineurin inhibitor and sirolimus usage. As the intrarenal cyclosporin concentration is thought to be significantly elevated when cyclosporin and sirolimus are used together, this may explain these findings, and mandates caution in their co-administration.     

针刺对肾血管性高血压大鼠的降压效应

目的　探讨针刺对肾血管性高血压大鼠的降压作用及其神经 -内分泌调节机制。方法　采用二肾一夹法制备高血压大鼠模型 ,测定实验各组大鼠血浆内皮素 (ET)、一氧化氮 (NO)含量和心率变异性 (HRV)的动态变化。结果　与模型组相比 ,针刺组血压 (BL 2 3:19.1± 1.1k Pa,ST36:18.1± 2 .5 k Pa)及 ET水平明显下降 (P<0 .0 1) ,其中针刺肾俞组血浆 ET水平 (91.3± 9.45 pg/ ml)较足三里组 (10 8.48± 13.0 6pg/ ml)下降更明显 (P<0 .0 5 ) ;针刺治疗组血浆 NO水平 (BL 2 3:5 0 .3±12 .7μmol/ ml,ST 36:49.71± 8.49μm ol/ m l)显著升高 (P<0 .0 5 )。足三里组针刺后 L F/ HF比值与模型组无明显差异 ,而肾俞组 L F/ HF值 (0 .5 7± 0 .13)明显低于模型组及足三里组 (0 .86± 0 .2 5 )。结论　针刺能降低肾血管性高血压模型大鼠动脉血压 ,肾俞与足三里两穴无明显差异 ,其作用机制可能与自主神经系统、NO及 ET参与的神经内分泌调节作用相关。     

Peritoneal dialysis patient survival: a comparison between a Swedish and a Korean centre.

BACKGROUND: Dialysis patient mortality remains high, and this high mortality may be due to many factors. In peritoneal dialysis (PD) patients, old age, co-morbid diseases, malnutrition, low residual renal function (RRF) and a high peritoneal transport rate have been shown to influence survival, but the relative importance of these factors may differ between different patient populations. Besides, centre practice patterns may differ between centres and may influence patient survival. In addition, the literature suggests that dialysis patient survival may be better in Asian than in Caucasian patients. METHODS: The influence of centre and patient characteristics on patient survival was investigated in 132 Korean and 106 Swedish incident PD patients, who underwent initial biochemical measurements and assessment of adequacy of dialysis, nutritional status, RRF and peritoneal transport characteristics. RESULTS: At the start of PD, Korean patients had a higher prevalence of diabetes, peritoneal Kt/V(urea), peritoneal creatinine clearance and peritoneal fluid removal, and lower body mass index, RRF and dialysate to plasma creatinine concentration ratio (D/P Cr) compared with Swedish patients. Significantly more patients from Korea were placed on temporary haemodialysis before PD (100 out of 132) when compared with Swedish patients (21 out of 106). During the follow-up, there was a significantly higher rate of transfer to other units in Korea and a significantly higher rate of kidney transplantation in Sweden. On Kaplan-Meier analysis, overall patient survival did not differ and relative risk for death was also not different between the two centres even after adjustment for age, diabetes, cardiovascular disease, RRF and D/P Cr. On Cox proportional hazards multivariate analysis, age, diabetes, RRF and D/P Cr were found to be independent predictors of mortality in the combined cohort of patients. While age, diabetes and D/P Cr were independent predictors of mortality in Korean patients, age and RRF independently predicted mortality in Swedish patients. CONCLUSION: Although there were significant differences in centre and patient characteristics, we were unable to confirm a survival advantage for Korean over Swedish PD patients. The results of this study suggest that the reported difference in survival between Asian and Caucasian dialysis patients may have been due, in part, to differences in centre and patient characteristics rather than to race as such. The genetic influence on patient characteristics remains, however, to be elucidated.     

氟伐他汀对老年动脉粥样硬化所致肾动脉狭窄的临床疗效观察

目的观察氟伐他汀对老年肾动脉粥样硬化所致肾动脉狭窄(ARAS)的治疗作用及其抗炎机制。方法将在我院门诊及住院的54例老年ARAS患者,随机分为治疗组及对照组,对照组给予常规降压治疗,治疗组每晚加服氟伐他汀40 mg。比较两组治疗前及治疗后尿蛋白排泄率(UAER)、血肌酐(Scr)、C反应蛋白(CRP)及肾脏血管多普勒超声中肾动脉收缩期峰值速度(PSV)、肾动脉血流加速度时间(AT),肾动脉峰值流速与肾动脉开口处腹主动脉流速之比(RAR)等指标。结果观察期间,两组上述指标均呈下降趋势,治疗组UAER,PSV,AT,RAR下降较对照组明显(P<0.05,P<0.01),治疗组CRP下降明显(P<0.05,P<0.01),对照组CRP变化不明显(P>0.05)。而且在两组血脂正常的老年ARAS所致肾动脉狭窄的患者进行比较分析也得出类似结果。结论氟伐他汀因降低CRP的致炎效应而改善肾动脉狭窄,且不依赖氟伐他汀的降血脂作用。     

盐酸丁咯地尔治疗椎-基底动脉供血不足的效果

①目的　观察盐酸丁咯地尔对椎 基底动脉供血不足的治疗作用。②方法　将 82例椎 基底动脉供血不足病人随机分为两组 ,治疗组 4 2例 ,给予盐酸丁咯地尔 2 5 0mL静滴 ,每日 1次 ;对照组 4 0例 ,给予维脑路通0 .5g、胞二磷胆碱 0 .5 g静滴 ,每日 1次 ,均治疗 7d。检测两组治疗前后血液流变学和血流动力学指标的变化。 ③结果　治疗后治疗组全血高切黏度明显低于对照组 ,椎动脉平均血流速度 (VA)明显快于对照组 ,差异均有显著性(t=3.96 0 ,P <0 .0 1 ;t=2 .0 92 ,P <0 .0 5 )。治疗组治疗后全血高切、低切和血浆黏度明显低于治疗前 ,差异有显著性 (t=2 .74 6～ 2 .95 1 ,P <0 .0 1 ) ;VA、基底动脉平均血流速度 (BA)和外周血管阻力指数 (PI)高于治疗前 ,差异有显著性 (t=2 .732～ 5 .1 0 4 ,P <0 .0 1 )。对照组治疗后血浆黏度、PI明显低于治疗前 ,VA高于治疗前 ,差异均有显著性 (t=2 .1 6 8～ 2 .732 ,P <0 .0 5 ) ;全血高切、低切黏度、BA治疗前后差异无显著性 (t=0 .346～ 2 .0 0 8,P >0 .0 5 )。④结论　盐酸丁咯地尔对椎 基底动脉供血不足有良好的改善作用 ,其疗效明显优于维脑路通加胞二磷胆碱的治疗效果