SURGICAL MANAGEMENT OF PSEUDOANEURYSM COMPLICATING ARTERIOVENOUS FISTULA FOR HEMODIALYSIS

Objective To report surgical experience in pseudoaneurysm (PA) repair of arteriovenous fistula (AVF) for renal hemodialysis. Methods Twenty patients undergoing PA repair of AVF for renal hemodialysis were treated in Central Hospital Conde S. Januario of Macao. Sixteen patients had PAs of AVF in upper extremities, 4 in lower extremities. All patients were treated with surgical therapy. Results All operations were finished without death. One patient suffered from acute thrombosis, recovered without any complication through instant thrombectomy. One patient with postoperative incision bleeding recovered after low molecular weight heparin was ceased. And one AVF could not be mature six weeks later, was recovered after ligation of branch vein. And one patient died due to recurrent cerebral infarction. Conclusion Surgical repair is the best choice for PA of AVF for renal hemodialysis.     

急危重症肾功能衰竭血液净化透析患者颈内静脉置管护理体会

目的：针对颈内静脉置管护理在急危重症肾功能衰竭患者血液透析中的应用,总结出颈内静脉置管的临床护理经验及体会。方法：针对性的对92例急危重症肾功能衰竭患者进行颈内静脉置管术行血液透析治疗,随时跟踪观察患者的治疗情况并及时进行有效科学的护理,详细登记护理体会。结果：穿刺92例,其中右侧颈内静脉84例,左侧颈内静脉8例,均采用seldinger置管技术,穿刺成功,未发生与置管相关的严重并发症。结论：颈内静脉置管术具有操作简便、并发症少、感染率小等特点,经过术后有效的规范对患者颈内静脉置管护理的相关操作,其留管时间相对较长的优势,可在急危重症肾功能衰竭患者血液净化的治疗中推广应用,对肾功能衰竭患者的治疗和恢复具有长远的意义。     

移植肾功能延迟恢复的临床研究

目的 探讨肾移植术后移植肾功能延迟恢复(DGF)的病因及诊治方法.方法 回顾性分析15例肾移植术后DGF患者的临床资料及诊治过程.15例DGF的病因不同,在血液透析的基础上,分别给予急性排斥反应冲击治疗、调整免疫抑制剂,近期移植肾切除后再次原位移植等方法进行治疗.结果 15例患者术后发生急性排斥8例;急性肾小管坏死5例;移植肾静脉血栓1例;环孢素A肾毒性1例,所有患者经治疗.肾功能在术后10～35 d恢复正常.随访0.5～3年,无并发症发生.结论 DGF是肾移植术后常见并发症之一,主要原因是急性排斥和急性肾小管坏死,区别不同原因采用相应治疗,可获得满意疗效.     

20例肾病综合征合并肾静脉血栓的介入性溶栓治疗

目的：探讨经皮选择性肾动脉内注射肾上腺素的肾静脉造影法对肾静脉血栓形成的诊断效果及留置肾动脉、肾静脉导管，区域性溶栓对肾病综合征(NS)合并肾静脉血栓的治疗作用。方法：20例经肾静脉造影确诊有肾静脉血栓形成的NS患者在激素及免疫抑制剂等治疗基础上，用介入性经皮穿刺插管技术，将导管插入到肾动脉及肾静脉，固定后给尿激酶冲击继而予微泵以维持量持续7-14天区域灌注溶栓治疗。结果：20例区域溶栓患者，溶栓后7-14天水肿及腹水消退、尿量增加、尿蛋白减少、肾功能改善。随访并继续常规方法治疗3曲个月，15例完全缓解，5例部分缓解，元明显出血副反应。结论：注射肾上腺素的选择性血管造影方法对肾静脉血栓诊断率高，肾动脉、静脉留置管区域灌注尿激酶方法溶栓效果好，可提高NS治疗缓解率，值得推广。     

血透患者中心静脉置管导致深静脉血栓368例分析

目的探讨血液透析患者经中心静脉置管导致深静脉血栓的病因、治疗以及预防措施。方法回顾性分析血液净化中心421例次留置中心静脉导管患者发生深静脉血栓（DVT）情况,并探讨相关因素与发生DVT之间的关系。结果 8例发生相关深静脉血栓并发症,其中股静脉留置导管7例（87.5%）,锁骨下静脉留置导管1例（12.5%）,两组之间比较有显著性差异（P〈0.01）;8例患者中有4例（50%）是糖尿病肾病,2例（25%）慢性肾小球肾炎,1例（12.5%）高血压肾病,1例（12.5%）多发性骨髓瘤相关性肾炎。糖尿病肾病组与其他疾病组相比有显著性差异（P〈0.01）。带管时间8小时~9个月,平均6.3个月。8例患者留置时间平均7.6个月,与总时间相比具有显著性差异（P〈0.01）。60岁及以上病例中下肢深静脉血栓发生率明显高于60岁以下病例（P〈0.01）。结论 DVT发生与中心静脉置管直接相关,还与年龄、疾病、导管留置时间密切相关。     

Antiphospholipid syndrome with pulmonary artery embolism and multiple venous thromboses

We report a case of a 21-year-old university student with underlying lupus nephritis who presented with recurrent symptoms of fever, haemoptysis, and pleuritic chest pain. CT pulmonary angiogram confirmed pulmonary embolism in the right subsegmental pulmonary arteries. One week later, she developed left renal vein and left common iliac vein thromboses, with new emboli in the left subsegmental pulmonary arteries. We hereforth discuss the diagnostic issues of a patient with systemic lupus erythematosus (SLE) on corticosteroids therapy, and also treatment of the antiphospholipid syndrome.     

Heparin prophylaxis of deep vein thrombosis in patients with a fractured neck of the femur.

A double-blind controlled clinical trial of the efficacy of the prophylactic subcutaneous administration of calcium heparin in preventing deep vein thrombosis has been conducted in 50 patients with a fractured neck of the femur. Heparin was given every eight hours in a dose of 100 international units per kilogram of body weight and was commenced as soon as possible after the patient's admission to hospital. Treatment was continued for two weeks. In the placebo group, 12 of 25 patients developed a deep venous thrombosis and in five of these patients the thrombosis propagated to the thigh. There were no deep venous thromboses in the heparin-treated group during the two weeks of treatment, but four patients developed a deep venous thrombosis within a week of stopping the heparin. The heparin regime was safe; operative blood loss was not increased, nor was there an increased incidence of wound complications as compared to the placebo group.     

Extensive intraglomerular fibrin deposition after renal transplantation: recovery without anticoagulation.

Acute renal failure developed in a 55-year-old man 6 days after he had received a cadaver renal allograft. This was associated with thrombocytopenia. Extensive intraglomerular fibrin deposition was seen in a renal biopsy specimen. He was treated with corticosteroids, azathioprine, cyclophosphamide and hemodialysis with regional heparinization but not with systemic anticoagulation. This was followed by complete recovery of both renal function and histologic damage despite the fact that he did not receive anticoagulant therapy. This suggests that treatment with anticoagulants may not be necessary for all patients with intraglomerular deposits of fibrin.     

血液透析患者颈内静脉置管相关血栓形成的危险因素

目的观察血液透析患者颈内静脉置管血栓发生率及相关风险因素。方法选择首都医科大学附属北京天坛医院首次使用颈内静脉置管血液透析患者53例,B超检测血栓形成情况并分析颈内静脉置管血栓发生率、病变特点及相关风险因素。结果患者血栓发生率为52．8％（28／53）。糖尿病、高脂血症和高同型半胱氨酸血症患者血栓形成比例均显著性增高,其优势比值分别为3．45（95％CI1．89—18．53）,2．69（95％CI2．01～20．21）及2．87（95％CI2．83～15．36）（P〈0．05）。结论糖尿病、高胆固醇血症和高同型半胱氨酸血症是血液透析患者颈内静脉置管血栓发生风险的独立风险因素。     

小儿原发肾病综合征并发急性肾功能衰竭8例临床分析

目的探讨小儿原发性肾病综合征（PNS）并发急性肾功能衰竭（ARF）的临床特点。方法对本院2001年1月～2009年8月收治的578例PNS患儿的临床资料特点进行回顾性分析。结果 578例PNS患儿中8例并发ARF,其发生率为1.38%;8例中7例合并感染。8例患儿确诊后,治疗上主要使用肾上腺皮质激素,2例患儿联合环磷酰胺静脉冲击治疗,2例患儿接受血液透析治疗。经积极治疗后4例患儿肾功能恢复正常,2例肾功能好转,3例单纯型肾病中2例肾功能于2周内恢复。结论感染可能为PNS患儿并发ARF的诱因;单纯型肾病并发ARF经积极综合治疗预后较肾炎性肾病好;积极控制肾病状态有利于ARF的恢复。     

Severe rhabdomyolysis induced acute renal failure, caused by diabetic ketoacidosis

A 23 year-old obese Chinese gentleman was admitted to our hospital with the main problem of conscious disturbance for one day. The physical examination and laboratory data confirmed that this is a case of diabetic ketoacidosis complicated with rhabdomyolysis resulting in acute renal failure three days after admission, and regained his renal function after intensive hemodialysis and other conservative treatment.     

Portal vein thrombosis in a complicated case of Crohn's disease.

Portal vein thrombosis is a rare complication of ulcerative colitis and is invariably fatal. This report describes a patient with severe Crohn''s disease who underwent elective surgery complicated by an anastomotic disruption with faecal peritonitis. Following emergency laparotomy he developed left hypochondrial pain which was a manifestation of splenomegaly consequent upon portal vein thrombosis. Anticoagulation was successful in preventing further spread of the thrombosis as monitored by colour Doppler ultrasound. Severe active disease, surgery and sepsis have been recognized as predisposing factors for thromboembolic complications in inflammatory bowel disease and this patient was exposed to all three. It is conceivable that portal vein thromboses occur more commonly than suspected and ultrasound scanning could ascertain the prevalence if performed prospectively.     

PAIN ABDOMEN AT EXTREME ALTITUDES: SINISTER IMPLICATIONS

2 cases of portal, splenic and superior mesenteric vein thromboses related to prolonged stay at high altitude are presented. Both presented initially with innocuous appearing vague pain in abdomen with no physical signs. Later hepatosplenomegaly, and pleural effusion (left) was also detected. Diagnosis was based on CT scan and colour Doppler study showing thrombosed veins and porto-systemic collateral. 1 patient developed a large splenic haematoma requiring splenectomy. Both were managed with early anticoagulation and have done well in the short follow up.KEY WORDS: High altitude, Mesenteric vein thrombosis, Portal vein thrombosis, Splenic vein thrombosis     

静脉用蔗糖铁治疗血液透析患者肾性贫血的疗效观察及护理思路

目的：分析和研究静脉用蔗糖铁治疗血液透析患者肾性贫血的疗效观察及护理方法。方法我们选取2011年7月至2013年12月血液透析肾性贫血患者62例，将其按数字随机表法分为观察组31例与对照组31例。对照组患者给予维铁缓释片口服治疗；观察组患者给予蔗糖铁静脉滴注治疗，将两组患者治疗效果进行对比。结果观察组患者治疗后的血红蛋白、血细胞比容、血清铁、铁蛋白等检测值明显优于对照组（P＜0．05），具有统计学意义。结论将蔗糖铁静脉给药方法应用于血液透析肾性贫血患者的治疗中，起效快速，能够有效改善患者贫血症状，并且通过精心、细致临床护理，可以提高患者治疗依从性，对提高患者生存质量有重要意义。     

Renal vein thrombosis with recurrent pulmonary emboli in the nephrotic syndrome: use of the Greenfield filter

We describe a case of renal vein thrombosis in association with the nephrotic syndrome. The patient had recurrent pulmonary emboli which, having failed to respond to routine anticoagulant treatment, were managed successfully by the insertion of a Greenfield filter into the inferior vena cava above the renal vein thrombosis site. The only coagulation abnormality in this patient was a deficiency of antithrombin III.     

改良腔门静脉半转位肝移植术(附二例成功报告)

目的:探讨改良的腔门静脉半转位肝移植术治疗门脉系统广泛栓塞的外科处理方法.方法:对2例门脉系统广泛栓塞患者进行改良的腔门静脉半转位肝移植术(采用腔静脉肠系膜上静脉吻合 辅助性门静脉脾静脉吻合重建门脉血流),观察术后肝功能恢复情况、术后门脉血流灌注、术后肾功能不全、下肢水肿及食管胃底静脉曲张等情况.结果:2例患者手术顺利,术后肝功能恢复正常,门脉血流灌注良好,无肾功能不全、下肢水肿及食管胃底静脉曲张等并发症.结论:改良的腔门静脉吻合半转位肝移植术是治疗门脉系统广泛栓塞的有效方法.     

多时相增强CT对肾静脉主干血栓的诊断

目的探讨和研究多时相增强CT对肾静脉主干血栓的诊断价值。方法选取我院近年来收治的13例典型肾静脉血栓患者的CT表现进行回顾性分析。结果患者均不同程度表现出患侧肾脏体积明显增大的现象,但相较对侧正常肾脏而言并无明显形态改变,肾实质密度降低且肾蒂增粗。动态增强的CT检查结果显示,本组患者中均存在明显的肾静脉血栓充盈缺损的影像,包括3例患者存在下腔静脉明显血栓影,位置处在肾静脉的入下腔静脉部位。此检测结果与肾静脉血管造影的检查结果相符合。结论多时相增强CT对肾静脉主干血栓的诊断准确性好,具有较高的临床应用价值。     

肾细胞癌分期与复发的CT诊断

目的 探讨CT对肾癌病人术前分期与术后复发的诊断价值.方法 分析18例经手术病理证实肾细胞癌病人在手术前后的CT表现.右肾10例,左肾8例,术后7例行CT复查,复查时间3个月至1年半,CT发现3例病人有不同形式的复发与转移.使用GE Lightspeed Plus型CT机,全部病例行平扫与增强检查.结果 CT显示肿块位于肾包膜内3例,突破肾包膜并侵及肾筋膜12例,肿块突破肾周筋膜并肾静脉或下腔静脉瘤栓3例,其中1例侵及同侧肾上腺.未突破肾包膜的3例中CT表现与术中所见一致.12例CT显示肾周侵犯者中4例手术中和病理下未见肾周侵犯,为假阳性(4/12,33.3%),病理显示未受侵犯的肾周筋膜呈水肿伴炎性细胞浸润改变.在CT显示肿块突破肾周筋膜产有肾静脉或下腔静脉内瘤栓的3例中,手术所见与病理结果一致,准确性达100%.结论 CT检查可准确描绘原发肿瘤的大小,但对判断原发肿瘤有否突破肾被膜,肾周脂肪与肾筋膜是否受侵犯方面有一定限度,假阳性较假阴性率高.CT对肾细胞癌腹膜后淋巴结转移的假阴性率较高.     

万花油外用结合物理疗法治疗慢性肾衰竭血液透析患者动静脉内瘘血肿48例

目的 观察万花油外用结合物理疗法对慢性肾衰竭血液透析患者动静脉内瘘血肿的临床疗效.方法 将96例慢性肾衰竭血液透析动静脉内瘘血肿患者随机分为对照组和治疗组,每组各48例.对照组给予冰敷、热敷及红外照射的物理治疗,治疗组在对照组疗法基础上加用万花油,两组均治疗至血肿消失.比较两组患者治疗3d后血肿消退情况、血肿局部疼痛评分情况及治疗结束后随访6个月时的并发症发生情况.结果 治疗组血肿消退情况明显优于对照组(P＜0.05).两组治疗后内瘘局部血肿疼痛均明显减轻(P＜0.05),但治疗组治疗后疼痛评分下降程度显著大于对照组(P＜0.05).随访6个月后,治疗组患者内瘘血流不足、静脉炎、内瘘狭窄、血栓形成的发生率均明显低于对照组(P＜0.05).结论 万花油外用结合物理疗法可促进透析患者动静脉内瘘血肿的消退,减轻局部疼痛,减少并发症的发生.     

床边血液透析救治急性肾功能衰竭患者的护理

目的:总结急性肾功能衰竭患者床边行血液透析治疗的护理要点。方法:采用血液透析器、股静脉插管留置或者颈内静脉留置针建立血管通路,保证透析的流量充足,使透析顺利进行。结果:18例经抢救症状改善,2例死亡。结论:重症肾功能衰竭患者床边行血液透析效果理想,患者症状明显改善。