血糖水平及其变异性与重症患者预后关系的前瞻性观察研究

目的 了解血糖水平及其变异性与重症患者预后的关系.方法 采用前瞻性研究方法,对2011年6月至2012年1月入住重症监护病房(ICU)的成人非糖尿病患者进行血糖监测及预后观察,血糖监测终点为转入ICU后72 h,预后观察终点为转入ICU后28 d;计算患者转入ICU时的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分及血糖变异性[血糖标准差(SD)、平均绝对血糖波动幅度(MAGE)、血糖不稳定指数(GLI)].按患者预后分为死亡组与生存组,比较两组间转入ICU时APACHEⅡ评分、平均血糖及血糖变异性的差异;按不同血糖水平分组,比较各组间转入ICU时APACHEⅡ评分、血糖变异性以及28 d病死率的差异.结果 共纳入重症患者85例,与生存组(58例)比较,死亡组(27例)患者转入ICU时APACHEⅡ评分(分:28.9±6.6比23.8±5.9)、平均血糖(mmol/L:11.9±2.9比9.4±1.8)、血糖SD(mmol/L:3.7±1.6比2.4±1.0)、MAGE(mmol/L:0.86±0.46比0.54±0.25)、GLI(255.9±232.7比111.7±110.9)明显升高(均P＜0.05).血糖＞11.1 mmol/L组(22例)血糖SD(4.3±1.4)、MAGE( 1.1 ± 0.4)、GLI( 345.3±210.3)、28 d病死率(63.6％)均明显高于≤11.1 mmol/L组(63例,分别为2.3±0.9、0.5±0.2、91.9±91.2、20.6％,均P＜0.05)和7.8 ～ 11.1 mmol/L组(52例,分别为2.3±0.9、0.5±0.2、85.2±66.4、25.0％,均P＜0.05),而7.8 ～ 11.1 mmol/L组与＜7.8 mmol/L组(11例)间血糖SD(2.0±0.9)、MAGE(0.5±0.3)、GLI( 123.8±166.7)、28 d病死率(0)比较差异无统计学意义(均P＞0.05).结论 血糖变异性与重症患者28 d病死率相关,并可能与APACHEⅡ评分一样能够较好地预测病死率.     

不同模式连续性血液净化对多器官功能障碍综合征患者的影响

目的探讨连续性静脉血液透析滤过(continuous venovenous hemodiafiltration,CVVHDF)和高容量血液滤过(high-volume hemofiltration,HVHF)对多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)患者急性生理学与慢性健康状况评分系统Ⅱ(Acute Physiology and Chronic Health EvaluationⅡ,APACHEⅡ)评分及细胞因子水平的影响。方法 APACHEⅡ评分为15~25分的MODS患者18例,采用CVVHDF治疗9例为CVVHDF组,血流量为150mL/min,透析液流速2 500mL/h,置换液流速为1 000mL/h;采用HVHF治疗9例为HVHF组,血流量为180mL/min,置换液流速2 000 mL/h;2组均采用前稀释法输入,治疗时间24h。分别于治疗前、治疗后记录APACHEⅡ评分,采用ELISA法检测血清谷丙转氨酶(glutamic-pyruvic transaminase,GPT)、谷草转氨酶(glutamicoxaloacetic transaminase,GOT)、尿素氮、肌酐及肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)、白细胞介素(interleukin,IL)-6、IL-10水平。结果HVHF组与CVVHDF组治疗后GPT[(109.26±64.31)、(113.38±35.75)u/L]、GOT[(140.40±21.44)、(127.68±7.66)u/L]、尿素氮[(16.12±5.76)、(16.33±6.62)mmol/L]、肌酐[(300.29±142.96)、(281.97±181.64)μmol/L]、APACHEⅡ评分[(9.33±2.17)、(11.00±2.45)分]均低于治疗前[GPT:(243.16±133.08)、(236.02±189.46)u/L;GOT:(384.79±325.33)、(321.74±62.08)u/L;尿素氮:(28.31±6.22)、(27.68±7.66)mmol/L;血肌酐:(452.78±149.54)、(419.53±248.36)μmol/L;APACHEⅡ评分:(18.44±2.79)、(20.78±2.38)分](P0.05),2组治疗后GPT、GOT、尿素氮、肌酐、APACHEⅡ评分比较差异无统计学意义(P0.05);HVHF组与CVVHDF组治疗后血清TNF-α[(764.59±68.95)、(744.67±96.83)ng/L]、IL-6[(1 554.52±139.50)、(1 628.98±190.47)ng/L]、IL-10[(201.51±49.90)、(228.54±50.67)ng/L]水平均低于治疗前[TNF-α:(979.62±78.41)、(979.95±106.01)ng/L;IL-6:(1 789.50±146.68)、(1 790.53±202.17)ng/L;IL-10:(331.34±63.39)、(316.91±66.67)ng/L](P0.05),HVHF组治疗后血清IL-6水平低于CVVHDF组(P0.05),TNF-α、IL-10与CVVHDF组比较差异无统计学意义(P0.05)。结论 CVVHDF、HVHF均可降低MODS患者APACHEⅡ评分,抑制炎性因子表达,改善患者肝、肾功能,但HVHF降低IL-6水平的作用更明显。     

连续性静-静脉血液透析滤过在心脏外科手术后重症急性肾衰竭的应用

目的 研究连续性静-静脉血液透析滤过(continuous veno-venous hemodiafiltration,CVVHDF)在心脏术后重症急性肾衰竭(acute renal failure,ARF)中应用的疗效.方法 回顾分析20例心脏术后重症ARF患者采用CVVHDF治疗,比较治疗前后血尿素氮(BUN)、肌酐(Cr)、氧合指数(PaO2/FiO2)、APACHEⅡ评分和电解质(K 、Na 及Cl-)的变化,以及CVVHDF过程中血流动力学:心率(HR)、平均动脉压(MAP)及中心静脉压(CVP)的变化.结果 12例存活,8例死亡.CVVHDF治疗后BUN、Cr和血清K 、Na 及Cl-明显下降,而且CVVHDF过程中MAP显著上升,CVP显著下降(与治疗前比较,差异有统计学意义,P＜0.05),HR变化不大.结论 CVVHDF是治疗心脏外科手术后重症ARF的一种有效、方便而安全的方法.     

脓毒性休克患者血中一氧化碳含量的变化与APACHEⅡ评分的关系

目的观察脓毒性休克患者血中一氧化碳含量的变化及其与APACHE Ⅱ评分的关系及意义.方法选择ICU脓毒性休克患者62例,在入ICU 24 h 内对每个患者进行APACHE Ⅱ评分,同时测动脉血中Hb和碳氧血红蛋白(COHb)含量,按照预后分为死亡组24例,存活组38例.另选同期无感染行择期手术的患者为对照组20例,测患者术前动脉血中Hb和COHb含量.结果对照组血中Hb含量为(135.1±9.3) g/L,脓毒性休克患者血中Hb含量较对照组略低,为(126.3±15.4) g/L,但差异无显著性.脓毒性休克患者血中COHb含量明显高于对照组,两组分别为(2.19±0.76)%和(0.64±0.31)%,P＜0.05.脓毒性休克患者APACHE Ⅱ各分段血中COHb含量与病死率随APACHE Ⅱ评分的增加而增加,COHb含量与APACHE Ⅱ评分呈显著正相关关系(r＝0.78,P＜0.05).死亡组血中COHb含量及APACHE Ⅱ评分高于存活组.结论内源性一氧化碳与脓毒性休克的病理机制密切相关,且与APACHE Ⅱ评分呈正相关关系,动态监测血中COHb含量的变化可能为预测病情提供参考.     

低分子肝素治疗脓毒症的前瞻性临床研究

目的 探讨低分子肝素对脓毒症的治疗作用。方法 40例脓毒症患者随机分为常规治疗组和 低分子肝素治疗组。观察两组患者治疗前后急性生理学与慢性健康状况Ⅱ(APACHEⅡ)评分、住重症监护治 疗病房(ICU)时间和28 d病死率差异,以及治疗前后白细胞介素-6(IL-6)、丙二醛(MDA)、超氧化物歧化酶 (SOD)、凝血功能和血小板计数(PLT)变化。结果 低分子肝素治疗组随治疗时间的延长,APACHEⅡ评分 和IL-6水平均下降,治疗后7 d与治疗前比较差异均有显著性(P均<0．05);而常规治疗组呈现先降后升 的趋势;治疗后7 d低分子肝素治疗组APACHE Ⅱ评分和IL-6水平均明显低于常规治疗组(P均<0．05)。 低分子肝素治疗组住ICU时间为(9．92±6．81)d,28 d病死率为40．9％,均低于常规治疗组(12．85±9．14)d 和50．0％,但差异无显著性。低分子肝素治疗组治疗后SOD明显升高[(159．13±99．31)kU／L比(318．38± 254．29)kU／L],MDA明显下降[(17．72±14．89)μmol／L比(6．62±5．53)μmol／L];常规治疗组则均呈相反 的变化趋势[SOD(180．99±169．40)kU／L比(135．16±107．73)kU／L;MDA(17．25±15．74)μmol／L比 (20．77±16．87)μmol／L];治疗后两组比较差异均有显著性(P均<0．05)。两组患者凝血酶原时间(PT)、白陶 土部分凝血酶原时间(KPTT)、纤维蛋白原(FIB)、PLT水平治疗前后差异均无显著性。结论 低分子肝素治 疗脓毒症可抑制炎性介质和氧自由基的释放,临床应用安全,无严重并发症。     

序贯结肠透析对慢性肾功能衰竭早中期的疗效观察

目的探讨序贯结肠透析对慢性肾功能衰竭早期及中期毒素清除及肾脏保护作用。方法对185例慢性肾功能衰竭早中期患者进行序贯结肠透析治疗,采用自动分析仪检测治疗前后尿素氮、肌酐、血尿酸、电解质水平及体重的变化;应用比浊法检测透析前后中分子物质的吸光度;同时观察其临床症状改善情况。结果176例(185例治疗过程中剔除9例)患者中,血尿酸水平较透析前明显下降[(722.71±206.21)μmol/L比(501.56±146.93)μmol/L,P<0.01],肌酐[(318.03±94.92)μmol/L比(280.08±195.18)μmol/L,P<0.05]、尿素氮[(14.85±2.86)mmol/L比(10.39±3.78)mmol/L,P<0.01]及中分子物质吸光度(0.4265±0.2123比0.2828±0.1202,P<0.01)水平也有明显变化;透析过程中及透析后K+、Na+、Cl-、Ca2+水平及体重等均无明显变化;患者临床症状明显改善且无严重不良反应发生。结论序贯结肠透析对慢性肾功能不全早期及中期具有毒素清除及肾脏保护作用。     

间断血液透析与日间连续性肾脏替代治疗法抢救心脏术后急性肾功能衰竭

目的观察血液透析与连续性肾脏替代治疗(CRRT)在心脏术后急性肾功能衰竭患者中的应用效果.方法分别用常规血透、简易床边血透和连续性静脉静脉血液滤过(CVVH)或透析滤过(CVVHDF)治疗25例心脏术后急性肾功能衰竭患者.结果2例常规血透患者因循环稳定、无并发症全部康复.23例行床边治疗,其中简易血透的15例,死亡8例,占53.3%;8例日间CVVH或CVVHDF患者死亡3例,占37.5%,但两组死亡率差别不显著.简易透析和滤过均能有效清除体内多余水分,纠正高钾血症,血尿素氮、肌酐较透析前有不同程度下降.死亡组患者衰竭脏器数明显多于存活组(2.80±0.92vs1.57±0.64,P＜0.01),首次透析治疗前血肌酐浓度高于存活组(412.6±200.6μmol/Lvs292.9±138.5μmol/L,P＜0.05).结论影响心脏术后急性肾功能衰竭患者死亡率的一个重要因素是受累脏器的个数,早期血液净化治疗可能改善患者预后;虽然差别不显著,但CRRT治疗组死亡率有下降趋势.     

APACHEⅡ与SAPSⅡ评分系统对急诊内科危重患者病情评估价值的比较

目的评价急性生理与慢性健康状况评分Ⅱ(APACHEⅡ)评分系统和简化急性生理学评分Ⅱ(SAPSⅡ)评分系统在急诊内科危重患者病情评估中的适用性和可行性;比较二者评价效力的优劣.方法对207例急诊内科危重患者分别进行APACHEⅡ、SAPSⅡ评分和计算预计死亡危险度,以校准度及分辨度评价其预测效力.结果存活组(178例)与死亡组(29例)之间的APACHEⅡ和SAPSⅡ分值差异有统计学意义(P<0.01),死亡组患者分值[(22.66±7.30)分,(52.48±11.59)分]明显高于存活组患者[(11.26±6.32)分,(33.12±11.67)分].随着分值增加,病死率也增加.APACHEⅡ的预计死亡危险度(18.81%)与实际病死率(14.01%)之间差异无统计学意义(P>0.05),即APACHEⅡ能准确预测病死率.而SAPSⅡ则不能,SAPSⅡ的预计死亡危险度(23.51%)高于实际病死率(P<0.05).APACHEⅡ和SAPSⅡ都有较大的ROC曲线下面积(>0.85),其分辨度好,能较好区分可能死亡的患者和可能存活的患者.结论APACHEⅡ和SAPSⅡ评分系统均有较好的分辨度;APACHEⅡ的校准度优于SAPSⅡ.临床上对急诊内科危重患者病情的评价及预测预后宜以APACHEⅡ为首选.     

动态APACHEⅡ评分在重症急性胰腺炎中的应用价值

目的:探讨动态APACHEⅡ评分在预测重症急性胰腺炎严重度及预后中的作用。方法:将34例重症急性胰腺炎患者分成两组。A组:胰腺感染组,动态观察该组患者的APACHEⅡ评分;B组:未继发胰腺感染组,观察其入院第一天的APACHEⅡ评分。结果:A组感染后的APACHEⅡ评分为21.10±4.52.明显高于发生胰腺感染前13.25±1.74及B组评分11.36±1.65(P<0.01);A组中死亡患者及存活患者在感染后同期的APACHEⅡ评分有差异(P<0.05)。结论:动态APACHEⅡ评分在预测重症急性胰腺炎严重度及预后中有重要作用。     

连续性血液净化在急性肾功能衰竭伴多器官功能障碍综合征中的应用

目的　观察连续性血液净化治疗 (CBP)对急性肾功能衰竭 (ARF)及多器官功能障碍综合征 (MODS)的应用。方法　采用CBP的主要模式CVVH治疗 2 6例ARF合并MODS患者 ,检测治疗前及第 2 4、4 8、72小时后其血浆生化、水电解质及酸碱平衡、血常规等变化 ,观察疗效 ,结果 2 6例患者治疗前Cr 12 16 5 6± 2 96 84 μmol/L ,BUN 4 5 80± 18 4 0mmol/L ,WBC(15 70± 10 96 )× 10 9/L ,pH 7 10± 0 2 6 ,BE - 11 4± 3 76mmol/L ,AG 34 5 0± 6 34,K 7 0 6± 1 83mmol/L。CBP治疗后Cr181 4 2± 4 6 10 μmol/L ,BUN 14 5 0± 15 86mmol/L ,WBC(7 74± 3 86 )× 10 9/L ,pH 7 4 1± 0 0 6 ,BE 2 7± 0 96mmol/L ,AG 11 12±4 0 1,K 3 86± 0 72mmol/L。各观察指标治疗前后比较好转显著 (P <0 0 1)。 2 6例患者中 16例 (6 1% )度过疾病的急性期 ,10例 (38% )在急性期死亡。观察APACHEⅡ评分 >2 0分 ,高龄、合并肾外脏器衰竭及严重感染、应用机械通气及低血压等因素与患者预后相关。结论　①CBP以其有效的清除效应 ,稳定的血流动力学 ,实现机体内环境稳定 ,成为危重患者的重要支持疗法 ;②可提高MODS患者的存活率及预后 ;③MODS患者预后受APACHEⅡ评分、年龄、合并肾外脏器衰竭等多因素影响。     

慢性肾病的彩色多普勒研究

以彩色多普勒检测３８例慢性肾病患者（７６只肾）和３２例正常对照者（６４只肾）的肾门动脉，叶段动脉，叶间动脉的最大流速和最小流速以及阻力指数，结果发现肾门动脉、叶段动脉及叶间动脉最大流速（Ｖｍａｘ），最小流速（Ｖｍｉｎ），均低于正常对照组（Ｐ＜０．００１），肾门动脉、叶段动脉和叶间动脉阻力指数高于对照组（Ｐ＜０．００５）。同时用二维测量肾脏大小，发现肾脏大小和肾内各段动脉阻力指数呈负相关，与肾内各段动脉最大流速呈正相关。     

Renal colic: A diagnostic and therapeutic review

Renal colic is a common presenting problem in emergency departments where the focus of treatment is on prompt analgesia, limited supportive investigations and exclusion of other serious disorders. This review gives an overview of the pathophysiology of this condition and those aspects of its care that are specific to the emergency department. The role of narcotics and non-steroidal anti-inflammatory drugs in treatment is examined, and the available imaging techniques are described and evaluated. Alternative diagnoses and indications for hospital admission are discussed.     

Spontaneous renal tract rupture from obstructing vesico‐ureteric junction calculus

Spontaneous or non‐traumatic rupture of the renal tract is an infrequent presentation, and it is most frequently caused by ureteric obstruction. Rupture could occur at any level of the upper urinary tract. However, it is most common at the renal calyces and complications that could arise include; urinoma, and or hematoma collection which could progress to abscess formation and sepsis. We report a 77‐year‐old male patient who attended the emergency department following referral from his general practitioner with a 6‐day history of progressively worsening left sided abdominal pain. Due to his co‐morbidities, presenting blood pressure and age, he was suspected of having an aortic dissection or ruptured abdominal aortic aneurysm and subsequently had a CT (computed tomography) Angiogram. This showed extravasation of contrast from the left kidney with a 12 mm obstructing vesico‐ureteric junction calculus necessitating urgent urology referral and prompt review. He was worked up for a ureteric double J stent insertion, however, the procedure was unsuccessful due to complex multiple urethral strictures. The patient subsequently had a nephrostomy inserted and was planned for optical urethrotomy, rigid cystoscopy, rigid/flexible ureteroscopy, and laser stone fragmentation of left obstructing vesico‐ureteric junction calculus.     

肾脏病理结合肾功能显像评价慢性肾病残余肾功能的临床意义

目的探讨肾脏病理结合肾功能显像综合评价慢性肾病(CKD)残余肾功能的临床意义。方法 105例临床初步诊断为慢性肾炎伴慢性肾功能不全患者,同时进行经皮肾穿刺活组织检查及99 Tcm-DTPA肾动态显像(ECT)检查,对CKD残余肾功能进行综合评价,并确定治疗方案,动态观察CKD进展情况,回顾性验证两种检查方法对CKD残余肾功能判断的可靠性。结果 105例CKD患者中,肾脏病理显示肾小球硬化及肾小管间质慢性化程度,多数情况下(92%)与ECT对于CKD残余肾功能的判断是相符的,但8%的患者二者并不相符。根据形态学及功能学检查结果,所有2～5期的CKD患者共105例进行相应的治疗,随访2～3年,共35例进入透析。结论 对于各种CKD的诊断除病因诊断外,肾组织病理形态学诊断及肾脏功能诊断两者间既不能相互替代,又密不可分。仅根据CKD肾脏组织病理形态学判断CKD残余肾功能具有局限性。结合肾功能显像进行综合评价,正确评估保护CKD残余肾功能的治疗价值,对CKD治疗方案的确定具有重要临床指导意义。     

Benign essential tremor

Exposure to air pollution or a case of the common cold, which means little to a person with normal lung function, can be very serious to a patient with chronic obstructive pulmonary disease. It is helpful for primary care and emergency department physicians to know how to assess the severity of acute exacerbations and how to arrest deterioration of respiratory function. Dr Hagedorn describes pharmacologic treatment as well as mechanical ventilation in these patients.     

High venous pressure in the main renal vein causing development of peritransplant venous collaterals in renal transplant patients: a rare finding

We will show the sonographic appearance of peritransplant venous collaterals in renal transplants with renal venous hypertension. Three cases of renal transplants with pericapsular vessels were identified at our institution. Two cases were related to renal vein thrombosis. The third case had pericapsular vessels secondary to venous hypertension from arterialization of the transplant renal vein by a preexisting right thigh arteriovenous graft. The development of high venous pressures in renal transplants leading to the collaterals' venous drainage has been rarely described. This finding should be recognized as a rare complication of renal transplants but does not necessarily lead to transplant failure.     

Sonographic mimics of renal calculi.

OBJECTIVES: To review sonographic findings that can mimic renal calculi. METHODS: We comment on a number of echoes that can mimic renal calculi. RESULTS: There are a number of sonographic renal artifacts, vascular and nonvascular, that may confound a correct diagnosis. CONCLUSIONS: Awareness of these potential artifacts will result in a more specific sonographic examination and will accurately guide the referring physician toward appropriate patient treatment. The importance of other imaging modalities is also emphasized to ensure that a correct diagnosis is obtained whenever the sonographic findings are inconclusive.     

Autosomic dominant polycystic kidney disease and metformin: Old knowledge and new insights on retarding progression of chronic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most common congenital kidney disorder, generally caused by mutations in the PKD1 and PKD2 genes, coding for polycystins 1 and 2. Its pathogenesis is accompanied by alterations of the cAMP, mTOR, MAPK/ERK, and JAK/STAT pathways. ADPKD is clinically characterized by the formation of many growing cysts with kidney enlargement and a progressive damage to the parenchyma, up to its complete loss of function, and the onset of end-stage renal disease (ESRD). The current aim of ADPKD therapy is the inhibition of cyst development and retardation of chronic kidney disease progression. Several drugs have been recently included as potential therapies for ADPKD including metformin, the drug of choice for the treatment of type 2 diabetes mellitus, according to its potential inhibitory effects on cystogenesis. In this review, we summarize preclinical and clinical evidence endorsing or rejecting metformin administration in ADPKD evolution and pathological mechanisms. We explored the biology of APDKD and the role of metformin in slowing down cystogenesis searching PubMed and Clinical Trials to identify relevant data from the database inception to December 2020. From our research analysis, evidence for metformin as emerging cure for ADPKD mainly arise from preclinical studies. In fact, clinical studies are still scanty and stronger evidence is awaited. Its effects are likely mediated by inhibition of the ERK pathway and increase of AMPK levels, which are both linked to ADPKD pathogenesis.     

移植肾动脉狭窄介入治疗的彩色多普勒超声评价

目的：探讨彩色多普勒血流显像技术（CDFI）评估移植肾动脉狭窄经皮血管成形术（PTRA）和支架植入术（PTRAS）疗效的应用价值。方法：对11例移植肾肾动脉狭窄者于介入治疗前、后行CDFI检查并每隔3－4个月随访复查,取多普勒参数肾内段动脉血流加速度（Ac)和主肾动脉峰速度（Vp)进行统计学分析。结果：介入治疗后Ac显著增加,Vp明显减低,治疗前后差异有显著性意义（P＜0．01）。植入的支架呈并行相间的线样回声,支架出、入口血流速度最高,依次大于支架内、大于支架外流速。术后并发症包括支架脱落、假性动脉瘤、静脉血栓和再狭窄,均经CDFI准确诊断从而得以及时处理。结论：CDFI检查是评价移植肾动脉狭窄介入治疗近、远期疗效和诊断并发症的理想、可靠方法。     

Challenges and Considerations When Using Shear Wave Elastography to Evaluate the Transplanted Kidney,With Pictorial Review

The gold standard in evaluating renal allograft dysfunction has traditionally been renal biopsy. However, not only does biopsy come with inherent risks, the time frame from biopsy to detecting renal dysfunction is often inefficient. It is therefore advantageous to have a noninvasive, low‐cost, time‐saving method, such as shear wave elastography (SWE), to detect fibrosis early, to maximize immunosuppressive care. It is important to consider factors that affect tissue stiffness in the kidney, as well as the challenges incurred when using SWE in this anisotropic organ, in order to select the most appropriate patients for this exam.