维生素 D、非含钙的磷结合剂与含钙的磷结合剂对慢性肾脏病患者血管钙化进展的影响

【目的】探讨维生素 D、非含钙的磷结合剂与含钙的磷结合剂对慢性肾脏疾病患者血管钙化进展的影响。【方法】随机选取本院自2010年1月至2014年12月收治的78例慢性肾脏病患者作为研究对象,按就诊顺序编号,参照随机数字表法分为 A、B 两组,每组39例,均采用维生素 D 治疗,A 组在此基础上加用非含钙的磷结合剂碳酸镧治疗,B组则采用常规含钙的磷结合剂醋酸钙治疗,比较治疗前后两组血钙、血磷、钙磷乘积、全段甲状旁腺激素(iPTH)水平的变化,比较两组维生素 D、钙磷结合剂使用情况,配合影像学检查评估患者冠脉钙化积分(CACs)的变化,统计治疗期间不良事件发生率。【结果】①治疗后,两组血磷、钙磷乘积、iPTH 水平均较治疗前明显降低,但两组间相比较差异无显著性(P >0.05),A 组血钙水平降低至(2.24±0.17)mmol/L,降低幅度高于 B 组,两组相比较差异有显著性(P <0.05);②A 组磷结合剂摄入量为(1719.21±410.22)mg/d,明显低于 B 组的(4913.34±1332.26)mg/d,两组相比较差异有显著性(P <0.05);③B 组中重度钙化分别占20.51%、10.26%,均高于 A 组(P <0.05);④A 组不良事件发生率为10.26%,明显低于 B 组的48.72%,两组相比较差异有显著性(P <0.05)。【结论】在慢性肾脏病血管钙化的防治中,采用维生素 D联合非含钙的磷结合剂碳酸镧干预,血钙控制效果好,不良事件发生率低,可延缓患者血管钙化进展。     

Urinary calculi composition in patients with spinal cord lesions

Because of the reported production of predominantly phosphatic calculi by hypercalciuric patients there was a need to confirm the analysis of such stones using quantitative methods. Calcium, magnesium, ammonium, orthophosphate, oxalate, carbonate and urate were therefore determined in 148 calculi from 113 patients with spinal cord lesions. There were 145 (98%) composed of calcium phosphate and magnesium ammonium phosphate. Only trace amounts of calcium oxalate were present in most. The remaining 2% were calcium oxalate stones. The ratio of nonoxalate calcium to magnesium was inversely related to the duration of paralysis. This study revealed that, when this variable was taken into account, the composition of a stone was not related to its weight, site of occurrence, level of the cord lesion, sex of the patient, or therapy with acidifying drugs.     

彩色多普勒闪烁伪像在泌尿系结石定性诊断中的应用价值

目的探讨彩色多普勒闪烁伪像对泌尿系不同化学成分结石的定性诊断价值。方法选出500例彩色多普勒超声检查有不同闪烁伪像的典型泌尿系结石患者,其中肾结石260例,输尿管结石200例,膀胱结石40例。对每例患者逐一编号后,在超声检查时叠加彩色多普勒并详细记录和保存每一块结石在体内产生闪烁伪像的图像情况,嘱患者将治疗后排出体外的结石送回,编号与原编号相同,然后化验结石成分。结果500例结石患者动态情况下闪烁伪像显示率达96.8%(484/500)。化验证实,二水草酸钙结石占32.0%,沿结石声影方向形成五彩束状伪像;磷酸钙结石占15.5%,结石表面五彩点状伪像,动态时形成"彗星尾征"的束状伪像;磷酸镁结石占19.5%,结石表面五彩团状伪像;混合成分的结石占15.0%,呈点状闪烁伪像;一水草酸钙结石1.7%,氨类结石占1.7%,酸类结石及有机物结石等共占14.6%,均无闪烁伪像。结论充分利用彩色多普勒闪烁伪像通过体外检查基本可达到对体内结石的定性诊断。     

湖南地区163例儿童泌尿系结石临床资料与结石成分分析

【目的】研究湖南地区儿童泌尿系结石的临床特点与结石成分。【方法】收集2013年6月至2014年10月在本院住院手术并取得结石标本的163例儿童资料,对结石进行红外光谱分析,对患者的临床资料进行回顾性分析。【结果】163例资料中男女比例约为3．7：1115（70．6％）例发生上尿路结石,36例（22．1％）发生下尿路结石,12例（7．4％）合并上下尿路混合结石。左侧、右侧和双侧上尿路结石儿童分别为41例（25．2％）、57例（35．o％）和29例（17．8％）。结石成分显示110例（67．5％）含有草酸钙成分,62例（38％）含有磷酸钙成分,23例（14．1％）合有感染性成分,53例（32．5％）含有尿酸成分,14例（8．6％）含有胱氨酸成分以及3例其他类结石成分。77例（47．2％）为单一成分结石,以单纯草酸钙类结石为最常见,其次为单纯尿酸类结石,86例（52．8％）为混合性结石,以草酸钙＋磷酸钙最常见,其次为草酸钙＋尿酸类。【结论】湖南地区儿童泌尿系结石各年龄阶段均有发生,在性别上主要以男性为主,发病部位主要为上尿路结石,结石成分中含草酸钙成分最多,其次为磷酸钙以及尿酸,约52．8％的儿童泌尿系结石为两种及以上混合成分结石。     

Nephrocalcinosis: molecular insights into calcium precipitation within the kidney

Nephrocalcinosis may be defined as a generalized increase in the calcium content of the kidneys. This renal calcification may occur at a molecular, microscopic or macroscopic level leading to progressive amounts of renal damage. The major causes include those associated with an increase in urinary levels of calcium, oxalate and phosphate. Under these conditions, urine concentration and supersaturation leads to calcium crystal precipitation, which may be an intratubular event or initiate within the renal interstitium. The focus of discussion concerning renal calcification is often limited to factors that lead to renal stones (calculi and nephrolithiasis); however, nephrocalcinosis is a more sinister event, and often implies a serious metabolic defect. This review will discuss the hypotheses concerning initiating lesions of nephrocalcinosis using available laboratory and clinical studies and will examine whether new understanding of the molecular basis of tubulopathies, that lead to nephrocalcinosis, has given further insights.     

A wet chemistry method for the analysis of urinary calculi

A procedure for the routine investigation of urinary calculi is described. The investigation scheme was based on existing methods in the routine laboratory for calcium(II), magnesium(II), phosphate and urate in serum. The substance content of oxalate was calculated as non-phosphate-bound calcium(II). Furthermore the test for cystine in urine was utilized. Two specially designed tests were used, one for carbonate apatite and one for verification of the presence of oxalate. The scheme was applied to 30 specimens of human origin. The sum of the mass fractions of identified and calculated components in the calculi was found to be 0.88 on the average (s = 0.05). Low values for this sum may serve as an indication of the presence of rare components that are not included in this analytical programme. A few calculi containing rare components required special methods for the investigation and are most conveniently investigated in a specialized laboratory using X-ray diffraction or infra-red spectrometry. In this paper, however, we describe wet chemistry methods, suitable for reliable cystine determinations and for oxalate in calculi containing, for example, brushite, where the calculated oxalate value is uncertain. These methods may be used as an alternative to the physical methods for many of the rare calculi.     

Non-calcium-containing phosphate binders: comparing efficacy, safety, and other clinical effects

Phosphate-binder therapy for hyperphosphataemia is key to the treatment of patients with chronic kidney disease (CKD)-mineral and bone disorder (MBD). Calcium-free phosphate binders are increasingly favoured since calcium-based agents potentially cause harmful calcium overload and vascular calcification that confound the benefits of reducing serum phosphorus. Several calcium-free phosphate binders are available, including the non-absorbed agent sevelamer and the absorbed agents, e.g. lanthanum and magnesium salts. Randomised controlled studies consistently show that sevelamer and lanthanum carbonate offer equivalent lowering of serum phosphorus and often effectively achieve phosphorus targets versus calcium salts, with sevelamer having a positive effect on bone disease, vascular calcification, and patient-level outcomes in dialysis patients in several trials. There is also evidence that lanthanum carbonate can improve bone health, but data are limited to its effects to vascular calcification or patient-level outcomes. Magnesium salts have also been shown to reduce serum phosphorus levels, but clear evidence is lacking on bone, vascular, or clinical outcomes. It also remains to be established whether long-term systemic accumulation of lanthanum and magnesium, in tissues including bone, has clinically relevant toxic effects. This review summarises the evidence of efficacy and safety for newer calcium-free phosphate binders in CKD-MBD management.     

泌尿系统结石成分谱及与血清TG、TC及PGE2水平的相关性

目的分析泌尿系统结石成分谱及与血清三酰甘油(TG)、总胆固醇(TC)及前列腺素E2(PGE2)水平的相关性。方法选取2015年5月至2018年12月于该院就诊的肾结石患者1875例为患者组,选取同期于该院体检合格的健康者83例为对照组。在征得受试者同意的前提下,分别于进入研究队列时刻(T0)及治疗后即入选后第90天(T1)对受试者进行血液标本采集(对照组仅采集T0时的血液标本),采用酶联免疫吸附测定(ELISA)检测血清TG、TC及PGE2水平。结果1875例患者中1677例患者的主要结石成分为草酸钙;主要结石成分为磷酸磷灰石的患者为117例;主要结石成分为尿酸的患者55例;主要结石成分为磷酸镁铵的患者23例;主要结石成分为胱氨酸的患者3例。不同结石成分患者24h尿量及尿pH值比较,差异均无统计学意义(P>0.05)。患者组和健康组血清TG、TC及PGE2水平比较,差异均有统计学意义(P<0.05)。患者组T0和T1的血清TG、TC及PGE2水平比较,差异均有统计学意义(P<0.05)。以治疗后水平为基线,血清TG、TC及PGE2水平均存在两两间的正相关(P<0.05)。草酸钙结石患者肾组织标本切片的HE染色显示,肾小管有扩张表现,且多数肾小管中存在草酸钙结晶或结晶团块。结论荆门地区泌尿系统结石成分以草酸钙为主,血清TG、TC及PGE2水平有助于泌尿系统结石的诊断;相比于其他结石成分,草酸钙结石对肾组织损伤更为明显。     

A wet chemistry method for the analysis of urinary calculi

A procedure for the routine investigation of urinary calculi is described. The investigation scheme was based on existing methods in the routine laboratory for calcium(II), magnesium(II), phosphate and urate in serum. The substance content of oxalate was calculated as non-phosphate-bound calcium(II). Furthermore the test for cystine in urine was utilized. Two specially designed tests were used, one for carbonate apatite and one for verification of the presence of oxalate. The scheme was applied to 30 specimens of human origin. The sum of the mass fractions of identified and calculated components in the calculi was found to be 0.88 on the average (s = 0.05). Low values for this sum may serve as an indication of the presence of rare components that are not included in this analytical programme. A few calculi containing rare components required special methods for the investigation and are most conveniently investigated in a specialized laboratory using X-ray diffraction or infra-red spectrometry. In this paper, however, we describe wet chemistry methods, suitable for reliable cystine determinations and for oxalate in calculi containing, for example, brushite, where the calculated oxalate value is uncertain. These methods may be used as an alternative to the physical methods for many of the rare calculi.     

Effects of low-protein diet on experimental diabetic nephropathy in the rat

To evaluate the role of glomerular hyperfiltration in the development and progression of diabetic nephropathy, we performed clearance and histopathologic studies in 24 rats with streptozocin-induced diabetes after 3 months of diets with different protein compositions. Calcium phosphate was added to an 8% protein diet in group I (nine rats), and calcium carbonate to a 24% protein diet in group II (nine rats) to equalize calcium and phosphate contents in these diets. Group I and II rats also received small doses of insulin to reduce the excessive hyperglycemia induced by the high sucrose content of the diets. In group III, six rats given an 8% protein diet, no calcium, phosphate, or insulin was added. In groups I and III, low dietary protein significantly reduced glomerular filtration rate and renal plasma flow per gram of kidney weight as compared with rates observed in group II rats with a higher protein intake. Features of diabetic glomerulopathy including mesangial hypercellularity and mesangial matrix expansion were also significantly milder in the groups with a low protein diet. On the other hand, medullary calcification and interstitial changes were most prominent in group I, given calcium phosphate supplement; the increase in the kidney weight was greater in groups I and II, which received insulin, than in group III, which did not. It was concluded that low protein diet significantly ameliorates diabetic glomerulopathy but that supplementation with inorganic phosphate in an amount equal to organic phosphate contained in the higher protein diet causes medullary calcification and interstitial nephritis. Also, administration of suboptimal doses of insulin in diabetic animals greatly enhances renal growth, more than that induced by diabetes alone.     

碳酸镧对骨化三醇冲击治疗慢性肾衰竭持续非卧床腹膜透析继发性甲状旁腺功能亢进患者血钙、血磷影响的研究

目的探讨碳酸镧在慢性肾衰竭持续非卧床腹膜透析(CAPD)患者应用骨化三醇治疗继发性甲状旁腺功能亢进(SHPT)时对血钙和血磷的影响。方法将2013年3~6月青岛市市立医院东院腹膜透析中心的CAPD导致SHPT的患者随机分为两组。碳酸镧组予以口服碳酸镧和骨化三醇冲击治疗,碳酸钙组给予碳酸钙和骨化三醇治疗,观察患者血清钙、磷、iPTH的变化。统计分析采用SPSS 17.0软件。结果共纳入40例患者,两组各20例。治疗12周后,碳酸镧组患者血磷(t=5.095,P=0.000)和iPTH(t=1.225,P=0.000)水平均明显下降,且碳酸镧组血钙(t=1.127,P=0.001)、血磷(t=2.035,P=0.000)水平明显低于碳酸钙组。结论碳酸镧能有效治疗CAPD患者应用骨化三醇冲击治疗SHPT时的高钙血症和高磷血症。     

经皮肾镜取石术后感染性休克的诊治体会

【目的】探讨经皮肾镜气压弹道碎石术（PCNL）术后感染性休克的救治。【方法】分析361例PC—NL术后并发感染性休克11例患者的临床资料,总结诊治经验。【结果】术后并发感染性休克的发生率为3％。11例患者尿培养阳性,均为革兰阴性杆菌。7例发生严重肺部感染,3例出现呼吸衰竭并进行气管插管机械通气维持呼吸。结石成分分析：9例主要成分为碳酸磷灰石及磷酸镁铵,2例为草酸钙。11例患者均在3～5d后逐渐停用升压药物,生命体征稳定,术后3～8d后体温及血常规恢复正常。【结论]PCNL术后严重感染易致感染性休克,肺脏是最易受累的器官。推荐早期应用疗效确切的抗生素如美罗培南、亚胺培南。     

Relationship between serum magnesium, parathyroid hormone, and vascular calcification in patients on dialysis: a literature review.

Secondary hyperparathyroidism is present in most patients with end-stage renal disease and has been linked to uremic bone disease, vascular calcification, and mortality. Current literature suggests an association between hypomagnesemia and cardiovascular disease in the general population. We reviewed all published studies on the relationship between serum magnesium and parathyroid hormone and the relationship between serum Mg and vascular calcification in dialysis patients. Of these, 10 of 12 studies of patients on hemodialysis and 4 of 5 studies of patients on peritoneal dialysis showed a significantinverse relationship between serum Mg and serum intact parathyroid hormone. Hyperparathyroidism develops in peritoneal dialysis patients dialyzed with a solution containing normal calcium (1.25 mmol/L) and low Mg (0.25 mmol/L), even though serum calcium is maintained at a normal level. Four of the hemodialysis studies and one of the peritoneal dialysis studies indicated that there is an inverse relationship between serum Mg and vascular calcification in these patients. Potential benefits have been attributed to magnesium carbonate as a phosphate binder and it may possibly be an effective, less toxic, less expensive phosphate binder. We believe that the role of Mg in secondary hyperparathyroidism and vascular calcification merits further investigation.     

高钙、高磷诱导的大鼠血管平滑肌细胞钙化过程中骨桥蛋白表达的动态变化

目的观察大鼠血管平滑肌细胞（VSMCs）在高钙、高磷条件下骨桥蛋白（OPN）表达的动态变化及其分布特点,探讨其与血管钙化的关系。方法应用大鼠原代VSMCs进行体外实验,细胞生长至80％融合后更换不同培养基进行培养。根据培养基中钙磷浓度不同分为3组：对照组、高钙组和高磷组。更换培养基当天定义为D0。应用原子分光光度计检测细胞内钙含量。应用免疫组化染色观察各组第3、6、10和17天OPN的在细胞中的表达：同时收集第4、8、12天各组细胞,提取总蛋白,Western blot方法检测OPN表达。最后应用电镜、免疫电镜观察OPN在VSMCs的分布。结果对照组未观察到钙盐沉积,VSMCs钙含量在10天内无明显变化,高钙组VSMCs钙含量D2有明显增加,D8、D10进一步增加;高磷组钙含量D8、D10明显增加,与D0比较差异均有显著性（P〈0．01）。在D0-D10,高钙组、高磷组VSMCsOPN的表达逐渐增强。但这以后,无论是D12 Western blot结果,还是D17免疫组化结果均显示OPN表达下调。对照组OPN表达一直很弱,且随时间变化无明显性。D10高钙组和高磷组VSMCs在电镜下可见细胞外基质沉积,为丰富的胶原纤维,其间可见直径100～200nm的小泡。高密度电子致密物主要呈颗粒样沿胶原纤维沉积;也可见于小泡的泡壁。免疫电镜显示,高钙组和高磷组VSMCs胞浆中均可见较多与OPN相结合的胶体金颗粒,而在细胞外基质中仅偶见。结论大鼠VSMCs在高钙和高磷条件下培养发生钙化过程中, OPN表达呈先增强再减弱的变化：对照组OPN的表达一直在一个很低的水平。免疫电镜显示OPN主要表达于细胞胞浆中,细胞外基质分布很少。     

延续性护理干预对降低泌尿系结石患者复发率的影响

目的探讨延续性护理干预对降低泌尿系结石患者复发率的影响。方法选择2016年2月至2017年6月250例在达州市中西医结合医院进行治疗的泌尿系结石患者,采用随机数字表法将患者分为两组,每组各125例。对照组实施常规护理,观察组在此基础上加以延续性护理。对比两组患者的复发率、自我护理能力及治疗依从性。结果对照组复发率为14. 4%,明显高于观察组的4. 0%(P<0. 05)。干预后两组患者心理、躯体活动、饮食及治疗方面自我护理能力均得到明显提升,但观察组提升幅度更大(P<0. 05)。观察组治疗依从良好率为96. 0%,明显高于对照组的88. 0%(P<0. 05)。结论延续性护理较常规护理可明显降低泌尿系结石患者复发率,提高其自我护理能力及治疗依从性。     

Calcium Balance and Negative Impact of Calcium Load in Peritoneal Dialysis Patients

Like hemodialysis patients, peritoneal dialysis (PD) patients are facing an excessively increased burden of vascular and valvular calcification. According to some surveys, more than 80% of prevalent PD patients are complicated with vascular calcification, and more than one third have heart valve calcification.Dysregulated phosphate metabolism is well recognized to play an important role in inducing vascular calcification, but increasing evidence is suggesting that dysregulated calcium metabolism also promotes vascular calcification and might in fact be more potent than phosphate in inducing that calcification. Growing evidence from randomized controlled trials shows more progression of vascular calcification and higher mortality among chronic kidney disease (CKD) patients receiving calcium-based phosphate binders than among those receiving non-calcium-containing phosphate binders. Those results raise important safety concern about the use of high-dose calcium-based phosphate binders in the CKD population, including both non-dialysis and dialysis patients (especially anuric dialysis patients), who have markedly reduced urinary calcium excretion. To prevent calcium overload, this review recommends restricting the dose of calcium-based phosphate binders in CKD patients, especially those who are elderly, who have increased cardiovascular risk, who already have baseline vascular or valvular calcification, or who have low intact parathyroid hormone and adynamic bone disease.     

CALCIFICATION OF THE SUPRARENAL GLANDS OF CATS

Calcification of the fascicular zone of the cortex has been observer in 64 of 257 cats. It is always calcification and never ossification It is more common in young animals and in our experience is associated with distemper. In its severe forms it may be recognized clinically. The symptoms resemble those seen in cats surviving double suprarenalectomy for 2 to 3 weeks. The toxin producing the focal degeneration is dearly a very specific one since attempts to produce such lesions by several types of experimental injury have failed. The sequence of events appears to be similar to that present in other degenerative processes associated with calcification, namely cell injury and necrosis, deposition of calcium at first as fatty compounds which later change to carbonate and phosphate. It is suggested that this lesion should be considered in interpreting experiments in which cats are used.     

Calcified gallstone fissures: The reversed mercedes benz sign

This article describes the occurrence of an unusual radiating pattern of calcification in the center of large radiolucent gallstones. The radiographic findings are attributed to calcium deposition within the fissures of biliary calculi.     

Calcium use increases risk of calciphylaxis: a case-control study.

OBJECTIVE: To investigate the risk factors for the development of calciphylaxis in renal failure, a poorly understood and often fatal condition characterized by calcium deposition in tissues. DESIGN: Retrospective case-control study. SETTING: University hospital peritoneal dialysis center. PATIENTS: Eight continuous ambulatory peritoneal dialysis (CAPD) patients with calciphylaxis were identified in a 3-year period. We matched up to five controls for dialysis modality and length of time on dialysis with each case. STATISTICS: Multivariate conditional logistic regression analysis for matched case-controls. MAIN OUTCOME MEASURES: Laboratory data and demographics were collected as well as cumulative calcium and vitamin D ingestion over the year prior to disease onset. RESULTS: All the patients were female, versus only 38% (14/37) of controls (p < 0.0001). While not statistically significant, a majority of the patients were diabetic [62.5% (5/8) vs 32% (12/37)]. Peak and average levels of serum calcium, phosphate, calcium x phosphate product, parathyroid hormone (PTH), albumin, iron, total iron-binding capacity (TIBC), and ferritin were not significantly different in cases compared with controls.The use of calcitriol alone or with calcium carbonate was not found to be a significant risk factor for the development of calciphylaxis. In a multivariate analysis, iron intake seemed to be protective, contrary to previous reports, while the use of calcium carbonate was associated with a strong trend to increased risk of calciphylaxis development (odds ratio = 1.029/g and 1.011/g calcium ingested per month, at 1 and 2 - 3 months prior to calciphylaxis development; p = 0.0556 and 0.0565, respectively). CONCLUSION: These data, although limited by the small numbers of index cases, suggest that calcium ingestion is a risk factor for calciphylaxis. The increased use of calcium salts as a phosphate binder in recent years might explain the apparent increased incidence of calciphylaxis in our and other centers. The preponderance of female diabetics among cases reported elsewhere was confirmed in our study.     

Biodegradation and bioresorption of calcium phosphate ceramics

The use of several calcium phosphate (Ca-P) materials for bone repair, augmentation, substitution and as coatings on metal implants has gained clinical acceptance in many dental and medical applications. These Ca-P materials may be of synthetic or natural origin, available in different physical forms (dense or macroporous, particles or blocks) and are used in bulk as coatings for metallic and non-metallic substrates or as components in composites, cements and bioactive glasses. Biodegradation or bioresorption of calcium phosphate materials implies cell-mediated degradation in vitro or in vivo. Cellular activity during biodegradation or bioresorption occurs in acid media; thus the factors affecting the solubility or the extent of dissolution (which in turn depends on the physico-chemical properties) of the Ca-P materials are important. Enrichment of the microenvironment due to the release of calcium and phosphate ions from the dissolving Ca-P materials affects the proliferation and activities of the cells. The increase in the concentrations of the calcium and phosphate ions promotes the formation of carbonate apatite which are similar to the bone apatite. The purpose of this invited paper is to discuss the processes of biodegradation or bioresorption of Ca-P materials in terms of the physico-chemical properties of these materials and the phenomena involved including the formation of carbonate apatite on the surfaces and in the vicinity of these materials. This phenomenon appears to be related to the bioactivity of the material and the ability of such materials to directly attach to bone and to form a uniquely strong material-bone interface.