慢性肾脏病基础上急性肾损伤的病因和预后分析——附38例报告

目的:探讨慢性肾脏病(chronic kidney disease,CKD)基础上急性肾损伤(acute kidney injury,AKI)的病因和预后的影响因素.方法:对38例CKD基础上的AKI患者按照RIFLE标准对AKI进行分层诊断,并对38例患者的病因、预后等临床资料进行数理分析.结果:38例中,符合R标准2例(5%)、I标准3例(8%)、F标准5例(13%),L标准11例(29%),E标准17例(45%);其中符合F、L、E标准33例,占87%.导致AKI最常见的病因是恶性高血压(32%)和严重感染(21%).CKD患者发生AKI后的血清肌酐较发生AKI前明显升高,GFR则明显降低(均为P＜0.01).需要肾脏替代治疗28例(74%),其中发生终末期肾脏病(end-stage renal disease,ESRD)21例,占55%;无需肾脏替代治疗7例(18%);死亡3例,病死率8%.多变量Logistic 回归分析显示,恶性高血压分别是CKD基础上的AKI患者需要肾脏替代治疗(r＝2.42,P＜0.05)和发生ESRD(r＝2.08,P＜0.05)的独立危险因素;而少尿、感染和CKD的基础病因与患者的肾脏预后无关 (P＞0.05).结论:恶性高血压和严重感染是CKD患者并发AKI的主要病因,恶性高血压是这类患者肾脏预后不良的独立危险因素,严格控制血压是预防CKD患者并发AKI和改善患者预后的关键措施之一.     

Imaging tests in CKD

In chronic kidney disease (CKD), imaging tests are useful to evaluate pathophysiology and in some cases, directly lead to the clinical diagnosis, although histological diagnosis still requires renal biopsy. In addition to use of conventional gray-scale ultrasonography (US) for examination of renal anatomy, duplex Doppler US has also permitted assessment of renal hemodynamics. Magnetic resonance angiography and multi-detector row computed tomography angiography are widely used with a high sensitivity and specificity for the diagnosis of renal artery stenosis. We review the clinical application of such imaging tests in CKD and in addition, emphasize the potentially fatal disorder of nephrogenic systemic fibrosis associated with gadolinium-based contrast media.     

Clinical epidemiology of cardiovascular disease in chronic kidney disease

Cardiovascular disease (CVD) is the most common cause of death in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The clinical epidemiology of CVD in CKD is challenging due to a prior lack of standardized definitions of CKD, inconsistent measures of renal function, and possible alternative effects of 'traditional' CVD risk factors in patients with CKD. These challenges add to the complexity of the role of renal impairment as the cause or the consequence of cardiovascular disease. The goal of this review is to summarize the current evidence on: (1) the incidence and prevalence of CVD in chronic renal insufficiency and in ESRD, (2) risk factors for CVD in CKD, (3) the outcomes of patients with renal failure with CVD, and (4) CKD as a risk factor for CVD. The epidemiological associations implicating the huge burden of CVD throughout all stages of CKD highlight the need to better understand and implement adequate screening, and diagnostic and treatment strategies.     

慢性肾脏病合并感染的治疗

慢性肾脏病(ChronicKidneyDiseases,CKD)是临床上常见的疾病,是肾小球肾炎、肾盂肾炎、肾病综合 征、肾小管间质性疾病、糖尿病肾病、高血压肾病、肾血管性疾病等绝大多数肾脏疾病的统称。CKD患者极易并发各 种感染,促使肾功能进一步恶化造成慢性肾脏衰竭(ChronicRenalFailure,CRF),直接影响患者的生存质量,并常常 是患者的直接死因。因此,了解CKD感染的危险因素及其特点,并积极控制感染,是提高CKD诊疗水准、改善患者预 后的一项重要措施。     

慢性肾脏病并发医院真菌感染的易感因素和真菌特点分析

目的探讨慢性肾脏病（CKD）并发医院真菌感染（NFI）情况及其易感因素。方法评价CKD并发NFI的真菌特征和实验室指标与NFI的关系。结果65例CKD并发NFI者中最常见的感染部位是泌尿道25例次（38．46Voo）,其次是消化道20例次（30．77％）;最常见的病原菌是白色念珠菌50例次（68．49％）,其次是热带念珠菌13例次（17．81％）;白色念珠菌对氟康唑的敏感率为90％。易感因素有住院时间长、贫血、营养不良、低IgG血症、大量蛋白尿、肾功能不全、大剂量使用激素、环磷酰胺和广谱抗生素等。结论CKD易并发NFI,最常见的病原菌是白色念珠菌,控制易感因素是预防NFI的有效方法。     

彩色多普勒与超微血流显像对慢性肾脏病血流灌注的研究

目的 探讨彩色多普勒血流成像（Color doppler flow imaging,CDFI） 和超微血流显像（Super microvascular imaging,SMI）对慢性肾脏病（Chronic kidney disease,CKD）患者肾血流灌注改变的临床价值。方法 采用CDFI及SMI分别观察正常受检者和CKD1-5期患者双侧肾脏血流灌注情况,并对肾脏血流分布情况进行分级,检测CDFI与SMI对CKD患者肾血流灌注改变的评价效果,并比较SMI与CDFI对各级肾血管的显示能力。同时采用Spearman分析法,将CDFI、SMI血流灌注分级与CKD前三期临床分期进行相关性分析。结果 1.对照组与CKD1期、CKD2期的CDFI及SMI肾血流灌注分级两两比较差异均无统计学意义（P>0.01）。2.CDFI肾血流灌注显像中,CKD前三期肾血流灌注两两比较差异无统计学意义（P>0.01）;CKD4-5期与前三期比较差异有统计学意义（P<0.01）。3.SMI肾血流灌注显像中,CKD3期与CKD1期、CKD2期及 CKD4-5期之间差异有统计学意义（P<0.01）,CKD4-5期与前三期比较差异有统计学意义（P<0.01）。4.随着CKD临床分期越高,SMI及CDFI的肾血流灌注分级均降低,且各期的SMI肾血流灌注分级均高于CDFI ,同时每组SMI检测出的高占比的血流分级均高于CDFI,差异均有统计学意义（P<0.05）,SMI尤其对弓形动脉和小叶间动脉的显示更清晰。5.SMI肾血流灌注分级与CKD临床分期有较强相关关系（Rs为－0.657,P＜0.01）;CDFI肾血流灌注分级与CKD临床分期有中等相关关系（Rs为－0.419,P＜0.01）。结论 SMI可作为评价CKD肾血流灌注改变重要的影像方法,可有效协助临床对CKD患者的诊断、治疗及预后评估,具有重要临床应用价值     

Current chronic kidney disease practice patterns in the UK: a national survey

BACKGROUND: There is an increasing focus on improving the detection and management of patients with chronic kidney disease (CKD). Data on CKD prevalence based on population sampling are now available, but there are few data about CKD patients attending nephrology services or how such services are organized. AIM: To survey services for CKD patients nationally. METHODS: A pre-piloted questionnaire was sent to all 72 renal units in the UK, referring to the situation in June 2004. RESULTS: Seventy units (97%) responded. The median ratio of prevalent CKD patients/prevalent renal replacement therapy (RRT) patients in the 25 units with data was 3.7 (IQR 2.7-5.7) and the median ratio of CKD stage 4 and 5 patients/prevalent RRT patients was 0.6 (IQR 0.4-1.1). This gives an estimated 140 000 CKD patients under the care of UK nephrologists, with 23 000 at CKD stage 4 or 5 (excluding those on RRT). Very few units had a full complement of the recommended multi-skilled renal team. Counsellors and psychologist were the most common perceived shortages. Of 70 responding units, 50 (74%) were using low clearance clinics for management of advanced CKD patients. Elective dialysis access services often had long delays, with median waiting time for vascular access ranging between 1 and 36 weeks, and for Tenchkoff catheter, between 0 and 12 weeks. DISCUSSION: CKD patients are a significant workload for UK nephrologists. Current provision of service is variable, and services need to be re-designed to cope with the expected future increase of referral of CKD patients.     

超声造影定量分析与彩色多普勒血流显像评价慢性肾功能不全患者肾功能状态的对比研究

目的 应用实时谐波超声造影定量分析技术评价慢性肾功能不全患者肾皮质血流灌注曲线及定量灌注参数,并与彩色多普勒血流成像技术相比较.方法 对33例临床确诊的慢性肾功能不全Ⅲ～Ⅴ期患者和45例健康志愿者行双肾皮质实时灰阶超声造影灌注成像,超声造影剂为SonoVue,每侧肾使用剂量为1 ml.QLAB图像分析软件计算感兴趣区域内造影剂回声信号的强度,生成时间-强度曲线(time intensity curve,TIC),得到超声造影定量灌注参数.结果 慢性肾功能不全Ⅲ～Ⅴ期患者肾超声造影TIC曲线表现为上升缓慢,下降缓慢,到达峰值时间延迟.与正常人相比,慢性肾功能不全患者肾皮质定量灌注参数中,曲线下面积(AUC)增大,达峰绝对值(DPI)减低,曲线上升支斜率(A)增大,达峰时间(TTP)延长,差异有统计学意义(P＜0.05).曲线下降支斜率(a)增大,但差异无统计学意义(P＞0.05).AUC、DPI、A、TTP诊断慢性肾功能不全Ⅲ～Ⅴ期的灵敏性分别为91.2%、84.9%、90.9%、85.3%,特异性分别为95.4%、88.9%、93.3%、90.9%,准确性分别为93.6%、87.2%、92.3%、88.5%,明显高于彩色多普勒超声中的RI指标.结论 实时灰阶超声造影定量分析技术在评估慢性肾功能不全Ⅲ～Ⅴ期患者肾功能损害方面优于彩色多普勒技术.

Abstract：

Objective To evaluate the value of contrast-enhanced ultrasonography (CEUS) in quantitative diagnosis of chronic kidney dysfunction(CKD) by comparing it with color Doppler imaging (CDFI). Methods Tirty-three cases (15 males and 18 females) of clinical confirmed CKD (stage Ⅲ～Ⅴ)were included. Forty-five healthy volunteers were performed as control group. CEUS and CDFI were performed on each patient. After intravenous bolus injection of 1ml SonoVue each side,CEUS of renal cortex blood perfusion was collected successively,and a time-intensity curve(TIC) was created with Philips iU22 system's QLAB software. Resistance index(RI) and peak systolic velocity(PSV) of renal partial arteries were also tested. Results Compared with normal kidney,CKD patients had delayed perfusion and decreased intensity. Changes of area under curve(AUC), derived peak intensity(DPI), slope rate of ascending curve(A)and time to peak(TTP) were statistically significant ( P ＜0. 05). Sensitivities of AUC,DPI,A and TTP in diagnosis of CKD (stage Ⅲ～Ⅴ ) were 91.2% ,84. 9% ,90.9% and 85.3%, their specificities were 95.4%,88.9% ,93.3% and 90.9%, their accuracies were 93.6%, 87. 2%, 92.3% and 88. 5%, respectively. The results of CEUS were better than RI in CDFI (sensitivity 70.4%, specificity 37. 8%, accuracy 52.2%).Conclusions CEUS can precisely display the hemodynamic change in CKD ( stage Ⅲ～Ⅴ ), and is more sensitive than CDFI.     

叶间动脉血流动力学参数对慢性肾疾病的早期诊断价值

目的 探讨彩色多普勒超声检测叶间动脉血流动力学参数对慢性肾疾病(chronic kidney disease,CKD)的早期诊断价值.方法 运用彩色多普勒超声对78例CKD患者和65例健康人的叶间动脉进行超声检查,测量收缩期峰值流速(PSV)、舒张末期血流速度(EDV)、搏动指数(PI)、阻力指数(RI),同时进行血清...     

Urinary exosomes derived circRNAs as biomarkers for chronic renal fibrosis

BackgroundChronic renal disease (CKD) is a common and irreversible loss of renal function. Renal fibrosis reflected the degree of renal dysfunction. However, the current biomarkers only characterize the renal function instead of indicating the fibrosis degree. The potential diagnostic value of urinary exosomes derived circRNAs for renal fibrosis needs to be further studied.MethodsUrine exosomes from 3 chronic kidney disease (CKD) patients without renal fibrosis and 3 renal fibrotic patients were collected and human circRNAs microarray analysis were performed to detect the circRNAs expression profile. 110 biopsy-proven CKD patients and 54 healthy controls were enrolled and urine exosomes derived RNA was isolated. The expression of hsa_circ_0036649 was measured and the correlation with renal function parameter and pathological indicators was performed. The receiver operating characteristic (ROC) curve for the diagnosis of renal fibrosis was calculated.ResultsHuman circRNAs microarray showed 365 circRNAs up expressed and 195 circRNAs down expressed in renal fibrotic patients compared to none fibrosis CKD patients. The expression of hsa_circ_0036649 was decreased in renal fibrotic patients according to RT-PCR and correlated with serum creatinine, blood urea nitrogen (BUN), estimated glomerular filtration rate and cystatin c. Further, the expression of hsa_circ_0036649 was correlated with the score of tubulointerstitial fibrosis (TIF) and the score of glomerular sclerosis. The ROC curve showed that hsa_circ_0036649 may predict renal fibrosis at a cut-off value of 0.597 with a sensitivity of 45.5% and specificity of 87.9%.ConclusionExpression of urinary exosomes derived hsa_circ_0036649 associated with the degree of renal fibrosis. Its potential role as a biomarker in CKD remained to be supported by further follow-up studies.

Key Messages

• circRNAs profile in urine exosomes in renal fibrosis patients was revealed.
• The expression of urine exosomes derived hsa_circ_0036649 was correlated to renal function and fibrosis degree.
• circRNAs derived from urinary exosomes may become a new research direction for biomarkers of renal fibrosis.

     

The ratio of urinary TREM-1/TREM-2 mRNA expression in chronic kidney disease and renal fibrosis

BackgroundThe non-invasive identification of novel renal fibrosis biomarkers needs to be further studied.MethodsWe collected urine samples from 77 biopsy-proven CKD patients and 15 healthy controls. The expression of urinary TREM-1 and TREM-2 was measured and the correlation with renal function parameter and pathological indicators was performed. The receiver operating characteristic (ROC) curve for the diagnosis of renal fibrosis was calculated. The protein expression of TREM-1 and TREM-2 in kidney tissues was measured.ResultsThe TREM-1/TREM-2 ratio was decreased in CKD patients and correlated with serum creatinine, estimated glomerular filtration rate and cystatin c. Further, the TREM-1/TREM-2 ratio was significantly decreased in moderate-severe fibrosis patients compared with none-mild renal fibrosis. TREM-1/TREM-2 ratio was correlated with the score of tubulointerstitial fibrosis (TIF) and the score of glomerular sclerosis. The ROC curve showed that the urinary TREM-1/TREM-2 ratio can diagnosemoderate-severe renal fibrosis at a cut-off value of 1.338 with a sensitivity of 86.4% and specificity of 81.8%. In human moderate-severe fibrosis kidney tissue, the protein expression of TREM-1 was lower and the TREM-2 was higher than none-mild fibrosis kidney tissue.ConclusionUrinary TREM-1/TREM-2 ratio was a potential biomarker for the diagnosis of renal fibrosis in CKD patients.     

外泌体在肾间质纤维化中作用的研究进展

慢性肾脏病（CKD）已成为全球性的公共卫生问题,CKD患者的最终结局往往会发展为终末期肾病（ESRD）。肾间质纤维化（RIF）是不同病因的CKD进展为ESRD的共同途径。因发病机制复杂,目前RIF尚无有效的治疗方法,近期研究表明外泌体在多种肾脏疾病的发生发展中发挥着重要作用。该文对外泌体在RIF发病机制中作用的最新研究...     

Dialysis and fatigue: implications for nurses--a case study analysis

Fatigue is one of the most common symptoms experienced by patients receiving dialysis. When patients with chronic kidney disease (CKD) and end-stage renal disease are admitted to acute care settings, they require management of their often profound fatigue. CKD, renal pathology, and renal fatigue are examined in relation to a case study.     

慢性肾脏病患者的甲状腺功能和血脂水平分析

目的探讨慢性肾脏病(CKD)患者的甲状腺功能和血脂状况。方法收集2017年1—10月该院肾脏科CKD患者412例,分别检测血清尿素(Urea)、肌酐(Cr)、总胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)和促甲状腺素(TSH)水平,计算估算肾小球滤过率(eGFR)。比较CKD各期患者的甲状腺激素和血脂水平,对甲状腺激素和血脂水平与肾功能指标Cr和eGFR进行相关性分析,并对CKD各期患者的甲状腺功能和血脂疾病进行比较。结果 CKD各期患者间Urea、Cr、TC、LDL-C、HDL-C、FT4和TSH差异有统计学意义(P<0.05),FT3差异无统计学意义(P>0.05)。FT4、HDL-C水平与Cr呈负相关(r=-0.312、-0.207,P<0.05),与eGFR呈正相关(r=0.282、0.160,P<0.05);TSH、TC、LDL-C水平与Cr呈正相关(r=0.143、0.205、0.218,P<0.05),与eGFR呈负相关(r=-0.12...     

Anaemia is common and predicts mortality in diabetic nephropathy

BACKGROUND: Diabetes is the single largest cause of chronic renal failure, accounting for 18% of patients on renal replacement therapy in the UK. AIM: To investigate the chronic kidney disease stage at which patients with diabetic nephropathy are referred to renal services, determine the prevalence of anaemia in patients with diabetic nephropathy, examine patient outcome and identity prognostic factors. DESIGN: Retrospective review. METHODS: Patients with diabetic nephropathy referred to our renal services between 1989 and 2004 were identified from electronic records. Estimated glomerular filtration rate (calculated using the MDRD formula) and haemoglobin at referral were collected. Times to renal replacement therapy and death were noted. RESULTS: We identified 508 patients. At referral, mean eGFR was 34 ml/min/1.73 m(2) and 48% of patients were at CKD stages 4 and 5. Mean haemoglobin was 11.7 g/dl; 21% had a haemoglobin <10 g/dl at referral. Median survival was 37.9 months (95%CI 33.2-42.6); median survival independent of renal replacement therapy (RRT) was 21 months (95%CI 17.8-24.6). Of patients starting RRT, 38% did so within 1 year of referral. Older age (RR 1.02, 95%CI 1.01-1.04) and lower haemoglobin (RR 0.9, 95%CI 0.85-0.99) at referral predicted death on multivariate analysis. DISCUSSION: At referral to renal services, almost 50% of patients with diabetic nephropathy were at CKD stages 4 and 5. Anaemia was common and predicted mortality. All diabetic patients from CKD stage 3 should be screened for anaemia. We believe that patients with diabetic nephropathy should be discussed with renal services when they reach CKD stage 3 with evidence of progression of renal disease.     

超声造影评估慢性肾病的研究进展

慢性肾病由于患病率和发病率的日益增加,已经发展成为一个主要的全球性的公共健康问题。慢性肾病的发生及发展均与肾血流的灌注密切相关。准确评估肾血流灌注可为临床诊断慢性肾病提供重要信息。超声造影可用于评估慢性肾病的肾血流灌注情况。本文就超声造影评估慢性肾病的研究进展进行综述。     

慢性肾脏病的单中心横断面流行病学研究

目的 调查单中心肾内科门诊慢性肾脏病(CKD)患者的基础状况,判断CKD患者肾功能下降的危险因素.方法 对门诊就诊的CKD患者进行为期9个月的前瞻性横断面调查.结果 共有780例CKD病例入选.前4位CKD的病因分别为原发性肾小球疾病(59.0%),高血压肾病(7.6%),狼疮肾炎(6.4%),糖尿病肾病(6.3%).病例平均年龄41.9岁.CKD各期的分布为CKD 1期47.8%、2期18.7%、3期14.0%、4期8.1%、5期11.4%.多因素回归提示年龄、蛋白尿、高血压与CKD患者的肾功能下降独立相关.结论 目前针对中国CKD患者最大规模的单中心横断面调查,有助于确定CKD患者的基本状况,为进一步纵向随访奠定基础.     

Strategies to retard the progression of chronic kidney disease

Chronic kidney disease (CKD) is a common and, in advanced cases, highly morbid disorder. The most severe form of CKD is end-stage renal disease (ESRD), in which the patient requires some form of renal replacement therapy to survive. The increasing incidence, prevalence, and costs of ESRD are major national health care concerns; interventions that may prevent or slow the progression of CKD towards ESRD are extremely important and the focus of this article.     

Statin therapy in patients with chronic kidney disease: to use or not to use

Dyslipdemia is a common complication of chronic kidney disease (CKD) and contributes to high cardiovascular morbidity and mortality of CKD patients. Experimental studies have demonstrated that lipids induce glomerular and tubulointerstitial injury and that lipid-lowering treatments ameliorate renal injury. Therapy with statins not only has the potential to lower cardiovascular morbidity and mortality in patients with CKD but also to slow progression of renal disease. Whereas the guidelines for treatment of hyperlipidaemia in nonrenal patients are based on prospective, randomized, placebo-controlled mega-trials, such data are not available for CKD patients. This review outlines the limited information currently available on the effect of statins among patients with CKD and summarizes the ongoing randomized trials designed to address this question.     

Risk factors associated with coronary artery calcification should be examined before kidney transplantation

The best treatment for end stage renal disease (ESRD) patients is kidney transplantation, but the renal transplant recipients still have a higher incidence of cardiovascular events compared with general population. Cardiovascular risk factors were imposed long before ESRD, as the majority of patients starting dialysis or kidney transplantation already have signs of advanced atherosclerosis. Artery calcification is an organized, regulated process similar to bone formation. Coronary artery calcification (CAC) is found frequently in advanced atherosclerotic lesions and could be a useful marker of them. We evaluated the prevalence of CAC in 49 stable renal transplant recipients and in 48 age- and gender-matched patients with chronic kidney disease (CKD) in stages 2-5 not requiring dialysis to assess risk factors associated with CAC. Computed tomography was used for CAC detection and quantification (CAC score). The prevalence of CAC was 43.8% in transplant recipients and 16.7% in CKD patients (p < 0.001). Transplant recipients with CAC were significantly older and had longer duration of CKD and/or dialysis than recipients without CAC. In contrast, the serum levels of fetuin A (an inhibitor of vascular calcification) and albumin were significantly lower in CKD patients with CAC than those without CAC. During the observation period (30 months), 30 patients, including 23 CKD patients, began dialysis, and 4 transplant recipients and 2 CKD patients died. Independent predictors of mortality were age, serum amyloid A and the CAC score. In conclusion, the examination and prevention of risk factors associated with atherosclerosis should be started at the beginning of renal failure.