经皮血管腔内成形术(PTA)治疗肾血管性高血压

自1984年以来,我们应用经皮血管腔内成形术(PTA)治疗8例肾血性高血压患者。其中女性6例。男性2例,年龄界于15～33岁。高血压史1个月至3年。所有病例的肾动脉狭窄均由大动脉炎引起。5例(单侧病变4例,双侧1例)PTA肾动脉狭窄由原1～2mm扩张至4～5mm。随访2～14个月,3例高血压治愈,2例改善。作者认为PTA是治疗肾血性高血压的首选方法,简单而安全。     

Renal artery digital-subtraction angiography. An outpatient investigation for renovascular hypertension

The adequacy and convenience of the digital-subtraction angiographic procedure by means of a Diasonics DF100 as an investigation in renovascular disease were assessed over a nine-month period in 82 sequential renal artery studies, of which 76 were carried out in patients referred for the investigation of hypertension. Contrast medium was injected as a bolus by way of a centrally placed venous catheter, or a small (5 French size or smaller) arterial catheter. Patients tolerated the procedure well, and were fully mobile within 10 minutes to one hour (venous injection) and within two hours (arterial injection) after the procedure. Of the 82 studies, nine were judged as inadequate. All technical failures occurred with the venous injection technique. Of the 76 patients with hypertension, the main renal artery was judged as normal in 61. Renal artery lesions were demonstrated in 15 studies (13 patients). Renal vein renin studies, and the clinical or postoperative course supported the diagnosis of renovascular hypertension in 11 of these. Digital-subtraction angiography of the renal artery is a useful investigation in suspected renovascular hypertension. Its major advantage over conventional angiography is that it can be performed on an outpatient basis.     

Renal vein plasma adenosine 3'',5''-cyclic monophosphate in renovascular hypertension.

The concentration of plasma adenosine 3',5'-cyclic monophosphate (cyclic AMP) and plasma renin activity (PRA) were measured concomitantly in blood from both renal veins and in arterial blood in 22 hypertensive patients. In the nine patients with true renovascular hypertension the concentration of plasma cyclic AMP was greater in the venous effluent of the kidney affected by the renal artery stenosis than in that of the unaffected or less affected kidney. The arteriovenous difference in cyclic AMP concentration was less on the affected side in all but one patient. The arteriovenous differences in PRA identified the affected kidney as the source of hyper-reninemia and showed that renin release from the other kidney was suppressed. In the 13 patients with hypertension associated with but unrelated to renal artery stenosis there were no consistent patterns of cyclic AMP concentration or PRA in the venous effluent of the kidneys or of their arteriovenous differences. In renovascular hypertension the venous effluent of the kidney affected by renal artery stenosis contains not only more renin but also more cyclic AMP, owing to either increased cyclic AMP production or decreased excretion or extraction of cyclic AMP by the affected kidney. This unilateral increase in cyclic AMP concentration may become a complementary diagnostic feature of true renovascular hypertension.     

16层螺旋CT动脉造影对肾血管性高血压病诊断的临床应用

目的探究肾血管性高血压病早期诊断的检查方法,并研究16层螺旋CT动脉造影技术对肾动脉狭窄的检出率。方法收集2011年1月~2012年6月我院收治的疑似肾血管性高血压病患者19例,综合分析患者的血压水平、家族遗传病史,采用16层螺旋CT动脉造影对疑似病例进行检查,分析其应用价值。结果 19例患者经过多层螺旋CT动脉造影检查后,肾血管正常者6例,13例显示不同程度肾动脉狭窄,其中,起始段狭窄9例,肾动脉中端狭窄4例;轻度狭窄2例,中度狭窄4例,重度狭窄6例,血管闭塞1例;局限性狭窄10例,全程性狭窄3例。结论 16层螺旋CT动脉造影能清晰的显示肾动脉主干及分支狭窄程度及范围,值得临床推广应用。     

肾血管性高血压大鼠肾脏A型心房肽受体的表达及意义

目的 研究高血压大鼠肾脏A型心房肽受体（ANPR—A）的蛋白表达并探讨其意义。方法 采用狭窄单侧肾动脉的方法建立二肾一夹（2K1C）肾血管性高血压大鼠模型。用尾套法测血压,免疫组织化学染色法观察缩窄术后不同时期。肾脏组织各部位ANPR—A蛋白的表达,并用计算机图像分析系统半定量检测ANPR—A蛋白的表达水平。结果 肾动脉缩窄术后4周,模型组大鼠肾脏ANPR—A蛋白在肾小球表达增加,在肾小管表达降低,与对照组的差异有统计学意义（P〈0．01）,在髓质集合管表达无明显改变（P〉0．05）。缩窄术后8周．模型组大鼠肾脏ANPR—A蛋白在肾小管和髓质集合管的表达均降低,与对照组的差异有统计学意义（P〈0．01）．在肾小球有微弱表达,与对照组相比差异无统计学意义（P〉0．05）。结论 随着高血压的发展,肾脏组织中的ANPR—A表达显著减少,提示高血压的发展与肾脏ANPR—A的表达下降有关。     

经导管选择性静脉采血技术对肾血管性及异体肾移植术后高血压的应用

采用选择性静脉导管分段取血对10例肾血管性和3例异体肾移植术后高血压病人测定肾素活性水平,比较左右肾静脉和下腔静脉肾素活性的比值,判定肾动脉狭窄取得了满意的结果。异体肾移植术后高血压患者行分测移植肾和自体病肾静脉血肾素活性,发现自体病肾静脉血肾素活性明显高于移植肾,动脉造影证明移植肾动脉无狭窄。为病肾肾素依赖性高血压。用无水乙醇枪塞自体病肾动脉,结果有效。     

肾性高血压大鼠模型制备方法的改进

目的：建立一种改良的普遍适用且成活率高的肾性高血压大鼠模型。方法：健康雄性SD大鼠32只,随机分为手术组（n=16）和假手术组（n=16）。采用缝合线和针灸银针对手术组大鼠造成单侧肾动脉狭窄,形成肾性高血压。假手术组仅游离肾动脉,不予缩窄。结果：肾动脉缩窄术后14d,手术组血压较术前明显增高（t=6.366,P〈0.01）,术后28d血压进一步升高,达到稳定的高水平（t=12.806,P〈0.001）;左肾动脉缩窄术后28d手术组血压显著高于假手术组（t=10.41,P〈0.01）,大鼠成活率75%（12/16）,成活的大鼠全部形成高血压模型。结论：该动物模型可模拟人单侧肾动脉狭窄所致的高血压病变,其制作方法简便,可操作性强,成功率高,符合高血压实验研究的需要。     

肾血管性高血压大鼠蓝斑核内NE能神经元的变化

目的　研究肾血管性高血压大鼠蓝斑内NE能阳性神经元的变化。方法　雄性SD大鼠 6 0只 ,随机分为两组 (n =30 )。手术组用钳夹肾动脉法复制高血压模型 ,对照组手术过程同手术组 ,但不上银夹。于术后 7d ,30d ,90d处死动物 ,取脑 ,ABC免疫组化染色。结果　对照组大鼠蓝斑内NE能神经元密度在术后 7d、30d无变化 ,术后 90d显著增加 ;手术组NE能神经元密度先减少 ,再增加。手术组和对照组NE神经元密度相比 ,术后 30d两组间无差异 ;术后 7d、90d手术组高于对照组 (P <0 .0 5 ) ;结论　NE能阳性神经元在高血压的发生过程中起一定作用     

青年人肾动脉狭窄所致高血压的诊断与治疗

本文总结了我院近年来经体检、X线、放射核素和手术探查确诊为肾动脉阻塞性病变所致高血压62例。其年龄除1例系外伤性肾动脉瘤为43岁外其余均在40岁以下,最后诊断为肾动脉肌纤维结构不良者46例(单侧29例、双侧17例)、多发性大动脉炎11例、转移瘤波及肾动脉4例,外伤后肾动脉瘤1例。32例行外科手术治疗,肾切除15例,自体肾移植17例,约80%的患者术后血压降至正常或联用降压药后血压明显下降。     

犬Stanford B型主动脉夹层动物模型的建立

目的探索建立犬Stanford B型主动脉夹层动物模型。方法9只健康杂种犬,全麻下开胸在左头臂干动脉开口以远降主动脉壁分离中膜后,经腹膜后入路结扎左肾动脉一支以形成肾性高血压。3～6周饲养后,通过数字减影血管造影（digital subtraction angiography,DSA）及处死后解剖验证Stanford B型主动脉夹层是否形成。结果手术过程中和术后各有2只犬死亡,其中术后死亡的1只经解剖发现死于主动脉夹层破裂．另1只未形成主动脉夹层;3只犬被成功地建立了主动脉夹层模型;存活的另外2只在术后6周处死时仍未形成主动脉夹层。结论通过破坏主动脉中膜、诱发肾性高血压可建立犬Stanford B型主动脉夹层动物模型。     

Predictive value of renin determinations in renal artery stenosis

The prognostic value of renal vein and peripheral renin levels was analyzed in 66 patients with unilateral renal artery stenosis who underwent corrective surgery. Patient selection for operation was independent of renin results. Fifty-three percent of those with confirmed renovascular hypertension had renal vein renin ratios less than 2.0, ie, within the 95% confidence limit for the control group of 82 patients with essential hypertension. Thirty-four patients with clearly lateralizing renin data (ipsilateral:contralateral greater than or equal to 1.5 and contralateral:peripheral less than or equal to 1.3) were benefited by operation, but 23 additional patients with nonlateralizing data also benefited. No proposed scheme for renin data analysis detected more than 75% of those with renovascular hypertension. Although lateralizing renin data are highly predictive of operative benefit, nonlateralizing data do not necessarily herald operative failure and should not be dogmatically used to exclude surgical intervention.     

Renovascular hypertension in neurofibromatosis

We present two patients with renovascular hypertension in association with neurofibromatosis. In both cases the diagnosis was established by angiography. The first patient suffered occlusion of the right renal artery combined with intrarenal arterial lesions. Treatment was by autotransplantation. The second patient suffered bilateral intrarenal arterial lesions alone and was treated medically. In both patients, control of the hypertension was established. We discuss the aetiology of renovascular hypertension in neurofibromatosis and consider its treatment.     

速尿-卡托普利肾功能显像诊断肾血管性高血压

目的:探讨速尿-卡托普利肾功能显像(CRS)诊断肾血管性高血压(RVH)临床价值及相关因素.方法:对比研究50例怀疑RVH患者的速尿-CRS和选择性数字减影肾血管造影资料.计算速尿-CRS诊断RVH的敏感性、特异性和准确性.结果:速尿-CRS对诊断RVH的总体敏感性、特异性和准确性分别为77.8%,98.2%,89%;速尿-CRS诊断双侧、单侧肾动脉狭窄(RAS)的敏感性分别为67.8%,95.3%.结论:速尿-CRS对RVH的诊断有重要的价值.     

彩色多普勒超声对肾动脉狭窄的诊断价值

目的探讨彩色多普勒超声对肾动脉狭窄(RAS)的诊断价值。方法对35例临床可疑肾血管性高血压患者共70条肾动脉采用彩色多普勒超声检测,并得到肾血管数字减影血管造影(DSA)证实,进行回顾性分析。结果彩色多普勒超声肾动脉检测成功率为94%,诊断狭窄≥50%RAS的正确率为87%、敏感性为91%、特异性为90%。结论彩色多普勒超声可作为诊断具有血流动力学意义的RAS(狭窄≥50%)的有效筛查手段,为临床提供重要的诊断信息。     

Evaluation of the Urea Washout Pyelogram and Urography in the Assessment of Renovascular Hypertension

The urea washout (UWT) modification of the intravenous pyelogram was used to study 146 hypertensive patients in order to detect the presence of significant renovascular abnormalities. A positive result was obtained in 55 patients and direct confirmation of main renal artery stenoses by selective renal arteriography was obtained in 26. Bilateral abnormalities were confirmed in seven of the 26 patients. No false-negative results were encountered. The usefulness of this test as a comprehensive screening test is outlined. It demonstrated a high degree of accuracy in the diagnosis of significant unilateral or bilateral main renal artery stenosis in addition to the detection of diffuse intrarenal arteriolar disease. It was of value in the postoperative assessment of operative repair of main renal artery defects. The urea washout test embodies both an anatomical and a physiological approach in the roentgen diagnosis of curable renovascular hypertension. The altered physiology resulting from significant main renal artery stenosis makes possible the use of the urea washout intravenous pyelogram. The value of other forms of intravenous pyelography is described.     

肾型高血压大鼠不同血管组织中血管紧张素的变化

通过对两肾一夹肾血管性高血压大鼠在发病过程中血浆及内脏血管中AngⅠ、AngⅡ含量进行测定,结果发现在高血压形成过程中血浆及内脏血管床中AngⅠ、AngⅡ水平均有变化,血浆中的AngⅠ、AngⅡ含量在狭窄左肾动脉后10d内升高,10d后开始下降,高血压形成后降到正常水平;内脏血管中AngⅠ、AngⅡ水平在狭窄后不断增加,高血压形成后AngⅠ、AngⅡ维持在较高水平。右肾动脉、肠系膜动脉、肺动脉的AngⅠ含量是对照组的2.67,1.95和2.95倍,AngⅡ含量是对照组的5.74,3.20和3.45倍。从而证实在高血压形成过程中,外周血管中的RAS比循环血液中的RAS起的作用大。     

肾动脉型大动脉炎的外科治疗

肾动脉型大动脉炎造成的难治性高血压及肾功能不全是大动脉炎药物治疗的难点,临床面临难治性肾血管性高血压且肾动脉狭窄程度≥70%时,应积极考虑行外科手术治疗。可选择的治疗方式有开放手术或介入治疗,但目前对于术式的选择尚无明确指南。本文总结了开放手术、球囊扩张术、支架置入术的临床效果、长期通畅率及并发症发生率,旨在为肾动脉型大动脉炎的临床手术术式选择提供参考。     

Newer tests for the diagnosis of renovascular disease.

OBJECTIVE--To evaluate published reports of diagnostic methods for renovascular hypertension, including Doppler ultrasonography, magnetic resonance imaging, the captopril test, and captopril scanning. DATA SOURCES--MEDLINE and selected references from appropriate published articles. STUDY SELECTION--Studies included those that calculated sensitivities and specificities; studies that derived diagnostic criteria without application to another population of patients were excluded. Consensus of both authors was necessary for inclusion. DATA EXTRACTION--Articles were critically assessed independently by the authors and a consensus critique was developed. DATA SYNTHESIS--Major sources of variability exist in the investigations of recently developed tests for renovascular hypertension. These include variability in patient populations, performance of tests, and determination of outcome measures. CONCLUSIONS--Among the newer diagnostic tests, both magnetic resonance imaging and Doppler ultrasonography hold promise for the anatomic detection of renal artery stenosis, but clear diagnostic criteria have not been universally accepted. There is more information concerning the captopril test, which has a sufficiently high sensitivity to be useful in the screening of high-risk patients for renovascular hypertension. Scans after captopril administration, which appear to be more specific, may enable the prediction of a blood pressure response to angioplasty or surgery.     

Stroke-prone renovascular hypertensive rats

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Renal artery stenosis: a disease worth pursuing

Consider renovascular hypertension (HT) when: Newly diagnosed hypertension presents with features that are atypical of essential hypertension; Resistant hypertension is associated with risk factors for atheroma; or Angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II-receptor antagonist therapy is associated with increasing plasma creatinine levels. Atheromatous renovascular HT can often be managed medically, which includes intensive correction of cardiovascular risk factors. ACE inhibitors are probably second-line antihypertensives for patients with unilateral renal artery stenosis and two kidneys. First-line antihypertensives are diuretics, beta-blockers and calcium-channel blockers. Bilateral renal artery stenosis, or a unilateral stenosis in a patient with only one kidney, is an absolute contraindication to ACE inhibition.