特发性肾脏替代性脂肪瘤(附1例报告并文献复习)

目的探讨特发性肾脏替代性脂肪瘤(RRL)的临床特点、诊断和治疗方法。方法回顾性分析1例肾脏替代性脂肪瘤患者的临床资料。男性,48岁,体检发现左肾占位入院,超声提示左肾实质破坏,肾盂内强回声团伴声影,左肾被高回声软组织影包裹。CT提示左肾占位,可见明显负值,无明显强化,肾盂内可见高密度影,肾实质不均匀破坏。结果患者行手术治疗,术中探查见左肾被巨大脂肪组织包裹,行肾脏切除术。病理所见患肾皮质高度萎缩,肾脏体积明显增大,肾脏被过度增生的脂肪纤维组织所替代,光镜下可见到大量异常肥大的脂肪细胞。患者术后1周痊愈出院,随访18个月未见肿物复发转移。结论 RRL临床极为罕见,目前国内外文献仅见少数个案报道。RRL需要与慢性感染性肾脏疾病、脂肪瘤、脂肪肉瘤、血管平滑肌脂肪瘤和畸胎瘤等含有脂肪组织的肾脏肿瘤、黄色肉芽肿性肾盂肾炎、肥胖及Cushing综合征等疾病相鉴别。治疗以手术为主,通常需要行肾脏切除术。     

肾盂结石并发肾盂鳞状细胞癌超声漏诊1例

患者男，52岁。因左肾结石30年，时有肉眼血尿入院行超声引导下经皮肾镜气压弹道碎石术。术前超声检查提示左肾铸型结石伴。肾盂积水。术后复查超声示左肾小结石伴。肾盂积水，肾盂内透声差，见不均质回声团（图1）。后因反复血尿入院发现肾周严重感染，并行左肾切除术，病理结果为左肾盂泌尿上皮癌，伴大片坏死并侵犯肾门脂肪组织。患者终因感染性休克、     

超声引导经皮肾镜治疗肾脏鹿角状结石

目的探讨超声引导、超声气压弹道碎石经皮肾镜治疗肾脏鹿角状结石的可行性、临床疗效及临床经验。 方法2006年1月至2015年1月北京大学人民医院泌尿外科采用超声引导经皮肾镜、超声气压弹道碎石共治疗完全鹿角状结石患者128例,共142个肾脏鹿角状结石,结石体积：3~179 ml。其中双侧鹿角状结石14例,孤立肾或功能性孤立肾伴鹿角状结石13例,合并肾功能不全22例,合并肾积脓25例,合并脊柱畸形4例。 结果128例患者142个肾脏鹿角状结石手术均获成功,手术时间30~150 min,平均（64.5±39.1）min;一次手术净石率76.8%（109/142）,63.4%（90/142）的肾脏为Ⅰ期单通道,17.6%（25/142）的肾脏为Ⅰ期双通道;16.9%（24/142）的肾脏为Ⅱ期3通道,2.1%（3/142）的肾脏为Ⅲ期4~5通道,9例患者术后行体外冲击波碎石辅助治疗,1个月后净石率为85.2%（121/142）。6例患者（4.2%）术后输血,3例患者（2.1%）行选择性肾动脉栓塞。3例患者（2.1%）出现感染中毒性休克,经抗休克、加强抗炎治疗后好转。3例患者（2.1%）出现一过性肾功能减退,均为孤立肾Ⅰ期双通道取石术后;无一例发生其他严重并发症。 结论超声引导、超声气压弹道碎石经皮肾镜治疗肾脏鹿角状结石安全、有效。     

微创双导管超声碎石治疗复杂性肾结石

【目的】总结cyberwand（双导管超声）经皮肾镜碎石（PCNL）治疗复杂性肾结石的治疗经验,探讨超声引导下PCNL治疗肾结石的方法、疗效和安全性。【方法】回顾本院2010～2011年超声引导下采用美国cYBERWAND双导管超声碎石清石系统治疗5l例肾结石患者（铸型结石46例、马蹄肾并结石2例、孤立肾肾结石3例）的临床资料,对手术时间、结石清除率、手术并发症等临床资料进行分析。【结果】平均结石直径（4．3±1．6）cm,建立通道时间10～28rain,平均15rain,手术时间45～110rain,平均60rain,一次性清石率82．3％（42／51）,发热4例,1例达40℃以上,其余均低于38℃,2例因大量出血行介入栓塞治疗后治愈,1例出现大量胸腹腔积液于术中发现及时行胸腹腔引流后治愈。【结论】B超引导下经皮肾镜Cyberwand双导管超声碎石清石系统治疗肾铸型结石,具有结石清除率高、手术时间短、出血少、并发症少等优点,是治疗体积较大、多发性、鹿角性及铸型等复杂肾结石的理想方法,但对处理坚硬结石存在局限性。     

超声引导经皮肾镜取石术的临床经验

临床资料：2006年1月至2007年10月，我科与泌尿外科合作为138例患者（151个肾脏）行实时超声引导定位建立肾脏通道完成经皮肾镜碎石取石术（mini percutaneous nephrolithotomy，MPCNL）。其中男83例，女55例，年龄24～65岁，中位年龄49．4岁。术前均行静脉肾盂造影、超声检查明确诊断。其中肾单发结石30例，多发结石121例，结石最大径约7．8cm。     

髓质海绵肾的诊断和治疗

目的提高髓质海绵肾的诊断和治疗水平。方法回顾分析11例髓质海绵肾患者的临床资料。男4例,女7例。临床表现肾结石8例,血尿7例,腰痛5例,泌尿系感染3例。CT、泌尿系平片（KUB）检查11例,静脉肾盂造影（IVU）检查9例,彩色多普勒超声检查8例,实验室检查5例。结果11例患者CT检查均确诊;KUB检查11例,8例合并结石患者确诊;IVU检查9例,8例确诊;彩色多普勒超声检查8例均提示诊断。近期5例患者行实验室检查确诊合并远端肾小管酸中毒3例。3例海绵-肾结石患者行经皮。肾镜超声碎石术,效果满意。结论髓质海绵肾的诊断主要依据影像学检查资料,CT是其诊断金标准;治疗主要针对其并发症,经皮肾镜碎石术能有效减轻患者结石负荷,是一种有效的治疗方法;应重视髓质海绵肾患者合并的代谢异常。     

3D打印技术在肾脏铸型结石经皮肾镜手术中的应用

目的评价3D打印技术在肾脏铸型结石经皮肾镜手术(PCNL)中的应用价值。方法选取5例肾铸型结石患者,采集患者CT数据,建立肾铸型结石数字3D模型,采用3D打印机制作1︰1结石模型。利用肾铸型结石3D打印模型与患者进行术前沟通并预测残留结石;根据3D打印模型的三维形态特征设计取石通道;在3D打印模型的引导下利用直角法定位皮肤穿刺点并穿刺目标肾盏;术中在3D打印模型的引导下探查肾盏及结石。结果医患沟通问卷4个问题的得分为(8.9±0.7)、(8.1±0.7)、(8.5±0.8)、(9.1±0.7)分。利用肾铸型结石3D打印模型共设计13个目标肾盏,其中1例患者术中增加1个前组中盏为目标肾盏,目标肾盏符合率为93.0%。在3D打印模型的引导下成功利用直角定位法完成13个预计目标肾盏的皮肤穿刺点定位以及目标肾盏轴径的穿刺,平均每个目标肾盏穿刺时间为(7.3±2.6) min。手术中在3D打印模型的引导下,肾镜下快速熟悉集合系统内解剖形态,并引导肾镜进入各肾盏。术后3D重建显示穿刺点与术前预计穿刺点符合率为92.0%,穿刺通道和肾盏轴径的符合率为100.0%。术后结石残留位置和数量均符合术前预测,5例手术均顺利完成,血红蛋白和术前比较平均下降(8.8±3.5) g/L。结论 3D打印肾脏铸型结石模型可以在精准诊断、经皮肾通道设计、经皮肾穿刺、术中引导以及医患沟通等方面为PCNL手术提供有力的帮助。     

超声引导下经皮肾穿刺钬激光碎石术治疗肾结石的价值

目的 探讨超声引导下建立皮肤肾脏通路，进行经皮肾穿刺钬激光碎石术（pereutaneous nephrolithotomy，PCNL）的安全性和有效性。方法2007年1月到2008年1月采用术中B超引导下，进行穿刺建立通路，行PCNL术治疗肾结石患者53例，并记录结石取净率及手术并发症。结果53例患者均一期成功建立皮肤肾脏通路，52例行一期碎石术，1例行二期碎石术。所有患者术后无气胸、腹腔脏器损伤等严重并发症发生。术后复查，45例患者排净结石，8例有结石残余，结石清除率为84．91％。结论采用B超引导行PCNL术治疗肾结石安全、方便，疗效可靠，     

B超引导单通道第11肋间上盏入路 经皮肾镜碎石取石术的体会

目的 探讨B超引导下经第11肋间上盏入路行经皮肾镜碎石取石术（PCNL）治疗肾及上段输尿管结石的安全性及临床疗效。方法 回顾分析该科2008年9月-2011年3月采用第11肋间上盏入路行PCNL治疗肾及上段输尿管结石142例患者的临床资料,其中鹿角型结石38例、肾脏多发性结石69例和输尿管上段结石并肾脏多发结石35例。术后第4天行CTKUB复查。结果 结石完全清除率78.2%（111/142）、残余结石9.2%（13/142）、残余碎片12.6%（18/142）,总治愈率90.8%;需二次PCNL 3例、二次体外冲击波碎石（ESWL）10例;输血2例。无胸膜、肺脏及腹腔脏器损伤等严重并发症发生。结论 B超引导11肋间入路是安全、有效的通道。     

螺旋CT三维成像联合超声在经皮肾镜取石术中的应用

目的 探讨螺旋CT三维成像联合超声在经皮肾镜取石术（PCNL）中的临床应用.方法 实验组69例复杂性上尿路结石患者术前常规行螺旋CT及超声检查,对CT图像行三维重建,结合超声检查确定肾盂肾盏结构、结石位置及最佳穿刺途径,在超声引导下经皮肾穿刺造瘘碎石取石术.选择同期44例复杂性上尿路结石相似患者作对照组,除未行螺旋CT扫描外其余处理相同.结果 实验组69例均经单一通道行PCNL获得成功,手术平均时间85 min,一期结石总清除率 95.7 %,平均术中出血量100 ml,平均住院9.5 d;对照组44例中有5例2次造瘘成功,手术时间平均130 min,一期结石总清除率86.4 %,平均术中出血量200 ml,平均住院l5 d.两组均未出现大出血、肾盂穿孔和邻近脏器损伤等严重并发症.结论 螺旋CT三维成像联合超声对PCNL治疗上尿路结石有重要的临床应用价值.     

Ruptured renal angiomyolipoma presenting as renal colic

The case of a patient with acute onset of flank pain and hematuria is presented. Initial therapy was directed toward relief of pain believed to be caused by renal colic. It was not until the patient developed atypical features that the true diagnosis, ruptured renal angiomyolipoma, was discovered. The case and discussion emphasize the need to carefully consider a complete differential diagnosis when evaluating patients with flank pain and hematuria who have atypical clinical features or an atypical course.     

Functional renal imaging: nonvascular renal disease

Functional renal imaging—a fast-growing field of MR-imaging—applies different sequence types to gather information about the kidneys other than morphology and angiography. This update article presents the current status of different functional imaging approaches and presents current and potential clinical applications. Apart from conventional in-phase and opposed-phase imaging, which already yields information about the tiusse composition, BOLD (blood-oxygenation level dependent) sequences, DWI (diffusion-weighted imaging) sequences, perfusion measurements, and dedicated contrast agents are used.     

Cortical renal leiomyoma with extension to renal pelvis

We describe a case of renal leiomyoma in a 21-year-old woman who presented with flank pain and hematuria. Urographic and computed tomographic (CT) studies revealed a large right renal mass with polypoid outgrowth protruding into the renal pelvis. Cortical renal leiomyoma with this radiographic manifestation is extremely rare.     

Epidemiology of renal recovery after acute renal failure

PURPOSE OF REVIEW: Recovery of renal function after acute renal failure is an important clinical determinant of patient morbidity. Herein, the epidemiology of renal recovery after acute renal failure will be described, along with potential predictive factors and interventions. RECENT FINDINGS: Renal recovery has been variably defined, most often as recovery to independence from renal replacement therapy. A recent consensus definition for acute renal failure has been published and included provisions for defining renal recovery. Renal recovery to renal replacement therapy independence occurs in the majority by hospital discharge and peaks by 90 days. All of older age, female sex, co-morbid illnesses, especially chronic kidney disease, and late initiation of renal replacement therapy or conventional intermittent renal replacement therapy have been coupled with non-recovery. Analysis of the literature suggests several interventions may influence recovery. SUMMARY: The prognosis is generally good for recovery after acute renal failure. Most patients will be independent of renal replacement therapy by 90 days. Additional research is necessary, however, to understand recovery rates not only to independence from renal replacement therapy, but also to complete and partial recovery. Future studies need to consider the health economic implications for survival and non-recovery. Finally, questions on the role of various interventions require characterization in randomized controlled trials to determine how they may influence renal prognosis.     

急性肾功能损伤与衰竭生物标志物

急性肾功能损伤（ARI）与急性肾功能衰竭（ARF）是加强医疗病房（ICU）的常见疾病．ICU中80％的ARF由急性肾小管损伤所致，而非肾小球或间质性病变引起。其死亡率较高，寻找敏感性和特异性较好的ARI或ARF生物标志物，对早期诊断、治疗和改善预后有着重要意义。本文介绍和评估了ARI或 ARF生物标志物的研究现状。并展望了其未来的前景。[第一段]     

Biomarkers of acute renal injury and renal failure

Acute renal failure (ARF) is a frequent problem in the intensive care unit and is associated with a high mortality. Early recognition could help clinical management, but current indices lack sufficient predictive value for ARF. Therefore, there might be a need for biomarkers in detecting renal tubular injury and/or dysfunction at an early stage before a decline in glomerular filtration rate is noted by an increased serum creatinine. A MEDLINE/PubMed search was performed, including all articles about biomarkers for ARF. All publication types, human and animal studies, or subsets were searched in English language. An extraction of relevant articles was made for the purpose of this narrative review. These biomarkers include tubular enzymes (alpha- and pi-glutathione S-transferase, N-acetyl-glucosaminidase, alkaline phosphatase, gamma-glutamyl transpeptidase, Ala-(Leu-Gly)-aminopeptidase, and fructose-1,6-biphosphatase), low-molecular weight urinary proteins (alpha1- and beta2-microglobulin, retinol-binding protein, adenosine deaminase-binding protein, and cystatin C), Na+/H+ exchanger, neutrophil gelatinase-associated lipocalin, cysteine-rich protein 61, kidney injury molecule 1, urinary interleukins/adhesion molecules, and markers of glomerular filtration such as proatrial natriuretic peptide (1-98) and cystatin C. These biomarkers, detected in urine or serum shortly after tubular injury, have been suggested to contribute to prediction of ARF and need for renal replacement therapy. However, excretion of these biomarkers may also increase after reversible and mild dysfunction and may not necessarily be associated with persistent or irreversible damage. Large prospective studies in human are needed to demonstrate an improved outcome of biomarker-driven management of the patient at risk for ARF.     

Cardiac enzymes, renal failure and renal transplantation

Diagnostic accuracy of the currently available serum markers of cardiac injury, such as myoglobin, creatine kinase and its myocardial isoform, are altered in patients with renal failure. It is shown that cardiac troponins have decreased diagnostic sensitivity and specificity in patients receiving renal replacement therapy. Data regarding serum levels of these cardiac biomarkers, especially those of the cardiac troponins, in patients with a transplanted kidney are limited. Current data show that levels of cardiac troponin I are unaltered in patients who have undergone renal transplantation, while levels of cardiac troponin T may be elevated.We believe that cardiac troponin I should be the biomarker of choice for diagnosis of myocardial injury in these patients. However, further trials are required for conclusive results.     

Preservation of renal function in chronic renal failure.

Mechanisms of progression of chronic renal failure (CRF) have been well documented in the rat but may not be relevant in man. Factors which may modify clinical CRF include underlying disease, diet, hypertension, intercurrent events, and adverse or beneficial effects of drug therapy. It has been argued that progression in many forms of renal disease is inexorable below a certain level of renal function. In other diseases, eg primary malignant hypertension, analgesic nephropathy, function frequently improves in both the short and long term with appropriate management. Thus knowledge of the nature of the underlying disease is essential in assessing progression. The value of diet in preserving renal function has been debated, particularly the relative roles of protein and phosphate control. In our own unit, a prospective randomized study showed a benefit of protein restriction. Development of accelerated hypertension is an important cause of progression of renal disease and clinical and experimental evidence supports the view that non-accelerated hypertension is also a factor in progression, amenable to treatment. Various intercurrent events may accelerate progression and function may be lost permanently following sepsis, urinary tract obstruction, renal arterial or venous obstruction, hypotension and in some cases pregnancy. Numerous drugs can have deleterious effects on the kidney. The possibility that converting enzyme inhibitors might preserve renal function is attracting attention but in view of their side effects their place in therapy should be determined by prospective controlled studies in which the above factors are carefully considered.