不同治疗方案应用于IgA肾病患者中的效果分析

目的研究不同西医方案治疗IgA肾病患者的临床疗效以及安全性。方法以2016年1月至2018年6月于高州市人民医院接受治疗的72例IgA肾病患者作为研究对象。将其按照随机数字表法均分成环磷酰胺组、霉酚酸酯组以及对照组,每组各24例。对照组予以单纯糖皮质激素治疗,环磷酰胺组予以糖皮质激素联合环磷酰胺治疗,霉酚酸酯组则采用糖皮质激素联合霉酚酸酯治疗。3组患者均治疗6个月,比较3组临床疗效、治疗前后各项生化指标水平以及不良反应发生情况。结果环磷酰胺组、霉酚酸酯组、对照组不同Haas分型患者的临床治疗总有效率之间无显著差异(均P0.05)。治疗后环磷酰胺组、霉酚酸酯组患者24 h尿蛋白定量、血肌酐、血清尿素、血尿酸均显著低于对照组(均P0.05);而环磷酰胺组、霉酚酸酯组上述指标水平对比无明显差异(均P0.05)。霉酚酸酯组不良反应发生率为0.00%(0/24),相比环磷酰胺组16.67%(4/24)以及对照组25.00%(6/24)均较低(均P0.05)。结论糖皮质激素联合环磷酰胺以及糖皮质激素联合霉酚酸酯治疗IgA肾病患者的临床疗效相当,但后者不良反应发生率较低,具有更好的安全性,值得临床推广应用。     

贫血加重IgA肾病患者的临床和病理改变

目的 分析IgA肾病合并贫血患者的临床病理特征.方法 收集经肾活检确诊的IgA肾病患者临床资料409例,按照贫血与否分为非贫血组和贫血组,回顾性分析两组患者的临床和病理资料.结果 与非贫血组比较,贫血组患者的肾小球损伤和肾小管间质萎缩程度较重、24 h尿蛋白增多和eGFR降低.Spearman相关分析结果显示,血红蛋白、eGFR与肾脏病理损伤呈负相关(P＜0.05),血尿酸、24h尿蛋白与肾脏病理损伤呈正相关(P＜0.05).多因素Logistic回归分析发现贫血是肾小管间质萎缩的独立危险因素.结论 IgA肾病合并贫血患者的临床和病理损伤重于IgA肾病非贫血的患者,贫血参与IgA肾病的进展.     

中等量蛋白尿IgA肾病糖皮质激素与雷公藤治疗对比观察

目的：观察中等量短程糖皮质激素和常规剂量雷公藤多苷在中等量蛋白尿IgA肾病患者治疗中的作用,比较两组治疗蛋白尿的临床有效率。方法：患者均为临床和病理确诊的IgA肾病,24h尿蛋白定量在1-3.5g,血清肌酐正常或轻度升高（〈177μmol/L）,病理诊断符合Hass分型标准（Ⅰ-Ⅱ型）,分为激素组和雷公藤组,两组分别给予中等量短程糖皮质激素（参照意大利方案）和常规剂量雷公藤多苷（1mg·kg^-1·d^-1）治疗6个月,同时给予降血压等治疗。完成治疗及随访共59例,观察两组治疗前后的24h尿蛋白定量变化以及肾功能等指标,以尿蛋白定量减少程度作为是否有效指标,进行统计学的分析。结果：6个月后,两组患者的蛋白尿治疗有效率（尿蛋白减少〉50%）分别为59.4%和44.4%,但无统计学差异;病理类型为Ⅰ型的患者治疗有效率分别为66.7%和43.8%,病理类型为Ⅱ型的患者治疗有效率分别为50.0%和45.5%,均无统计学差异。结论：对于诊断明确的中等量蛋白尿、肾功能正常或基本正常且肾脏病理为Ⅰ-Ⅱ型（Hass分型）的IgA肾病患者,采用中等量短程糖皮质激素或常规剂量的雷公藤多苷治疗均有一定效果,且两者在有效率方面并无统计学差异。     

来氟米特治疗以肾病综合征为主要表现的IgA肾病的对照研究

目的探讨来氟米特治疗以肾病综合征为主要表现的IgA肾病患者的疗效及安全性。方法60例患者随机分为治疗组和对照组,每组30例。治疗组应用泼尼松联合来氟米特治疗;对照组应用泼尼松联合环磷酰胺冲击治疗。观察治疗前后24h尿蛋白定量,血浆白蛋白,肝、肾功能及治疗后药物的不良反应。结果治疗组与对照组的总有效率分别为86．7％和83．3％;不良反应总发生率分别为30．0％和73．3％。结论来氟米特联合泼尼松治疗以肾病综合征为主要表现的IgA肾病疗效可靠,不良反应发生少,为临床治疗提供的一种新的方法。     

吗替麦考酚酯治疗难治性肾病综合征的临床观察

目的:研究吗替麦考酚酯(MMF)治疗原发性难治性肾病综合征(NS)的疗效及其安全性.方法:对糖皮质激素和环磷酰胺治疗无效或复发的30例原发性难治性肾病综合征患者,采用皮质激素和MMF联合治疗;MMF初始剂量1.0～1.5 g/d,3个月后逐渐减量为半量,疗程6个月以上;同时口服泼尼松20～40 mg/d,根据病情加快皮质激素的撤药速度.定期随访并记录疗效、副作用.结果:MMF 联合皮质激素治疗可以使患者尿蛋白定量下降和血清白蛋白上升(P<0.01),87%患者尿蛋白定量下降, 90%患者血清白蛋白上升,缓解率83%.大部分患者肾功能明显改善至正常,6例透析患者也完全脱离透析.未见明显副作用.结论:MMF对传统免疫抑制剂和糖皮质激素治疗无效或复发的难治性肾病综合征患者有效,未见明显副作用.对MMF的临床应用还有待进一步研究.     

伴高尿酸血症IgA肾病的临床、病理特点及预后的相关分析

目的：研究伴高尿酸血症IgA肾病患者的临床、病理特点及预后的相关因素。方法：对2006年～2009年经肾活检确诊为IgA肾病的72例患者的临床与病理资料进行分析。根据血尿酸水平,将72例IgA患者分为高尿酸血症组与血尿酸正常组,比较两组间临床指标、肾功能指标及病理学参数。结果：临床指标中年龄、血尿酸及尿蛋白定量均与血肌酐、肾小球滤过率有显著相关性（P〈0.05）。多元逐步回归分析血尿酸对IgA肾病肾功能进展的预测优于尿蛋白定量。病理参数中肾小球积分、肾小管间质积分与血肌酐、肾小球滤过率显著相关（P〈0.05）。高尿酸血症组肾功能指标均差于血尿酸正常组。高尿酸血症组肾小管间质损害均高于血尿酸正常组。结论：IgA肾病的预后主要与尿蛋白定量、血尿酸、肾小管间质损害、球性硬化有关,IgA肾病37.5%患者合并高尿酸血症、其临床尿蛋白、肾功能损害及病理肾小管间质损害均高于血尿酸正常组IgA肾病患者,应重视血尿酸在IgA肾病中的作用。     

正清风痛宁辅助治疗IgA肾病的临床观察

目的:观察正清风痛宁对IgA肾病的临床疗效.方法:经肾活检并结合临床确诊为原发性IgA肾病68例,尿蛋白在1～2.5 g/d,肾功能正常,并有白细胞减少、肝功能损害或应用雷公藤后出现副作用等之一特殊情况,随机分成治疗组和对照组.对照组接受洛汀新或科素亚、百令胶囊及潘生丁治疗,治疗组在此基础上加用正清风痛宁治疗.结果:治疗3个月时,治疗组与对照组的24 h尿蛋白分别由治疗前的(2.05±0.57)g/d、(1.92±0.54)g/d减少至(0.56±0.30)g/d、(1.48±0.38)g/d,两组有统计学差异(P＜0.01);治疗组5例腰痛全部缓解,对照组仅1例(1/4)缓解;两组肝肾功能、血象及月经情况在治疗前后无明显变化.结论:正清风痛宁是辅助治疗IgA肾病的安全有效的药物.     

IgA肾病是否应该使用糖皮质激素治疗

IgA肾病是最常见的原发性肾小球肾炎。IgA肾病临床及病理呈现多样性。糖皮质激素(激素)是治疗IgA肾病的基础药物之一,激素能减少IgA肾病患者尿蛋白,降低中、高危IgA肾病患者进入ESRD危险,改善IgA肾病患者的预后。     

来氟米特联合小剂量强的松治疗对IgA肾病临床疗效、肾功能以及尿蛋白的影响

目的观察分析来氟米特联合不同剂量强的松(泼尼松)治疗对IgA肾病临床疗效、肾功能以及尿蛋白的影响。方法将2016年2月至2018年2月于陕西省核工业二一五医院肾内科就诊治疗的86例IgA肾病患者作为研究对象,根据治疗方式的不同分为对照组和观察组各43例。对照组在IgA肾病基础治疗上给予口服泼尼松治疗,观察组予以来氟米特联合小剂量泼尼松治疗,治疗后比较两组患者临床疗效、肾功能和尿蛋白水平以及不良反应。结果对照组的临床总有效率明显低于观察组(P0.05)。治疗后,两组患者Scr、24 h尿蛋白定量和BUN水平与治疗前比较都明显降低,而eGFR水平则明显升高(P0.05);治疗后观察组患者eGFR水平则明显高于对照组,Scr、24 h尿蛋白定量、BUN水平较对照组明显低(P0.05)。观察组不良反应发生率(6.97%)显著低于对照组(39.53%)。结论来氟米特联合小剂量泼尼松治疗IgA肾病患者其临床有效率更高,能更大程度的改善其肾功能指标水平和有效降低患者24 h尿蛋白定量,提高eGFR至正常水平,且具有一定的安全性,更值得临床推广和广泛应用。     

78例IgA肾病血管病变的临床意义分析

目的:探讨IgA肾病血管病变的临床意义.方法:分析78例经肾活检诊断的IgA肾病患者的临床指标(病程、血压、肾功能、血脂等)及病理改变与血管病变的关系.结果:78例IgA肾病患者中有不同程度血管病变者占46.2%,其中轻度占32.1%,中度占10.3%,重度占3.8%.重度血管病变组较无、轻度血管病变组临床病情加重,表现为血压更高、血肌酐升高、尿蛋白定量增多、病理分级加重等.结论:在IgA肾病中血管病变与血压、尿蛋白定量、血肌酐水平等临床指标及病理改变相平行,能反应病变的程度,可以作为判断预后的一项重要病理指标.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.