肾盂输尿管连接处的临床解剖学观察

目的 为肾盂输尿管连接处(UPJ)的形态学定位提供临床应用解剖学研究资料. 方法 取材于32例10%福尔马林固定的成人尸体双侧泌尿系标本,进行大体测量、组织学染色、神经纤维银染和图像分析. 结果 UPJ外径(3.12±0.81)mm和内径(2.26±0.15)mm分别小于肾盂中部和输尿管中部的各自相应值(P<0.05). UPJ神经纤维分布比肾盂中部和输尿管中部稀疏,胶原纤维较丰富.UPJ肌层厚度 (0.34±0.03)mm和管壁厚度(0.63±0.04)mm也分别小于肾盂中部和输尿管中部各自相应值(P<0.05). 肾倾斜角平均为61°,与肾倾斜角有关的UPJ位置平均在肾下极平面以上1.2～1.3cm处, 且肾倾斜角越大,UPJ位置相对越高. 结论 UPJ约位于距肾下极平面以上1.25cm处.UPJ存在生理性内、外径狭窄,神经纤维分布较稀疏,平滑肌较薄弱,且排列不规则.     

肾盂输尿管连接部梗阻的开放手术治疗

目的 探讨肾盂输尿管连接部梗阻(UPJO)的手术治疗效果.方法 UPJO患者64例,其中肾盂输尿管连接部狭窄引起梗阻的46例,输尿管肾盂高位连接10例,纤维索带或异位血管压迫者8例.64例均手术,其中Anderson-Hynes离断式肾盂成形术52例,异位血管切断及纤维索条松解术10例,肾切除术2例.结果 52例离断式肾盂成形术患者随访3～60个月,平均24个月.B超及IVU检查提示患肾实质明显增厚,肾积水消失42例,轻度积水18例,2例中度积水,患者肾功能术后复查均正常.结论 Anderson-Hynes离断式肾盂成形术是治疗肾盂输尿管连接部梗阻的首选手术方法,疗效确切.     

迷走血管与小儿先天性肾积水因果关系分析

目的探讨肾盂输尿管连接部(UPJ)迷走血管与该处梗阻引起的小儿先天性肾积水的因果关系、选择合理手术方式,提高迷走血管存在的小儿先天性肾积水临床诊治水平.方法回顾性分析了我科1998-2003年收治12例迷走血管存在的小儿肾积水诊断治疗随访情况.结果全部病人经开放手术证实,术后随访无复发.肾盂输尿管连接处管壁病理检查结果显示在有迷走血管存在与无迷走血管存在的小儿先天性肾积水中病理改变基本相同.结论该病中迷走血管存在可能不是引起肾盂输尿管连接部梗阻的始动因素.手术必须在转换盂管交界与迷走血管位置同时行肾盂输尿管成形术,切除病变的肾盂输尿管连接部,病理检查的结果为术式的选择提供了依据.     

鞍侧腔外侧壁手术切开的应用解剖学研究

目的为经鞍侧腔(LSC)外侧壁手术切开提供解剖学基础。方法对15例(30侧)成人头颅标本的LSC外侧壁进行解剖观测。结果①硬膜内途径沿前岩床皱襞分离LSC外侧壁脑膜时却可将LSC外侧壁明确的分为3层;②动眼神经鞘膜袋前部深(4.69±1.31)mm,后部深(6.50±1.58)mm;③滑车神经LSC段可分为4型:近眼神经型30%(9侧)、近动眼神经型33.3%(10侧)、"S"型10%(3侧)、直型26.7%(8侧)。结论熟悉LSC外侧壁膜层次、动眼神经鞘膜袋及滑车神经走行特点,有助于减少或避免LSC外侧壁手术切开的并发症,有助于扩大手术显露。     

成人肾盂输尿管连接部梗阻的手术治疗

目的 总结成人肾盂输尿管连接部梗阻的诊治经验。方法 对我院1990年7月至2003年6月收治的56例成人肾盂输尿管连接部梗阻患者的病因、诊断及治疗结果进行回顾性分析。结果 肾盂输尿管连接部狭窄引起梗阻者46例(82．1％)，其中3例为双侧；粘连带压迫者3例(5．3％)，输尿管肾盂高位连接者4例次(7．3％)，异位血管压迫者3例次(5．3％)。共行手术59例次，Anderson—Hynes离断式肾盂成形术47例次，肾盂Y—V成形术4例，纤维条索松解3例，异位血管切断3例，肾切除术2例。本组病例除2例肾切除者外，余54例均于术后3个月至1年进行复查随访，50例痊愈。总治愈率92．8％。4例(7．2％)发生再狭窄，二次行肾盂成形术后均痊愈。结论 IVU和RU是诊断成人肾盂输尿管连接部梗阻的主要方法，Anderson-Hynes离断式肾盂成形术是治疗成人肾盂输尿管连接部梗阻的首选术式。     

输尿管与生殖股神经的应用解剖及临床意义

目的:为临床输尿管手术中避免损伤生殖股神经提供应用解剖学资料。方法:在21具42侧经甲醛固定的成人尸体标本上,对生殖股神经腰大肌穿出点的位置关系、在髂嵴最高点平面和髂总血管分叉平面生殖股神经与输尿管的位置关系、生殖股神经与输尿管交叉点的位置关系等进行了解剖观测。结果:①生殖股神经腰大肌穿出点距髂嵴最高点平面上方的垂直距离,左侧(2.93±0.14)cm、右侧(3.61±0.19)cm;距腰大肌外侧缘的水平距离,左侧(2.14±0.83)cm、右侧(1.87±0.85)cm;生殖股神经穿出点位于输尿管内侧占80.95%。②在髂嵴最高点平面,生殖股神经位于输尿管外侧占71.43%,其平均距离在左侧为(1.09±0.71)cm、右侧(1.36±0.62)cm。③在髂总血管分叉水平面,生殖股神经全部行于输尿管的外侧。④生殖股神经与输尿管80.95%发生交叉,交叉点距髂嵴最高点平面上方的垂直距离在左侧为(0.73±0.21)cm、右侧(0.56±0.16)cm;交叉点距腰大肌外侧缘的水平距离在左侧为(1.66±0.42cm)、右侧(1.65±0.38cm)。结论:在输尿管起始段手术应从其后外侧分离较安全;在输尿管第2狭窄附近的手术应从后内侧分离较安全。     

足背外侧皮神经营养血管皮瓣的应用解剖学

目的:为足背外侧皮神经营养血管皮瓣设计提供解剖学依据。方法:32侧乳胶灌注的成人下肢标本,对足背外侧皮神经及其营养血管进行解剖,观察其起始、直径、走行、分支及分布情况。结果:足背外侧皮神经于外踝后方续于腓肠神经,起始处直径(2.65±0.57)mm,主干于外踝前下方(1.5±0.9)cm处发出分1～2条分支。足背外侧皮神经营养血管平均每侧4.8支,最为恒定的分支穿深筋膜时分别位于外踝后方平外踝最凸点,直径(0.75±0.16)mm;第5跖趾关节外侧近端(1.5±0.3)cm,直径(0.47±0.07)mm。结论:足背外侧皮神经营养血管皮瓣血供可靠,可以用来修复足前端或足底外侧创面。     

肾盂内结石手术有关的应用解剖学

观察了90例成人肾标本和30例成人肾管道的铸型标本。肾盂的门内型占56.7%,中间型占43.3%。肾盂肾盏后方越过的动脉:后段动脉出现率为100%,尖段动脉仅见5.8%,下段动脉出现34.2%。紧贴肾盂后面有一层结缔组织膜,称为肾盂外膜,富有脂肪组织,是手术分离的良好径路。根据肾后部动脉分布规律,肾窦内肾盂切开部位应在肾门后段下侧,可避免损伤血管主干。本文测量数据,对经皮肾造瘘取石术有参考价值。     

膝周血管的应用解剖与骨肿瘤保肢术受区血管的选择

目的:为临床施行带血管骨移植修复膝关节周围肿瘤性骨缺损、选择恰当的受区吻合血管提供解剖学依据。方法:在30具(60侧)成人尸体下肢标本上,观测膝关节周围血管来源、走行、管径、可游离长度等。结果:膝降动脉于股骨内上髁最高点近侧(11.23±1.30)cm处起自股动脉前内侧壁,外径(2.39±0.32)mm,主干长3.2cm;半膜肌支于股骨内上髁最高点近侧7.9cm处起自腘动脉后壁,外径(2.17±0.20)mm,蒂长(5.39±1.09)cm;腓肠动脉内侧支于股骨内上髁最高点近侧(0.69±0.57)cm处起自腘动脉内侧壁,起始外径(2.16±0.24)mm,主干长(3.90±0.95)cm;腓肠动脉外侧支于腓骨头最高点近侧(4.3±0.80)cm处起自腘动脉外侧壁,起始外径(2.09±0.22)mm,主干长(4.03±1.16)cm。结论:①选取最佳的受区血管应综合考虑血管的解剖位置、变异情况、外径、蒂长以及是否受肿瘤侵犯等因素;②腓肠血管可作为膝周骨肿瘤保肢术的首选吻合血管,膝降血管、半膜肌血管可作为备选血管;③腘动脉关节支不适于作为骨肿瘤保肢术的受区吻合血管;④行同种异体全关节或半关节移植时应选下肢的主干血管作为吻合血管。     

微创经皮肾输尿管镜下电切扩张治疗继发性肾盂输尿管连接部梗阻并发症的预防与分析

目的:探讨微创技术治疗继发性肾盂输尿管连接部梗阻(UPJO)并发症产生的原因和防范措施。方法:采用经皮肾微造瘘输尿管镜下电切扩张治疗继发性UPJO 34例患者。结果:34例中一次性行肾盂输尿管连接部狭窄切开取得成功的有31例,3例行二次手术取得成功。其中肾周尿外渗的发生率为5.9%,大出血的发生率为5.9%。结论:微创经皮肾输尿管镜下电切扩张治疗继发性UPJO,手术创伤小,疗效好;熟悉局部解剖,熟练掌握手术和腔镜操作技巧,术中精细操作,可以最大限度的减少手术并发症的发生。     

Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass

Acute kidney injury (AKI) is a common complication following cardiac surgery performed on cardiopulmonary bypass (CPB) and has important implications for prognosis. The aetiology of cardiac surgery‐associated AKI is complex, but renal hypoxia, particularly in the medulla, is thought to play at least some role. There is strong evidence from studies in experimental animals, clinical observations and computational models that medullary ischaemia and hypoxia occur during CPB. There are no validated methods to monitor or improve renal oxygenation during CPB, and thus possibly decrease the risk of AKI. Attempts to reduce the incidence of AKI by early transfusion to ameliorate intra‐operative anaemia, refinement of protocols for cooling and rewarming on bypass, optimization of pump flow and arterial pressure, or the use of pulsatile flow, have not been successful to date. This may in part reflect the complexity of renal oxygenation, which may limit the effectiveness of individual interventions. We propose a multi‐disciplinary pathway for translation comprising three components. Firstly, large‐animal models of CPB to continuously monitor both whole kidney and regional kidney perfusion and oxygenation. Secondly, computational models to obtain information that can be used to interpret the data and develop rational interventions. Thirdly, clinically feasible non‐invasive methods to continuously monitor renal oxygenation in the operating theatre and to identify patients at risk of AKI. In this review, we outline the recent progress on each of these fronts.     

Renal cholesterol granulomas: identification and morphological pattern of development

Cholesterol granulomas are infrequent and rarely described renal lesions occurring usually in the interstitium, characterized by clusters of foreign body giant cells containing ingested cholesterol crystals. Over a seven-year period, we observed them in 5 of 789 (0.6%) renal biopsies from patients with nephrotic syndrome of varying glomerulopathies. Four patients had renal insufficiency at the time of biopsy, while the fifth developed it within three months. To define the lesions we studied the morphogenesis of cholesterol granulomas by light and electron microscopy. Initially small cholesterol crystals formed in tubular epithelium; the crystals enlarged and were released into tubular lumina where they elongated or were passed in the urine. Further luminal growth caused the crystals to become lodged at some point in the nephron, distort and destroy tubule cells, and pierce through basement membranes with subsequent exposure to interstitial monocytes and formation of granulomas. It is likely these morphological abnormalities evolve from lipid disturbances in the nephrotic syndrome.     

The innervation of the kidney in renal injury and inflammation: a cause and consequence of deranged cardiovascular control

Extensive investigations have revealed that renal sympathetic nerves regulate renin secretion, tubular fluid reabsorption and renal haemodynamics which can impact on cardiovascular homoeostasis normally and in pathophysiological states. The significance of the renal afferent innervation and its role in determining the autonomic control of the cardiovascular system is uncertain. The transduction pathways at the renal afferent nerves have been shown to require pro‐inflammatory mediators and TRPV1 channels. Reno‐renal reflexes have been described, both inhibitory and excitatory, demonstrating that a neural link exists between kidneys and may determine the distribution of excretory and haemodynamic function between the two kidneys. The impact of renal afferent nerve activity on basal and reflex regulation of global sympathetic drive remains opaque. There is clinical and experimental evidence that in states of chronic kidney disease and renal injury, there is infiltration of T‐helper cells with a sympatho‐excitation and blunting of the high‐ and low‐pressure baroreceptor reflexes regulating renal sympathetic nerve activity. The baroreceptor deficits are renal nerve‐dependent as the dysregulation can be relieved by renal denervation. There is also experimental evidence that in obese states, there is a sympatho‐excitation and disrupted baroreflex regulation of renal sympathetic nerve activity which is mediated by the renal innervation. This body of information provides an important basis for directing greater attention to the role of renal injury/inflammation causing an inappropriate activation of the renal afferent nerves as an important initiator of aberrant autonomic cardiovascular control.     

^99mTc-DTPA肾动态显像及β2-m水平在评价肾移植受者肾功能中的价值

目的：探讨^99mTc-DTPA肾动态显像半定量参数和血、尿β2-m水平测定对肾移植术后早期并发症诊断与鉴别诊断的价值。方法：28例肾移植病人术后均进行放射性核素^99mTc-DTPA肾动态显像,同时测定移植肾的肾小球滤过率（GFR）、膀胱放射性计数与移植肾放射性计数比值（B/K值）和移植肾放射性1min计数与腹主动脉放射性1min计数比值（K1min/A1min比值）。在进行放射性核素肾动态显像前所有病人均收集其血液和尿液标本,采用放射免疫分析测定血、尿β2-m水平。结果：12例肾功能正常者肾动态显像示肾血流灌注及功能良好,GFR值为（49.1±6.1）ml/min,B/K值均〉3,K1min/A1min比值为8.18±1.41;4例急性排斥反应者肾血流灌注受损程度重于功能相,GFR值为（33.2±5.3）ml/min,B/K值均〈1,K1min/A1min比值为2.59±0.86,β2-m水平以血β2-m升高明显;8例慢性排斥反应者肾血流灌注和功能相均同时受损,GFR值为（19.8±7.5）ml/min,B/K值均〈1,K1min/A1min比值为2.19±0.84,β2-m水平也以血中升高明显;2例肾小管坏死者及2例环孢素A肾中毒者肾血流灌注受损均轻于功能相,GFR值分别为（38.5±4.1）ml/min和（39.4±5.81）ml/min,B/K值均〈1,K1min/A1min比值分别为5.83±0.84和6.01±0.66,β2-m水平以尿中升高显著。结论：放射性核素肾动态显像半定量参数K1min/A1min比值和B/K值,结合肾移植病人术后血、尿β2-m水平联合分析可早期初步鉴别排斥反应的类别,可作为判断移植肾受损程度、原因及预后估测的敏感指标。     

The human renal lymphatics under normal and pathological conditions

AIMS: The renal lymphatics have not been fully documented in humans. The aim of this study was to clarify the morphology of the human renal lymphatic system under normal and pathological conditions by immunohistochemistry using anti-D2-40 antibody. METHODS AND RESULTS: Normal and pathological renal tissues obtained at autopsy as well as nephrectomy specimens with renal cell carcinoma (RCC) were used. Thin sections were immunostained with antibodies against D2-40 and CD31. In normal kidney, D2-40+ lymphatics were abundant in the interstitium around the interlobar and arcuate arteries/veins but sporadic in those around the glomeruli or between the tubules in the cortex. A few lymphatics contained erythrocytes in their lumina. Lymphatics were seldom present in the medulla. In RCC cases, lymphatics were evident at the tumour margin, whereas CD31+ capillaries were abundant throughout the tumour and lymphatics were increased in the fibrous interstitium around the tumour. Lymphatic invasion by RCC cells was also detectable. D2-40+ lymphatics were evident in other pathological conditions and end-stage kidney had a denser lymphatic distribution than normal kidney. CONCLUSIONS: Lymphatics are abundant around the arteries/veins and are also present in the renal cortex and medulla. D2-40 immunostaining is helpful for investigating the pathophysiological role of renal lymphatics.     

Comparison of characteristics of chronic kidney diseases between Tibet plateau and plain areas

Background: The purpose of the current study was to investigate the pathological characteristics of chronic kidney diseases in the Tibet plateau and the plain. Methods: 77 cases from the Tibet plateau and 154 cases from the plain of renal biopsied patients with chronic kidney diseases were compared in a randomized, and parallel controlled manner. Pathological characteristics were defined according to the standards of WHO and associated classifications. Results: The ration of sex was shown that most of patients in the plateau region were female, whereas those in the plain were male. The characteristics of pathological types were shown that the patients in the plateau region were primarily minimal change disease, but IgA nephropathy was rare; meanwhile, the proportional lupus nephritis (LN) ratio of the secondary glomerulonephritis in the plateau region was significantly lower than those in the plain region. Conclusions: The current data demonstrated that the most common kidney disease in the Tibet Plateau region is still the primary glomerulonephritis as the same as those in the plain region. However, the primary glomerular disease in the plateau region is minimal change disease, and the most common clinical manifestations are the nephrotic syndrome. The IgA nephropathy in the plain is the most frequent disease. In terms of the secondary renal diseases, Henoch-Schnolein purpura nephritis are dominated in the plateau region, whereas LN-based diseases are frequently found in the plain. There is a statistical significance existed between those two groups.     

肾小管上皮细胞转分化及逆转的分子机制

肾小管上皮细胞转分化(EMT)过程广泛存在于胚胎发生和肾纤维化过程中,其调节是一个复杂有序的过程,受多种细胞因子和细胞外基质的调节。促纤维化细胞因子如TGF-β1具有诱导EMT的作用,而抗纤维化细胞因子如骨形成蛋白-7(BMP-7)和肝细胞生长因子(HGF)能抑制纤维化过程。     

Dialysate calcium and plasma calcium fractions during and after haemodialysis

Summary Dialysate Calcium and Plasma Calcium Fractions during and after Haemodialysis:The effect of different dialysate Ca concentrations on the plasma Ca fractions was examined in 28 patients. In 10 patients dialysed with a dialysate Ca concentration of 3.0 mEq/l the Ca fractions were determined at the start and end of dialysis. 8 patients were dialysed with dialysate Ca of 3.5 mEq/l. In this group the Ca fractions were also estimated in the dialysis-free interval. The third group was dialysed with a dialysate Ca of 4.5 mEq/l. Total calcium and protein-bound calcium rose significantly in all groups. Ionised calcium in the first group was significantly reduced, in the second group it remained constant and in the third group it was significantly raised. Since parathyroid function depends on the plasma ionised calcium it is concluded that a dialysate concentration of 3.0 mEq/l is partly responsible for the pathogenesis of secondary hyperparathyroidism and of renal osteodystrophy. In normocalcaemic patients a dialysate Ca concentration of 3.5 to 4.0 mEq/l is optimal. In patients entering long-term haemodialysis treatment with pronounced calcium deficiency symptoms a dialysate Ca of up to 4.5 mEq/l may be indicated for a short period after having normalized the inorganic phosphate levels in order to prevent extraosseous calcification.