肾脏疾病与维生素D代谢

肾脏不仅是一个排泄器官,而且是体内的一个重要的内分泌器官,可产生和分泌多种激素和生物活性物质。对血压、水电解质平衡、酸碱平衡、红细胞生成及钙磷代谢等多方面都有重要作用。1,25(OH)_2D_3是25(OH)D_3经肾脏羟化而生成的一种激素,调节钙磷代谢。肾脏疾患时,维生素D代谢可出现紊乱。近年来,对维生素D代谢与肾脏疾病的关系逐渐引起了人们的关注,并对肾脏疾病时维生素D代谢的改变机理进行了探讨。     

彩色多普勒超声在肾髓质钙质沉着症中的应用分析

[目的]探讨肾髓质钙质沉积症的超声特点及血流动力学改变,提高对肾髓质钙质沉着症的认识,为临床诊疗提供更好依据.[方法]回顾性分析11例确诊为肾髓质钙质沉着症超声特点及血流动力学改变.[结果]超声结果显示肾脏大小、形态基本正常,皮质、髓质界限清楚,髓质内可见沿锥体分布的密集点状强回声,形状与锥体形态一致, 后无明显声影,仅一例有弱声影.双肾彩色多普勒检查示肾脏血流分布无明显异常.[结论]肾脏髓质钙质沉积症具有特征性超声改变,对于肾髓质钙质沉着症鉴别诊断及疗效观察有不可忽视的作用.     

肾钙质沉着的超声检查

小儿肾周脂肪层较薄,有利于B型超声显示肾脏的解剖结构,容易发现肾锥体回声强度异常。我院1986年1月至1992年1月B超检查诊断肾钙质沉着(Nephrocalcinosis)7例,现予以分析报告。     

肾含钙结晶盐形成与维生素D受体基因启动子单核苷酸多态性的相关性研究

目的:研究肾含钙结晶盐形成与维生素D受体(VDR)基因启动子Fok Ⅰ位点单核苷酸多态性(SNP)之间的关系.方法:根据超声检查进行分组:80例肾皮质含钙结晶盐形成患者(A组)及80例无结晶盐形成者(B组).应用聚合酶链反应-限制性片段长度多态性(PCR-RFLP)对两组进行Fok Ⅰ多态性检测,分析两组间基因型和等位基因的分布情况.结果:A组基因型分布FF:30％(24/80),Ff:50％(40/80),ff:20％(16/80);B组FF:34％(27/80),Ff:60％(48/80),ff:6％(5/80);其中ff分布在两组中差异有统计学意义(P＜0.05).A、B两组F等位基因频率分布分别为55％(88/160)和64％(102/160);f分别为45％(72/160)和36％(58/160),差异均无统计学意义(均P＞0.05).结论:VDR基因起始密码子中FokⅠ多态性与肾皮质含钙结晶盐形成有关系,超声作为一种无创简便的早期诊断方法在本研究中有着较重要的作用.     

小儿维生素D中毒误诊1例分析

现对小儿维生索D中毒误诊1例分析如下。[第一段]     

肾错构瘤的超声表现

目的 探讨肾错构瘤的超声表现。方法 对37例肾错构瘤行灰阶及彩色多普勒（部分）检查，全部病例均经手术和病理证实。结果 肾错构瘤主要表现为高回声，直径≤3cm及＞3cm组中各占91％和76％。肾错构瘤呈外突出或出现无回声区者分别为32个和5个。肾多发错构瘤13例，同侧肾错构瘤出现高低回声并存者2例。14例肾错构瘤行彩色多普勒血流显像检查，发现肿瘤彩色血流分布类型有5种，瘤内血流以中心型和穿透型多见，阻力指数＞0．60。结论 灰阶超声和彩色超声联合检查对诊断肾错构瘤有重要价值。     

肾脏罕见炎性肿块患者超声表现

目的 总结肾脏罕见的黄色肉芽肿性肾盂肾炎(XGP)及肾脏炎性假瘤(RIP)患者肾脏炎性肿块的超声表现.方法 回顾性分析2004-2011年我院收治的4例XGP及2例RIP患者的超声声像图特征,包括肿块大小、肿块形态、边界、回声强弱及局限性回声改变、内部血流等情况.6例肾脏罕见炎性肿块患者均经术后病理证实,且1例患者合并肾早期透明细胞癌.结果 6例肾脏罕见炎性肿块超声声像图多表现为形态不规则、边界清或不清、内部以低回声为主或中等回声为主或强回声为主,肿块伴有强回声团伴声影,部分肿块内血流信号丰富,均未见肿块内液化、坏死.其中超声提示2例良性,1例恶性,2例恶性不排除,1例误诊为肾结核或肾脏畸胎瘤.结论 肾脏罕见炎性肿块的超声表现有一定的特点,但并无特异性表现.超声检查可协助鉴别诊断,具有一定的临床价值.     

肾淋巴瘤超声表现1例

患者男,64岁,因"左侧腰部胀痛不适3天"入院.查体:左肾区叩痛,双侧输尿管走行区无压痛.8年前因睾丸恶性淋巴瘤接受左侧睾丸切除术.超声:左肾增大,形态失常,左肾实质中部腹侧近肾门处回声不连续,缺损处见约12.2 cm×9.4 cm×7.4 cm的低回声肿块(图1),形态不规则,边界欠清,包绕肾实质,回声不均质;CDFI示其内丰富血流信号(图2),脉冲多普勒测及高速高阻动脉型频谱;左侧输尿管未见明显扩张.超声提示:左肾实性占位,符合左肾恶性肿瘤声像图改变.     

肾嗜酸细胞瘤超声表现

目的 探讨肾嗜酸细胞瘤(RO)的声像图特征.方法 回顾性分析手术病理证实的12例RO患者的超声表现,包括病变大小、边界、形态、回声水平及血流特点.结果 12例RO患者中,超声准确定位所有病灶,其中3例误诊为肾癌,9例未能做出定性诊断.超声发现8.33%RO有中央星状瘢痕,66.67%回声均匀、75.00%边界清晰、91.67%形态规则和58.33%为等回声,66.67%肿瘤周边见环绕血流,50.00%内部多血供,且呈轮辐状分布,41.67%少血供,8.33%无血供.结论 超声对RO定性诊断较困难,但对内部回声均匀、界清、血流轮辐状分布、尤其有中央星状瘢痕的肾实性肿物,应考虑RO可能.     

成批家族性维生素D中毒临床分析

目的 探讨家族性维生素D中毒的病因、临床表现和治疗.方法 分析了11例家族性维生素D中毒的临床资料.结果 11例中毒表现涉及多个系统,以神经系统、消化系统、泌尿系统表现最为突出.出现头晕、头胀、头痛、步态不稳、嗜睡或烦躁、谵妄、厌食、恶羽、呕吐、烦渴、多尿、发热、心悸、血压增高、肾功能不全等表现.结论 强调详细采集病史,提高对维生素D中毒表现的认识,重视寻找客观依据至关重要.对于不明原因出现消化、泌尿、神经系统等症状时,常规检测血、尿钙,以免误漏诊.     

Life-threatening complications of vitamin D intoxication due to over-the-counter supplements

Introduction. Ninety percent of hypercalcemic cases are caused by primary hyperparathyroidism or malignancy. Less frequent causes are granulomatous diseases, drug-induced diseases, and intoxications. Case report. We present two women with life-threatening hypercalcemia due to the intake of vitamin D-concentrated supplements, which turned out to be 100–1,000 times higher than stated on the label of over-the-counter dietary supplements. Laboratory analysis revealed ionized calcium levels of 4.00 (16.00) and 4.56 mmol/L (18.24 mg/dL) with vitamin D₂₅ concentrations of 1,372 and 644 nmol/L, respectively. Apart from a patient with general symptoms of hypercalcemia, a case of refractory status epilepticus after correction of serum calcium levels, and in need of prolonged ICU treatment, is described. Conclusion. Initial drug-taking history in the presented cases did not reveal the use of over-the-counter supplements, which underlines the importance of a thorough evaluation of (non-)prescribed medication. Moreover, these supplements may contain higher levels of vitamin D than the label states. As a result, hypercalcemia may be an underlying cause for life-threatening complications, including a well-documented refractory status epilepticus.     

维生素D对脓毒性休克导致急性呼吸窘迫综合征患者的干预价值研究

目的探索维生素D对脓毒性休克致急性呼吸窘迫综合征（ARDS）的干预效果。 方法选取2017年6月至2019年6月入住山西医科大学第一医院重症监护室发生脓毒性休克导致ARDS的80例患者,根据25-羟维生素D水平分级分为维生素D正常组（17例,25-羟维生素D ≥ 50 nmol /L）和维生素D降低组（63例,25-羟维生素D < 50 nmol /L）。然后再根据25-羟维生素D水平的降低程度进一步将维生素D降低组分为维生素D缺乏组（35例,30 nmol /L ≤25-羟维生素D ≤ 49.9 nmol /L）和维生素D严重缺乏组（28例,25-羟维生素D <30 nmol/L）。采用随机数字表法将维生素D缺乏组患者分为A组（对照组,17例）和B组（干预组,18例）,将维生素D严重缺乏组患者分为C组（对照组,14例）和D组（干预组,14例）。A、C组患者给予经胃管、肠内营养管补充淀粉胶囊0.5 g/d;B、D组患者给予经鼻胃管、鼻肠管补充阿法骨化醇软胶囊0.5 g/d,疗程均为7 d。记录所有患者的年龄、性别、25-羟维生素D、氧合指数、急性病生理学和长期健康评价（APACHE）Ⅱ评分、血管外肺水指数（EVLWI）、肺血管通透性指数（PVPI）及28 d死亡情况,采用Cox回归分析影响脓毒性休克致ARDS患者28 d病死率的危险因素。 结果维生素D正常组和维生素D降低组患者25-羟维生素D [（57 ± 4）nmol /L vs.（33 ± 8）nmol /L]、氧合指数[（135 ± 25）mmHg vs.（114 ± 18）mmHg]、APACHEⅡ评分[（14.7 ± 1.6）分vs.（16.0 ± 2.0）分]、EVLWI [（11.4 ± 2.1）mL/kg vs.（14.5 ± 2.7）mL/kg]、PVPI [（3.61 ± 0.32）vs.（5.05 ± 0.68）]及28 d死亡情况（1/17 vs. 20 /63）比较,差异均有统计学意义（t = 11.448、3.872、8.864、5.097、8.409,χ² = 4.626;P均< 0.05）。Cox回归分析结果显示,25-羟维生素D [相对危险度= 4.183,95%置信区间（1.787,10.594）,P = 0.012]是脓毒性休克致ARDS患者预后的保护因素。且干预后,C、D组患者25-羟维生素D [（25 ± 4）nmol /L vs.（37 ± 4）nmol /L]、氧合指数[（152 ± 18）mmHg vs.（171 ± 13）mmHg]、APACHEⅡ评分[（12.8 ± 1.4）分vs.（11.0 ± 1.7）分]、EVLWI [（9.5 ± 0.9）mL /kg vs.（7.9 ± 1.4）mL /kg]及PVPI [（3.63 ± 0.28）vs.（2.95 ± 0.48）]比较,差异均有统计学意义（t = 7.493、3.246、3.016、3.420、4.373,P均< 0.05）,而28 d死亡情况（6 /14 vs. 4 /14）比较,差异无统计学意义（χ² = 0.622,P = 0.430）。 结论维生素D降低在脓毒性休克致ARDS患者中普遍存在,且维生素D是脓毒性休克ARDS患者28 d病死率的保护因素,而补充维生素D可改善维生素D严重缺乏者ARDS的严重程度。     

Doppler sonography in the diagnosis of urinary tract obstruction by stone

PURPOSE: This study was conducted to evaluate the accuracy of Doppler sonography in renal colic due to obstruction and to assess whether the resistance index (RI) and interrenal RI difference (DeltaRI) are time-dependent parameters. SUBJECTS AND METHODS: Obstructed and unobstructed contralateral kidneys in 28 patients with renal colic and normal kidneys in 27 control subjects were prospectively evaluated with Doppler sonography. Mean RI, mean DeltaRI, and duration of pain were evaluated. Statistical analysis was done using paired and independent t-tests. RESULTS: Mean RIs of the control-group, obstructed, and contralateral kidneys were 0.60, 0.71, and 0.61, respectively; mean DeltaRI values of the obstructed and control-group kidneys were 0.10 and 0.03, respectively. Differences in mean RI between obstructed and contralateral or control-group kidneys were statistically significant (p < 0.001). There was a statistically significant difference in DeltaRI between patients and controls (p < 0.001). The difference between the RI values of kidneys with low-grade (0.70) and high-grade obstructions (0.72) was not statistically significant. The difference between the DeltaRI values of kidneys with low-grade (0.08) and high-grade obstructions (0.13) was statistically significant (p < 0.05). Differences in the mean RI and mean DeltaRI values between 3 groups of patients categorized according to the duration of pain were not statistically significant. CONCLUSIONS: Along with gray-scale sonography and intravenous urography, Doppler sonography can be used in the evaluation of renal obstruction. RI and DeltaRI are not time-dependent parameters.     

Ultrasound diagnosis of penile fracture

BACKGROUND: Rupture of the corpus cavernosum, penile fracture, is an uncommon occurrence. Diagnosis is straightforward when classical historical and physical examination findings are present. However, atypical presentations can make the diagnosis difficult. OBJECTIVES: Review the literature supporting use of ultrasound for the diagnosis of penile fracture. Review of the ultrasonographic findings in patients with penile fracture. CASE REPORT: A 32-year-old man presented with penile ecchymosis after sex but lacking several historical and physical examination elements for a diagnosis of penile fracture. Ultrasound performed by the treating physician revealed rupture of the tunica albuginea and presence of a hematoma, leading to a diagnosis of penile fracture. Conclusion: Ultrasound is a simple, efficient, and non-invasive imaging method to assist in the diagnosis of penile fracture.     

Structure-function relationships of vitamin D including ligand recognition by the vitamin D receptor

First, the general structure and function of nuclear receptors (NRs) are described briefly to help our understanding of the mechanism of action of vitamin D mediated by the vitamin D receptor (VDR), a member of the NRs. Then we discuss the structure-function relationship (SFR) of vitamin D on the basis of ligand structures and the interaction of the ligand with the VDR. The SFR of vitamin D side chain analogs is discussed extensively in terms of our active space group concept, which was derived from conformational analyses of the side chains of vitamin D analogs and from studies with conformationally restricted 22-methyl-1,25-(OH)(2)D(3) isomers. The mobile area of the side chain of vitamin D can be grouped into five regions (E, G, EA, EG, and F), and the SFR has been analyzed in terms of these spatial regions. The SFR of ligand/VDR interaction is discussed on the basis of the crystal structure of VDR-LBD(delta 165-215), docking of various vitamin D ligands into the ligand binding pocket (LBP) of the VDR, and functional analysis of amino acids lining the LBP. Finally, we discuss total SFR, combining the results of the two approaches, and future aspects of structure-based design of vitamin D analogs.     

彩色多普勒超声在乳腺良恶性肿瘤鉴别诊断中的应用价值

目的 探讨灰阶超声、彩色多普勒血流成像(CDFI)及能量多普勒(CDE)超声在乳腺实质性病灶中的血流信号及超声特点,评价其在乳腺良恶性肿瘤鉴别诊断中的价值.方法 采用二维超声、CDFI、CDE及复合超声成像技术对264例(392个肿块)乳腺实质性肿瘤进行超声检查,分析病变的形态、边缘、内部回声、包膜、纵/横比,有无钙化灶、血流信号分布等情况,并与术后病理结果对比.结果 病理诊断良性肿瘤178例,恶性肿瘤86例.其中恶性肿瘤内部及周边见丰富彩色血流信号显示(79/86),穿通血管和分支血管居多(66/86),且内部可见大量散在钙化或簇样钙化(83/86),而良性肿瘤内彩色血流信号及穿通血管较少,仅有4例肿块内部可见钙化.结论 二维超声结合CDFI、CDE检查在乳腺良恶性肿瘤鉴别诊断中有很好的临床应用价值.     

超声监测移植肾功能及鉴别肾功能异常组织学类型

目的 观察超声监测移植肾功能及鉴别肾功能异常组织学类型的价值。方法 以211例肾移植术后肌酐异常接受穿刺活检患者为异常组（A组）,80例同期移植肾功能转归正常患者为对照组（B组）,回顾2组移植肾二维、彩色及能量多普勒超声数据,对移植肾体积变化率（V-rate）、叶间动脉峰值血流速度（PSV）、舒张末期血流速度（EDV）、阻力指数（RI）、搏动指数（PI）及能量图信号分级（Power）进行统计分析,以受试者工作特征（ROC）曲线分析其对肾功能异常的诊断效能。按照病理类型将A组分为急性排斥反应亚组（A1组）和其他病变亚组（A2组）,分析超声对急性排斥反应的鉴别诊断效能。结果 A组V-rate显著高于B组（P<0.05）,2组RI分布及Power差异均有统计学意义（P均<0.05）,其余各参数差异均无统计学意义（P均>0.05）,V-rate、RI和Power诊断移植肾功能异常的曲线下面积（AUC）分别为0.576、0.542和0.810,三者联合AUC为0.843,敏感度90.50%,特异度57.50%。V-rate、RI和Power鉴别移植肾急性排斥反应的AUC分别为0.562、0.522和0.551,三者联合AUC 0.647,敏感度69.20%,特异度55.00%。结论 超声对于监测移植肾功能、鉴别移植肾功能异常组织学类型具有一定价值。     

单脐动脉的超声诊断及意义

目的：探讨二维超声及彩色多普勒超声对单脐动脉的诊断及其临床意义。方法：应用常规产前彩色超声检查，发现胎儿异常者仔细检查脐血管；发现单脐动脉者仔细检查是否合并胎儿畸形。同时测量脐动脉血流参数，估测胎儿大小并评价其与孕周是否相符。结果：2005年2月~2006年6月来我院就诊并做超声检查的7623名孕妇中，发现单脐动脉10例，5例伴有胎儿畸形，1例脐动脉阻力指数增高，3例脐动脉舒张期血流缺失，2例胎儿大小明显小于孕周。10例患者单脐动脉及其伴发畸形均经引产或正常产证实。结论：应用超声检查可以对单脐动脉做出明确诊断。单脐动脉与诸多胎儿异常关系密切，超声诊断医师应当高度重视脐血管的检查及单脐动脉的诊断，以有效指导临床。     

Emergency Ultrasound and Urinalysis in the Evaluation of Flank Pain

Objectives: To determine the sensitivity and specificity of limited emergency ultrasonography of the kidney in diagnosing renal colic. Methods: This was a prospective observational trial from December 2001 to December 2003 at a suburban emergency department. Patients who presented with flank pain suspicious for renal colic were enrolled. Exclusion criteria included fever, trauma, known current kidney stone, unstable vital signs, and inability to provide consent. All patients underwent sequential emergency ultrasonography and computed tomography of the kidneys and bladder. Data were analyzed using chi-square analysis. The primary outcome was the sensitivity and specificity of ultrasonography. Results were also stratified for presence of hematuria. Results: Fifty-eight of the 104 patients enrolled in the study were diagnosed with renal colic. The overall sensitivity and specificity of bedside ultrasonography for the detection of hydronephrosis were 86.8 (95% confidence interval [CI] = 78.8 to 92.3) and 82.4 (95% CI = 74.1 to 88.1), respectively. In patients with hematuria, hydronephrosis by emergency ultrasonography demonstrated a sensitivity and specificity of 87.8 (95% CI = 80.3 to 92.5) and 84.8 (95% CI = 73.7 to 91.9), respectively. In 55 of the cases, the initial computed tomograph was read by a resident and later re-read by an attending physician. Using the reading of the attending physician as the criterion standard resulted in a sensitivity and specificity of 83.3 (95% CI = 73.2 to 88.0) and 92.0 (95% CI = 79.9 to 97.6), respectively. Conclusions: Emergency ultrasonography of the kidneys shows very good sensitivity and specificity for diagnosing renal colic in patients with flank pain and hematuria.