造影剂肾病的防治进展

造影剂肾病（Contrast—induced nephropathy,CIN）的发病率逐年攀升,已经成为医源性急性肾功能衰竭的重要原因之一。因此,CIN近年来备受关注。关于CIN的研究工作,目前主要集中在危险因素、发病机制及防治措施等方面,其防治主要集中于水化疗法、N-乙酰半胱氨酸、钙离子拮抗剂以及干预肾小管上皮细胞凋亡等防治措施的研究。本文将就近年来CIN的防治进展作一综述。     

造影剂相关性肾病的研究现状

随着造影技术应用日益广泛，造影剂相关性肾病越来越多出现于临床，逐渐引起肾病及其它学者关注。本文重点综述近五年来研究焦点：造影剂肾病的危险因素、发病机制、高渗、低渗造影剂肾毒性的评估及防治造影剂肾病的有关方法。     

等渗透剂量20%甘露醇与3%高渗盐水对大脑半球胶质瘤切除术患者血浆渗透浓度和电解质影响的比较

目的 比较择期大脑半球胶质瘤切除术中应用等渗透剂量的3%高渗盐水(hypertonie saline,HTS)和20%甘露醇(mannitol,M)降颅内压(intracranial pressure,ICP)的同时,患者血浆渗透浓度和电解质的变化及其临床意义. 方法 择期行大脑半球胶质瘤切除术患者40例,根据计算机随机分组表分为高渗盐水组(HTS组)和甘露醇组(M组)(n=20).两组均行静吸复合麻醉,异氟醚呼气末浓度达1 MAC后,在15 min内输注等渗透剂量3%HTS(5.33 ml/kg)或20%M(1 g/kg).记录输注前即刻(T0)、输注后即刻、输注后5、15、30、60、90、120 min(T1～T7)平均动脉压(MAP)、心率(HR),同时采取5 ml动脉血测定血球压积、血浆Na+、K+、Cl浓度、血pH、血浆渗透浓度,同时监测颅内压.结果 两组血浆渗透浓度在输注高渗溶液后均明显升高,在T1达高峰[HTS组:(305.1+4.3)mOsm/L;M组:(304.6±3.5)mOsm/kg](P<0.05),HTS组血浆Na+和cl浓度明显升高,于T1达高峰(152.3+5.2)mEq/kg(P<0.05),M组血浆Na+度降低,在T1达低谷(131.2±3.3)mEq/kg(P<0.05);血浆Cl-浓度在HTS组升高(P<0.05),M组降低(P<0.05).HTS组ICP在T2～T5降低(P<0.05),尤以T1～T2时段降低幅度更为明显,M组ICP在T3～T5降低(P<0.05).结论 在实施择期神经外科手术的患者,单剂静脉输注5.49 mOsm/kg的3%HTS和20%M引起同等程度的血浆渗透浓度上升,并在输注末达到高峰.     

老年人造影剂肾病发生的相关危险因素

目的探讨老年人造影剂肾病（RCN）的发生率并对相关的危险因素进行分析。方法比较造影剂肾病患者与未发生造影剂肾病患者的基础疾病、临床特点、造影当日静脉液体入量、基础肾功能水平,探讨造影剂肾病发生的危险因素。结果60岁以上人群发生率为11．52％,明显高于30～59岁人群;合并冠心病、高血压、糖尿病的患者RCN的发生率增加;合并肾功能不全的患者RCN的发生率可达54．8％;RCN患者液体入量远远低于未发生RCN的患者。结论老年人造影剂肾病的发生率很高,可能与肾脏贮备能力降低有关;充分水化是防止造影剂肾病发生的有效方法。     

造影剂相关性肾病的研究现状

随着造影技术应用日益广泛，造影剂相关性肾病（ＣＡＮ）越来越多出现于临床，逐渐引起肾病及其它学者关注。本文重点综述近五年来研究焦点：造影剂肾病的危险因素、发病机制、高渗、低渗造影剂肾毒性的评估及防治造影剂肾病的有关方法。     

造影剂肾病的研究进展

造影剂肾病（contrast—induced nephropathy,CIN）是指在排除其他肾脏损害因素后,使用造影剂48-72 h内,出现血肌酐升高大于44.2μmol/L,或血清肌酐较基线升高大于25%[1]。随着碘造影剂在放射诊断和介入治疗领域的广泛应用,造影剂肾病发病率不断增加。造影剂肾病是继外科手术、低血压后第三大医源性急性肾损伤[2]。     

造影剂肾病的发病机制与诊断及防治

造影剂肾病（contrast induced nephropathy，CIN）是指使用造影剂后48h内发生的无其他原因可解释的急性肾损伤（acute kidney injury，AKI）。随着放射诊断技术的不断发展和介入治疗的广泛应用，造影剂的使用也口益广泛。尽管造影剂不断改良（由离子型到非离子型，由高渗型到等渗型），但因造影剂导致的AKI却频频发生，其发生率呈上升趋势，     

487例冠脉造影后造影剂肾病的临床研究

目的：调查住院冠状动脉造影患者造影剂肾病的发病情况。方法：收集上海市第六人民医院2008年1月~2009年7月31日的回顾性病历,收入2008年~2009年度冠脉造影（coronary angiography）/冠脉干预（percutaneous coronary intervention）病例,分析入选病例的疾病构成和造影剂肾病（contrast-induced nephropathy,CIN）在不同情况下的发病率,比较CIN组与非CIN组患者的各项资料,分析CIN患病的危险因素。结果：入选患者487例中CIN发病率10.5%（51例）,经过Mehran的危险积分分层后提示CIN发病率随着危险积分上升,在极高危的一组中达到18.0%,多因素回归分析显示术前低血压、心衰、贫血、eGFR≤30ml/min是CIN的危险因素。结论：CIN与术前低血压、心衰、贫血、肾功能以及其相应临床指标密切相关;等渗造影剂对与CIN的发病不优于低渗造影剂;需密切关注心内科行CAG的患者CIN的发病率,积极采取有效的措施预防CIN的发生。     

造影剂肾病的诊疗进展

本文综述了造影剂肾病的发病机制、危险因素、临床表现、诊断、治疗及预防。     

高渗氯化钠羟乙基淀粉溶液对脑动脉瘤出血介入术后脑血管痉挛的影响及机制

目的 探讨术中及术后输注高渗氯化钠羟乙基淀粉溶液(hypertonic sodium chloride hydroxyethyl starch solution,HSH)对脑动脉瘤破裂出血介入术后脑血管痉挛(cerebral vasospasm,CVS)的影响及其机制. 方法 发病后3d内拟行颅内动脉瘤介入栓塞术的动脉瘤破裂蛛网膜下腔出血(aneurysm subarachnoid hemorrhage,aSAH)患者30例.ASA分级Ⅱ、Ⅲ级,Hunt和Hess(原发性蛛网膜下腔出血的临床状态)分级Ⅱ、Ⅲ级,改良Fisher分级1、2级,格拉斯哥昏迷评分(Glasgow ComaScale,GCS) 13～15分,年龄18～80岁.按随机数字表法分为两组(每组15例):实验组(H组),输注4.2％ HSH 4 ml/kg;对照组(N组),输注等量生理盐水.两组均于术前(T0),输注HSH或生理盐水结束时(T1),手术结束时(T9及术后第1天(T3)、第2天(T4)、第3天(T5)、第4天(T6)、第5天(T7)的上午8点,分别记录MAP、CVP、血浆渗透压(plasma osmotic pressure,POP)、HR、Na+、K+、C1-等数值;采用经颅多普勒超声(transcranial doppler,TCD)监测T0及T3～T7时右侧大脑中动脉血流速度,ELISA检测上述时间点血浆中IL-6、TNF-α、内皮素-1(endothelin-1,ET-1)及一氧化氮(nitric oxide,NO)等因子浓度,同时记录患者GCS得分、神经功能缺损评分(china stroke scale,CSS)及24 h出入量. 结果 H组CVP在T1～T7时分别高于N组(P＜0.05);POP在T2～T7时高于N组(P＜0.05).两组患者大脑中动脉血流速度术后呈上升趋势,H组患者在T5～T7时低于N组(P＜0.05);H组患者在T7时血浆IL-6、TNF-α浓度低于N组(P＜0.05);T5～T7时,H组ET-1浓度低于N组(P＜0.05);T4～T7时,H组NO浓度高于N组(P＜0.05);上述指标其他时间点及两组间GCS得分、CSS评分、24h出入量比较,差异无统计学意义(P＞0.05). 结论 脑动脉瘤破裂出血患者围手术期小量输注HSH能有效减轻脑血管介入手术后CVS发生程度,其机制可能与抑制炎症介质及血管舒缩因子平衡紊乱有关.     

高氧复方氯化钠溶液用于大鼠烧伤后休克的观察

目的观察并探讨高氧复方氯化钠溶液对烧伤休克的防治作用. 方法 (1)将Wistar大鼠分为6组,A组正常对照组;B组制作30%TBSAⅢ度烧伤模型,伤后1 h补充复方氯化钠溶液;C组致伤后6 h补充复方氯化钠溶液;D组伤后1 h补充高氧复方氯化钠溶液;E组伤后6 h补充高氧复方氯化钠溶液;F组致伤后不治疗.动态观察各组大鼠内毒素(LPS)、白细胞介素6(IL-6)、二胺氧化酶(DAO)活性、D-乳酸、丙二醛(MDA)的变化.(2)选择烧伤面积为50%～69%TBSA、伤后3 h内入院的患者,随机分为治疗组补充高氧复方氯化钠溶液;对照组补充复方氯化钠溶液.观察患者休克期变化、经皮氧分压、血红蛋白、血细胞比容及有无并发症等. 结果大鼠伤后各组监测指标水平均较A组显著升高,呈逐步上升趋势,F组更加明显,其顺序为F组>C组>B组>E组>D组(P＜0.05).烧伤患者治疗组较对照组休克期度过平稳,补液量减少,氧分压明显升高,并发症少,但血氧饱和度差异无显著性意义. 结论早期应用高氧复方氯化钠溶液,对防治烧伤休克有较好的疗效.     

HTK和St.Thomas液在复杂先天性心脏病长时间心肌缺血心肺转流中的应用

目的 比较两种心肌保护液在患儿复杂先天性心脏病手术中的心肌保护效果.方法 40例复杂先天性心脏病患儿随机分为两组,分别应用St.Thomas液(T组,25 ml/kg,每25～30分钟复灌)和HTK液(H组,40 ml/kg,4～6 min灌注完毕.主动脉阻断时间超过3 h复灌),每组20例.观察患儿复苏情况,阻断前、停心肺转流(CPB)后肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)正性肌力药物的使用及ICU停留时间.结果 两组CPB时间及主动脉阻断时间差异无统计学意义.两组均自动复跳,H组术后心肌酶的变化明显小于T组(P＜0.05或P＜0.01).术后正性肌力药物的使用时间H组明显短于T组(P＜0.05).结论 HTK液具有较好的心肌保护效果,单次灌注对于长时间缺血心肌的保护安全有效,切实可行.     

The effect of HES130/0.4 sodium chloride solution on kidney function following early fluid resuscitation in shock patients

BackgroundDoctors often use a small dose of hydroxyethyl starch (HES) 130/0.4 sodium chloride solution in the emergency room; however, its effect on kidney function remains controversial. This study aimed to evaluate the effect of a small dose of HES130/0.4 sodium chloride solution on kidney function in shock patients during early fluid resuscitation.MethodsThis cohort study retrospectively analyzed the data of 129 shock patients requiring fluid resuscitation who had been admitted to the Emergency Department of the Affiliated Hospital of Nantong University from January 2019 to December 2020. Patients were divided into the observation group (n=40) and control group (n=89) according to the type of fluid resuscitation. In relation to the fluid resuscitation treatment, the observation group was treated with crystalloid solution, while the control group was treated with crystalloid and HES130/0.4 sodium chloride solution. To further explore the effect of a small dose of HES130/0.4 sodium chloride solution, the patients were further divided into the following 4 groups based on the specific fluid administered: (I) the HES(+), lactated Ringer’s (LR)(+) group (n=85); (II) the HES(+), LR(–) group (n=4); (III) the HES(–), LR(+) group (n=31); and (IV) the HES(–), LR(–) group (n=9). The outcomes were in-hospital mortality and changes in creatinine (CR) level after fluid resuscitation.ResultsThere were no significant differences in the in-hospital mortality rates between the observation and control groups (P=0.343). The CR levels of patients in the control and HES(+), LR(+) groups were reduced after fluid resuscitation (P=0.034; P=0.028). There was no significant change in patients’ CR levels in the HES(+), LR(–) group after fluid resuscitation (P=0.999).ConclusionsAdministering a small dose of HES 130/0.4 sodium chloride in patients with shock does not appear to affect kidney function and in-hospital mortality; however, these findings should be considered exploratory, and further studies should be conducted to confirm these results.     

高渗氯化钠羟乙基淀粉40注射液对外伤性颅内血肿伴失血性休克患者术中颅内压的影响

目的 探讨高渗氯化钠羟乙基淀粉40注射液(HH40)对外伤性颅内血肿伴失血性休克患者术中颅内压(ICP)的影响.方法 外伤性颅内血肿伴失血性休克患者40例,急诊行颅内血肿清除术,随机均分为HH40组(H组)和4.2%高渗盐水组(C组).麻醉诱导后,分别在15 min内快速静脉输入HH40 5ml/kg或4.2%高渗盐水5 ml/kg.在输注HH40或4.2%高渗盐水前即刻(T0)、输注后15 min(T1)、30 min(T2)、60 min(T3)、90 min(T4)、120 min(T5)记录MAP、HR、CVP、尿量,采集桡动脉血测定血浆Na+、K+浓度进行血气分析,并计算各时点脑灌注压(CPP):CPP=MAP-ICP.结果 与T0时比较,T1～T5时两组MAP、CVP、CPP升高,HR减慢,T2～T5时ICP降低(P＜0.05).与C组比较,T4、T5时H组HR减慢和T5时MAP升高(P＜0.05);H组降低ICP幅度与其相似,而降ICP作用维持时间较长(P＜0.05).结论 HH40可安全地用于外伤性颅内血肿伴失血性休克手术患者,能有效地纠正其休克,降低其ICP.     

Safety of troclosene sodium solution in decontamination of wounds: A prospective clinical and laboratory study

Debate persists regarding the safety of hypochlorite-containing solutions in the decontamination of infected wounds. In 2006, the Israeli Ministry of Health withdrew licensing approval for troclosene sodium as a wound irrigation solution. The aim of this prospective clinical and laboratory study was to investigate the safety of troclosene sodium solution for decontamination of infected wounds. Troclosene sodium solution was used to treat 30 patients with 35 infected skin wounds of various etiologies and body areas, over a treatment period of 8 days. Data were gathered according to a prospectively designed protocol including general findings, wound-specific observations on Day 1 and Day 8 and laboratory parameters on Day 1 and Day 8. Wound swabs and tissue biopsy for culture were taken on Day 1 and Day 8. Statistical analysis was executed. Tests were 2-sided and p values of <0.05 were considered statistically significant. Eighteen males and 12 females, with 35 infected skin wounds were enrolled. There were no adverse clinical events. No significant changes were observed in general clinical observations. Statistically significant improvements were observed in: pain (p < 0.0001); edema (p < 0.0001); area of wound covered by granulation tissue (p < 0.0001); exudate (p < 0.0001); and erythema (p = 0.002). Prior to treatment, bacteria were demonstrated on microscopy or on culture in 90% of wound samples. On Day 8, this frequency reduced to 40%. There were no abnormal laboratory tests. Serum sodium concentration increased significantly between Day 1 and Day 8, whilst serum concentration of urea and concentrations of thrombocytes, leucocytes and neutrophils showed statistically significant reductions, but all values remained within normal laboratory ranges throughout the study period. Troclosene sodium solution is clinically safe in the management of infected wounds. These findings were presented to the Israel Ministry of Health and as a result, troclosene sodium was re-approved and licensed for decontamination of infected wounds in Israel.     

地佐辛与帕瑞昔布钠在维吾尔族妇科患者术后镇痛效果的比较

目的 比较地佐辛与帕瑞昔布钠用于维吾尔族妇科患者经腹手术的术后镇痛中的效果. 方法 40例在全麻下行择期妇科经腹手术的维吾尔族女性患者,年龄25岁～55岁,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级,按随机数字表法均分为两组(每组20例):地佐辛组(A组)和帕瑞昔布钠组(B组),手术结束前30 min分别给予地佐辛0.1 mg/kg(A组)、帕瑞昔布钠40 mg(B组).分别记录两组患者拔管后的苏醒时间、Ramsay镇静评分、舒适度评分(bmgg-rmann comfort scale,BCS).采用双盲法进行术后视觉模拟(visual analogue scale/score,VAS)评分、芬太尼的追加剂量以及副作用. 结果 A组VAS评分在拔管后(2.4±2.2)及术后12 h(3.2±2.4)明显低于B组[(3.9±2.0)、(4.3±2.1)](P＜0.05),BCS评分A组(2.0±0.4)高于B组(1.4±0.9)(P＜0.05),A组苏醒期芬太尼追加量[(21±42)μg]明显低于B组[(47±40)μg](P＜0.05). 结论 采用地佐辛0.1 mg/kg静脉注射的镇痛效果在维吾尔族妇科手术中优于帕瑞昔布钠40 mg,适用于创伤较大的中、大型手术.     

The enhancing effect of cyclosporine A and sulfasalazine on the prevention of rejection in rat cardiac allografts

Sulfasalazine (SASP) has been used for many years as a disease-modifying agent in inflammatory bowel disease and in rheumatoid arthritis. However, its mode of action is not entirely clear. Evidence has been accumulated which indicates that its efficacy is due to an immunomodulatory effect. In the present communication, we report that SASP has an immunomodulatory capacity in an experimental rat cardiac allograft model. A combination of 100 mg/kg per day of SASP given orally until rejection and 10 mg/kg per day of cyclosporine A (CyA) given orally for 10 days resulted in a significantly increased graft survival time as compared to that in animals given CyA alone.     

The enhancing effect of cyclosporine A and sulfasalazine on the prevention of rejection in rat cardiac allografts

Abstract. Sulfasalazine (SASP) has been used for many years as a disease-modifying agent in inflammatory bowel disease and in rheumatoid arthritis. However, its mode of action is not entirely clear. Evidence has been accumulated which indicates that its efficacy is due to an immunomodulatory effect. In the present communication, we report that SASP has an immunomodulatory capacity in an experimental rat cardiac allograft model. A combination of 100 mg/kg per day of SASP given orally until rejection and 10 mg/kg per day of cyclosporine A (CyA) given orally for 10 days resulted in a significantly increased graft survival time as compared to that in animals given CyA alone.