Microcirculation and capillary permeability during hemodialysis in patients with renal insufficiency

Time course changes in microcirculation (MC) and capillary permeability (CP) were investigated in 191 patients with acute renal failure (ARF) and 45 patients with terminal chronic renal failure (CRF). Similar in type MC and CP disturbances were found in all CRF and oligoanuria ARF patients. These were more pronounced in CRF sufferers depending in degree on the disease severity. Knizeli's phenomenon ranged from 2.2.KII to 3.3.KIII. The total conjunctival index reached 22.99-25.20 in CRF and 19.4 in ARF. Unlike ARF patients, those with CRF had no positive trend in MC and CP. A transient change for the better came after hemodialysis and was seen in occasional patients. It is suggested that no response to hemodialysis is indicative of CRF and ARF poor prognosis. The trend in MC can help in prognostication of CRF development in acute cases.     

Metacarpal bone measurements in renal transplant recipients, in corticosteroid-treated patients with polymyalgia rheumatica and in patients with primary hyperparathyroidism

Quantitative radiological measurements on the second left metacarpal bone were carried out in 23 patients with primary hyperparathyroidism, 22 corticosteroid-treated patients with polymyalgia rheumatica and 40 renal transplant recipients treated with prednisone and azathioprine. Women with primary hyperparathyroidism and corticosteroid-treated women showed significantly decreased mean values of metacarpal bone compared to normal controls, probably due to a higher bone resorption than formation at the endosteal surface. Bone loss was more pronounced in corticosteroid-treated women than in women with primary hyperparathyroidism, partly due to age difference. In renal transplant recipients, bone loss took place during the initial period after renal transplantation, probably due to increased endosteal bone resorption. During this period a periosteal new bone formation took place in female renal transplant recipients. The quantitative radiological measurements make it possible to determine whether bone loss is due to a higher ratio of bone resorption than of bone formation at the periosteal and/or endosteal surface.     

Metabolic bone disease in chronic renal failure. II. Renal transplant patients.

Trabecular vertebral bone of renal transplant patients was quantitatively compared with bone from normal individuals and dialyzed and nondialyzed patienets with chronic renal failure reported in detail in an earlier study. Long- and short-term transplant patients have increased bone resorption and mineralization defects similar to renal osteodystrophy in dialyzed and nondialyzed patients. However, in transplant patients the magnitude of resorption is greater, and bone volume tends to decrease rather than increase. Resorptive activity in transplant patients is maximal during the first year after transplantation. Bone volume decreases continuously for at least 96 months after transplantation. Only decreased bone volume correlated with success or failure of the renal transplant. Morphologic findings in this study correlate with other clinical and morphologic data to suggest that reduction in bone volume in transplant patients results from a combination of persistent hyperparathyroidism and suppression of bone formation by steroid therapy.     

Oxalate bone disease--an emerging form of renal osteodystrophy

Rosette-like arrays of highly birefringent calcium oxalate crystals are commonly seen in the marrow space of bone biopsy specimens taken from patients with primary hyperoxaluria, particularly if complicated by renal failure. Similar deposits have been described in chronic hemodialysis patients with secondary forms of oxalosis. Large multinucleated histiocytes may be seen surrounding these crystal deposits. Many of these cells are histologically indistinguishable from osteoclasts. We present a patient in whom this histiocytic reaction appeared to be of sufficient magnitude to stimulate bone resorption and to cause severe osteodystrophy. This observation, and those of other investigators reviewed in the discussion, suggest that oxalate deposition within bone may contribute to the pathogenesis of uremic osteodystrophy in chronic renal failure patients with primary or secondary types of oxalosis.     

Relative importance of renal failure and increased bone resorption in the hypercalcaemia of myelomatosis.

In order to define the relative importance of renal failure and increased bone resorption in the hypercalcaemia of myelomatosis 22 untreated patients were studied, of whom 12 were hypercalcaemic. Most patients had malabsorption of radiocalcium from the gastrointestinal tract and evidence of increased bone resorption as assessed by fasting urinary hydroxyproline/creatinine ratio. The mean OHPr/Cr ratio, however, was similar in patients with and without hypercalcaemia. Renal failure and Bence Jones proteinuria occurred more frequently in the hypercalcaemic patients. In four patients with hypercalcaemia there was an increase in OHPr/Cr after saline infusion accompanied by an improvement in renal function and hypercalcaemia. Mithramycin given to the same patients further reduced hypercalcaemia, presumably by inhibiting bone resorption. It was concluded that the hypercalcaemia of myelomatosis is due to the combination of renal failure and increased bone resorption, but that the OHPr/Cr ratio in the untreated state is a poor indicator of the degree of bone resorption in hypercalcaemic patients.     

Cutaneous responses to histamine, compound 48/80, and codeine in patients with chronic renal failure

Pruritus is a common symptom associated with chronic renal failure (CRF). But increased plasma histamine levels and skin mast cell proliferation previously reported in these patients did not correlate with the intensity of the pruritus. Since increased mast cell releasability was described in chronic idiopathic urticaria, we attempted to examine whether this mechanism could explain pruritus in patients with CRF. Twenty-five patients with end stage renal failure were skin tested with histamine, codeine, and compound 48/80. There were nine patients on continuous ambulatory peritoneal dialysis, eight patients on hemodialysis, (tested both before and after dialysis) and eight patients with advanced CRF. Wheal area after intradermal injection of three concentrations of the above substances was measured. In general, the wheal areas in all patients with CRF were either similar to or smaller than those of the control group who were without renal impairment. In conclusion, patients with CRF with or without dialysis therapy demonstrated unchanged or decreased skin test responses to histamine, codeine, and compound 48/80. Increased mast cell releasability cannot explain the pruritus in patients with CRF.     

Secondary hyperparathyroidism in chronic renal failure

The metabolic bone disease associated with chronic renal failure has been described collectively by the terms "renal osteodystrophy" or "renal-glomerular-osteodystrophy" and consists of osteomalacia, osteitis fibrosa, and osteosclerosis. The skeletal abnormalities may occur either alone or in combination with one another. An increased concentration of circulating immunoreactive-parathyroid hormone (i-PTH) is a recognized feature of patients with chronic renal failure, and the values are usually much higher than those found in patients with primary hyperparathyroidism associated with a parathyroid adenoma. It must, however, be recognized that the high circulatory concentrations of parathyroid hormone found in patients with chronic renal failure are of immunoassayable material which may or may not be of biological significance in respect of activity. A disturbance in the homeostatic control mechanism governing parathyroid hormone, the secretion rate, its metabolism, and target organ resistance to its action are of major importance in the pathogenesis of some aspects of the metabolic bone disease in patients with chronic renal failure. The pathogenesis of the secondary hyperparathyroidism of chronic renal failure, however, also involves disturbances in cholecalciferol metabolism, phosphate retention, and the uremic state per se.     

Reticulocyte analysis in systemic lupus erythematosus and chronic renal failure using flow cytometry

The number and maturation of circulating reticulocytes were measured in patients with systemic lupus erythematosus (SLE) and chronic renal failure (CRF) using an automated hematological analyzer (Technicon H*3 RTX) for their erythropoietic activities. Both SLE and CRF patients had increased reticulocyte numbers with a low degree of maturation. The SLE patients had no changes in mean reticulocyte corpuscular volume (MCVr) as compared to normal subjects (110.20 +/- 15.43 fl. in SLE and 110.39 +/- 5.09 fl. in normal), whereas CRF patients had significantly increased mean corpuscular reticulocyte volume (MCVr = 120.99 +/- 8.09 fl., p-value = 0.0019 as compared with normal). Three cases of SLE with nephrotic syndrome (NS) had high degree of MCVr (113.4, 125.0 and 133.1 fl., respectively). The renal involvement in SLE patients and CRF patients may associate with increased reticulocyte corpuscular volume.     

彩超对慢性肾功能衰竭诊断的观察

目的:利用彩色多普勒血流显像,对慢性肾功能衰竭患者肾脏的血液动力学进行观察。方法:使用仪器是Acuson 128彩色多普勒超声仪,探头频率为3.5MHz,对30例慢性肾功能衰竭的患者肾脏的大小、肾回声强度及肾脏血流动力学参数进行了检测。结果:肾功能衰竭的第Ⅰ期病人上述指标均无明显改变;第Ⅱ期肾脏大小较第Ⅰ期减小,肾回声出现改变,但肾脏的RI指数与正常对照组比较无显著差异(P>0.05);第Ⅲ期肾脏大小较第Ⅱ期减少,肾回声出现明显异常,RI指数增高(P<0.01);第Ⅳ期,即尿毒症晚期,肾脏萎缩,肾实质回声明显增强,肾内血供明显减少,则指数明显增高(P<0.01)。结论:利用彩色多普勒血流像可以对慢性肾功能衰竭的分期进行诊断。     

Disturbance of the autonomic nerve system in patients with chronic renal failure--represented by variation coefficient of R-R intervals in the ECG as a parameter

Autonomic nerve dysfunction in patients with chronic renal failure has of late become an issue to be investigated. R-R intervals in resting electrocardiograms were measured to evaluate activities of the cardiac parasympathetic nerve system. A total of 140 patients with chronic renal failure were studied to be compared with 20 normal controls (cont.) and 39 with diabetes mellitus (DM). Of these patients 15 were subjected to conservative treatment (CRF), while 125 patients were undergoing hemodialysis due to chronic renal failure-100 of them derived from chronic glomerulonephritis (HD) and 25 from diabetes mellitus (DM.HD). The variation coefficient of the R-R interval (CVRR) was measured after the subject patients had rested for over 15 minutes before a dialysis session. The mean CVRR were 2.15 +/- 1.25% in CRF group, 2.36 +/- 1.37% in HD and 1.37 +/- 0.99% in DM.HD. These values were significantly lower than in control group (4.70 +/- 2.64%). On the other hand, the value in DM.HD group, as shown above, was significantly lower than in HD. In CRF group the CVRR values lowered as residual renal functions decreased. No significant correlations between CVRR S and the duration of hemodialysis treatment were noted among the groups. In HD group the CVRR S were significantly lower in patients with hypotensive tendency during hemodialysis than in those who enjoyed good control of blood pressure. These results suggest that the measurement of CVRR S can be of help in evaluating autonomic nerve dysfunction in patients with chronic renal failure.     

交感神经皮肤反应对评价慢性肾功能不全患者植物神经损害的意义

目的:探讨慢性肾功能不全(CRF)患者交感神经皮肤反应(SSR)的变化及其临床意义。方法:对52例CRF患者行SSR检测,并与32例正常对照组比较。结果:CRF组SSR波幅低于正常对照组,潜伏期较对照组延长(P<0.01)。CRF组SSR总异常率为71%,其中上肢异常率为48%,下肢异常率为71%;慢性肾衰早期组16例中7例(44%)SSR异常,慢性肾衰组19例中14例(74%)SSR异常,尿毒症组17例中16例(94%)SSR异常;CRF患者上下肢之间、不同亚组之间SSR异常率比较差异有极显著意义(P<0.01)。CRF组病程和血肌酐水平与SSR潜伏期间的偏相关系数分别为0.4732(P<0.01)和0.3247(P<0.05),而与SSR波幅间的偏相关系数为-0.3173和-0.3062(P均<0.05);年龄与SSR潜伏期偏相关系数为0.0434(P>0.05),与SSR波幅偏相关系数为-0.4445(P<0.01)。结论:SSR的异常反映了CRF患者常合并交感神经损害,且与病程、肾功能损害程度及年龄因素相关,SSR检测可作为评价CRF患者交感神经损害敏感的客观指标。     

促红细胞生成素对尿毒症患者血液流变性改变的影响

观察２０例慢性肾功能衰竭尿毒症患者应用促红细胞生成素（ＥＰＯ）治疗前后血液流变性的改变。结果表明，ＥＰＯ治疗后，低切至高切变率时的全血粘度均比治疗前明显升高达正常水平，进一步研究发现，全血粘度的升高主要与红细胞比积升高有关，与血浆粘度、红细胞聚集指数及Ｃａｓｓｏｎ粘度无关；而输血治疗对照组的血流变参数于输血前后则无明显改变。ＥＰＯ治疗后，体外血小板粘附功能增强，体外形成之血栓的长度、湿重及于重也明显增加。结果说明，应用ＥＰＯ治疗后，血液粘度增加，尽管在正常范围，但血栓形成的倾向明显增高，甚至高于正常人。     

Chronic renal failure after heart, lung, liver, or intestine transplantation

Acute and especially chronic renal failure (CRF) are relatively common and important risk factor for morbidity and mortality in patients after heart, lung, liver or intestine transplantation. Numerous factors contribute to the development of CRF in this group of patients, like treatment with calcineurin inhibitors and other nephrotoxic drugs in the perioperative period, hemodynamical changes during and after the surgery, preexistent renal disease, hypertension, diabetes mellitus, dyslipidemia and anemia. Pretransplant evaluation of renal function is mandatory to predict which patients have increased risk for development of CRF. In the posttransplantation course it is necessary to timely diagnose and treat renal failure, while patients with insufficient renal function have 4.55-fold increased risk of death compared to patients with normal renal function. Special problem is diagnostic approach to patients with suspected chronic renal disease who are candidates for transplantation of other parenhimatose organs. Diagnostic value of serum creatinine and estimation of renal function based on its value is very limited. Gold diagnostic standard is radioisotope estimation of glomerular filtration, but this method is not widely available. It seems that this problem may be solved with the use of cystatin C, but this approach needs to be validated in large studies. Numerous different immunosuppressive drugs available on the market enable individualization of immunosuppression. Different drugs combinations may have less nephrotoxic potential, but one must be careful because of the possible risk of organ rejection with the change of immunosuppression. Use of angiotensin convertase enzyme inhibitors and/or angiotensin receptor blockers, statins with drugs for control of hyperglycemia, may prevent or postpone development of CRF. Although technical advances of contemporary hemodialysis machines and peritoneal dialysis equipment enable well tolerated dialysis even in critically ill patients, renal transplantation remains the method of choice for treatment of patients with transplanted parenhimatous organ that developed CRF.     

Increased serum levels of human cardiac myosin light chain 1 in patients with renal failure]

In this study, we measured cMLC1 concentration in serum and urine from patients with acute myocardial infarction (AMI), chronic renal failure (CRF), and various grades of renal dysfunction (RD) in comparison with normal controls, by using enzyme immunoassay (EIA) with monoclonal antibody, and attempted to elucidate the mechanism of increased serum level of cMLC1 in patients with renal failure. The serum level of cMLC1 of CRF patients under maintenance hemodialysis (HD) was 20.3 +/- 19.6 ng/ml, markedly higher than normal controls (0.54 +/- 0.55 ng/ml). The patients with RD and CRF under conservative therapy had higher serum cMLC1 level than normal controls especially in advanced CRF, while each value not correlating with their creatine clearance (Ccr). cMLC1 in urine was detectable in only two cases with AMI accompanied with CRF or RD. In addition, immunohistological studies of renal biopsy specimens from RD patients did not show cMLC1 deposits in glomerulus. These results suggest that cMLC1 is assumably filtered through the glomerulus, and then absorbed in the renal tubule.     

Elevation of pro-inflammatory cytokines, C-reactive protein and cardiac troponin T in chronic renal failure patients on dialysis

Chronic renal failure (CRF) patients suffer from a chronic inflammation. They are at increased risk of cardiovascular disease. In order to investigate this inflammatory process and cardiovascular risk factors associated with haemodialysis (HD) and peritoneal dialysis (PD), we compared serum/plasma pro-inflammatory cytokines, C-reactive protein (CRP), and cardiac troponin T (cTnT) of 146 CRF patients treated or not treated with PD or HD. Serum cytokines and CRP as well as plasma cTnT were measured by enzyme-linked immunosorbent assay, chemiluminescence immunoassay, and electrochemiluminescence immunoassay, respectively. Results indicated that serum interleukin (IL)-18 concentrations were significantly higher in PD and low creatinine clearance pre-dialysis CRF (LCC) patients than HD patients (both p < 0.05). IL-6 and tumour necrosis factor (TNF)-alpha concentrations were significantly higher in PD patients than LCC patients (both p < 0.01). Serum hsCRP and plasma cTnT in HD were significantly higher than LCC (both p < 0.01). The elevation of pro-inflammatory cytokines should play an important role in the chronic inflammation and increased cardiovascular risk of CRF patients on dialysis. We are evaluating further the diagnostic and prognostic applications of pro-inflammatory cytokines and biochemical inflammatory markers for these patients.     

肾脏疾病时血与尿中的瘦素水平

目的探讨人瘦素 ( leptin,L EP)在肾脏疾病中的作用机制及其表达特征。方法采用放射免疫分析法对慢性肾功能衰竭等 10组肾脏疾病患者进行血清和尿液中瘦素水平检测。观察其浓度变化与 Cr、BU N的关系 ,并与 3 0例正常人比较。结果 15 2例患者中 ,除肾积水组外 ,其它各组瘦素水平均不同程度高于对照组 ,差异显著 ( P<0 .0 1)慢性肾衰组瘦素含量随 Cr、BU N增高而增高 ,呈正相关关系 ( r=0 .4 0 ,P<0 .0 1,r=0 .3 8,P<0 .0 5 )。尿液中瘦素在慢性肾炎和肾病综合症组含量增高 ,慢性肾衰和肾肿瘤组则较正常人降低。结论瘦素增高与多种因素有关 ,并与肾脏功能受损程度成正比。     

Reduced thickness of gastric mucosa and retarded progression of chronic gastritis in patients with renal failure

Conflicting results are reported in the literature on the structure and function of gastric mucosa in patients with chronic renal failure (CRF). In the present endoscopic study of 68 CRF patients on conservative treatment (regular dialyses or transplantations had not yet been undertaken), we sought to clarify whether CRF leads to hypertrophic or hypotrophic phenomena in gastric mucosa, as interpreted by the presence and grade of gastritis and by the thickness of the gastric mucosa. We found that the mean progression of gastritis in both antrum and body was significantly slower than expected in CFR patients, and that the thickness of both antral and body mucosa was significantly lower in CFR patients than in non-CRF controls. Furthermore, although the thickness of the oxyntic body mucosa in CRF showed a positive correlation to serum gastrin (SeGa) levels and even though 12 of the patients showed high SeGa levels corresponding to those seen in the Zollinger-Ellison synbdrome (300-1500 ng/l), the thickness of the oxyntic body mucosa in CRF patients did not exceed that seen in control subjects with normal SeGa. We conclude that CRF exerts inhibitory effects on the gastric mucosa resulting in retardation in the progression of chronic gastritis and hypotrophy of the gastric mucous membrane.     

Biochemical markers of bone turnover in rheumatoid arthritis. Relation to anti-inflammatory treatment, sex, and menopause

Bone turnover was determined in 125 patients with rheumatoid arthritis (RA). Bone Gla protein (BGP) and alkaline phosphatase (AP) were used as markers of bone formation. Fasting urinary calcium relative to creatinine (FU Ca/Cr) and fasting urinary hydroxyproline relative to creatinine (FU Hpr/Cr) were used as markers of bone resorption. These variables were compared to the values of two groups of normal controls in order to elucidate the pathophysiology of the osteopenia occurring in patients with RA. When the patients were divided into groups according to treatment (gold salts, penicillamine, or glucocorticoids), serum AP was highly significantly increased in all three groups, whereas serum BGP was below the normal mean. FU Ca/Cr and FU Hpr/Cr were moderately decreased in the groups treated with gold salts or penicillamine, but increased in the glucocorticoid-treated group. When divided according to sex and menopausal state and glucocorticoid treatment versus non-glucocorticoid treatment, there was a balance between bone formation and bone resorption parameters in all groups, except glucocorticoid-treated men and premenopausal women who had increased values of bone resorption parameters.     

Early skeletal changes of the hand phalanges in patients with chronic renal failure

Appearance time and the severity of skeletal changes in patients with chronic renal failure are still not well defined. In 61 patients with incipient to advanced renal insufficiency (glomerular filtration rate 70 to 5 ml/min X 1.73 m2), bone alterations (acro-osteolysis, subeperiosteal and intracortical resorption) were mammographically studied in hand phalanges. A high correlation (p less than 0.001) was found between the radiological score and the severity of the renal insufficiency. The earliest changes of renal osteodystrophy occurred in the tufts. Biopsy specimens were taken from the iliac crest in 22 patients. Qualitative bone histology correlated significantly (p less than 0.001) with the total radiological score. Mammography offers an effective and non-invasive means of studying early skeletal changes in patients with chronic renal failure.     

慢性肾衰患者外周血IL-18水平及血液透析对其的影响

为探讨慢性肾衰竭 (CRF )患者外周血IL 18表达量的变化以及血液透析 (HD )对其表达的影响 ,选取 10名健康志愿者及 2 9例CRF患者 ,应用ELISA测定血浆IL 18水平 ,同时采用半定量逆转录多聚酶链反应 (RT PCR )技术 ,检测PBMC中IL 18mRNA表达量。结果是未行HD的CRF患者血浆IL 18水平及PBMCIL 18mRNA表达量较正常对照组增高 ,差异有显著统计学意义 (P <0 0 1) ,单次HD对CRF患者血浆IL 18水平及基因表达无明显影响 (P >0 0 5 ) ,但长期维持HD则可使CRF患者外周血IL 18水平及基因表达增高 (P <0 0 5 )。提示外周血IL 18的高表达可能参与CRF的发病过程及HD相关并发症的发生发展