左生殖静脉-下腔静脉转流术治疗胡桃夹综合征合并精索静脉曲张一例

胡桃夹综合征是一种罕见疾病,可导致患者出现蛋白尿、肾功能受损及生殖静脉曲张等系列症状。传统开放手术方式首选左肾静脉转位术,但手术创伤较大,术后近、远期并发症较多,影响患者生活质量。本文报道1例胡桃夹综合征合并左精索静脉曲张的男性青年患者,采用左生殖静脉-下腔静脉转流术并左精索静脉高位结扎术的手术方式,取得了良好治疗效果。该手术方式为胡桃夹综合征合并精索静脉曲张患者提供了新的治疗思路,值得临床借鉴。     

彩超对“胡桃夹”综合征的诊断价值

"胡桃夹"综合征即左肾静脉压迫综合征,是指左肾静脉受压引起血尿、蛋白尿为主要临床症状的综合征."胡桃夹"综合征分为前"胡桃夹"综合征和后"胡桃夹"综合征,前"胡桃夹"综合征是指左肾静脉在腹主动脉与肠系膜上动脉之间的夹角内受压而引起的胡桃夹现象;后"胡桃夹"综合征是指左肾静脉在汇入下腔静脉的行程中走行于腹主动脉与脊柱间并受两者挤压而引起的胡桃夹现象.随着无创性影像诊断技术的发展,彩色多普勒超声已成为诊断左肾静脉压迫综合征的重要方法,本文就近年来的相关文献,对于该病的超声诊断作一探讨.     

胡桃夹综合征的诊治策略

胡桃夹综合征是指左肾静脉穿行于肠系膜上动脉与腹主动脉之间时受到两者的钳压,导致左肾静脉血液回流受阻而引起相应的临床症状。本文通过叙述胡桃夹综合征的发病机制、临床表现、影像检查、诊断以及治疗,使人们对胡桃夹综合征的研究趋势、动态、诊断及治疗水平有整体、客观的认识,从而熟悉本病,指导临床工作。     

螺旋CT血管成像对胡桃夹综合征的诊断价值

目的探讨螺旋CT血管成像对胡桃夹综合征的诊断价值。方法回顾性分析5例胡桃夹综合征患者进行螺旋CT增强多期扫描,并获得后处理图像。结果5例左肾静脉压迫综合征病例均可见肠系膜上动脉（SMA）压迫左肾静脉（LRV）的征象。CT血管成像多平面重建直观地显示了LRV与SMA之间的关系结论。结论多层螺旋CT三维血管成像在胡桃夹现象具有立体直观、无创简便优点,可作为胡桃夹现象临床筛查的一种常规确诊手段,具有潜在的应用价值。     

专题预告

正本刊2016年6月5日第31卷第6期拟出版"慢性肾脏疾病合并其他临床的治疗"专题,执行主编谷国强教授。具体内容如下:1.慢性肾脏病合并心力衰竭的诊治谷国强2.急性冠脉综合征合并慢性肾脏病患者治疗策略进展刘金明,李芳,谢亚囡3.慢性肾脏病疾病合并高血压的治疗杨秀春4.慢性肾脏疾病合并风湿病的治疗彭晨星5.慢性肾脏疾病合并感染的治疗潘文森6.慢性肾脏疾病合并糖尿病的治疗张松筠     

2例胡桃夹综合征腹腔镜下左肾脾静脉分流术的护理

胡桃夹综合征(nutcracker syndrome,NCS)即左肾静脉压迫 综合征,又称胡桃夹现象,是指左肾静脉穿经腹主动脉和肠系膜 上动脉(superior mesentericartery,SMA)形成的夹角受压,静 脉血流回流受阻所表现的一系列临床症状[1]。如：血尿、直立性 蛋白尿、左腰腹不适、慢性疲劳症状和自立调节障碍,男性患者还 可能有左侧精索静脉曲张等症状,目前临床上较为少见。目前外科手术治疗方法主要有：肠系膜上动脉移位术、左肾脾静脉分流术和自体肾移植术。其中左肾脾静脉分流术具有创伤小,肾缺血时间短,并发症较少等优点,疗效确切,逐渐被越来越多的医生采用。我院2010年11月—2011年8月年共收治2例胡桃夹综合征患者,其中2例行腹腔镜下左肾脾静脉分流术,效果满意。     

左肾静脉下移术治疗胡桃夹综合征患者的护理

胡桃夹综合征(nutcracker syndrome,NCS)即左肾静脉压迫综合征,又称胡桃夹现象,是指左肾静脉穿经腹主动脉和肠系膜上动脉(superior mesentericartery,SMA)形成的夹角受压,静脉血流回流受阻所表现的一系列临床症状.     

双源螺旋CT血管成像对胡桃夹综合征的诊断价值

目的:探讨双源螺旋CT血管成像对胡桃夹综合征的诊断价值。方法:分析8例胡桃夹综合征患者与20例正常肾血管的资料,测量腹主动脉与肠系膜上动脉的夹角,左肾静脉最窄处直径。结果:胡桃夹综合征患者腹主动脉与肠系膜上动脉间夹角为39.3,°正常对照组的为70°。正常对照组左肾静脉直径为12 mm,而胡桃夹综合征患者为3.1 mm。结论:双源螺旋CT血管成像能精确测量腹主动脉与肠系膜上动脉的夹角以及左肾静脉的直径。     

成人胡桃夹综合征3例围术期护理

2002年4月～2006年12月,我们治疗成人胡桃夹综合征患者3例,经精心护理,效果满意.现将围术期护理体会报告如下. 1 病历资料 本组共有成人胡桃夹综合征患者3例,男2例,女1例,年龄22～28岁.     

超声在胡桃夹现象诊断中的作用

胡桃夹综合征(NCS)又称左肾静脉压迫综合征，是走行于腹主动脉(AO)与肠系膜上动脉(SMA)间的左肾静脉(LRV)受压狭窄引起的一系侧临床症状。本文对15例患者进行超声声像图分析．以探讨超声检查对胡桃夹综合征的诊断价值：     

Nutcracker Syndrome in Children With Orthostatic Proteinuria

Objective . To evaluate the Doppler sonographic findings of the left renal vein in children with orthostatic proteinuria in comparison with healthy children and to propose more reliable sonographic criteria for diagnosing nutcracker syndrome in children. Methods . Doppler sonographic findings in 47 children with orthostatic proteinuria and in 27 healthy control subjects were compared. The diagnosis of orthostatic proteinuria was made on the basis of clinical and laboratory findings. The peak velocity and anteroposterior diameter were measured at the hilar and aortomesenteric portions of the left renal vein. The means ± 2 SD of the anteroposterior diameter ratio and peak velocity ratio between the 2 portions were calculated for control subjects and used as the cutoff levels for nutcracker syndrome. Results . The peak velocity ratios between aortomesenteric and hilar portions were 5.21 ± 2.55 in the patient group and 2.57 ± 0.70 in the control group. The anteroposterior diameter ratios between the 2 portions were 5.31 ± 2.65 in the patient group and 2.77 ± 0.69 in the control group. We set the cutoff level of anteroposterior diameter and peak velocity ratios for the diagnosis of nutcracker syndrome at mean ± 2 SD of the value for the control group (3.98 for the peak velocity ratio and 4.16 for the anteroposterior diameter ratio). When these cutoff levels were applied, the patients with orthostatic proteinuria had abnormal levels of anteroposterior diameter in 27 (57.4 %) of 47, peak velocity in 30 (63.8%) of 47, and both in 23 (48.9%) of 47. Conclusions . Nutcracker syndrome may be an important cause of orthostatic proteinuria in children. Doppler sonography of the left renal vein may be a useful screening tool in patients with suspected orthostatic proteinuria to evaluate whether the cause is nutcracker syndrome.     

胡桃夹综合征患者不同体位尿蛋白定量检测的日内变异分析

目的报道2例胡桃夹综合征患者随机尿微量清蛋白肌酐比(ACR)、总蛋白肌酐比(PCR)与24 h尿总蛋白定量(24hUTP)结果不一致的临床案例,并分析患者不同体位时随机尿蛋白的日内变异。方法用多普勒超声确诊2位患者为胡桃夹综合征,留取2位患者不同体位(平卧、正常活动)24 h期间所有尿标本,检测ACR、PCR、24hUTP,分析不同体位下ACR、PCR的变异及与24hUTP的一致性。结果平卧期间,2位患者随机尿ACR、PCR和24hUTP均在参考区间内,结果均一致;正常活动期间,2位患者随机尿ACR和PCR都有个别异常升高超出参考区间,24hUTP分别是0.21 g/24 h和0.05 g/24 h,结果严重不一致。结论胡桃夹综合征会引起体位性蛋白尿,从而导致患者随机尿蛋白日内变异较大,出现个别随机尿蛋白与24hUTP结果不一致的情况,建议患者用晨起第1次尿和24 h尿来监测尿蛋白的排泄情况。     

慢性心衰-心肾综合征及生物标志物

慢性心衰不仅是一种疾病诊断,更是一种复杂的临床综合征,在合并慢性肾病尤其是终末期肾病患者中,心衰发病率增加是死亡的主要原因。心脏和肾脏之间存在密切而复杂的关系(即所谓"心肾综合征"),心衰患者一旦合并慢性肾病或肾损伤均显示预后不良。因而,对于这类高风险患者应予以早期诊断并积极干预治疗。一些标志物已被证明在心血管疾病的诊断和预后评价中具有新的、重要的作用,由于其与慢性心衰-心肾综合征具有密切关系而备受关注,具有高度敏感性和特异性的生物标志物成为近年来研究的热点。     

腹膜透析治疗慢性肾脏病基础上的急性肾损伤

目的观察腹膜透析(peritoneal dialysis,PD)对慢性肾脏病基础上的急性肾损伤的疗效,并与间歇性血液透析(inermittent hemodialysis,IHD)进行比较。方法回顾性分析上海交通大学附属第一人民医院2005年至2009年收治的共183例慢性肾脏病基础上的急性肾损伤患者,其中78例采用PD或IHD治疗:PD组(35例):使用持续不卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)、间歇性腹膜透析(intermittent peritoneal dialysis,IPD)或自动腹膜透析(automated peritoneal dialysis,APD)治疗;IHD组(45例):采用IHD 1周3～4次治疗。观察一般资料(年龄、性别、原发病),透析前和透析后连续血尿素氮、肌酐、钾的变化,预后(肾功能恢复和存活),透析相关并发症。使用SPSS 10.0软件进行统计学分析,进行两组比较。结果两组患者治疗前年龄、性别、原发病构成及疾病严重程度差异无统计学意义(P0.05)。PD组透析后连续血尿素氮、肌酐水平明显高于IHD组(P0.05),而两组患者血钾、二氧化碳结合力等临床指标差异无统计学意义(P0.05)。随访显示,PD组肾功能恢复及存活与IHD组差异无统计学意义(P0.05)。PD组患者透析相关并发症发生率为11.4%,与IHD组(14.0%)相比差异无统计学意义(P0.05)。结论 PD治疗慢性肾脏病基础上的急性肾损伤效果与IHD基本相同,有利于患者肾脏功能的恢复,并且透析相关并发症发生率较低。     

慢性丙型肝炎合并肾脏疾病的研究进展

丙型肝炎病毒（HCV）感染导致的肝外损害以肾损伤多见,同时慢性肾脏病发展到终末期肾病行血液透析时可增加HCV感染风险。慢性丙型肝炎合并肾脏疾病可加速疾病的进程,造成患者的不良预后。该文对HCV致肾损伤的机制和慢性丙型肝炎合并肾脏疾病的直接抗病毒药物治疗等研究在近年所取得的进展进行综述,旨在加深临床医师对慢性丙型肝炎合并肾脏疾病患者行抗病毒治疗的认识,改善患者预后。     

Obesity in CKD

Metabolic syndrome, characterized by truncal obesity, hypertriglyceridemia, elevated blood pressure, and insulin resistance, is recognized increasingly as a major risk factor for kidney disease and also is a common feature of patients who are on dialysis. Obesity is considered a major generator of metabolic syndrome. Early in the course of obesity-initiated metabolic syndrome, structural and functional changes similar to diabetic kidney disease occur. Previous studies examined the histologic and functional changes that occur in the kidney in the early stages of obesity caused by a high-fat diet. They reported that a high-fat diet caused increased arterial pressure, hyperinsulinemia, activation of the renin-angiotensin system, glomerular hyperfiltration, and structural changes in the kidney that may be the precursors of more severe glomerular injury associated with prolonged obesity. Among several factors causing renal injury, Rho-kinase also plays an important role in the pathogenesis of obesity-related renal disease. We further propose that perinephric adipose tissues could be a source of inflammatory chemokines, which acts in concert with the renal Rho-kinase stimulated in situ to exacerbate renal inflammation. In this review, we note the mechanisms inducing chronic kidney disease (CKD) by obesity, especially the relation between insulin resistance and CKD.     

Severe hyperphosphatemia in a patient with chronic kidney disease and multiple myeloma–to strengthen the case toward renal replacement therapy?

We report a patient with multiple myeloma and chronic kidney disease who presented with severe hyperphosphatemia in the outpatient clinic without any related symptoms. Initial differential diagnosis: Tumor lysis syndrome or chronic kidney disease. Further work‐up revealed pseudohyperphosphatemia. In general, treatment is not necessary if the true phosphate level is within the reference range and the patient is asymptomatic.     

Superimposition of nutcracker syndrome in a haematuric child with Henoch-Schönlein purpura

We report a child with Henoch‐Schönlein purpura (HSP) who had shown persistent microscopic haematuria for 26 months and was found to have nutcracker syndrome by renal Doppler ultrasound. Haematuria subsided in accordance with radiological improvement of nutcracker syndrome. These findings suggest that the origin of urinary abnormalities in patients with HSP may not always be due to the renal involvement of vasculitis.