中西医结合治疗糖尿病肾病67例分析

糖尿病肾病是糖尿病患者的主要微血管病变并发症,也是慢性肾衰竭的常见病因,占国内外终末期肾脏病50%以上,而蛋白尿也是发生心脑血管事件的独立危险因素之一,通过对糖尿病肾病早期干预治疗,且逆转糖尿病肾病进展是糖尿病治疗     

1427例冠状动脉疾病患者慢性肾脏病的流行病学调查

目的:调查冠心病造影患者的中重度慢性肾脏病发病情况。方法:回顾性分析1457例冠心病造影患者临床资料,并进行logistic多因素分析。结果:冠心病造影患者中中重度肾病的患病率为30.96%,其中慢性肾脏病CKD3～5期所占比例分别为28.35%,2.06%,0.55%,与普通社区CKD的患病率相比明显升高。与肾功能正常组或者轻度肾病组相比,性别、年龄、体重指数、高血压、糖尿病差异具有统计学意义(P<0.01),胆固醇和低密度脂蛋白值相比差异无统计学意义,Lo-gistic回归分析得出年龄、高血压、糖尿病可能为影响冠心病造影患者发生慢性肾病的独立危险因素。结论:慢性肾脏病是心血管疾病的高发人群,冠心病造影患者中重度肾病的患病率明显高于普通社区人群,老年人是高危人群,高血压、糖尿病,是最主要的危险因素,故早期诊断、预防和干预CKD,降低造影剂肾病及终末期肾脏疾病的发生具有重要意义。     

糖尿病肾病患者的血压管理

高血压作为心血管疾病传统的危险因素,在糖尿病肾病进展中起到了重要作用。掌握糖尿病肾病高血压诊断标准、把握适当的干预时机、给予准确治疗和降压达标是减少糖尿病肾病进展至终末期肾脏病的重要措施。     

终末期肾病患者血管钙化的相关机制及临床诊治

血管钙化增加了终末期肾病患者心血管事件的发生率及死亡率,严重影响终末期肾病患者的生存质量和生存时间.除了传统的危险因素如年龄、吸烟、糖尿病、高血压、脂代谢紊乱等,终末期肾病患者的血管钙化还有其特殊的发病机制.临床诊治工作应着重对终末期肾病患者血管钙化的早期预防及防治其进展.     

早期糖尿病肾病血管内皮机能不全的表现

发生临床糖尿病肾病的糖尿病病人死于心血管并发症者是不伴肾病者的40倍。糖尿病肾病患者常有高血压、脂质和脂蛋白异常,血浆纤维蛋白增高及大量吸烟等心血管危险因素,但尚不能完全解释因心血管病死亡率的大幅度上升。作者们曾报道过有早期和明显临床肾病的糖尿病人的血管内皮机能不全的表现,诸如白蛋白排泄率增高,血浆VW因子(Von Willebrand)升高。本文进一步研究伴不同程度白蛋白尿病人血管内皮细胞释放组织纤溶     

足细胞病变与糖尿病肾病

糖尿病肾病是糖尿病的主要微血管病变之一,已成为糖尿病病人死亡的主要原因,而微量蛋白尿是糖尿病肾病早期临床表现,往往在数年内发展为大量蛋白尿和慢性肾功能不全。传统观点认为蛋白尿的发生主要与肾小球滤过屏障的损伤有关,近年来随着研究的深入,已发现足细胞的损伤病变与蛋白尿的发生密切相关,同时糖尿病时高血糖、胰岛素抵抗、高血压、氧化应激等因素亦可导致足细胞损害,进一步促进蛋白尿产生与肾小球硬化。本文就足细胞病变与糖尿病肾病的关系作一综述。     

糖尿病肾病患者营养不良评估和治疗的研究进展

正糖尿病肾病(DN)作为糖尿病微血管病变的常见慢性并发症,是导致终末期肾病(ESRD)的主要原因之一。DN主要表现为蛋白尿、水肿、高血压、不同程度的低蛋白血症和肾功能逐渐减退。DN患者常存在多种因素导致营养不良,其营养不良发生率高达50%以上[1]。改善DN患者营养状况对预防感染,减少并发症,提高患者生存质量和延长生存时间有重要意义[2]。1糖尿病肾病患者营养不良发生机制     

前部缺血性视神经病变疗效观察

目的探讨引起前部缺血性视神经病变(anterior ischemicoptic neuropadly,AION)的危险因素、临床特点及疗效。方法观察62例65眼AION危险因素、临床表现、眼底、FFA、视野变化。控制全身性疾病、应用糖皮质激素、神经营养剂,血管扩张剂,观察疗效。结果高血压、高血脂、糖尿病、心脑血管疾病、低血压等全身性疾病,视力突然下降占50%,视盘水肿呈灰白色占51.61%,偏盲性视野缺损占25.80%,FFA早期视盘弱荧光,晚期强荧光占56.45%。治疗后92.31%患者视力提高,视盘及视野改善。结论AION多数为突然视力下降、视盘水肿、视野缺损、FFA视盘早期弱荧光、晚期强荧光及渗漏。高血压、高血脂、糖尿病是其发生危险因素。联合治疗患者可恢复一定视功能。     

慢性肾脏病的心血管并发症

慢性肾脏病的心血管并发症包括左心室肥大、动脉粥样硬化和动脉硬化 ;在慢性肾脏病的早期往往已出现心血管并发症 ,随着肾功能的衰退死于心血管并发症者多于发展成终末期肾病者。慢性肾脏病所以心血管病发生率高 ,除与传统的危险因素如高血脂、糖尿病等有关外 ,血尿、蛋白尿、贫血、钙磷失调等尿毒症相关因素发挥了重要作用。因此 ,早期开展对传统和尿毒症相关危险因素的治疗意义重大。     

慢性肾脏病的心血管并发症

慢性肾脏病的心血管并发症包括左心室肥大、动脉粥样硬化和动脉硬化；在慢性肾脏病的早期往往已出现心血管并发症。随着肾功能的衰退死于心血管并发症者多于发展成终末期肾病者。慢性肾脏病所以心血管病发生率高，除与传统的危险因素如高血脂、糖尿病等有关外，血尿、蛋白尿、贫血、钙磷失调等尿毒症相关因素发挥了重要作用。因此。早期开展对传统和尿毒症相关危险因素的治疗意义重大。     

Nephrogenic systemic fibrosis: more hard times for renal failure patients

To date, more than 200 cases of nephrogenic systemic fibrosis have been documented worldwide. All patients have had renal failure, most of them requiring dialysis. We herein describe the course of a hemodialyzed patient who developed nephrogenic systemic fibrosis in the months following magnetic resonance angiography of the lower extremities. The disease is characterized by skin thickening and tendon fibrosis leading to joint contractures that can quickly confine the patient to a wheelchair. Systemic involvement may occur, leading to cardiomyopathy, pulmonary fibrosis, pulmonary hypertension or even death. No consistently effective therapy has been reported. An association between gadolinium exposure and the development of the disease has been found, although no causal link has yet been proven. In a patient with renal failure, magnetic resonance imaging with gadolinium enhancement should be done only after having seriously considered the risk/benefit ratio. Implications concerning the choice of imaging methods when searching for ischemic nephropathy or aorto-iliac disease before renal transplantation are discussed.     

Influence of diabetes on persistent nonhealing ischemic foot ulcer in end-stage renal disease

The aim of this study was to identify important atherosclerotic risk factors for characteristic nonhealing ischemic foot ulcers in patients with end-stage renal failure. We retrospectively studied 534 consecutive hemodialysis patients in five dialysis units of the Tokyo metropolitan area between 1980 and 1999. The influence of risk factors for ischemic foot ulcers in hemodialysis patients was determined using a multivariate logistic model. The characteristic features were also evaluated with further comparison of the prevalence of risk factors between hemodialyzed diabetic patients with ischemic foot ulcers and another 61 age- and gender-matched nonhemodialyzed diabetic patients with ischemic foot ulcers. In the logistic model, two factors emerged as important risk factors for ischemic foot ulcers: renal failure due to diabetes [odds ratio 21.580 (95% CI 4.838-96.251); p = 0.0001] and a history of cerebrovascular disease [odds ratio 2.782 (1.015-7.624); p = 0.0467]. On the basis of a comparison of age- and gender-matched control patients, associated diabetic triopathy, a history of cerebrovascular disease, and hypertension were more frequent in the hemodialysis patients. The development of ischemic foot ulcers in those with end-stage renal failure is strongly influenced by underlying advanced diabetic microangiopathy and such other factors as sequelae of cerebrovascular disease and patient debilitation.     

动脉粥样硬化性肾动脉狭窄与良性小动脉肾硬化临床特点的差异分析

目的 分析比较动脉粥样硬化性肾动脉狭窄(ARAS)与良性小动脉肾硬化(BN)患者的临床特征，以提高对这2种疾病的认识。方法 回顾性分析82例拟诊BN患者的肾血管彩色多普勒超声及肾动脉造影检查结果，统计ARAS的发生率。比较ARAS与BN患者的年龄、性别、家族史、血压、尿蛋白排泄、血清学等指标以及眼底、心脏结构、血管形态等临床参数的差异，探讨2种疾病与各临床参数的相关关系。 结果 82例拟诊BN患者中确诊缺血性肾病(IRD)17例(20.7%)，其中13例(15.9%)为ARAS。血管彩色多普勒超声诊断符合率为89.5%(17例/19例)。ARAS组与BN组在年龄、高血压家族史、高血压病程、冠心病史、体重指数、吸烟、总胆固醇、血糖、左心室重量指数、双肾长径等的差异有统计学意义。肾血管彩色多普勒超声显示ARAS组与BN组在肾动脉与主动脉峰值流速比、收缩期峰值速度、舒张末期速度、叶间动脉阻力指数等的差异有统计学意义。结论 临床拟诊的BN患者不能排除ARAS。部分BN与ARAS临床特征相似，病史、实验室检查等只能作为初步筛查手段。血管多普勒超声诊断在临床上实用性强。肥胖、吸烟、高血脂、高血糖是ARAS的危险因素。     

Off-pump coronary artery bypass grafting for unstable angina pectoris combined with hypothyroidism and chronic renal failure; report of a case

Coronary artery bypass grafting for patients with ischemic heart disease and hypothyroidism contains many controversies, and chronic renal failure causes perioperative water-electrolyte balance disorders. We experienced a case of unstable angina pectoris combined with hypothyroidism and chronic renal failure successfully treated by off-pump coronary artery bypass grafting (OPCAB). A 68-year-old man with a history of hypothyroidism and chronic renal failure was hospitalized with chest pain. Cardiac catheterisation revealed a 90% stenosis of segment 3, 11 and right ventricular (RV) branch, 75% stenosis of segment 6 and 50% stenosis of segment 5. His thyroid function was normal with orally administered levothyroxine. OPCAB was performed safely with hemodialysis until a day before operation and hemofiltration from a day after operation, and postoperative course was uneventful.     

Hemorrhagic fever with renal syndrome in an endemic area of Greece.

From 1983 to 1990, 32 patients with hemorrhagic fever with renal syndrome (HFRS) were admitted to our hospital. The diagnosis was confirmed by high IgM type titers of antibodies to Hantaan virus. All patients presented with serum and urine abnormalities suggesting renal involvement. Serum creatinine was elevated and ranged between 1.8 and 14.3 mg/dl. Proteinuria ranged between 0.5 and 6.4 g/24 h. Seven patients died due to shock or hemorrhage, while 6 patients were supported by hemodialysis or peritoneal dialysis. Five of them had a complete recovery. Two patients were discharged with some degree of renal impairment which remained stable 12-15 months later. Kidney biopsy in the first patient performed 1 year after his discharge revealed some degree of interstitial fibrosis and tubular atrophy as well as an area with ischemic and sclerosed glomeruli. We conclude that HFRS in Greece is a severe disease with a high mortality rate. The disease may cause chronic renal failure in a limited number of patients.     

Role of renal prostaglandin E2 in chronic renal disease hypertension

The role played by renal prostaglandin E2 in the maintenance of hypertension in chronic renal disease has been investigated through studying the response of body weight, blood pressure, glomerular filtration rate (GFR), 24-hour natriuresis, plasma renin activity (PRA), plasma aldosterone and urinary PGE2 excretion to the administration of indomethacin (2mg/kg daily, during 3 days). A group of 37 patients diagnosed as having chronic renal parenchymatous disease with creatinine clearance above 25 ml/min was included in the study. 21 of them were hypertensive (BP greater than 160/95). 27 normotensive volunteers were also studied and considered as the control group. The initial study disclosed similar levels of PGE2, PRA and plasma aldosterone in volunteers, normotensive patients and hypertensive patients, although the sodium intake was lower in the last two groups. A positive correlation between PRA and urinary PGE2 was found both in normotensive (r = 0.507, p less than 0.01) and in hypertensive patients (r = 0.609, p less than 0.01). The administration of indomethacin induced a diminution of PRA, plasma aldosterone and urinary PGE2 levels together with an increase in diastolic blood pressure (p less than 0.05-0.01) in both volunteers and patients. The remaining parameters measured did not change in volunteers or in normotensive patients. On the contrary, in hypertensive patients, during indomethacin administration, lower values of creatinine clearance (p less than 0.005) and 24-hour natriuresis (p less than 0.05) together with an increase in body weight (p less than 0.01) were observed. These results point to the existence of a protective role of renal prostaglandin E2 upon renal function when hypertension appears in the course of chronic renal parenchymatous disease.     

Polyunsaturated fatty acids and renal fibrosis: pathophysiologic link and potential clinical implications

The role of polyunsaturated fatty acids in renal fibrosis. Several studies suggest a close relationship between polyunsaturated fatty acids (PUFA) and renal inflammation and fibrosis, which are crucial stages in chronic kidney disease (CKD). Beneficial effects of n-3 PUFA on the course of experimental and human nephropathies have been reported. PUFA can ameliorate chronic, progressive renal injury beyond the simple reduction of serum lipid levels. These pleiotropic effects of PUFA are due to their properties of interfering with the synthesis of a variety of inflammatory factors and events, through effects related both to the modulation of the balance of n-6 and n-3-derived eicosanoids and to direct action on the cellular production of the major cytokine mediators of inflammation and on endothelium function. The mechanisms by which PUFA can favorably interfere with some stages in renal fibrosis processes, such as mesangial cell activation and proliferation and extracellular matrix protein synthesis, include the regulation of some pro-inflammatory cytokine production, renin and nitric oxide (NO) systems and peroxisome proliferator-activated receptor gene expression. An optimal n-6/n-3 PUFA ratio dietary intake could offer new therapeutic strategies aimed at interrupting the irreversible process of renal fibrosis and ameliorating chronic renal injury. However, further experimental, epidemiological and clinical investigations are needed to confirm the role of PUFA in the renal fibrosis pathway and the natural history of chronic nephropathies.     

Renal cell carcinoma co-existent with other renal disease: clinico-pathological features in pre-dialysis patients and those receiving dialysis or renal transplantation.

BACKGROUND: Patients on chronic dialysis are prone to developing acquired cystic kidney disease (ACKD), which may lead to the development of renal cell carcinoma (RCC). The risk factors for the development of RCC so far have not been determined in pre-dialysis patients with co-existent renal disease. The aim of this study was to evaluate the clinico-pathological features of RCC in pre-dialysis patients with associated renal diseases or in those undergoing chronic dialysis and renal transplantation. METHODS: We studied 32 kidneys from 31 patients with RCC and associated renal diseases. Of those, 18 kidneys were from 17 patients not on renal replacement therapy (RRT) when diagnosed with RCC; 14 patients received dialysis or dialysis followed by renal transplantation. Several clinico-pathological features were analysed and compared between the two groups. RESULTS: Overall, there was a preponderance of males (75%); nephrosclerosis was the predominant co-existent disease (31%). The median intervals from renal disease to RCC in the dialysis and transplanted groups were significantly longer than in the pre-dialysis group (15.8+/-1.1 vs 2.4+/-0.7 years, P<0.0001). In contrast to pre-dialysis RCC, the dialysis and transplant RCC groups had greater frequency of ACKD (100 vs 28%, P<0.0001), papillary type RCC (43 vs 11%, P<0.05) and multifocal tumours (43 vs 5%, P<0.05). At the end of the study, 71% of dialysis and transplanted patients and 72% of pre-dialysis patients were alive. CONCLUSIONS: ACKD develops in dialysis patients, as it does in those with renal disease prior to RRT. The duration of renal disease, rather than the dialysis procedure itself, appears to be the main determinant of ACKD and RCC. The RCC occurring in patients with ACKD and prolonged RRT is more frequently of the papillary type and multifocal than the RCC occurring in patients with no or few acquired cysts and a short history of renal disease. Long-term outcomes did not differ between the two groups.     

Influence of surgery on renal amyloidosis

It is well known that renal amyloidosis (RA) leads to ESRD in a few years. This evolution may be accelerated by several factors such as steroids, renal vein thrombosis, infections or surgery. We report 22 patients (14M,8F) mean age = 41.6 years (13-72) with RA in whom surgery revealed or aggravated renal disease. The group I includes 15 patients with no previous history of renal disease and who developed oedema few days after surgery with acute renal failure in 5 of them. Proteinuria was present in all the cases with a nephrotic syndrome in 10. Percutaneous kidney biopsy (KB) showed renal amyloidosis in all patients (AA+ = 8 cases, AA- = 3 cases). Only 9 patients were followed-up (mean period = 40 months): 2 patients are stationary; 1 is on complete remission 2 are on HD and 4 died. The group II includes 7 patients with a previous history of nephropathy (Histologically proven amyloidosis: 3 CRF = 1, Oedema: 3). All these patients developed oedema few days after surgery with acute RF in 4 patients. KB performed in all of them showed RA (AA+ = 33, AA- = 1). 6 patients were followed up for a mean period of 11 months: 5 died, 1 patient is on HD. The influence of surgery on renal amyloidosis is often unforeseeable. It may have no effect on renal disease, but very often it reveals RA and sometimes dramatically aggravates the course of the disease with occurrence of irreversible CRF. The pathogenic role of surgery on RA is discussed.     

Treatment of renovascular disease and of renovascular hypertension

ABSTRACT: Treatment of occlusive lesions of renal arteries, defined as renovascular disease (RVD), is aimed both at preventing ischemic renal disease (IRD) and rescuing renal function through revascularization procedures, such as PTRA, endovascular stenting and surgical revascularization, as well as curing or improving hypertension in the presence of renovascular hypertension (RVH), i.e. hypertension caused by these vascular lesions. Preventive treatment of IRD is still an individual decision making process based on the type of renal lesions, degree of renal stenosis and progressive loss of renal mass as well as on immediate and late technical success of revascularization procedures together with their rate of complications. Rescue of renal function and-or prediction of the outcome of renal function after successful revascularization depends not only on the possibility of clarifying whether the decrease in renal function is a functioning-reversible phenomenon linked to renal hypoperfusion but also on the potential risk that the revascularization procedure may induce irreversible kidney damage. The rationale for treating RVH through revascularization procedures derives from the possibility of establishing a pathogenetic link between the occlusive lesions and hypertension, mainly through renal vein renin measurement and captopril renography and possibly their combination. Finally, medical treatment of hypertension is needed in patients who cannot undergo or refuse revascularization and whose blood pressure is not normalized by these procedures.