5F微孔灌注导管在经皮肾动脉去交感神经消融术治疗顽固性高血压中的临床观察

目的 观察5 F微孔灌注导管在经皮肾动脉去交感神经消融术（RDN）治疗顽固性高血压中的临床效果。方法 选取2013年1月至2015年12月在我院接受RDN治疗的顽固性高血压患者30例作为研究对象,采用随机信封法将患者分为普通导管消融组和微孔灌注导管消融组,每组15例。普通导管消融组使用5 F温控消融导管,微孔灌注导管消融组使用头端带小侧孔的5 F微孔灌注导管,标测及消融时用冷盐水灌注。所有患者术后随访9个月,比较两组患者的术前及随访期间诊室血压、24 h动态血压、血生物化学指标和心脏功能。结果 所有患者均成功接受RDN治疗。随访期间,微孔灌注导管消融组24 h动态血压收缩压下降值较普通导管消融组更明显[（34.67±13.02）mmHg vs（17.00±16.74）mmHg,P<0.01;1 mmHg=0.133 kPa];微孔灌注导管消融组24 h动态血压舒张压明显下降,与普通导管消融组比较差异有统计学意义[（81.20±7.15）mmHg vs（87.60±8.17）mmHg,P<0.05]。微孔灌注导管消融组随访期间服用降压药物的种类较普通导管消融组有减少的趋势,尤其在利尿剂的使用方面,微孔灌注导管消融组服用利尿剂的比例低于与普通导管消融组（P<0.05）。在手术消融中微孔灌注导管消融组可显著降低导管消融时的温度（P<0.001）,获得更大的释放能量（P<0.05）,阻抗下降幅度也较普通导管消融组更大（P<0.05）。随访过程中两组患者均未出现低血压晕厥及黑矇,未出现肾功能恶化的表现。结论 5 F微孔灌注消融导管是一种安全有效的肾动脉消融导管,在RDN治疗顽固性高血压中,其在降低收缩压及减少利尿剂的使用方面较普通消融导管更具优势。     

经皮肾动脉交感神经消融术中消融点位对顽固性高血压患者降压效果的影响

目的 探索不同消融位点对经皮肾动脉交感神经消融术治疗顽固性高血压降压效果的影响。方法 选择16例顽固性高血压患者,随机分为近中段消融组和全段消融组,每组8例。完善相关检查后行经皮肾动脉交感神经消融术治疗。术中记录消融参数（起始阻抗值、最低阻抗值、消融实际功率、消融实际温度）,术后即刻复查肾动脉造影。所有患者术后继续监测血压,随访至术后3个月。结果 全部16例患者均成功完成经皮肾动脉交感神经消融术。所有患者消融起始阻抗平均值为（180.0±12.3）Ω,消融最低阻抗平均值为（157.8±12.8）Ω,阻抗下降率平均为（12.4±2.6）%;实际消融温度为40～50℃,功率为5～18 W。术后肾动脉造影显示全段消融组2例发生肾动脉痉挛,近中段消融组无一例发生肾动脉痉挛,两组肾动脉痉挛发生率差异无统计学意义（P=0.08）。术后3个月随访,两组患者血压未见明显差异。结论 在肾动脉近中段进行消融,特别是在肾动脉开口处消融,可能不会影响经皮肾动脉交感神经消融术的降压效果,并可一定程度上减少肾动脉狭窄的发生率。     

经皮肾动脉交感神经消融术中消融点位对顽固性高血压患者降压效果的影响

目的：探索不同消融位点在经皮肾动脉交感神经消融术（catheter-based renal sympathetic denervation, RDN）治疗顽固性高血压患者中的作用及影响。 方法：本次研究共入选了16名顽固性高血压患者。随机分为2组：近中段消融组,全段消融组。完善相关检查后行RDN术,术中记录消融参数（阻抗起始值、阻抗最小值、消融实际瓦数、消融实际温度）及消融点位（将肾动脉分为近、中、远三段,统计消融点在这三段的分布情况）,术后复查肾动脉造影。所有患者RDN术后继续监测血压,并于术后一周、二周、一月、三月随访血压。 结果：2组患者共16名患者均成功完成RDN术。在RDN术后3月随访时,两组患者血压相比,未见明显差异（收缩压136±9mmHg VS 136±12mmHg,P=0.91;舒张压80±3mmHg VS 79±6mmHg,P=0.76）。术后即刻肾动脉造影,全段消融组肾动脉痉挛率为25%,与近中段相比无统计学差异（P=0.08）。所有患者消融起始阻抗平均值为：180.1Ω,消融最低阻抗平均值为157.8Ω,阻抗下降率平均为12.4%。患者消融点位分布率分别为：近段：61.3%,中段：22.5%,远段：16.2%。 结论：在肾动脉近中段进行消融,特别是在肾动脉开口处消融,可能不会影响RDN术的降压效果,并可一定程度上减少肾动脉狭窄的发生率。     

导管消融肾动脉去交感神经术治疗难治性高血压的临床研究

目的：探讨导管消融肾动脉去交感神经术治疗难治性高血压的降压效果及安全性,为难治性高血压的治疗提供临床依据。方法：选取2011年9月～2013年10月在我院住院治疗的难治性高血压患者12例,于全麻下对患者行导管消融肾动脉去交感神经术,随访1个月～6个月,观察患者术前、术后血压的变化情况、降压药物的使用情况及肾动脉异常情况。结果：患者手术前与手术后1个月、3个月、6个月血压变化明显,比较具有统计学意义（P ＜0．05）;手术后有6例患者降压药的使用种类较之前有所减少;所有患者手术后均未有肾动脉均狭窄、动脉夹层及血肿等并发症的发生。结论：导管消融肾动脉去交感神经术是治疗难治性高血压有效,安全的新方法,适合在临床上进一步推广。     

肾动脉内支架置入治疗肾血管性高血压

目的探讨肾动脉内支架置入术(percutaneous translum inal renal artery stenting,PTRAS)治疗肾血管性高血压的疗效。方法对9例肾动脉狭窄(renal artery stenosis,RAS)患者进行了肾动脉支架置入术,并观察手术对患者血压的影响。结果9例患者均成功置入肾动脉支架。患者收缩压由术前的186.1±45.6 mmHg降至术后的139.4±15.4 mmHg(p<0.05),舒张压由术前的114.2±27.1 mmHg降至术后的89.4±17.9 mmHg(p<0.05),服用降压药物种类由术前的2.2±0.8种减少为术后的1.4±0.7种(p<0.05)。结论PTRAS技术成功率高,可有效降低肾血管性高血压患者血压。     

经桡动脉径路肾动脉支架术1例

目的初步探讨经桡动脉径路行肾动脉支架术的可行性和安全性。方法分析近期诊治的一例难治性高血压患者(血压190/105 mmHg)接受经桡动脉径路肾动脉支架术的临床经过和治疗情况。结果患者右侧肾动脉开口高度狭窄,右肾动脉支架术经桡动脉径路顺利完成,术后患者全身和桡动脉穿刺局部均无任何不适,控制(血压150/80～92 mmHg),肾功能均在正常范围。结论该高血压患者右侧肾动脉开口高度狭窄,经桡动脉径路肾动脉支架术完全可行,而且十分安全。     

10例经导管肾动脉交感神经射频消融术治疗顽固性高血压

目的：探讨经导管肾动脉交感神经射频消融术(RDN)治疗顽固性高血压的临床疗效。方法回顾性分析10例经RDN 治疗的顽固性高血压患者的临床资料,分析 RDN 治疗后患者血压的变化及并发症情况。结果患者术后2周收缩压、舒张压均较术前明显下降,术后3个月进一步下降,差异均有统计学意义(P <0.05),术后6个月与术后3个月比较差异无统计学意义(P >0.05);术前平均应用降压药种数为(5.3±0.9)种,术后6个月随诊平均用药种类(3.2±0.6)种,较术前明显减少,差异有统计学意义(P <0.05)。患者未出现不良反应。结论RDN 可迅速、持续地降低顽固性高血压患者的血压水平,具有较好的安全性。     

老年动脉粥样硬化性肾动脉狭窄支架置入术后血压变化随访

目的探讨经皮腔内肾动脉支架置入术(percutaneous transluminal renal angioplasty with stent,PTRAS)治疗动脉粥样硬化性肾动脉狭窄(atherosclerotic renal artery stenosis,ARAS)对血压的影响。方法经肾动脉造影确诊的ARAS并施行PTRAS的患者50例,术后随访3-48(16.3±14.8)个月,分析PTRAS术后患者血压水平。结果 50例PTRAS全部成功,术后所有患者血压改善,术后3、6、12个月的收缩压分别为(128.80±18.13)mmHg(1mmHg=0.133kPa),(125.41±16.70)mmHg,(129.48±9.67)mmHg;舒张压分别为(71.26±9.62)mmHg,(71.58±5.80)mmHg,(73.84±9.58)mmHg,各时间点分别与术前比较差异有统计学意义(P<0.05)。结论 PTRAS术后老年人肾动脉粥样硬化性狭窄患者血压水平下降,这种下降趋势至少维持12个月。     

肾动脉狭窄患者介入治疗的长期疗效观察

目的评价经皮肾动脉成形术对肾动脉狭窄患者血压、肾功能的长期影响。方法肾动脉狭窄患者229例(管腔狭窄≥70%),经肾动脉成形术重建肾动脉血运,术后平均随访(13±10)个月,观察患者血压、降压药物、肾功能的变化。结果229例患者肾动脉成形术成功率96.1%。病变动脉管腔直径狭窄率由70%±11%降至12%±10%。术后随访138例患者,血压由治疗前的(151±25/82±15)mmHg降至治疗后的(137±16/77±11)mmHg,差异有统计学意义(P<0.01),口服降压药由(2.4±1.2)种降至(1.8±0.9)种,差异均有统计学意义(P<0.01);患者手术前后肌酐水平(SCr)及肾小球滤过率(GFR)比较差异无统计学意义(P>0.05)。结论肾动脉狭窄患者经皮肾动脉成形术的手术成功率高,有助于此类患者血压的长期良好控制。     

肾动脉狭窄性高血压介入治疗疗效观察

目的观察肾动脉狭窄(RAS)所致肾动脉狭窄性高血压(RASH)患者,经肾动脉介入术后的血压及服用降压药物的变化。方法回顾性68例RASH患者,单侧狭窄42例,双侧狭窄26例,病变血管共94根,狭窄程度超过70%的68根;9例肾动脉球囊扩张术,59例肾动脉内支架置入术,观察术前、术后3~7d血压及服用降压药物的情况。结果68例患者肾动脉介入治疗,手术成功100%;术前血压(174.35±33.92/137.04±25.60)mm Hg(1mm Hg=0.133kPa),术后(103.95±24.95/82.83±18.91)mm Hg,血压明显下降,P<0.05;其中治愈40例(58.8%),好转8例(11.7%),无效20例(29.4%),总有效率为70.5%。服用降压药品种数术前平均(2.5±1.0)种,术后(1.6±1.0)种,用药品种数减少,P<0.05。结论肾动脉介入治疗为RASH安全有效的治疗手段,术后血压明显改善,服用降压药品种数明显减少。     

肾交感神经射频消融术治疗高血压犬的适宜消融温度探讨

目的探讨肾交感神经射频消融术治疗高血压的适宜消融温度。方法成年健康杂种犬20只,雌雄不拘,体质量15～25 kg,建立腹主动脉缩窄型高血压模型后,随机分为治疗组(行双侧肾交感神经射频消融术)和对照组(n=10)。治疗组根据预置消融温度随机分为45℃和50℃组(n=5)。20只犬分别于建模前、建模后1(射频消融术前)、2(术后1个月)、3个月(术后2个月)监测收缩压、舒张压和平均动脉压。建模后3个月治疗组复查肾动脉造影。肾动脉行HE染色观察病理改变。结果建模后1个月,治疗组和对照组血压均显著升高(P<0.01)。射频消融术后1月治疗组收缩压显著降低(P<0.05)。射频消融术后2个月,收缩压、舒张压、平均动脉压均明显低于射频消融术前(P<0.05,P<0.01),且显著低于对照组(P<0.05,P<0.01)。治疗组复查造影未发现肾动脉狭窄及其他异常。肾动脉血管壁病理检查结果显示,50℃组血管壁损伤明显比45℃组严重。结论 45℃可以作为肾交感神经射频消融术治疗高血压的常规消融温度。     

Short-term Safety and Efficiency of Cryoablation for Renal Sympathetic Denervation in a Swine Model

Background:

Renal sympathetic nerves are involved in the reflective activation of the sympathetic nervous system in circulatory control. Catheter-based renal denervation (RDN) ameliorated treatment-resistant hypertension safely, but 10%–20% of treated patients are nonresponders to radiofrequency denervation. The purpose of this study was to investigate the safety and efficiency of cryoablation for sympathetic denervation in a swine model and to explore a new way of RDN.

Methods:

Seven swines randomly assigned to two groups: Renal cryoablation (CR) group and control group. The control group underwent renal angiogram only. The CR group underwent renal angiogram plus bilateral renal cryoablation. Renal angiograms via femoral were performed before denervation, after denervation and prior to the sacrifice to access the diameter of renal arterial and the pressure of aorta abdominalis. Euthanasia of the swine was performed on 28-day to access norepinephrine (NE) changes of the renal cortex and the changes of renal nerves.

Results:

Cryoablation did not induce severe complications at any time point. There was no significant change in diameter of renal artery. CR reduced systolic blood pressure (BP) from 145.50 ± 9.95 mmHg at baseline to 119.00 ± 14.09 mmHg. There was a slight but insignificant decrease in diastolic BP. The main nerve changes at 28-day consisted of necrosis with perineurial fibrosis at the site of CR exposure in conjunction with the nerve vacuolation. Compared with the control group, renal tissue NE of CR group decreased by 89.85%.

Conclusions:

Percutaneous catheter-based cryoablation of the renal artery is safe. CR could effectively reduce NE storing in the renal cortex, and the efficiency could be maintained 28-day at least.     

Clinical observation on Breviscapine in treating hypertension patients complicated with micro-albuminuria of renal impairment

Incidence of renal impairment of essen tial hypertension (EH) has been displayingan ascending trend from year to year, great ly threatened the EH patients ' health andlife. According to the statistics of AmericanAssociation of Nephropathy, in the 5 yearsbetween 1983-1987, owing to renal impair ment by EH in the end stage renal disease(ESRD), the number of patients who werein need of dialysis and renal transplantationincreased by 1. 5 times, just next to thenumber …     

Effects of renal artery stenting on renal function and blood pressure in patients with atherosclerotic renovascular disease

Objective To study the effects of percutaneous renal artery intervention on renal function and blood pressure in patients with renal artery stenosis. Methods Eighty-seven patients with severe uni- or bi-lateral renal artery stenosis (luminal diameter narrowing ≥70%) and clinical hypertension received renal artery stenting between January 2002 and December 2002. The changes in blood pressure and serum creatinine level and creatinine clearance (CCr) 48 hours after intervention and during 6 months of follow-up were assessed.Results Renal stenting was performed in 98 stenotic arteries of 87 patients, and the procedural success rate was 100%. Serum creatinine level was slightly elevated from (176±21) μmol/L to (179±11) μmol/L (P=0.15) 48 hours after the procedure, but significantly decreased to (149±15) μmol/L at 6 months (P&lt;0.001). CCr was also greatly improved ［(37±11) ml/min before versus (51±8) ml/min at 6 months, P&lt;0.001］. During follow-up, 61% of the patients experienced a normal renal function. Despite conventional medical treatment, systolic and diastolic blood pressures were also significantly decreased after stenting ［(163±23)/(96±13) mm Hg before versus (148±12)/(79±15) mm Hg at 6 months, all P&lt;0.001］, and hypertension was well controlled in 67% of the patients at 6 months’ follow-up.Conclusion Renal artery stenting has a high success rate and is effective in improving renal function and blood pressure for patients with severe renal artery stenosis.     

TRPV4受体对血管紧张素Ⅱ诱导的小鼠肾损害的影响

目的通过利用瞬时受体电位香草酸亚型4(transient receptor potential vanilloid type 4,TRPV4)基因敲除(TRPV4-/-)小鼠,探讨TRPV4受体在血管紧张素Ⅱ(angiotensin Ⅱ,Ang Ⅱ)所诱导的肾损害中的作用。方法实验小鼠分为假手术组和Ang Ⅱ处理组。在野生型和TRPV4-/-小鼠中通过皮下灌注Ang Ⅱ建立Ang Ⅱ依赖型高血压模型,而假手术组小鼠皮下只灌注生理盐水。处理4周后,分别检测小鼠的尾动脉收缩压、24 h尿白蛋白排泄量及8-异构前列腺素、血清肌酐的改变,并且同时对肾组织病理学的变化进行分析。结果与相应的假手术组比较,Ang Ⅱ处理组小鼠血压升高、尿白蛋白及8-异构前列腺素排泄量增加,并同时伴有血清肌酐升高(P0.05);肾小球纤维样硬化及肾小管间质损伤程度均出现明显加重,并伴有肾胶原蛋白水平的增高(P0.05)。除血压外,TRPV4基因敲除能显著抑制上述所有病理变化,从而缓解Ang Ⅱ所诱导的肾损害(P0.05)。结论在Ang Ⅱ所诱导高血压的过程中,TRPV4基因敲除能够明显减弱由上述过程所诱发的肾损害。因此,上述研究结果提示TRPV4受体在促进Ang Ⅱ所诱导的肾损害中发挥重要的病理生理学作用。     

Changes of arterial pressure following relief of obstruction in adults with hydronephrosis

Abstract

Background: As much as 20% of all cases of hypertension are associated with kidney malfunctions. We have previously demonstrated in animals and in pediatric patients that hydronephrosis causes hypertension, which was attenuated by surgical relief of the ureteropelvic junction (UPJ) obstruction. This retrospective cohort study aimed to investigate: (1) the proposed link between hydronephrosis, due to UPJ obstruction, and elevated arterial pressure in adults; and (2) if elevated blood pressure in patients with hydronephrosis might be another indication for surgery.

Materials and methods: Medical records of 212 patients undergoing surgical management of hydronephrosis, due to UPJ obstruction, between 2000 and 2016 were assessed. After excluding patients with confounding conditions and treatments, paired arterial pressures (i.e. before/after surgery) were compared in 49 patients (35 years old; 95% CI 29–39). Split renal function was evaluated by using mercaptoacetyltriglycine (MAG3) renography before surgical management of the hydronephrotic kidney.

Results: Systolic (?11?mmHg; 95% CI 6–15?mmHg), diastolic (?8?mmHg; 95% CI 4–11?mmHg), and mean arterial (-9?mmHg; 95% CI 6–12) pressures were significantly reduced after relief of the obstruction (p?<?0.001). Split renal function of the hydronephrotic kidney was 39% (95% CI 37–41). No correlations were found between MAG3 and blood pressure level before surgery or between MAG3 and the reduction of blood pressure after surgical management of the UPJ obstruction.

Conclusions: In adults with hydronephrosis, blood pressure was reduced following relief of the obstruction. Our findings suggest that elevated arterial pressure should be taken into account as an indication to surgically correct hydronephrosis.     

超声血流动力学参数与实时剪切波弹性成像定量参数对肾移植后急性肾损伤的预测价值

目的 探究超声血流动力学参数与实时剪切波弹性成像定量参数对肾移植后急性肾损伤的预测价值。方法 选取2019年1月—2022年1月在海南医学院第二附属医院57例接受肾移植治疗的肾衰竭患者。采用彩色多普勒超声检测肾椎体叶间动脉、肾段动脉、肾主动脉的相关血流参数（搏动指数、阻力指数和峰值流速）;采用实时剪切波弹性成像检查肾皮质、髓质、肾窦的弹性模量。术后随访6个月,根据患者是否发生急性肾损伤分为急性肾损伤组和非急性肾损伤组。采用多因素Logistic逐步回归模型分析肾移植后急性肾损伤的危险因素;绘制受试者工作特征（ROC）曲线评估超声血流动力学参数与实时剪切波弹性成像定量参数对肾移植后急性肾损伤的预测效能。结果 57例接受肾移植治疗的肾衰竭患者术后发生急性肾损伤14例,发生率为24.56%。急性肾损伤组肾长径短于非急性肾损伤组（P <0.05）。急性肾损伤组肾椎体叶间动脉的搏动指数、阻力指数、肾皮质弹性模量均高于非急性肾损伤组（P <0.05）。多因素Logistic逐步回归分析结果显示,肾椎体叶间动脉搏动指数增加［O^R =3.522（95% CI：1.203,10.304）］、阻力指数增加［O^R =3.294（95% CI：1.125,9.637）］、肾皮质弹性模量增加［O^R =3.016（95% CI：1.031,8.825）］均是肾移植后急性肾损伤的危险因素（P <0.05）,肾长径增加［O^R =3.418（95% CI：1.168,9.998）］是肾移植后急性肾损伤的保护因素（P <0.05）。ROC曲线分析结果显示,肾椎体叶间动脉搏动指数、阻力指数及肾皮质弹性模量单一及联合预测肾移植后急性肾损伤的敏感性分别为71.4%（95% CI：0.420,0.904）、60.7%（95% CI：0.326,0.836）、71.4%（95% CI：0.420,0.904）、85.7%（95% CI：0.562,0.975）;特异性分别为74.4%（95% CI：0.585,0.859）、60.5%（95% CI：0.445,0.746）、60.5%（95% CI：0.446,0.746）、72.1%（95% CI：0.561,0.842）;AUC分别为0.740（95% CI：0.575,0.905）、0.648（95% CI：0.477,0.818）、0.718（95% CI：0.573,0.862）、0.803（95% CI：0.642,0.964）。结论 超声血流动力学参数与实时剪切波弹性成像定量参数可用于预测肾移植后急性肾损伤,尤以肾椎体叶间动脉搏动指数、阻力指数及肾皮质弹性模量对肾移植后急性肾损伤的预测效能较高。