充分认识和重视动脉粥样硬化性肾动脉狭窄

近年来。随着社会生活水平不断提高和全球人口的不断老龄化。慢性肾脏病（CKD）的发病率呈明显上升的趋势。美国肾脏病登记资料表明，在导致终末期肾脏病（ESRD）的病因中，肾血管病变占29％。仅次于糖尿病。动脉粥样硬化是引起肾血管性疾病的主要原因之一，常常伴随冠心病的发生。由于动脉粥样硬化性肾血管病变早期临床症状隐匿，常被漏诊或误诊。Harding等对1035例临床疑诊为冠心病患者同时进行冠状动脉和肾动脉造影，结果提示，在确诊的冠心病患者中有30％合并肾血管病交。其中肾动脉狭窄程度≥50％的为15％。在大于65岁的普通人群中，动脉粥样硬化性肾功能狭窄（ARAS）发生率达7％，而大于50岁的冠心病人群中ARAS可高达20％～45％。     

老年缺血性肾病的诊断与治疗新进展

<正>缺血性肾病(ischemic nephropathy)是特指肾动脉狭窄(renal artery stenosis,RAS)引起的血流动力学改变,并造成肾小球滤过率下降。RAS病因包括纤维肌性发育不良、大动脉炎、动脉粥样硬化性肾动脉狭窄(atherosclerotic renal artery stenosis,ARAS)等。其中ARAS是RAS最常见的原因。ARAS患病率随着年龄的增长而增加,6.8%的65岁以上老年人患有ARAS,50%的全身动脉病变患者有ARAS。因此,老年人是缺血性肾病的主要人群。ARAS是一种进展性疾病,     

国内冠心病患者中动脉粥样硬化性肾动脉狭窄发生危险性的Meta分析

冠心病患者中动脉粥样硬化性肾动脉狭窄 (ARAS)的发生率日益引起临床的重视。近年来国内学者作了一些冠心病患者中ARAS发病率的相关研究。我们采用Meta分析法对这些研究综合评价如下。     

国内冠心病患者中动脉粥狭窄发生危险性的Meta分析

冠心病患者中动脉粥样硬化性肾动脉狭窄(ARAS)的发生率日益引起临床的重视.近年来国内学者作了一些冠心病患者中ARAS发病率的相关研究.我们采用Meta分析法对这些研究综合评价如下.     

126例血管造影患者动脉粥样硬化性肾动脉狭窄的临床分析

目的了解中老年冠心病患者动脉粥样硬化性肾动脉狭窄（ARAS）的发生率及探讨患者ARAS的相关因素。方法对126例确诊或疑诊冠心病的中老年患者行冠状动脉、肾动脉造影。以肾动脉狭窄（RAS）为因变量，临床因素为自变量，进行单变量Logistic回归分析。结果126例中24例有RAS,占19．04％；13例有明显RAS，占10．32％。24例RAS患者有28支狭窄肾动脉，狭窄位于肾动脉开El处为60．7％（17／28），肾动脉主干处为35．7％（10／28），分支处狭窄为3．57％（1／28）。64例确诊为冠状动脉粥样硬化患者中18例有肾动脉狭窄，ARAS的发生率为28．13％（18／64）；62例冠脉造影阴性患者有6例存在肾动脉狭窄，ARAS发生率为9．68％（6／62）。Logistic回归分析显示，冠脉病变、高脂血症、吸烟、肾功能不全与ARAS病变密切相关。结论在确诊或疑诊冠心病的中老年患者中，ARAS的发生率为19．04％；在确诊冠脉粥样硬化的患者中．ARAS的发生率明显高于冠脉造影阴性者。冠脉病变、高脂血症、吸烟、肾功能不全是ARAS的相关因素。     

肾动脉狭窄的腔内治疗现状及进展

随着社会发展及人们生活方式的改变,动脉粥样硬化相关性疾病成为危害国人健康的主要问题之一,而其中动脉粥样硬化性肾动脉狭窄(atherosclerotic renal artery stenosis,ARAS)的发病率也在逐年增高.Holley等[1]在尸检中发现在非高血压人群中的肾动脉狭窄(renal artery stenosis,RAS)的比例为10%,而在高血压患者人群中,RAS(＞50%)的比例可高达56.4%.在接受冠状动脉治疗的患者中,RAS的比例在11%～28%[2],而在外周血管疾病的患者中比例可高达40%.同时,由RAS引起的缺血性肾病在透析患者中的比例也由20世纪80年代的8%升至16.5%[3].     

动脉粥样硬化性肾动脉狭窄的发病情况及临床特点

近年来，随着人口的老龄化和高血压、血脂紊乱患病率的增加，动脉粥样硬化性肾动脉狭窄（atherosclerotic renal arterial stenosis，ARAS）的患病率也随之升高。ARAS为进展性疾病，如不及早诊断、早期干预，肾功能可迅速恶化，发展为慢性肾衰竭（Chronic Renal Failure，CRF）。目前ARAS已成为老年CRF患者肾脏替代治疗的主要病因之一。     

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。     

冠心病患者动脉粥样硬化性肾动脉狭窄的临床筛选方法研究

目的建立从临床上筛选出动脉粥样硬化性肾动脉狭窄（ARAS）的简单易行的预测公式。方法分析892例冠状动脉造影并行非选择性肾动脉造影患者的临床资料，采用单因素相关分析得出与ARAS相关的风险因素，再通过多因素Logisitc回归分析得出各风险因素之间的比例关系，根据这种比例关系建立简单的评分系统，再将评分代人患者中，分析其敏感性及特异性。结果在冠状动脉粥样硬化人群中ARAS的患病率为12．7％，风险因素为年龄、体质量指数、血肌酐、高血压病史、糖尿病病史、缺血性脑血管病病史与顽固性高血压。根据以上风险因素建立相应的评分系统，患者的评分分值由5．5分至20．5分不等。随着分值的增加，ARAS的发病率明显升高。结论本研究所建立的简单临床预测公式可以有效的对冠状动脉粥样硬化患者进行初步的筛选，为是否采取敏感度高但较为昂贵的检查进行确诊提供参考。     

尿酸联合脂蛋白a预测动脉粥样硬化高危人群肾动脉狭窄

目的 研究动脉粥样硬化高危人群中尿酸和脂蛋白a[Lp(a)]预测动脉粥样硬化性肾动脉狭窄( ARAS)的价值.方法 回顾性分析2008年10月至2011年4月在北京协和医院怀疑为ARAS,并接受肾动脉造影的190例患者的临床资料,其中89例诊为ARAS;部分患者同时接受了冠脉造影.对照组为年龄、性别匹配的180例同期本院常规体检人群.收集一般临床资料、血尿酸(UA)、Lp(a)、胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白(HDL)、低密度脂蛋白( LDL)、Scr和C反应蛋白(CRP)等.分析ARAS患者的临床特点和相关危险因素,并利用二元Logistic回归分析尝试建立在高危人群中预测ARAS的临床决策工具.结果 ARAS患者的Scr、UA、Lp(a)和CRP水平显著地高于健康体检人群.高度怀疑ARAS或同时伴有冠状动脉病变而行肾动脉造影患者中,确诊ARAS组与非ARAS组生化指标、血脂、UA和肾功能差异均无统计学意义.二元Logistic回归分析显示,UA＞344μmol/L是ARAS发病的独立相关因素;且当UA＞344 μmol/L和Lp(a )＞242 mg/L时,预测ARAS的特异性达96％,阳性似然比为5.45,P=0.001,OR值为6.78,95％CI( 1.90～24.2),P=0.001.结论 ARAS的高危人群中,UA升高是ARAS的独立危险因素;UA联合Lp(a)对于预测ARAS有一定的临床意义.     

291例腰椎管狭窄症患者的临床特点分析

目的：总结腰椎管狭窄症的临床特点，探讨狭窄节段范围与临床表现的关系。方法：回顾性分析291例经手术证实的腰椎管狭窄症患者的临床资料，其中男125例，女166例，年龄28-89岁，平均60．2岁。对其发病规律，临床表现特点进行归纳分析。根据狭窄范围，分为2组，单节段狭窄组149例；多节段狭窄组142例。对两组患者的主要症状体征进行对比分析。结果：腰椎管狭窄症好发于中老年，慢性起病：首发症状以腰痛最常见，间歇性跛行（86．6％）、腰痛（82．8％）、下肢麻木（60．1％）为常见症状；临床体征以腰背部压痛（58．8％）、下肢皮肤针刺觉异常（58．0％）、腰椎活动受限（43.3％）和下肢肌力减弱（42.3％）多见。大小便功能异常发生率单节段狭窄组为0．67％，多节段狭窄组为5．63％，两组之间差异有显著性（P〈0．05）；下肢肌力减弱发生率前者为32．9％．后者为52．1％，两组之间有显著性差异（P〈0．05）；而两组患者的间歇性跛行、下肢放射痛、下肢麻木、下肢皮肤针刺觉异常等发生率无明显差异。结论：腰椎管狭窄症患者好发于中老年人，以慢性起病为主，临床主要表现为累及下肢的变化多样的神经症状和体征，多节段狭窄患者更容易引起下肢肌力减弱和马尾神经损害。     

Prevention and management of laryngeal stenosis in infants and children

Acquired laryngeal stenosis is a well-documented complication of endotracheal intubation. Premature infants requiring ventilatory support for respiratory distress syndrome are at increased risk for developing laryngeal stenosis. Until recently, the techniques for repair of laryngeal stenosis have required a temporary tracheotomy which complicates the management and has an associated mortality. In 1980 the use of an anterior cricoid split was described to treat laryngeal stenosis in infants. The technique has been modified: the anterior cricoid split procedure as originally described required a single midline vertical incision through the anterior cartilaginous ring of the cricoid cartilage and the upper 2 tracheal rings; the modification is an extension of the superior limit of the incision in the thyroid cartilage to within 2 mm of the thyroid notch. The technique has been used in 45 children whose ages range from 4 days to 28 months. In addition to being of value for the treatment of laryngeal stenosis in premature infants (29 patients), 2 other clinical groups of children who benefit from the produce have been identified; 11 infants who developed laryngeal stenosis in the first 2 years of life secondary to intubation and in whom the anterior cricoid split was used as an alternative to tracheotomy; 5 infants under 2 years of age, each with a tracheotomy for laryngeal stenosis in whom the anterior cricoid split was used as an alternative to more extensive methods of laryngotracheal reconstruction. Of the premature infants (29), 18 were successfully extubated, 5 still required a tracheotomy, and 6 died before extubation was accomplished; the predominant cause of death was respiratory failure secondary to the underlying bronchopulmonary dysplasia.(ABSTRACT TRUNCATED AT 250 WORDS)     

退行性腰椎管狭窄症的再认识（附50例分析报告）

目的 :通过 5 0例的分析 ,明确腰椎管狭窄的症状是由中央椎管狭窄还是由侧隐窝狭窄引起的 ,为临床有限手术提供依据。方法 :对 5 0例腰椎管狭窄症患者的临床症状、影像学检查及手术结果进行分析。结果 :针对引起症状的狭窄部位进行有限手术 ,5 0例患者中手术治疗的优良率为 90 %。结论 :诊断腰椎管狭窄症 ,应该明确症状是由中央椎管狭窄引起的还是由侧隐窝狭窄引起的。退行性腰椎管狭窄症 ,绝大多数是侧隐窝狭窄 ,以双侧椎板开窗入路最为适宜。     

PAEDIATRIC LARYNGOTRACHEAL RECONSTRUCTION: MELBOURNE EXPERIENCE AT THE ROYAL CHILDREN'S HOSPITAL

A retrospective study was carried out to evaluate the outcome following laryngotracheal reconstruction (LTR) performed in 15 children for the treatment of severe laryngotracheal stenosis between 1989 and 1993. The age ranged from 18 months to 19 years with all but one patient being tracheostomy-dependent. The trdcheostomy tube was successfully removed in 12 children who remain free of obstructive symptoms at follow up. One patient was successfully decannulated but required repeat tracheostomy 8 months later for intermittent severe supraglotticlpharyngeal obstruction. There were two failures, with one of these undergoing repeat LTR with successful decannulation. Surgery was complicated in one child by aspiration which improved spontaneously. These findings suggest that LTR is a safe and effective procedure for the management of severe paediatric laryngotracheal stenosis.     

THE MANAGEMENT OF POSTERIOR GLOTTIC STENOSIS FOLLOWING ENDOTRACHEAL INTUBATION

Four patients with bilateral vocal cord fixation due to isolated posterior glottic stenosis that developed following endotracheal intubation are presented. Two patients had previously undergone multiple endoscopic surgical procedures without obtaining a satisfactory airway. All four were treated by posterior cricoid split and costal cartilage interposition and were successfully decannulated. The assessment of vocal cord immobility following endotracheal intubation is presented and the surgical management of posterior glottic stenosis discussed.     

Treatment of transplant ureteral stenosis with Acucise endoureterotomy

Treatment of ureteral stenosis has been attempted in many patients with transplanted kidneys. Treatment with the Acucise catheter system is a new approach for such patients. Published results of the approach in eight patients promise safety, effectiveness, and low perioperative morbidity. We report two cases of transplant ureteral stenosis treated with Acucise. One patient with stenosis of the pyeloureteral junction was treated successfully and has been free of recurrence for 9 months. The other patient had long-distance stenosis of the lower portion of the transplant ureter. Acucise incision was successful, but the patient had to undergo ureteroneocystostomy because of a ureteroperitoneal fistula. We use these cases to illustrate the disadvantages of endourological ureteral surgery as a standard therapeutic approach after renal transplantation. We suggest that Acucise is reliable when used in patients with uncomplicated short-distance ureteral stenosis; however, patients with long-distance stenosis or stenosis caused by heavily scarred periureteral tissue will not profit from it because of a higher complication rate. Received: 14 January 1998 Received after revision: 9 March 1998 Accepted: 16 March 1998