血管活性药物在肝肾综合征治疗中的应用

肝肾综合征(HRS)是发生在肝硬化腹水患者中的一种并发症,临床上分为Ⅰ型和Ⅱ型HRS两型.Ⅰ型为快速进行性肾功能下降,定义为2周内最初的血肌酐增至226 mmol/L以上或最初24 h肌酐清除率下降50％至＜20 ml/min,平均生存期仅14天;Ⅱ型进展相对缓和,未达到Ⅰ型HRS的诊断标准,平均生存期6个月,病死率较Ⅰ型低,多发生在肝硬化难治性腹水患者中[1].近年来,随着对肝肾综合征发病机制的深入研究,血管活性药物在肝肾综合征治疗方面取得了一定进展.     

血管活性药在肝肾综合征中的作用

肝肾综合征(HRS)是晚期肝硬化患者(少数为急性肝功能衰竭)的肾动脉强烈收缩引起的进行性、功能性肾衰竭，在肝硬化患者中发生率为40％～80％。根据其临床过程分为两型：Ⅰ型肾功能衰竭进展迅速，2周内血肌酐(Scr)水平倍增，高于221μmol／L或24h肌酐清除率下降到原来的50％，并低于20ml／min，病死率高，平均生存期仅15d；Ⅱ型病情进展较慢，Scr低于176.8μmol／L，病死率比Ⅰ型低。     

肝硬化中的急性肾损伤：一个正在改变的疾病谱

肝硬化患者发生急性肾损伤（acute kidney injury,AKI）或肝肾综合征（hepatorenal syndrome,HRS）的治疗仍然是目前临床医师面临的一项巨大的挑战。很长时间以来,HRS被认为是一组具有相似病理和病理生理改变的临床综合征,采用的标准是1996年国际腹水俱乐部（International Ascites Club,IAC）定义的,分为1型和2型。1型HRS是快速发生的急性肾功能衰竭,常发生在急性失代偿性肝硬化患者,如酒精性肝硬化、慢性肝功能衰竭急性变、急性肝功能衰竭等。     

肝衰竭合并肝肾综合征的研究进展

肝肾综合征（hepatorenal syndrome,HRS）是发生于肝硬化腹水患者的一种有潜在可逆性的并发症,同时也可发生在急性肝衰竭或酒精性肝炎患者中。理解肝衰竭合并HRS的发病机制对于HRS的诊断、治疗非常重要。本文主要就肝衰竭合并HRS的诊断、发病机制、治疗和预防方面的进展进行综述。     

肝肾综合征的发病机制

肝肾综合征(HRS)是指严重肝病时,出现以肾功能损害、动脉循环和内源性血管活性系统显著异常为特征的综合征.临床以少尿或无尿、肌酐清除率降低及稀释性低血钠等为主要表现.因肾脏无器质性病变,又称为功能性肾衰竭.根据临床特征不同,HRS可分为2型.HRS Ⅰ型为HRS的急性型,常有诱因,如上消化道大出血、大量放腹水、过度利尿、外科手术后或感染等,后者最主要的是自发性细菌性腹膜炎.Ⅰ型HRS的主要表现为肾功能急剧恶化,2周内血肌酐超过原有水平的2倍至＞ 226 mmol/L.该型预后凶险,2周内死亡率可高达80％.Ⅱ型HRS通常发生于利尿抵抗型腹水患者,常表现为轻微的肾功能异常,即血肌酐133～226 mmol/L.该型患者肾衰竭多进展缓慢,部分患者病程可超数月.尽管Ⅱ型HRS患者平均存活时间长于Ⅰ型,但预后仍十分凶险[1].     

血管活性药物治疗肝肾综合征

肝肾综合征(hepatorenal syndrome)是肝硬化后期的常见并发症,也可见于其他严重的肝脏疾病,如急性肝功能衰竭、酒精性肝炎等.肾功能减退为肝肾综合征的主要临床表现之一.临床上将肝肾综合征分为Ⅰ型肝肾综合征和Ⅱ型肝肾综合征两种类型.Ⅰ型肝肾综合征系指患者的血清肌酐水平在2周内升高至221μmol/L(2.5 mg/dL)以上,肾小球滤过率通常低于20 ml/min,进行性少尿,临床表现为严重的肾功能衰竭;而Ⅱ型肝肾综合征主要表现为顽固性腹水,经一段时期后病情可突然恶化,达到Ⅰ型标准.     

肝肾综合征研究进展

肝肾综合征(hepatorenal syndrome,HRS)是发生在肝硬化腹水、急性肝衰竭或酒精性肝炎患者的一种严重并发症。主要发病机制为外周和内脏动脉舒张、心排量下降以及肾脏动脉收缩。国际腹水俱乐部(International Club of Ascites,ICA)在2015年制定了肝肾综合征-急性肾功能损伤诊断标准,为肝肾综合征的早期诊断和早期干预提供了新的临床路径。目前研究表明,特利加压素和白蛋白为标准治疗方案,去甲肾上腺素联合白蛋白为次选方案。预防感染及避免使用肾毒性药物等可以预防HRS的发生。     

肝肾综合征83例临床特征分析

目的探讨在肝硬化腹水基础上发生肝肾综合征(HRS)患者的临床特点,指导临床对HRS进行有效的预防和治疗。方法回顾性分析2005年1月至2009年1月温州医学院附属第一医院消化内科收治的83例HRS患者及92例肝硬化腹水而未发生HRS患者(non-HRS)的临床资料,对两组患者的常见诱因、肝功能分级、交感神经张力、一般情况、病死率及预后等进行比较分析。结果(1)大量腹水及继发感染多见于HRS患者,而消化道出血则多见于non-HRS患者,在HRS患者中大量腹水多见于Ⅱ型HRS,而诱因不明者多见于Ⅰ型HRS。(2)Ⅰ型HRS患者肝功能最差,Ⅱ型居中,non-HRS最好。(3)HRS患者交感神经张力明显高于non-HRS患者。(4)一般情况比较中HRS患者血肌酐(Scr)明显高于non-HRS患者,而血钠(Na+)、24h尿量及平均动脉压均较后者低。(5)Ⅰ型HRS的病死率最高,Ⅱ型次之,non-HRS患者最低。HRS患者的存活时间明显低于non-HRS患者。结论(1)HRS常见诱因有大量腹水、感染、消化道出血、大量放腹水、水与电解质紊乱等,应尽量避免,一旦发现,应积极采取措施,及时治疗。(2)HRS患者交感神经张力明显高于非HRS患者,此可为临床诊治提供参考依据。(3)较之non-HRS患者,HRS患者的病情非常严重,病死率极高,预后极差,尤以Ⅰ型为甚。     

肝肾综合征研究进展

肝肾综合征（HRS）是严重肝病患者发生的功能性急性肾衰竭。虽然肝硬化不是HRS的唯一原因,但HRS最常发生于肝硬化腹水患者。HRS最显著的特点是尽管肾功能严重减退,但无急性肾小管坏死或其他病理学异常,或仅具有与肾脏损害严重程度不成正比的轻微病理损害。如果将HRS患者的肾脏移植给无肝硬化者,移植肾可发挥正常功能;HRS患者在接受肝移植后,肾功能也恢复正常。     

肝肾综合征研究进展

肝肾综合征(HRS)系指严重肝病或急性重度肝损害患者在肝功能衰竭基础上所发生的特发性进行性肾前性肾功能衰竭,它是肝功能衰竭综合征的临床表现之一。其肾脏无原发疚患,肾脏的病理组织学无明显发现或仅有轻度非特异性改变。如果肝病获得改善,肾功能亦随之恢复正常。因此,HRS是严重肝病患者自发性或反应于肾血管循环改变而发生的肾功能不全,HRS的诊断需排除引起肾衰竭的其它原因。HRS常继发于各种类型的肝硬化失代偿期、暴发性肝衰竭、重型病毒性肝炎、原发或继发性肝癌及妊娠急性脂肪肝等严重肝痫。其特点为进行性少尿和氮质血症,但肾小管功能基本正常,尿钠低,尿渗透压/血浆渗透压之比〉1.1。HRS的持续和发展可转化为急性肾小管坏死(ATN),部分急性肝衰竭患者可不经HRS而直接发生ATN。临床上,无论是急性肝衰竭还是晚期肝硬化患者均常伴有HRS(发生率为42％～84％)。有报道称,死于肝昏迷的肝硬化和急性肝衰竭患者中分别有84％和73％伴有HRS。HRS患者预后不良,大多数近期内死于肝衰竭、胃肠道出血或感染,而肾功能衰竭本身并不是决定患者能存活多久的重要因素,真正死于尿毒症的HRS患者很少(低于11％)。     

Research and Evaluation of the Influence of the Construction of the Gate and the Influence of the Piston Velocity on the Distribution of Gases into the Volume of the Casting

Distribution of gasses to the cast volume and volume of pores can be maintained within the acceptable limits by means of correct setting of technological parameters of casting and by selection of suitable structure and gating system arrangement. The main idea of this paper solves the issue of suitability of die casting adjustment—i.e., change of technological parameters or change of structural solution of the gating system—with regards to inner soundness of casts produced in die casting process. Parameters which were compared included height of a gate and velocity of a piston. The melt velocity in the gate was used as a correlating factor between the gate height and piston velocity. The evaluated parameter was gas entrapment in the cast at the end of the filling phase of die casting cycle and at the same time percentage of porosity in the samples taken from the main runner. On the basis of the performed experiments it was proved that the change of technological parameters, particularly of pressing velocity of the piston, directly influences distribution of gasses to the cast volume.     

县级以下综合医疗机构医务人员对现代结控知识的认识现状调查

目的本文旨在了解医务人员现代结控知识掌握的现状及培训效果?方法于培训前后进行问卷调查,内容包括:病例发现?结核病诊断及化疗?结果培训前疫情报告和转诊,回答正确者占75.2%?71.7%;对临床表现?查痰和诊断依据,回答正确者占83.5%?42.5%?40.8%;抗痨药物?用药方法?化疗原则?短化方案?短化疗程?治愈标准六项,回答正确者占58%?14.4%?20.8%?9.2%?17%?24.3%?培训后再次调查发现,90%以上医务人员对现代结控基本知识已掌握?结论各级医务人员现代结控知识是很贫乏的,因此,对其进行系统培训是极为必要的,此项工作省时?省力?投入少,可收到事半功倍的效果。     

Preservation of the pylorus and resection of the head of the pancreas

The historical evolution of the pylorus-preservation resection of the head of the pancreas is traced from the first resections early in this century to relative standardization of the operation, to a lowering of the operative mortality, and to an interest in improving nutritional status after resection. There are many theoretical advantages for the function of the upper gastrointestinal tract after pylorus and gastric preservation, such as maintenance of gastric capacitance and equilibration of osmotic pressure in gastric digestants, foodstuff digestion and absorption, and bowel motility. After the pylorus-preserving resection, gastric emptying is normal, pyloric function to prevent duodenal reflux is often normal, and gastric acids and serum levels of duodenal hormones are at normal levels, whereas after standard pancreatoduodenectomy, all of these are often abnormal. No prospective blinded studies have been published comparing nutritional values after the two operative procedures, but evidence is presented of a satisfactory result with regard to gastric capacitance, body weight gain, and lack of postgastrectomy symptoms. An undoubted advantage of the pylorus-preserving feature is a simplification of the operation. These gains are achieved without increase in operative mortality, without increase in the incidence of jejunal ulcer, and without theoretical or actual decrease in value of the procedure as a cancer operation, except in patients with duodenal carcinoma proximal to the ampulla of Vater.     

Preservation of the pylorus in resection of the head of the pancreas

Pylorus preservation has been advocated to decrease the morbidity associated with the classical or standard pancreaticoduodenectomy. The proposed advantages are decreased incidence of peptic ulceration, dumping syndrome, and nutritional problems. However, after an initial period of enthusiasm for the procedure, it is now being found that marginal ulceration at the duodenojejunal anastomosis is encountered with increasing frequency. Delay in gastric emptying occurs frequently, with an overall incidence of 30%. With the availability of better pancreatic enzyme supplements, the current incidence of nutritional problems and weight loss after the standard Whipple procedure is unknown. Whether there is a difference in long-term survival after the two procedures performed for adenocarcinoma of the head of the pancreas is still debatable. A controlled trial is needed to answer many of these questions, and pylorus-preserving pancreaticoduodenectomy should be used cautiously until further data become available.