索拉非尼治疗伴有终末期肾病的转移性肾癌一例报告并文献复习

目的 探讨索拉非尼治疗伴有终末期肾病的转移性肾癌的可行性. 方法 应用索拉非尼治疗伴有终末期肾病的转移性肾癌患者1例.患者,女,65岁.左肾透明细胞癌接受根治性肾切除术后4个月,因终末期肾病开始血液透析.术后12个月,发现双肺转移.应用干扰素或IL-2治疗无效.二线应用索拉非尼400 mg,2次/d口服.维持血液透析每周3次.通过PubMed检索相关文献报道结果,总结其可行性. 结果 索拉非尼治疗前右肺病灶大小2.7 cm ×2.4 cm,左肺病灶2.6 cm×2.0 cm.服药2个月时因手足皮肤反应停药2周,恢复治疗后持续用药至2011年12月共52个月.用药6个月时,双肺转移病灶均有缩小,疗效评价为稳定(SD,REGIST标准).服药12个月时,双肺病灶继续缩小,右肺病灶1.8cm×1.0,cm;左肺病灶呈条索样,疗效评价为部分缓解(PR).至随访截止,双肺病灶均已呈条索样改变.检索PubMed共有6篇类似报道,患者9例,其中疗效评价7例,PR 3例,SD 4例.药物不良反应无明显加重. 结论 索拉非尼治疗伴有终末期肾病的转移性肾癌疗效确实,不良反应与肾功能正常患者相似.     

单核细胞趋化蛋白-1在终末期肾病血液透析患者中的检测及意义

目的 探讨终末期肾病血液透析患者血浆单核细胞趋化蛋白-1(MCP-1)的水平及其意义.方法 对本院维持性血液透析患者66例及健康志愿者22例,用ELISA法测定血浆MCP-1水平,用全自动生化仪测定血清总胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白-胆固醇(HDL-C)、低密度脂蛋白-胆固醇(LDL-C)、血肌酐(Scr)与血白蛋白(ALB)值.比较其结果并分析其意义.结果 血液透析组血浆MCP-1水平(115.9pg/ml±10.3pg/ml)明显高于对照组(60.3pg/ml±8.4pg/ml),其差异有统计学意义(P＜0.05).血液透析合并冠心病组血浆MCP-1水平明显高于非合并冠心病组[(136.2±11.7)pg/ml vs(91.6±9.4)pg/ml,P＜0.05].结论 终末期肾病血液透析患者血浆MCP-1水平显著高于正常人,合并冠心病患者血浆MCP-1水平更高,提示MCP-1水平升高与肾功能衰竭有一定关系,且是合并冠心病的重要危险因素.     

The diabetic foot in end stage renal disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5-10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies--neuropathy, ischemia, and infection--are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.     

Frequent vascular access thrombosis in a patient with end stage kidney disease on hemodialysis

Vascular access thrombosis (VAT) is common among patients receiving hemodialysis and leads to missed dialysis treatments, hospitalizations, catheter placement, and graft/fistula abandonment. This article reviews the association between hypercoagulability and VAT and the high prevalence of hypercoagulable states in end-stage kidney disease (ESKD). This article reviews the role of antithrombotic and anticoagulant medications in preventing VAT. The article concludes by reviewing the unique challenges of using vitamin K antagonists in patients with ESKD.     

Psoas abscess with osteomyelitis in a patient undergoing long-term hemodialysis.

We describe a 69-year-old male patient on maintenance hemodialysis for 24 years who developed a fatal left psoas abscess with osteomyelitis at the hip joint following acute enterocolitis. He had systemic beta(2)-microglobulin amyloid deposition in colon epithelium and psoas muscle. Cultures from abscess fluid and femoral bone marrow yielded Bacteroides fragilis. To our knowledge, this is the first case on hemodialysis having a psoas abscess following acute gastrointestinal infection. This rare case suggested that a secondary psoas abscess could be one of the occult infections in patients undergoing long-term maintenance hemodialysis.     

Successful treatment of brainstem abscess with stereotactic aspiration

BACKGROUND: Brainstem abscess is an uncommon condition associated with a high mortality. We report a case of brainstem abscess in a 51-year-old female with a pulmonary arteriovenous fistula that was cured after appropriate antibiotic therapy following stereotactic aspiration. The value of stereotactic aspiration in the management of brainstem abscess is documented with a review of the relevant literature. CASE REPORT: A 51-year-old female with a pulmonary arteriovenous fistula suffered fever, diplopia and weakness on the right side. Magnetic resonance (MR) imaging of the brain showed a large cystic mass with ring-like enhancement in the brainstem. A diagnosis of brainstem abscess as a complication of pulmonary arteriovenous fistula was made. MR imaging-guided stereotactic exploration was carried out via the suboccipital transcerebellar approach and the pathogen of the brainstem abscess was identified. The brainstem abscess was cured after treatment employing antibiotics to which the pathogen was sensitive. CONCLUSIONS: Stereotactic aspiration is an effective procedure for brainstem abscesses. This procedure is less invasive than open surgery and can be performed even in patients in poor general condition.     

Pyocystis, pyonephrosis and perinephric abscess in end stage renal disease

We report 8 patients with end stage renal disease on maintenance hemodialysis who had pyocystis, pyonephrosis or a perinephric abscess. Delay in diagnosis was frequent because the urine-deprived bladder and kidneys were dismissed as potential sites of infection. Treatment of pyocystis with bladder irrigations often was successful and obviated cystectomy. Pyonephrosis or perinephric abscess was a more serious problem and required unilateral nephrectomy.     

Renal transplantation in a patient with end stage renal disease due to cholesterol embolism

BACKGROUND: Renal failure due to cholesterol emboli is mostly irreversible. Therefore chronic renal replacement therapy is necessary. However, to the best of our knowledge no published experience exists with renal transplantation in patients with end-stage renal disease (ESRD) due to cholesterol embolization (CE). METHODS: Renal transplantation was performed in a 64-year-old man who suffered from ESRD due to CE after coronary angiography. Because our patient presented with a typical profile of cardiovascular risk factors effective long-term control of these risk factors before and after transplantation was a mandatory prerequisite before considering transplantation. RESULTS: After one rejection episode serum creatinine values have been stable and no major complications have occurred during a follow-up of 18 months. No signs of recurrent cholesterol emboli into the donated kidney were seen in renal biopsies performed due to graft rejection. CONCLUSION: Cholesterol embolization is an uncommon reason for ESRD and mainly occurs after invasive vascular procedures in patients with hyperlipidemia, arterial hypertension, and smoking. Because ESRD due to CE often is irreversible, chronic renal replacement therapy may be necessary. As demonstrated in our report, renal transplantation should be considered. However, in this setting effective long-term control of the underlying risk factors before and after renal transplantation has to be ensured.     

Encephalopathy caused by isoniazid in a patient with end stage renal disease with extrapulmonary tuberculosis

Tuberculosis infection is common in patients on maintenance hemodialysis, and the extrapulmonary presentations, which is usually asymptomatic, and only mild clinical presentation, are not uncommon. These hemodialysis patients were always prescribed multiple antituberculosis agents, including isoniazid, rifampin, ethambutol, and pyrazinamide, alongside their usual medication. Conscious disturbance was also frequently observed in these patients, with different paramount etiologies in the pre- and post-hemodialysis phases. We report a case undergoing maintenance hemodialysis, showing disturbed consciousness ten days following antituberculosis treatment for his established extrapulmonary tuberculosis infection. Consciousness was regained seven days later, after discontinuation of isoniazid.     

腹膜透析联合血液透析对终末期肾脏疾病患者心血管病变的改善作用

目的通过对腹膜透析联合血液透析(peritoneal dialysis combined with hemodialysis,PHD)后与联合治疗前相关指标进行比较,探讨联合治疗对终末期肾脏疾病(end stage renal disease,ESRD)患者心血管病变的改善作用。方法回顾性分析济宁医学院附属医院肾内科14例腹膜透析(peritoneal dialysis,PD)治疗不充分的ESRD患者,改用PHD治疗后的临床疗效。随访观察患者的一般状况、临床表现、营养状态,收集其治疗前后生化指标、甲状旁腺素、β_2微球蛋白(β_2-microglobulin,β_2-MG)、颈动脉内中膜厚度(carotid intima media thickness,CIMT)、收缩压、舒张压、左室射血分数、B型钠尿肽(B type natriuretic peptide,BNP)进行分析。结果经过PHD治疗后患者饮食好转,恶心、呕吐等消化道症状消失,曾反复心力衰竭的3例患者行PHD治疗后未再出现,皮肤瘙痒及不宁腿症状明显减轻。PHD前与PHD治疗后比较,血磷:(1.76±0.41)mmol/L与(1.48±0.28)mmol/L,P0.05;甲状旁腺素:(367.93±166.66)ng/L与(237.07±76.21)ng/L,P0.05;BNP:(1 521.7±701.0)μg/L与(712.1±535.0)μg/L,P0.01;左室射血分数:(49.7±3.1)%与(52.2±1.8)%,P0.05;颈动脉内中膜厚度:(1.65±0.36)mm与(1.72±0.33)mm,P0.05,PHD治疗后较PHD前无明显改变。结论 PHD能减轻患者的临床症状,改善患者的营养状态,降低血磷,减轻继发性甲状旁腺功能亢进,延缓动脉硬化进展,可作为一种新的肾脏替代治疗模式在临床推广。     

Coronary artery disease among diabetic and non-diabetic patients with end stage renal disease.

Cardiovascular disease is the major cause of death among patients with end stage renal disease and accounts for about half the deaths among the dialysis population. Several researchers have reported a high prevalence of coronary artery disease among diabetic patients with renal failure and coronary arteriography is often considered an integral part of the pre-transplant evaluation of diabetic patients with end stage renal disease. However, very few reports have addressed the question of coronary disease in non-diabetic patients, and the pattern and prevalence of coronary artery disease in non-diabetic patients with end stage renal disease are not well defined. We evaluated the clinical and coronary angiographic findings in 158 consecutive patients (84 diabetic and 74 non-diabetic) with end stage renal disease. The coronary arteries were divided into 16 segments and each segment was analyzed for the presence of coronary disease, which was defined as the presence of > or = 50% luminal diameter stenosis. Diabetic patients had more adverse risk factors for coronary artery disease, yet there was no significant difference in the prevalence of coronary artery disease between the diabetic and non-diabetic patients (67% vs. 55%, p = 0.15), or in the number of affected coronary artery segments (2.0 vs. 1.4, p = 0.05). Triple vessel coronary artery disease was however, significantly more common among the diabetic subjects (27% vs. 12%, p = 0.005). Non-diabetic patients with end stage renal disease also have a high prevalence of coronary artery disease and may merit as careful investigation of their coronary status as their diabetic counterparts.     

Spontaneous renal subcapsular hematoma in a patient undergoing hemodialysis

We describe a patient on hemodialysis in whom a spontaneous renal subcapsular hematoma developed. The diagnosis was confirmed by computerized tomography and angiography, and the patient was treated conservatively. We recommend conservative management in such cases based on radiological findings that rule out underlying pathological changes.     

Prevalence and predictors of arrhythmia in end stage renal disease patients on hemodialysis

BACKGROUND: Sudden death is common in end-stage renal disease (ESRD). Cardiac arrhythmia is observed frequently in patients with ESRD and is thought to be responsible for this high rate of sudden death. This study investigated the prevalence and the predictors of arrhythmia in patients on maintenance dialysis. METHODS: Ninety-four patients on hemodialysis program were enrolled in the study. Routine laboratory results were noted. Arrhythmia, periods of silent ischemia, and heart-rate variability analyses were obtained from 24-hour Holter monitor recordings. Corrected QT (QTc) dispersion was calculated from 12-lead surface EKG. Echocardiographic and tissue Doppler examinations were performed on interdialytic days as well. Ventricular arrhythmia was classified according to Lown classification; classes 3 and above were accepted as complex ventricular arrhythmia (CVA). RESULTS: The mean age was 52.5+/-13.2 years; 44 (46.8%) were women. Ventricular premature contractions were detected in 80 (85.1%) patients, of whom 35 (37.2%) were classified as complex ventricular arrhythmia (CVA). Coronary artery disease, hypertension, and QTc dispersion appeared as independent factors predictive of CVA development. Atrial premature contractions (APC) were detected in 53 patients (56.4%) and supraventricular arrhythmia in 15 (16%) patients; all were identified as atrial fibrillation. Duration of dialysis therapy was found as an independent predictor of APC. CONCLUSION: Arrhythmia is frequently observed in ESRD patients receiving hemodialysis and may be responsible for the high rate of sudden mortality. Hypertension, CAD, and QTc dispersion are independent predictors of CVA, and duration of dialysis therapy is an independent factor affecting APC development in these patients.     

Malignant hypertension in a patient with end of stage renal disease (ESRD) treated by renal transplant

Control of hypertension is often a problem in the management of end stage renal disease (ESRD). Multiple modalities of treatment are required to prevent cardiovascular and cerebrovascular mortality and morbidity. These include fluid and salt restriction, multidrug regimes and dialysis. We report a case of young 25 years old patient, admitted with chronic renal failure, complicated by malignant and refractory hypertension, not responding to hemodialysis and antihypertensive agent. During stay in hospital, patient also had intracerebral hemorrhage, fits due to uncontrolled hypertension requiring ventilatory support followed. Renal transplant was considered to be the final therapeutic modality. After gradual recovery, a successful live-related renal transplant was performed. As soon as good graft was established, the blood pressure settled and 4 of the 5 antihypertensives were withdrawn. After 2 weeks, patient was discharged in a stable condition with a total stay of about 2 months.     

Infection-associated hemophagocytic syndrome in a diabetic patient undergoing chronic hemodialysis

Hemophagocytic syndrome (HPS) is an uncommon but severe illness associated with a variety of infections, malignant tumors, and autoimmune diseases. We report a case of infection-associated HPS in a patient receiving chronic hemodialysis. Peptostreptococcus-induced sepsis and abscess formation in the left iliopsoas muscle led to the onset of infection-associated HPS in this patient. The patient had diabetes mellitus and end-stage renal disease, and it is likely that immunological dysfunctions from these disorders played a part in the onset of both severe bacterial infections and HPS.     

Pregnancy in end stage renal disease

The ovulatory menstrual cycle is known to be affected on multiple levels in women with advanced renal disease. Menstrual irregularities, sexual dysfunction, and infertility worsen in parallel with the renal disease. Pregnancy in women with ESRD on dialysis is therefore uncommon. Furthermore, when pregnancy does occur, it can prove hazardous to both mother and baby owing to a multitude of potential complications including accelerated hypertension and preeclampsia, poor fetal growth, anemia, and polyhydramnios. Data are emerging, however, to suggest that pregnancy while on intensified renal replacement regimens may result in better pregnancy outcomes, and emerging trends include the decreased rate of therapeutic abortions probably reflecting a change in counseling practices over time. Nevertheless, a pregnant woman on intensive dialysis requires meticulous follow-up by a dedicated team including nephrology, obstetrics, and a full multidisciplinary staff. In this article, we will address fertility issues in young women with ESRD, review pregnancy outcomes in women on both hemodialysis and peritoneal dialysis, and provide suggestions for the management of the pregnant women on intensive hemodialysis.     

贵阳市维持性血液透析患者生活质量调查

目的了解贵阳市终末期。肾脏疾病（end stage renal disease,ESIm）接受维持性血液透析患者的一般状况、病因构成和生活质量现状。方法收集贵阳市12个血液透析中心ESRD血液透析患者756例患者的一般资料、透析方法、肾脏病和生活质量问卷（KDQOL-SF36量表）等信息并进行分布特征描述。结果756例患者中,男女之比为1．45：1．00;平均年龄（49．1±14．7）岁,原发病前三位分别为慢性肾小球肾炎407例（占53．84％）、糖尿病肾脏病132例（占17．46％）、高血压。肾损害124例（占16．40％）;患者月均总医疗费用为（6072．55±3381．01）元;不同透析时间的血液透析患者’肾脏病和透析相关生活质量各维度得分具有显著差异（P〈0．05）。结论贵阳市维持血液透析患者中,其原发病以慢性肾小球肾炎为主;透析时间〉60个月的血液透析患者生活质量、一般健康相关生活质量各维度得分较低。     

Acquired renal cystic disease mimicking adult polycystic kidney disease in a patient undergoing long-term hemodialysis.

Acquired renal cystic disease (ARCD) is defined as the development of multiple cysts in the renal cortex and medulla in patients with chronic renal failure who are free from congenital polycystic kidney disease. ARCD develops generally in contracted kidneys. We report a case of grotesque enlargement of a single kidney in a patient who had been receiving hemodialysis for 18 years. Although the exact causes of ARCD are not known, 3 factors may contribute to the development of nephromegaly; the sex, the duration of hemodialysis and previous unilateral nephrectomy. As in polycystic disease, when the involved kidney reaches considerable size, ARCD may have a favorable effect on anemia caused by chronic renal failure.