中华临床医师杂志（电子版）2008年第4期继续教育试题

老年人肾动脉粥样硬化导致肾动脉重度狭窄时，即可引发缺血性肾脏病。缺血性肾脏病好发于中老年人，常伴全身（心、脑、外周血管）动脉粥样硬化表现，伴或不伴肾血管性高血压。患者尿改变轻微，肾小管功能损害常在先（出现夜尿多等浓缩功能障碍表现），之后才逐渐出现肾小球功能损害，肾功能损害进展较慢。晚期肾脏体积缩小，两侧缩小常不一致。疑诊病例应先做筛选检查，包括肾动脉彩色多普勒超声、螺旋CT血管造影及磁共振血管造影检查等，     

肾动脉狭窄

1引言 肾动脉狭窄常由动脉粥样硬化、纤维肌性发育不全及大动脉炎引起.青年患者多见于后两种疾病,而老年患者以动脉粥样硬化为主;西方国家常见前两种疾病,而中国大动脉炎的发病率高.     

内蒙古呼伦贝尔地区成人慢性肾脏病流行病学调查

Objective To investigate the prevalence and risk factors of chronic kidney disease (CKD) in the general adult population in the Hulunbeir Prefecture, Inner Mongolia Autonomous Region where many minorities of north China live. Methods Sampling surveywas performed in the residents aged 20 years and older in the Hulunbeir Prefecture. All the investigated subjects were tested for urinary albumin to creatinine ratio (ACR); hematuria by microscopy of urinary sediment; and GFR estimated by modified MDRD equation for Chinese adults (eGFR). The related risk factors of CKD were also investigated. Results A total of 4522 subjects were enrolled in the study. The prevalence of albuminuria was 7.11％, hematuria was 2.64％ and reduced eGFR [60 ml-min-1·(1.73 m2)-1] was 2.75％. The prevalence of hypertension was 38.90％; hyperglycemia 6.61％; hyperlipidemia 2.72％; increased waist 24.79％ and metabolic syndrome 15.02％. After the subjects with combined microalbuminuria, hematuria and reduced eGFR were excluded, the prevalence of CKD was 12.95％. Logistic regression analysis and stratified analysis showed increased age, increased waist, elevated systolic pressure, hyperglycemia,hypertriglyceridemia and metabolic syndrome were independently associated with albuminuria;increased age, elevated systolic pressure and hyperglycemia were independently associated with reduced eGFR; increased age was independently associated with hematuria. Conclusions The prevalence of adult CKD is 12.95％ in the Hulunbeir Prefecture, Inner Mongolia Autonomous Region. Independent risk factors of CKD include increased age, increased waist, hypertension,abnormal blood glucose or lipid, and metabolic syndrome.     

国人肾小球大小正常值测定及测量方法探讨

目的 确定国人肾小球大小正常值并探讨肾小球直径测量法。 方法 选择我科1998至2008年肾穿刺病理检查病例中体质量及血糖正常、病理诊断为肾小球轻微病变或薄基底膜肾病的100例患者作为正常值检测组,在其肾小球最大剖面上用直接及间接两种方法测量毛细血管袢直径。同时随意选择体质量及血糖正常的微小病变肾病、局灶节段性肾小球硬化（FSGS）及膜性肾病患者各10例,进行上述肾小球直径测量,并与正常值检测结果比较。 结果 直接和间接测量法结果一致,性别与年龄对肾小球直径无明显影响。通过不同方法获得的肾小球毛细血管袢直径正常值范围如下：（1）含极（血管极、尿极）肾小球：直接法结果为101.3～182.9 μm;间接法为100.3～181.5 μm;（2）含极肾小球加大于它们的无极肾小球：直接法结果为108.5～182.9 μm;间接法为107.6～183.2 μm。另外,30例肾脏病患者的肾小球直径均在此正常值范围内。 结论 本研究应用的两种肾小球直径检测法均可行,获得的国人肾小球直径正常值范围可以推广。     

内蒙古呼伦贝尔地区成人慢性肾脏病流行病学调查

目的 探讨我国内蒙古自治区呼伦贝尔少数民族聚居区成年人群中慢性肾脏病（CKD）患病率及其危险因素。 方法 对该地区20岁以上常住居民进行CKD抽样调查,被调查者均检测了尿白蛋白/肌酐比率、血尿（离心后尿沉渣显微镜检查）及估计肾小球滤过率（eGFR,检验血清肌酐后用国人校正的简化MDRD公式计算）;并同时调查了CKD的相关危险因素。 结果 符合入选条件的被调查者共4522例,白蛋白尿阳性率为7.11%;血尿阳性率为2.64%;eGFR低于60 ml•min-1•(1.73 m2)-1者为2.75%;去除白蛋白尿、血尿及eGFR下降共同存在造成的重复,该地区CKD患病率为12.95%。高血压患病率38.90%,糖代谢异常6.61%,脂代谢异常34.60%,腰围增大24.79%,代谢综合征15.02%。多因素Logistic回归分析及分层分析显示,年龄增加、腰围增大、收缩压升高、空腹血糖升高、血清三酰甘油增高及患代谢综合征与白蛋白尿发生相关;年龄增加、收缩压升高及空腹血糖升高与肾功能下降相关;年龄增加与血尿发生相关。 结论 内蒙古自治区呼伦贝尔地区CKD患病率为12.95%。相关危险因素包括年龄增加、腰围增大、高血压、血糖或血脂异常、及代谢综合征。     

肾素-血管紧张素系统及其拮抗剂:回顾与现状

一、肾素-血管紧张素系统(RAS)认识史 从100多年前发现肾素开始,对RAS的认识一直在不断深化,有着如下重要里程碑:1898年Tigerstedt及Bergman发现肾素;1939-1940年Braun-Manendez等及Page等发现血管紧张素(Ang);1954-1956年Skeggs等成功地提纯了Ang Ⅱ、Ang Ⅰ及血管紧张素原,并发现了血管紧张素转换酶(ACE);1970年Yang和Erdos等报道ACE又为激肽酶Ⅱ,除能催化Ang Ⅰ生成Ang Ⅱ外,还能降解缓激肽~([1-3]).1970年Goodfriend和Lin~([4])发现Ang Ⅱ存在两个受体,即Ang Ⅱ1型和2型受体(AT1R和AT2R).     

内蒙古呼伦贝尔地区成人慢性肾脏病流行病学调查

Objective To investigate the prevalence and risk factors of chronic kidney disease (CKD) in the general adult population in the Hulunbeir Prefecture, Inner Mongolia Autonomous Region where many minorities of north China live. Methods Sampling surveywas performed in the residents aged 20 years and older in the Hulunbeir Prefecture. All the investigated subjects were tested for urinary albumin to creatinine ratio (ACR); hematuria by microscopy of urinary sediment; and GFR estimated by modified MDRD equation for Chinese adults (eGFR). The related risk factors of CKD were also investigated. Results A total of 4522 subjects were enrolled in the study. The prevalence of albuminuria was 7.11％, hematuria was 2.64％ and reduced eGFR [60 ml-min-1·(1.73 m2)-1] was 2.75％. The prevalence of hypertension was 38.90％; hyperglycemia 6.61％; hyperlipidemia 2.72％; increased waist 24.79％ and metabolic syndrome 15.02％. After the subjects with combined microalbuminuria, hematuria and reduced eGFR were excluded, the prevalence of CKD was 12.95％. Logistic regression analysis and stratified analysis showed increased age, increased waist, elevated systolic pressure, hyperglycemia,hypertriglyceridemia and metabolic syndrome were independently associated with albuminuria;increased age, elevated systolic pressure and hyperglycemia were independently associated with reduced eGFR; increased age was independently associated with hematuria. Conclusions The prevalence of adult CKD is 12.95％ in the Hulunbeir Prefecture, Inner Mongolia Autonomous Region. Independent risk factors of CKD include increased age, increased waist, hypertension,abnormal blood glucose or lipid, and metabolic syndrome.     

慢性马兜铃酸肾病大鼠贫血发生的机制

目的 探讨慢性马兜铃酸肾病（CAAN）贫血的发生机制。 方法 用62只SD大鼠筛查血红蛋白（Hb）,求正常值。随机选择24只Hb正常的大鼠,分为对照组及模型组,各12只,后者予关木通浸膏水溶液间断灌胃制作CAAN模型。在给药前及8周末,分别检测两组各6只大鼠体质量、Hb、尿蛋白量（24 h）及肌酐清除率（Ccr）,然后处死大鼠,留取肾组织做Masson染色观察肾间质纤维化程度;实时定量PCR法检测肾组织中红细胞生成素（EPO）mRNA表达;免疫组化染色观察肾组织中Ⅰ型胶原（ColⅠ）、氨基肽酶P（APP）、低氧诱导因子（HIF）1α及2α的蛋白表达。 结果 大鼠的正常Hb值为（155.9±16.5） g/L,低于123.6 g/L为贫血。给药前,对照组与模型组间各指标的差异均无统计学意义。8周末时,与对照组比较,模型组大鼠Hb和Ccr显著下降[（121.66±15.68） g/L比（169.00±12.89） g/L,（0.63±0.13） ml/min比（1.27±0.18） ml/min];尿蛋白量（24 h）显著增多[（27.04±9.40） mg/d比（6.11±0.84） mg/d];肾间质纤维化相对面积及ColⅠ相对面积显著增加[（12.89±2.33）%比（0.55±0.10）%,（13.92±2.92）%比（1.32±0.84）%];肾组织APP蛋白表达和EPO mRNA表达显著下调 [（0.55±0.23）%比（3.77±1.06）%,0.005±0.001比0.032±0.013];HIF-1α和HIF-2α蛋白表达显著上调 （2.55±0.16比1.12±0.46,2.33±0.33比1.15±0.27）（均P < 0.01）。 结论 CAAN的贫血发生可能与肾小管周毛细血管毁坏所导致的EPO产生减少有关,虽然HIF表达已代偿性增强,但仍未能阻止贫血发生。     

肾性骨营养不良

笔者强调了肾性骨营养不良的概念.叙述了肾性骨营养不良发生的相关因素,包括慢性肾脏病继发甲状旁腺功能亢进、金属中毒、局部细胞因子异常、代谢产物残留、生长和分化因子异常等,以及其发生的机理.叙述了肾性骨营养不良的分类:高转运骨病、低转运骨病以及混合型骨病.肾性骨营养不良的临床表现:骨痛、骨骼畸形、异位钙化、皮肤瘙痒和肌病等.诊断方法 :影像学、骨活检及化验检查.进而还对其治疗方法 进行了总结.     

糖尿病肾病治疗的其他方法和进展

常规治疗糖尿病肾病的主要措施为:控制血糖,血压,调脂,饮食治疗(限制蛋白质摄入),戒烟,抗凝,肾脏替代治疗(透析治疗和肾脏移植)等.尽管这些治疗能够延缓部分患者的肾病进展,但是总体治疗效果还是不理想.目前,人们对糖尿病肾病发生机制的研究已经有了长足的进步,相应地也出现了一些防治糖尿病肾病的新药物.