活体肾移植供肾肾小球滤过率对受体早期肾功能的影响

目的 探讨活体肾移植供肾肾小球滤过率( GFR)对受体早期肾功能的影响.方法 2006年至2011年在本中心接受活体肾移植172例为研究对象,其中亲属供肾166例(96.5％),夫妻供肾5例(2.9％),帮扶供肾1例(0.6％).术前应用放射性核素99mTC-DTPA肾动态显像测定供体左右肾GFR.供体的双肾GFR为62～148 ml/min,将对象分为供肾GFR≤45ml/min受体76例和供肾GFR＞45 ml/min 96例.两组受体的透析情况、冷、热缺血时间、抗体诱导及免疫抑制方案、HLA错配率等基本资料相似.评价患者术后早期肾功能变化情况.结果 两组患者术后急性排斥反应以及肾功能延迟恢复( DGF)发生率差异无统计学意义.与供肾GFR≤45 ml/min组比较,供肾GFR＞45 ml/min组的Scr在术后1周、1个月、3个月、1年均较低,其中术后1周的差异有统计学意义(P＜0.05);术后1个月、3个月、1年的差异均无统计学意义.重复测量的方差分析显示术后1年内两组受体Scr变化差异无统计学意义.结论 活体肾移植供肾GFR高低对受体术后1周Scr下降水平有影响,供肾GFR高者受体术后1周Scr水平低,但是对受体术后早期(1年内)的Scr整体水平及变化趋势无显著影响.     

Renal hyperfiltration related to diabetes mellitus and obesity in human disease

High intraglomerular pressure is associated with renal hyperf iltration, leading to the initiation and progression of kidney disease in experimental models of diabetes mellitus (DM). In humans, hyperf iltration is observed in patients with type 1 and type 2 DM, and is also seen in patients with pre-diabetic conditions, such as the metabolic syndrome. From a mechanistic perspective, both vascular and tubular factors likely contribute to the pathogenesis of hyperf iltration. Until now, human studies have primarily focused on the use of medications that inhibit the renin angiotensin system to reduce efferent vasoconstriction and thereby improve hyperfiltration. More recent advances in the development of investigational adenosine antagonists and inhibitors of sodium glucose cotransport may help to elucidate tubular factors that contribute to afferent vasodilatation. In this review, we summarize available data from experimental and human studies of type 1 and type 2 DM and obesity to provide an overview of factors that contribute to the hyperf iltration state. We have focused on the renin angiotensin system, cyclooxygenase-2 system, nitric oxide, protein kinase C and endothelin as vascular determinants of hyperfiltration. We also dis-cuss relevant tubular factors, since experimental models have suggested that inhibition of sodium-glucose cotransport may be renoprotective.     

Outcomes and Native Renal Recovery Following Simultaneous Liver–Kidney Transplantation

With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liver–kidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post‐SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre‐SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20–40 mL/min), although at the most conservative cut‐off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post‐SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre‐SLK renal imaging (OR 3.85, CI 1.22–12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.     

2型糖尿病病人同型半胱氨酸水平与靶器官功能损伤的关联性研究

目的 探讨2型糖尿病病人同型半胱氨酸(homocysteine,Hcy)水平与肾、心血管功能损伤的关联性。方法 自2014年1月至2016年1月,收集周口市人民医院收治的2型糖尿病120例,根据病人血液中同型半胱氨酸水平将病人分为研究组(Hcy≥10 μmol/L)和对照组(Hcy＜10 μmol/L)。观察两组病人颈动脉内膜中膜厚度(carotid intima-media thickness,cIMT)、动脉硬化指数、冠心病指数、肾小球滤过率、空腹血糖、胰岛素抵抗指数(HOMA-IR)和胰岛素功能指数(HOMA-β)。结果 与对照组比较,研究组HOMA-IR水平显著升高［(7.48±2.52)比(6.81±2.53),P＝0.000］;HOMA-β水平显著降低［(67.83±9.29)比(78.62±11.53),P＝0.000］。两组空腹血糖水平差异无统计学意义［(11.81±5.48) mmol/L比(11.40±5.93)mmol/L,P＝0.7530］。与对照组比较,研究组cIMT水平显著增高［(1.31±0.21) mm比(1.12±0.18) mm,P＝0.000］;动脉硬化指数显著增高［(3.93±2.21)比(2.74±1.83),P＝0.000］;冠心病指数显著升高［(2.39±0.65)比(1.92±0.58),P＝0.002］;肾小球率过滤显著降低［(110.48±15.96) mL/min比(120.82±18.92) mL/min,P＝0.000］;24 h尿微量蛋白尿显著增高［(23.58±8.38)mg/24 h比(17.48±7.92)mg/24 h,P＝0.000］。Pearson线性相关性分析显示Hcy与2型糖尿病病人cIMT、动脉硬化指数、动脉硬化指数、冠心病指数和24 h尿微量蛋白尿等显著正相关,与肾小球滤过率显著负相关(P＜0.01)。结论 同型半胱氨酸水平升高是2型糖尿病病人肾和心血管功能损伤的危险因素。     

Long-term renal function after urinary diversion by ileal conduit or orthotopic ileal bladder substitution

Background

Data on long-term renal function are scarce for ileal conduit diversion (ICD) and even rarer for orthotopic ileal bladder substitution (BS).

Objective

Explore the changes in renal function of patients who lived ≥10 yr with an ICD or BS and determine the risk factors contributing to renal function deterioration.

Design, setting, and participants

Fifty consecutive ICD patients and 111 consecutive BS patients who lived ≥10 yr after undergoing surgery between January 1985 and December 2000 were retrospectively analyzed.

Measurements

The glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease (MDRD) equation before and 10 yr after surgery. Decreased renal function was defined as a decrease in GFR >10 ml/min per 1.73 m² in 10 yr.

Results and limitations

Median GFR values in patients with ICD or BS decreased from 65.5 (range: 23-90) to 57 (range: 7-100) ml/min per 1.73 m² and from 68 (range: 33-106) to 66 (range: 16-100) ml/min per 1.73 m², respectively. Eighteen ICD patients (36%) and 23 BS patients (21%) had deteriorating renal function. Seven of 12 ICD patients with obstruction (ureteroileal stricture, stomal stenosis/parastomal hernia) (58%) had renal function deterioration, as did 17 of 46 BS patients with obstruction (ureteroileal/nipple stricture and/or bladder outlet obstruction) (37%). Logistic regression analysis confirmed that obstruction was the leading, and an independent, risk factor for renal function deterioration for both ICD patients (p = 0.045) and BS patients (p = 0.002). Patients with diabetes or hypertension were significantly more likely to have deterioration of renal function if they had ICD (p = 0.002 and p = 0.05, respectively). The limitation of the study is its retrospective nature and its composition that included many patients who did not survive 10 yr.

Conclusions

Urinary tract obstruction was the leading cause of long-term renal function impairment, regardless of whether the patient had ICD or BS. ICD patients with predisposing risk factors, such as diabetes or hypertension, were at increased risk for impaired renal function.     

CT增强扫描与SPECT测定活体肾移植供体肾小球滤过率的对照研究

目的研究螺旋CT多期增强扫描测定活体肾移植供体肾小球滤过率(GFR)的方法及其准确性。方法 60例健康活体肾移植供体术前均行双肾CTA检查,扫描程序包括平扫、动脉期、静脉期及延迟CTU扫描,应用Patlak方程原理计算双肾GFR,并与SPECT 99mTc-DTPA肾动态显像所测定的GFR对照,并对两组结果进行直线回归与相关分析。结果 60例肾移植供体,CT法测得的左肾GFR和右肾GFR分别为(64.36±5.38)ml·min-1·(1.73 m2)-1和(65.72±5.73)ml·min-1·(1.73 m2)-1,总肾GFR为(129.48±10.49)ml·min-1·(1.73 m2)-1;SPECT测得的左肾GFR和右肾GFR分别为(41.74±5.49)ml·min-1·(1.73 m2)-1和(43.36±6.31)ml·min-1·(1.73 m2)-1,总肾GFR为(85.09±10.73)ml·min-1·(1.73 m2)-1。相关性分析显示,两种方法测定的GFR相关性良好,左肾GFR相关系数r=0.877,P<0.01,直线回归方程为GFR(CT)=28.525+0.859×GFR(SPECT),n=60;右肾GFR相关系数r=0.877,P<0.01,直线回归方程为GFR(CT)=31.209+0.785×GFR(SPECT),n=60;总肾GFR相关系数r=0.867,P<0.01,直线回归方程为GFR(CT)=57.337+0.848×GFR(SPECT),n=60。结论螺旋CT增强扫描所测定的活体肾移植供体的GFR与SPECT所测定的GFR具有良好的相关性,应用螺旋CT多期增强扫描可以同步完成活体肾移植供体术前肾功能的评价和解剖结构的评价。     

A new Classification of Diabetic Nephropathy 2014: a report from Joint Committee on Diabetic Nephropathy

The Joint Committee on Diabetic Nephropathy has revised its Classification of Diabetic Nephropathy (Classification of Diabetic Nephropathy 2014) in line with the widespread use of key concepts, such as the estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD). In revising the Classification, the Committee carefully evaluated, as relevant to current revision, the report of a study conducted by the Research Group of Diabetic Nephropathy, Ministry of Health, Labor and Welfare of Japan. Major revisions to the Classification are summarized as follows: (i) eGFR is substituted for GFR in the Classification; (ii) the subdivisions A and B in stage 3 (overt nephropathy) have been reintegrated; (iii) stage 4 (kidney failure) has been redefined as a GFR <30 mL/min/1.73 m², regardless of the extent of albuminuria; and (iv) stress has been placed on the differential diagnosis of diabetic nephropathy versus non‐diabetic kidney disease as being crucial in all stages of diabetic nephropathy.     

以双血浆法为标准评估肾动态显像法与CKD-EPI公式法测定老年慢性肾病患者肾小球滤过率的临床应用研究

目的 对比分析99Tcm-DTPA肾动态显像法(Gate's法)与CKD-EPI SCr公式法判定老年患者GFR的临床适用性,探索性地建立基于双血浆法以及不同检查方法的回归模型.方法 收集我院2011年4月至2013年1月行双血浆法(tGFR)以及Gate's测量GFR的老年患者资料72例,以双血浆法为参考标准,对比分析CKD-EPI Scr公式(eGFR)以及Gate's法(gGFR)测量GFR的准确性.结果 tGFR与gGFR的相关性较好(r=0.724),与eGFR的相关性较差(r=0.632),差异具有统计学意义(P＜0.05).3～5期老年CKD患者的tGFR与eGFR和gGFR之间均具有较好相关性,相关系数分别为0.736和0.749(P ＜0.05).结论 Gate's法在老年CKD患者GFR的评估中显示出了较为准确的结果,但仍不推荐作为各种临床公式评估GFR的参考标准.Gate's法和CKD-EPI Scr均可以对3～4期老年CKD患者的GFR进行准确评估,但老年CKD患者GFR的评估仍需要以患者实际情况为基础,进行综合判断.