SURGERY OF PERIURETERIC OBSTRUCTION IN 101 CHILDREN OVER ONE YEAR OF AGE

One hundred and one children over 1 year of age have had surgery for pelviureteric obstruction over an 11 year period. The common clinical features were abdominal pain, urinary infection or haematuria, but number presented as an incidental finding. Less commonly, the patients presented with an abdominal mass or with hypertension. The diagnosis was usually made on intravenous pyelography (IVP) but in the latter part of the series, renal nuclide scan (RNS) and ultrasonography (US) were preferred. Ninety–three patients had unilateral pyeloplasty, three had bilateral pyeloplasty and five had nephrectomy or heminephrectomy. Whereas initially nephrostomy drainage was used in the majority of patients after pyeloplasty, trend away from nephrostomy evolved in the latter part of the series. With experience, the incidence of postoperative complications was also reduced and there was reduction in the period of hospitalization. Clinical results were consistently satisfactory. Postoperative assessment after pyeloplasty was made by IVP and/or RNS and also US. A review of these investigations showed that RNS provided more factual information of the result when compared with the IVP.     

Acute renal failure as a result of bilateral ureteral obstruction by Candida albicans fungus balls

A 73-year-old male with a history of diabetes mellitus was admitted to our hospital for acute renal failure. An ultrasonogram revealed bilateral hydronephrosis, which worsened despite insertion of a bladder catheter. Nephrostomy catheters were positioned bilaterally, and Candida albicans was found in the urine culture. The patient was successfully treated with intermittent direct irrigation and i.v. antifungal agent therapy. Since 1977, approximately 50 cases of fungus balls or fungal bezoars in the urinary tract have been reported, but the majority of these cases have been characterized by unilateral ureteral or bladder involvement. Herein, we report a case of acute renal failure as a result of bilateral ureteral obstruction by Candida albicans fungus balls.     

大陷胸汤灌肠治疗流出急性肾衰的观察与护理

目的 探讨中药大陷胸汤高位保留灌肠对流行性出血热（EHF）急性肾衰的治疗作用。方法 将60例EHF急性肾衰患者随机分为对照组与治疗组各30例，对照组予以常规治疗，治疗组在常规治疗的基础上加用大陷胸汤高位保留灌肠，观察两组患者治疗前后的疗效。结果 治疗组治愈23例，好转6例，无效1例，总有效率96．7％；对照组治愈17例，好转7例，无效6例，总有效率80．0％；两组疗效比较，有显著差异性p〈0．05（x^2=4．630）。结论 大陷胸汤高位保留灌肠治疗EHF急性肾衰疗效显著，且简便、安全、经济、病人乐于接受等优点。     

影响终末期肾衰竭患者心脏扩大的因素

目的了解成都铁路分局医院血液进化中心终末期肾衰竭并维持性血液透析患者心脏扩大的影响因素,以便提高患者的血液透析质量和生存率。方法回顾本血液净化中心收治的216例终末期肾衰竭并维持性血液透析2月以上患者,根据心脏彩色多普勒检查,分为心脏扩大与心脏未扩大2组,对可能影响心脏扩大的因素:年龄、血液透析病程、每周血液透析时间、高血压、容量超负荷、血红蛋白水平、低蛋白血症等用SPSS10.0软件作Logistic回归分析。结果终末期肾衰竭并维持性血液透析患者216例,心脏扩大者183例,未扩大者33例,心脏扩大的发生率为84.72%。心脏扩大与容量超负荷呈显著正相关,P=0.002,OR值42.619;心脏扩大与高血压呈正相关,P=0.026,OR值15.353;心脏扩大与血红蛋白水平呈负相关,P=0.043,OR值0.934。心脏扩大与年龄、血液透析病程、每周血液透析时间和低蛋白血症无相关关系。结论终未期肾衰竭并维持性血液透析患者心脏扩大发生率高,而容量超负荷、高血压、血红蛋白水平是影响它的关键,高血压及容量超负荷是促进心脏扩大的独立危险因素,血红蛋白水平下降亦是促进心脏扩大的独立危险因素。     

Individualized Mycophenolate Mofetil Dosing Based on Drug Exposure Significantly Improves Patient Outcomes After Renal Transplantation

Efficacy and safety of mycophenolate mofetil (MMF) may be optimized with individualized doses based on therapeutic monitoring of its active metabolite, mycophenolic acid (MPA). In this 12-month study, 137 renal allograft recipients from 11 French centers receiving basiliximab, cyclosporine A, MMF and corticosteroids were randomized to receive either concentration-controlled doses or fixed-dose MMF. A novel Bayesian estimator of MPA AUC based on three-point sampling was used to individualize doses on posttransplant days 7 and 14 and months 1, 3 and 6. The primary endpoint was treatment failure (death, graft loss, acute rejection and MMF discontinuation). Data from 65 patients/group were analyzed. At month 12, the concentration-controlled group had fewer treatment failures (p = 0.03) and acute rejection episodes (p = 0.01) with no differences in adverse event frequency. The MMF dose was higher in the concentration-controlled group at day 14 (p < 0.0001), month 1 (p < 0.0001) and month 3 (p < 0.01), as were median AUCs on day 14 (33.7 vs. 27.1 mg*h/L; p = 0.0001) and at month 1 (45.0 vs. 30.9 mg*h/L; p < 0.0001). Therapeutic MPA monitoring using a limited sampling strategy can reduce the risk of treatment failure and acute rejection in renal allograft recipients 12 months posttransplant with no increase in adverse events.     

Thrombotic Micro‐Angiopathy with Sirolimus‐Based Immunosuppression: Potentiation of Calcineurin‐Inhibitor‐Induced Endothelial Damage?

Thrombotic microangiopathy is a rare but important finding in the context of organ transplantation. Acute renal insufficiency in the setting of hemolysis and thrombocytopenia, a triad that constitutes 'hemolytic uremic syndrome', can be associated with, or triggered by, conditions such as verocytotoxin-producing Escherichia coli, viral infections, malignant hypertension, scleroderma, allograft rejection, lupus erythematosus, pregnancy, and medications including mitomycin C, calcineurin inhibitors, and oral contraceptives. After renal transplantation, it can occur, as either a de novo episode, or recurrent disease. Calcineurin inhibitors have long been associated with post-transplantation thrombotic microangiopathy. Sirolimus has been used as a primary immunosuppressant in patients transplanted with a history of earlier hemolytic-uremic syndrome, and also as rescue therapy in patients with calcineurin-inhibitor-associated thrombotic microangiopathy. We describe four cases where there was significant thrombotic microangiopathy in the context of contemporaneous or contiguous calcineurin inhibitor and sirolimus usage. As the intrarenal cyclosporin concentration is thought to be significantly elevated when cyclosporin and sirolimus are used together, this may explain these findings, and mandates caution in their co-administration.     

针刺对肾血管性高血压大鼠的降压效应

目的　探讨针刺对肾血管性高血压大鼠的降压作用及其神经 -内分泌调节机制。方法　采用二肾一夹法制备高血压大鼠模型 ,测定实验各组大鼠血浆内皮素 (ET)、一氧化氮 (NO)含量和心率变异性 (HRV)的动态变化。结果　与模型组相比 ,针刺组血压 (BL 2 3:19.1± 1.1k Pa,ST36:18.1± 2 .5 k Pa)及 ET水平明显下降 (P<0 .0 1) ,其中针刺肾俞组血浆 ET水平 (91.3± 9.45 pg/ ml)较足三里组 (10 8.48± 13.0 6pg/ ml)下降更明显 (P<0 .0 5 ) ;针刺治疗组血浆 NO水平 (BL 2 3:5 0 .3±12 .7μmol/ ml,ST 36:49.71± 8.49μm ol/ m l)显著升高 (P<0 .0 5 )。足三里组针刺后 L F/ HF比值与模型组无明显差异 ,而肾俞组 L F/ HF值 (0 .5 7± 0 .13)明显低于模型组及足三里组 (0 .86± 0 .2 5 )。结论　针刺能降低肾血管性高血压模型大鼠动脉血压 ,肾俞与足三里两穴无明显差异 ,其作用机制可能与自主神经系统、NO及 ET参与的神经内分泌调节作用相关。     

Peritoneal dialysis patient survival: a comparison between a Swedish and a Korean centre.

BACKGROUND: Dialysis patient mortality remains high, and this high mortality may be due to many factors. In peritoneal dialysis (PD) patients, old age, co-morbid diseases, malnutrition, low residual renal function (RRF) and a high peritoneal transport rate have been shown to influence survival, but the relative importance of these factors may differ between different patient populations. Besides, centre practice patterns may differ between centres and may influence patient survival. In addition, the literature suggests that dialysis patient survival may be better in Asian than in Caucasian patients. METHODS: The influence of centre and patient characteristics on patient survival was investigated in 132 Korean and 106 Swedish incident PD patients, who underwent initial biochemical measurements and assessment of adequacy of dialysis, nutritional status, RRF and peritoneal transport characteristics. RESULTS: At the start of PD, Korean patients had a higher prevalence of diabetes, peritoneal Kt/V(urea), peritoneal creatinine clearance and peritoneal fluid removal, and lower body mass index, RRF and dialysate to plasma creatinine concentration ratio (D/P Cr) compared with Swedish patients. Significantly more patients from Korea were placed on temporary haemodialysis before PD (100 out of 132) when compared with Swedish patients (21 out of 106). During the follow-up, there was a significantly higher rate of transfer to other units in Korea and a significantly higher rate of kidney transplantation in Sweden. On Kaplan-Meier analysis, overall patient survival did not differ and relative risk for death was also not different between the two centres even after adjustment for age, diabetes, cardiovascular disease, RRF and D/P Cr. On Cox proportional hazards multivariate analysis, age, diabetes, RRF and D/P Cr were found to be independent predictors of mortality in the combined cohort of patients. While age, diabetes and D/P Cr were independent predictors of mortality in Korean patients, age and RRF independently predicted mortality in Swedish patients. CONCLUSION: Although there were significant differences in centre and patient characteristics, we were unable to confirm a survival advantage for Korean over Swedish PD patients. The results of this study suggest that the reported difference in survival between Asian and Caucasian dialysis patients may have been due, in part, to differences in centre and patient characteristics rather than to race as such. The genetic influence on patient characteristics remains, however, to be elucidated.     

川芎嗪对肾缺血再灌注时c-fos bcl-2 ICAM-1蛋白表达的影响

目的　探讨大鼠肾缺血再灌注损伤不同时间c -fos、细胞淋巴瘤 /白血病 - 2、细胞间粘附分子- 1蛋白的表达及川芎嗪对其影响。方法　用免疫组化法检测大鼠急性肾缺血再灌注不同时间内及川芎嗪干预后c -fos、细胞淋巴瘤 /白血病 - 2、细胞间粘附分子 - 1蛋白表达的分布及强度变化。结果　c -fos蛋白分布于近曲小管、远曲小管、集合管上皮细胞的细胞核、细胞浆内 ,再灌注后 1h表达明显增强 ,3h达高峰 ,6h锐减。细胞淋巴瘤 /白血病 - 2蛋白主要分布于近曲小管上皮细胞的细胞浆 ,再灌注后 1h表达明显增强 ,6h达高峰 ,2 4h仍有较强表达。细胞间粘附分子 - 1蛋白分布在肾血管、肾小管等部位 ,其中以肾血管为著 ,其表达增强于再灌注后 1h ,直到 2 4h仍有增高趋势。川芎嗪干预后c -fos、细胞间粘附分子 - 1蛋白表达明显下降 (P <0 0 1 )。细胞淋巴瘤 /白血病 - 2表达明显增高 (P <0 .0 1 )。结论　川芎嗪对肾缺血再灌注损伤有较好的保护作用     

Tacrolimus Exposure and Evolution of Renal Allograft Histology in the First Year After Transplantation

Tacrolimus has a narrow therapeutic window and is characterized by a large inter-individual variability in bioavailability. The impact of tacrolimus exposure on subclinical evolution of graft histology has not been studied in renal recipients. This analysis included 239 protocol biopsies (obtained at implantation, 3 and 12 months) of 120 consecutive kidney recipients treated with tacrolimus, mycophenolate mofetil (MMF) and corticosteroids. Biopsies were scored according to the Banff 2001 criteria and a chronicity score was calculated. Prospective pharmacokinetic data were included in the analysis (5544 tacrolimus predose blood concentrations and tacrolimus AUC(0-12) at 3 and 12 months). Higher donor age and higher number of human leukocyte antigen-DR (HLA-DR) mismatches were independent predictors of subclinical acute rejection at 3 months, present in 8.7% of patients. The number of HLA-DR mismatches was independently associated with biopsy-proven clinical acute rejection. Biopsy-proven acute rejection episodes and low mean tacrolimus exposure were independently associated with higher increase in chronicity scores between 3 and 12 months after transplantation. This observational study suggests that rejection phenomena and immune-mediated mechanisms remain important in the early progression of chronic allograft pathology. Tacrolimus doses or systemic exposure were not associated with lesions of calcineurin inhibitor nephrotoxicity, suggesting that other factors determine susceptibility to tacrolimus nephrotoxicity.