Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease

BackgroundIn patients with end-stage renal disease (ESRD), surgical aortic valve replacement is associated with higher early and late mortality, and adverse outcomes compared with patients without renal disease. Transcatheter aortic valve replacement (TAVR) offers another alternative, but there are limited reported outcomes.ObjectivesThe purpose of this study was to determine the outcomes of TAVR in patients with ESRD.MethodsAmong the first 72,631 patients with severe aortic stenosis (AS) treated with TAVR enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT (Transcatheter Valve Therapies) registry, 3,053 (4.2%) patients had ESRD and were compared with patients who were not on dialysis for demographics, risk factors, and outcomes.ResultsCompared with the nondialysis patients, ESRD patients were younger (76 years vs. 83 years; p < 0.01) and had higher rates of comorbidities leading to a higher STS predicted risk of mortality (median 13.5% vs. 6.2%; p < 0.01). ESRD patients had a higher in-hospital mortality (5.1% vs. 3.4%; p < 0.01), although the observed to expected ratio was lower (0.32 vs. 0.44; p < 0.01). ESRD patients also had a similar rate of major vascular complications (4.5% vs. 4.6%; p = 0.86), but a higher rate of major bleeding (1.4% vs. 1.0%; p = 0.03). The 1-year mortality was significantly higher in dialysis patients (36.8% vs. 18.7%; p < 0.01).ConclusionsPatients undergoing TAVR with ESRD are at higher risk and had higher in-hospital mortality and bleeding, but similar vascular complications, when compared with those who are not dialysis dependent. The 1-year survival raises concerns regarding diminished benefit in this population. TAVR should be used judiciously after full discussion of the risk-benefit ratio in patients on dialysis.     

不同血液净化模式对急性肾损伤患儿血清β2微球蛋白的清除效果及安全性研究

目的 探讨不同血液净化模式对急性肾损伤(acute kidney injury,AKI)患儿血清β2微球蛋白(β2-microglulin,β2-MG)的清除效果和安全性研究.方法 收集2011年3月至2013年3月收治于贵阳市儿童医院肾脏免疫科和儿童重症监护病房(PICU)行血液净化治疗98例次的小儿AKI的患者38例.其中男20例,女18例,年龄5个月～14岁.其中持续性肾脏替代治疗(continuous renal replacement therapy,CRRT) 66例次[包括连续性静-静脉血液透析(continuous veno-venous hemofiltration,CVVH)及连续性静-静脉血液透析滤过(continuous veno-venous hemodiafiltration,CVVHDF)],间歇性血液透析(intermittent hemodialysis,IHD) 32例次.原发性疾病:循环障碍7例,各种肾毒性药物及毒物中毒10例,脓毒症伴多器官衰竭9例,肾脏实质性疾病如肾病综合征、链球菌感染后肾小球肾、狼疮性肾炎、急进性肾炎等12例.依据不同血液净化方式分为CRRT组和IHD组,其中CRRT组上机治疗8 ～16h,IHD组治疗2.5～3h.评价患儿血尿素氮(blood urea nitrogen,BUN)、肌酐(serum creatinine,SCr)及水电解质酸碱平衡、β2-MG等.结果 AKI行血液净化治疗共38例98例次,其中CRRT组(包括CVVH、CVVHDF) 66例次,IHD组32例次.进展至终末期肾病需长期维持透析治疗2例(占5％),病死率0. (1) CRRT组治疗前后血BUN、Scr分别为[(22.34 ±2.08) mmol/L,(12.24 ±0.98) mmol/L]、[(310.23 ±85.34) μmol/L、(178.15 ±34.12) μmol/L],差异有统计学意义(t=12.39,t=5.906,P均＜0.05);IHD组冶疗前后血BUN、Scr分别为[(23.80±2.14) mmol/L,(7.39±0.88) mmol/L]、[(350.11±78.42) μmol/L,(108.20 ±28.20) μmol/L],差异有统计学意义(t =29.04,t=13.83,P均＜0.05);(2) CRRT组及IHD组β2-MG清除率分别为(40.50±7.20)％、(1.50±0.05)％,CRRT组β2-MG清除效果优于IHD组,差异有统计学意义(P＜0.05);(3) CRRT组中不良反应出现少,患儿安全性较IHD为高.结论 CRRT对小儿急性肾损伤具有清除血清β2-MG好、血流动力学稳定等特点,是治疗小儿急性肾损伤的一种快速、有效和安全的方法.     

Efectividad de una intervención educativa y de ejercicio físico sobre la capacidad funcional de los pacientes en hemodiálisis

Objective

To describe the impact of a standard hospital educational intervention including active physical exercises on personal well-being, functional capacity and knowledge of the benefits of prescribed physical activity for patients undergoing haemodialysis.

The exploration of population pharmacokinetic model for meropenem in augmented renal clearance and investigation of optimum setting of dose

In recent years, augmented renal clearance (ARC), in which renal function is excessively enhanced, has been reported, and its influence on β-lactam antibiotics has been investigated. In this study, we aimed to determine the optimum population pharmacokinetic model of meropenem in patients with sepsis with ARC, and evaluated dosing regimens based on renal function. Seventeen subjects (6 with ARC and 11 without) were enrolled in this study. Predicted meropenem concentrations were evaluated for bias and precision using the Bland–Altman method. To examine the dosing regimen, Monte Carlo simulation was performed to calculate the cumulative fraction of response (CFR). In patients with ARC, the bias (average of the predicted value and measured value residuals) of models constructed by Crandon et al. (2011), Roberts et al. (2009), and Jaruratanasirikul et al. (2015) were 5.96 μg/mL, 10.91 μg/mL, and 4.41 μg/mL, respectively. Following 2 g meropenem every 8 h (180 min infusion), CFR ≥ 90%, a criterion of success for empirical therapy, was achieved, even with creatinine clearance of 130–250 mL/min. For patients with sepsis and ARC, the model of Jaruratanasirikul et al. showed the highest degree of accuracy and precision and confirmed the efficacy of the meropenem dosing regimen in this patient population.     

平糖固肾方治疗早期糖尿病肾病临床研究

目的:观察自拟平糖固肾方对早期糖尿病肾病(diabetic nephropathy,DN)的血糖、血红蛋白、血脂等指标的影响。方法:50例DN患者随机分为对照组25例,治疗组25例。对照组给予常规降糖药物,治疗组在此基础上给予自拟平糖固肾方。比较治疗前后空腹血糖(fasting blood-glucose,FBG)、动脉血压、糖化血红蛋白、尿素氮、肌酐、24小时尿微量白蛋白、总蛋白、总胆固醇(total cholesterol,TC)、三酰甘油(triacylglycerol,TG)、高密度脂蛋白胆固醇(high density lipoprotein cholesterol,HDL-C)和低密度脂蛋白胆固醇(low density lipoprotein cholesterin,LDL-C)。结果:治疗前后两组FBG、糖化血红蛋白和动脉血压比较,差异无统计学意义(P0.05);两组患者尿微量蛋白、总蛋白、肌酐和尿素氮水平较治疗前明显下降,治疗组下降更明显;两组TC、TG、LDL-C水平均显著降低,HDL-C水平显著升高,治疗组改善更明显。结论:自拟平糖固肾方联合常规降糖药物治疗早期DN,可明显改善血脂水平,降低尿蛋白,改善肾功能,对早期DN的临床效果明显。     

经皮肾镜碎石术后发热的相关因素分析*

目的探讨经皮肾镜碎石术(PCNL)治疗肾结石术后引起发热的相关因素及防治措施。方法回顾性分析2015年1月-2017年6月该院应用PCNL治疗150例肾结石患者的临床资料,包括年龄、性别、合并糖尿病病史、既往同侧肾脏手术史、结石类型、结石最长径、有无并发输尿管上段结石、术前泌尿系感染、肾积水程度、术前肾盂积脓、术前肾造瘘管的使用、术后中心静脉压、术中灌注量和手术时间,术后分为发热组和未发热组,对两组PCNL术后发热的相关因素进行分析。结果术后发热共27例,占18.0%。性别比例、糖尿病病史、铸型结石或鹿角形结石、结石长径、合并输尿管上段结石、术前尿常规白细胞计数、脓肾、术前使用肾造瘘管、术后中心静脉压、术中灌注量和手术时间在两组间比较,差异均有统计学意义(P0.05);Logistic多因素分析显示,女性患者、合并输尿管上段结石、术中灌注量、术前肾积脓、手术时间长是术后发热的独立危险因素(OR1,P0.05)。结论 PCNL术前需常规尿细菌培养,彻底治疗尿路感染和肾脏积脓,合理控制手术时间和灌注液量,以降低术后患者发热的发生率。     

超声引导下穿刺置管治疗继发性肾功能衰竭72例

目的 分析超声引导下肾造瘘术对肾功能衰竭患者肾功改善的临床意义。方法 72例因肿瘤原因致肾功能衰竭患者经肾造瘘术后,观察治疗前、后血肌酐（Cr）和尿素氮（BUN)变化。 结果 72例均一次穿刺成功,穿刺成功率100%。随访4周,其中一周内肾功能明显改善69例,有效率95.8%,其余3例两周内肾功能明显改善。Cr下降范围120-270umol/L,BUN下降范围3.9-8.1mmol/L。 本组发生轻微并发症5例,发生率为6.9% 。结论 超声引导下肾造瘘能够明显改善肾功能,短期内治疗肾功能衰竭效果满意。     

3.0 T磁共振弥散加权成像表观弥散系数对肾脏肿瘤性病变的诊断价值

目的:探讨3.0T磁共振(MRI)弥散加权成像(DWI)量化指标对肾脏肿瘤性病变的诊断和鉴别诊断价值。方法:收集行肾脏MRI检查并经病理确诊的肾脏实质肿瘤89例。其中,肾细胞癌60例,包括39例肾透明细胞癌、8例乳头状肾细胞癌、9例肾嫌色细胞癌、4例多房囊性肾细胞癌;良性病变29例,包括肾血管平滑肌脂肪瘤25例,嗜酸细胞瘤4例。所有患者采用GE Signa HD 3.0T MR进行横断面DWI成像并行表观弥散系数(apparent diffusion coefficient,ADC)值测量。结果:肾透明细胞癌、乳头状肾细胞癌、肾嫌色细胞癌、多房囊性肾细胞癌ADC平均值分别为(1.681 5±0.176 9)×10~(-3)、(1.165 0±0.217 0)×10~(-3)、(1.121 0±0.231 6)×10~(-3)、(2.030 0±0.235 1)×10~(-3) mm~2/s,肾血管平滑肌脂肪瘤、肾嗜酸细胞瘤ADC平均值分别为(1.155 2±0.132 0)×10~(-3)、(1.580 0±0.212 3)×10~(-3) mm~2/s。肾透明细胞癌ADC值与乳头状肾细胞癌、肾嫌色细胞癌、肾血管平滑肌脂肪瘤ADC值差异均有统计学意义(P=0.000);而与多房囊性肾细胞癌、肾嗜酸细胞瘤ADC值差异无统计意义。结论:3.0T MR-DWI成像ADC值对肾脏肿瘤性病变具有鉴别诊断价值,有利于指导患者治疗方案的选择。