人工髋关节置换术早期并发症临床分析

目的探讨人工髋关节置换术早期并发症的防治方法。方法分析21例人工髋关节置换术患者发生早期并发症的原因并提出防治措施。结果21例中假体柄周围骨折7例,术后早期脱位5例,下肢深静脉栓塞8例,下肢不等长1例。经治疗后效果满意。结论术中正确的手术操作、术后早期进行功能康复能有效地防止或减少早期并发症的发生。     

外周血单个核细胞宫腔内灌注治疗对反复种植失败患者妊娠结局的影响

目的探讨自体外周血单个核细胞（PBMCs）宫腔内灌注治疗对反复种植失败（RIF）患者胚胎种植率和临床妊娠率的影响。方法按随机数字表法将纳入的39例拟行冷冻胚胎移植的RIF患者随机分为治疗组（20例）和对照组（19例）,治疗组在移植前3d抽取外周血20ml,应用淋巴细胞分离液分离PBMC后行宫腔灌注。对照组移植前未行自体PBMC宫腔灌注。结果两组患者年龄、血清卵泡刺激激素（FsH）、取卵周期数、移植周期数、移植胚胎数和单周期移植优质胚胎数均无统计学差异（P〉0．05）。两组胚胎种植率（22．8％VS．6．4％）和临床妊娠率（50．0％VS．17．6％）比较,治疗组均显著高于对照组（P％0．05）。两组单周期活婴出生率（45．0％VS．17．6％）比较无统计学差异（P〉0．05）。结论自体PBMC宫腔内灌注治疗可以提高RIF患者胚胎种植率和临床妊娠率,故可作为RIF患者胚胎移植前提供可选择的处理方案。     

Mortality Risk Factors and Validation of Severity Scoring Systems in Critically Ill Patients with Acute Renal Failure

Background. Risk stratification and prediction of outcome in acute renal failure patients in the intensive care unit are important determinants for improvement of patient care and design of clinical trials. Methods. In order to identify mortality risks factors and validate general and specific predictive models for acute renal failure (ARF) patients in the intensive care unit (ICU), 324 patients were prospectively evaluated. Multivariate analysis by logistic regression was utilized for identification of mortality risk factors. Discrimination and calibration were used to evaluate the performance of the following models at referral to nephrologist and at initiation of renal replacement therapy: APACHE II, SAPS II, LODS, and ATN-ISI. Organ failure was assessed by SOFA and OSF. Results. The hospital mortality rate was 85%. The identified mortality risk factors were: age ≥ 65 yr, BUN ≥ 70 mg/dL, ARF of septic origin, and previous hypertension. Serum creatinine ≥ 3.5 mg/dL, systolic blood pressure ≥ 100 mm Hg, and normal consciousness were associated with mortality risk reduction. Performance of all prognostic models was disappointing with unsatisfactory calibration and underestimation of mortality on the day of referral to the nephrologist and at initiation of renal replacement therapy. Conclusions. Cross-validation of prognostic models for ARF resulted in poor performance of all studied scores. Therefore, a specific model is still warranted for the design of clinical trials, comparison of studies, and for prediction of outcome in ARF patients, especially in the ICU.     

Prognostic Value of Acute Physiology and Chronic Health Evaluation II and Organ System Failure in Patients with Acute Renal Failure Requiring Dialysis

Background. Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality. Methods. From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed. Results. A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P< 0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P< 0.01) and oliguria (odds ratio 4.2; P = 0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P = 0.001) or the APACHE II score (chi-square for trend; P< 0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)= 0.752–0.942; P< 0.01) and 0.769 (95% CI = 0.646–892; P< 0.001), respectively, indicating good model discrimination. Conclusions. This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II score ≥ 24 was found to have 63% sensitivity and 96% specificity, and OSF number ≥ 2 had 81.6% sensitivity and 60.9% specificity.     

Protective Effect of Resveratrol,a Polyphenolic Phytoalexin on Glycerol-Induced Acute Renal Failure in Rat Kidney

Rhabdomyolysis-induced myoglobinuric acute renal failure (ARF) accounts for about 10% to 40% of all cases of ARF. Reactive oxygen intermediates have been demonstrated to play an etiologic role in myoglobinuric renal failure. This study was designed to investigate the effect of resveratrol, a polyphenolic phytoalexin in glycerol-induced ARF in rats. Seven groups of rats were employed in this study, group I served as control; group II was given 50% glycerol (8mL/kg, intramuscularly); groups III, IV, and V were given glycerol plus resveratrol (2mg/kg, 5mg/kg, and 10mg/kg p.o. route, respectively) 60 min prior to the glycerol injection; group VI received L-NAME (10mg/kg, i.p.) along with glycerol and resveratrol (5 mg/kg), group VII animals received L-NAME (10 mg/kg) 30 min prior to glycerol administration. Renal injury was assessed by measuring plasma creatinine, blood urea nitrogen, creatinine, and urea clearance. The oxidative stress was measured by renal malondialdehyde levels and reduced glutathione levels, and by enzymatic activity of catalase, glutathione reductase, and superoxide dismutase. Tissue and urine nitrite levels were measured as an index of total nitric oxide levels. Glycerol treatment resulted in a marked decrease in tissue and urine nitric oxide levels, renal oxidative stress, and significantly deranged the renal functions along with deterioration of renal morphology. Pretreatment of animals with resveratrol (5 and 10 mg/kg) 60 min prior to glycerol injection markedly attenuated the fall in nitric oxide levels, renal dysfunction, morphologic alterations, reduced elevated thiobarbituric acid reacting substances, and restored the depleted renal antioxidant enzymes. This protection afforded by resveratrol was significantly reversed by cotreatment of L-NAME along with resveratrol, clearly indicating that resveratrol exerts its protective effect through nitric oxide release along with the antioxidative effect in glycerol-induced ARF.     

The Effect of Seventy-Two-Hour Continuous Infusion of Long-Acting Natriuretic Peptide on Acute Ischemic Renal Failure in the Rat

Objectives. Atrial natriuretic peptide (ANP_1-28) protects the kidneys against acute renal failure in animals; however, its use in humans has been disappointing. Long-acting natriuretic peptide (LANP_1-30) has natriuretic and diuretic actions similar to ANP_1-28, but it has a longer half-life and a different receptor site. Therefore, this study's aim was to determine if LANP_1-30 has better renal protection than ANP_1-28, which may make it useful in the treatment of acute renal failure. Subjects/Methods. Three groups of male Sprague-Dawley rats were used, each with a body weight between 250-300 gm. Group 1 (ischemia only, n = 6) had a right nephrectomy followed by 30 minutes of left renal pedicle clamping. Group 2 (LANP Peptide treated, n = 7) had renal ischemia similar to Group 1, followed by an intraperitoneal bolus of 10 μg of LANP_1-30 and the placement of mini-osmotic pumps delivering LANP_1-30 at a rate of 1μg/hr for 72 hours. Group 3 (controls, n = 6) was used to measure the baseline creatinine level and had no renal ischemia or surgery. Results. Seventy-two hours post-renal ischemia, the weight loss in the ischemia group was similar to the peptide treated group (7.65 ± 1.14% and 10.03 ± 0.9% body weight loss, respectively, p?=?0.126). The ischemia group had significantly higher creatinine levels compared to the controls (66.3 ± 5.3 versus 30.1 ± 0.9 μmol/L, p?=?0.002). The peptide-treated group had higher creatinine (174.1 ± 77.8 versus 66.3 ± 5.3 μmol/L, p?=?0.035) and LANP_1-30 levels (673.14 ± 69.64 versus 45.83 ± 8.45 pg/mL, p?=?0.001) than the ischemia group. Conclusion. Prolonged use of LANP_1-30 has no renal protective effect.     

Prevalence of Occult Hepatitis B and Hepatitis C Virus Infections in Turkish Hemodialysis Patients

Background and Objective. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are important causes of morbidity and mortality in maintenance hemodialysis patients. Although their exact prevalence is not known, HBV and HCV viral infections and occult viral hepatitis are frequent in these patients. This study aimed to determine the prevalence of occult HBV and HCV infections in maintenance hemodialysis patients. Materials and Methods. One hundred and eighty-eight end-stage renal disease patients on maintenance hemodialysis (100 male, mean age 49±29 [16–80] years, and mean duration of hemodialysis 98±66 [12–228] months) were enrolled in this study. Serological markers for HBV and HCV were determined with immunoenzymatic assay (ELISA) by using commercial diagnostic kits (Access and BioRad, Beckman-Coulter). HCV-RNA (Cobas Amplicor HCV kit) and HBV-DNA (Artus GmbH HBV kit) were determined quantitatively by polymerase chain reaction. Results. Among the patients screened, 25 (13.3%) had HBV infection alone and 38 (20.2%) had HCV infection alone, while seven (3.7%) had dual infection of both viruses. Serological markers for occult hepatitis B and occult hepatitis C were positive in five (2.7%) and nine (4.8%) of the patients, respectively. Isolated anti-HBc was positive in 12 (6.4%) of all patients, three (7.9%) of the patients with anti-HCV and two (40%) of the patients with occult hepatitis B. Isolated anti-HBc positivity was more frequent in patients with occult hepatitis B than in those without (40% [2/5] vs. 5.5% [10/183], p=0.002). None of the patients with HCV had occult hepatitis B. Conclusions. Both occult and non-occult forms of HCV infection are more prevalent than HBV infection in hemodialysis patients. Especially the patients with isolated anti-HBc positivity should be tested for probable occult hepatitis B infection.     

Effects of Low Sodium Dialysate in Chronic Hemodialysis Patients: An Echocardiographic Study

Background. Chronic kidney disease (CKD) and hemodialysis (HD) patients who cannot restrict sodium consumption in their diets sometimes develop significant saline excess and hypertension between dialyses. This study assessed the effect of relatively low sodium dialysate dialysis on changes of echocardiography in hemodialysis patients. Methods and Results. Eighteen patients with end stage renal failure on chronic HD were studied (8 females, 10 males) with a mean age 48.3 ± 14.6 (24–70) years. The mean time on HD was 30.8 ± 14.0 (12–60) months. Patients with hematocrit levels under 24% were excluded from the study. In all patients, echocardiography was performed thrice weekly before and after eight-week HD treatment with low sodium dialysate hemodialysis by the same operator (135 mEq/L for patients with sodium levels less than 137, 137 for patients with sodium levels over 137). Left atrium (LA) and left ventricle (LV) volumes and ejection fractions were measured, specifically: LV systolic diameter (LVSD), LV diastolic diameter (LVDD), interventricular septum (IVS), tricuspid regurgitation (TR), mitral regurgitation (MR), pulmonary artery pressure (PAP), and inferior vein cava diameter (IVCD). Results. In terms of echocardiographic parameters, LVSD, TR, PAP, and IVCD were statistically decreased after low-sodium dialysate treatments (p?=?0.002, 0.04, 0.013, and 0.00, respectively). Predialysis systolic and diastolic blood pressure (BP), post-dialysis systolic blood pressure, and interdialytic weight gain was statistically decreased when compared to basal levels (p?=?0.00, p?=?0.011, p?=?0.022, p?=?0.001, respectively). Conclusion A reduction of the dialysate sodium concentration based on the predialysis sodium levels of the patients could reduce the systolic BP and decrease the volume load on the heart as assessed by echocardiography. Within this short period, postdialysis diastolic BP could not be lowered. The effect of this approach should be studied in broad and lengthy series.     

The Effect of Renal Replacement Therapies on Serum Gastrointestinal System Hormones

Background. The kidney is a major site for the inactivation, degradation, and clearance of a variety of peptide hormones. It has been shown that the uremia increases or decreases gastrointestinal system (GIS) hormones. Moreover, studies investigating the serum GIS hormones levels in chronic renal failure (CRF) were conducted mainly in a particular period of the renal replacement therapy, and the changes caused by continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) could not be fully demonstrated. In this study, we investigated the effect of CAPD and HD on serum GIS hormones (amylase, lipase, trypsinogen, and gastrin) levels in CRF patients who were diagnosed for the first time. Methods. Serum amylase, lipase, trypsinogen, and gastrin levels were measured in 36 patients who were just diagnosed with CRF, 22 patients with CAPD and 14 patients with HD. GIS hormones of these patients were measured before treatment and three months from the beginning of CAPD and HD treatment. As the control group, 20 normal healthy cases with well-matched age and gender were used. Results. The mean serum amylase, lipase, secretin, and gastrin levels were found meaningfully decreased according to the beginning values at third months of the CAPD and HD treatment. However, they were higher than control group. Conclusion. In patients receiving CAPD or HD as renal replacement therapy, GIS hormone levels were found to be lower, albeit higher than the healthy control group.     

The Prevalence and the Characteristics of Tuberculosis Patients Undergoing Chronic Dialysis Treatment: Experience of a Dialysis Center in Southeast Turkey

Tuberculosis remains a significant health problem for patients receiving chronic dialysis. The purpose of this study was to evaluate the prevalence, clinical characteristics, and outcomes of tuberculosis among patients with end-stage renal failure (ESRF) undergoing chronic hemodialysis and continuous ambulatory peritoneal dialysis. Between 1999 and 2006, we diagnosed 21 active tuberculosis patients among a total of 674-dialysis patient in our dialysis center (582 patients on hemodialysis and 92 patients on continuous ambulatory peritoneal dialysis program). Fourteen patients developed extrapulmonary tuberculosis (generally tuberculous lymphadenitis, n = 8) and seven patients developed pulmonary tuberculosis. All patients who developed tuberculosis after starting dialysis had low creatinine clearances and, in general, anemia and hypoalbuminemia. Three of patients greater than 40 years died. In conclusion, tuberculous lymphadenitis was the most frequent form of extrapulmonary tuberculosis in our dialysis population. If no cause is found despite extensive investigations in an end stage renal failure case with fever, loss of weight, and/or atypical lymphadenopathy, the physician should consider the possibility of tuberculosis. Finally, it was considered that ESRF is associated with depressed immune system and elevated risk of tuberculosis; thus, in this population, clinicians must evaluate patients carefully.