连续性肾脏替代治疗时枸橼酸药物代谢动力学数学模型的构建

Objective To establish a citrate pharmacokinetics model which is applied to evaluate the risk of citrate accumulation in patients with liver dysfunction in the continuous renal replacement treatment (CRRT) with regional citrate anticoagulation (RCA). Methods The source of citrate for extracorporeal anticoagulation, the body clearance and filter elimination of citrate, which were the three major citrate fluxes of systemic citrate level, were combined into a single-pool, first order kinetic equation. The data from a published clinical study of systemic citrate kinetics in the intensive care unit patients with or without liver cirrhosis were adapted and the citrate kinetic equation was applied to predict the risk of systemic citrate accumulation in patients with normal, impaired and absent liver clearance while different RCA-CRRT protocols were carried out. Results The single pool, first order citrate kinetic modeling equation was as follows:Csys=C(0)·e-[(clb+clf)·t/V]+G/CLb+CLf×(1-e-[(clb+clf)·t/V])There was excellent agreement between published citrate measurements and our predictions. Kinetic modeling showed that the plasma citrate concentration of patients with normal citrate body clearance was no more than 1 mmol/L during common RCA-CRRT. The model predicted that when the single pass fractional extraction of citrate on the artificial kidney was above 66％, systemic steady citrate concentration would be among the safe range even in patients of impaired body metabolism of citrate.Conclusions The citrate kinetic model of RCA-CRRT can predict the risk of systemic citrate accumulation and provide the basis for designing the safe RCA-protocols for the patients with impaired body clearance of citrate.     

经远端桡动脉路径行冠脉造影和经皮冠状动脉介入治疗的安全性和有效性Meta分析

目的 通过Meta分析评估经远端桡动脉路径（distal radial access, DRA）行冠脉造影（coronary angiography,CAG）和经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）的安全性和有效性。DRA是一个新的手术路径，已发表的一些随机对照试验结果不完全一致，其安全性和有效性仍存在争议。方法 检索2017年1月1日至2022年9月1日发表在PubMed、Embase、Cochrane、万方、中国知网、维普数据库的文献，筛选出符合要求的随机对照试验，提取数据后进行Meta分析。结果 检索到537项研究，最终纳入18项随机对照试验进行分析（共7 143例患者）。DRA与桡动脉路径（transradial artery access,TRA）相比，桡动脉闭塞（radial artery occlusion,RAO）发生率更低（RR:0.27,95%CI:0.18～0.39,P<0.001,I2=10.4%），穿刺部位血肿发生率无统计学差异（RR:0.89,95%CI:0.67～1.18,P=0.417,...     

中医经方治疗红皮病型银屑病验案一则

红皮病型银屑病是寻常型银屑病的一种少见、病情严重的变型。本案为运用经方配合局部治疗一长期使用激素后反复发作的红皮病型银屑病并继发肺部感染患者的成功案例,从经典的六经辨证出发,灵活运用真武汤、越婢汤合方加减,方简而效速。该患者全程未使用西医药物,其良好的治疗效果肯定了中医六经辨证及经方治疗反复发作的重型红皮病型银屑病的疗效和重要意义。通过对本案例诊治过程中“理、法、方、药”的分析,期望给临床医生进一步加深经方运用的认识和思考。     

血清胱蛋白酶抑制剂C能用于周围动脉疾病腔内治疗术后造影剂肾病的诊断吗?

目的 分析腔内治疗周围动脉疾病术后造影剂肾病( CIN)发生的危险因素,以及血清胱蛋白酶抑制剂C(Cys C)与血清肌酐(Scr)在诊断肾损伤时的符合情况.方法 本研究为前瞻性、单中心研究,2010年7月至2011年4月在本院血管外科接受非急诊周围动脉疾病腔内治疗术的住院患者入选.根据造影后Scr升高≥25％标准判断是否发生CIN,分为非CIN组和CIN组,比较两组患者的一般临床资料和血液生化指标;行相关危险因素的Logistic回归分析;分析造影前后Scr和血清Cys C变化分布以及两者诊断CIN的符合情况.结果 367例患者入选.CIN组并发糖尿病比例、造影剂用量、术前利尿剂合并用药比例均显著高于非CIN组,差异有统计学意义(P分别＜0.05、＜0.01、＜0.01).Logistic回归分析结果显示,并发糖尿病、造影剂用量为CIN的危险因素.采用术后24 h血清Cys C任何程度的升高、升高≥5％、≥8％、≥10％、≥15％、≥25％及绝对值升高≥0.2 mg/L标准预测Scr诊断标准诊断的CIN的灵敏度均较低.维恩图显示两指标诊断肾损伤患者的集合重叠区域均较小.结论 造影剂用量、糖尿病为CIN发生的独立危险因素.造影后血清Cys C升高标准与Scr标准在诊断肾损伤上符合情况较差.     

局部枸橼酸抗凝在连续性肾脏替代治疗中的应用

<正>体外循环抗凝技术是保证连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)能否顺利、有效进行的关键的环节,但也是CRRT面临的最严峻的挑战之一。临床上,需要接受CRRT治疗的危重病患者往往存在活动性出血、近期重大手术、严重创伤、凝血功能障碍等高危出血状况,传统的全身肝素化抗凝可显著增加出血风险甚或造成肝素诱导血小板减少,而无肝素抗凝往往因为体外循     

IgA肾病免疫治疗的循证医学

原发性IgA肾病是世界范围内最常见的肾小球肾炎,是引起终末期肾功能衰竭的重要原因之一。迄今为止,其发病机制仍不完全明了,也无统一的治疗方案。本文就近年来免疫抑制剂治疗IgA肾病的循证医学进展进行综述。     

危重病评分系统预测急性肾损伤患者预后优于RIFLE分级

目的评价并比较序贯性脏器衰竭评分(sequential organ failure assessment,SOFA)、急性生理学与慢性健康状况评分(acute physiology and chronic health evaluation,APACHE)Ⅱ、简明急性生理学评分(simplified acute physiology score,SAPS)Ⅱ和Liano评分4种危重病评分系统及RIFLE标准对急性肾损伤(acute kidney injury,AKI)患者的预后评估价值。方法本研究为前瞻性、单中心研究,收集2008年12月到2009年11月复旦大学附属华山医院各种病因引起的AKI患者。AKI的诊断标准为RIFLE的肌酐标准,除外肾后性、肾小球性、肾血管性和间质性肾炎等引起的急性损伤。研究的主要终点是28d死亡率。比较存活组和死亡组的RIFLE分级、SOFA、APACHEⅡ、SAPSⅡ和Liano评分,并进行各种评分系统对死亡的ROC曲线分析,同时将4种评分方法根据RIFLE分级进行分层分析。结果共入选194例符合入选标准的AKI患者。存活组和死亡组的RIFLE分级、AKI病因、是否需要透析差异无统计学意义(P0.05)。死亡组的机械通气比例、SOFA、APACHEⅡ、SAPSⅡ和Liano评分显著高于存活组(P0.001)。SOFA、APACHEⅡ、SAPSⅡ和Liano评分预测死亡的受试者工作特性(ROC)曲线下面积分别为0.900、0.885、0.888、0.875(均P0.001),而RIFLE的ROC曲线下面积为0.566(P0.05)。按AKI的RIFLE级别进行分层分析时发现,4个评分方法在衰竭组(Fc)ROC曲线下面积最大,其中又以Liano评分最高。结论 RIFLE分级对AKI患者的预后无明显的判断价值,而危重病评分包括SOFA、APACHEⅡ、SAPSⅡ和Liano评分对AKI的预后具有良好的预测价值。     

连续性肾脏替代治疗时枸橼酸药物代谢动力学数学模型的构建

目的 构建连续性肾脏替代治疗（CRRT）时枸橼酸药物代谢动力学数学模型,并运用该模型预测肝功能异常患者进行局部枸橼酸抗凝（RCA）-CRRT时发生枸橼酸蓄积的风险。 方法 将体外枸橼酸输注速度、体内枸橼酸药物动力学、体外枸橼酸透析清除动力学等影响血浆枸橼酸浓度的参数综合,构建一个服从一室模型、一级消除动力学的枸橼酸药物代谢动力学数学模型。运用模型采用文献报道的肝硬化和非肝硬化危重患者体内枸橼酸药物代谢动力学参数,预测枸橼酸代谢正常、肝功能损害及肝衰竭的患者在实施不同CRRT治疗方案时发生枸橼酸蓄积的风险。 结果 枸橼酸药物代谢动力学数学模型： 。由模型得到的血浆枸橼酸浓度预测值与文献报道的实测浓度拟合理想。根据模型推算,体内枸橼酸清除正常的患者在接受RCA-CRRT时,血浆枸橼酸浓度始终﹤1 mmol/L;当CRRT抽提分数高于66%时,肝功能异常患者体内枸橼酸稳态浓度将低于中毒浓度。 结论 枸橼酸药物代谢动力学模型可预测危重患者在实施RCA-CRRT时发生枸橼酸蓄积的风险,并为体内枸橼酸代谢清除障碍的患者选择合适安全的RCA-CRRT方案提供理论依据。     

连续性肾脏替代治疗时枸橼酸药物代谢动力学数学模型的构建

Objective To establish a citrate pharmacokinetics model which is applied to evaluate the risk of citrate accumulation in patients with liver dysfunction in the continuous renal replacement treatment (CRRT) with regional citrate anticoagulation (RCA). Methods The source of citrate for extracorporeal anticoagulation, the body clearance and filter elimination of citrate, which were the three major citrate fluxes of systemic citrate level, were combined into a single-pool, first order kinetic equation. The data from a published clinical study of systemic citrate kinetics in the intensive care unit patients with or without liver cirrhosis were adapted and the citrate kinetic equation was applied to predict the risk of systemic citrate accumulation in patients with normal, impaired and absent liver clearance while different RCA-CRRT protocols were carried out. Results The single pool, first order citrate kinetic modeling equation was as follows:Csys=C(0)·e-[(clb+clf)·t/V]+G/CLb+CLf×(1-e-[(clb+clf)·t/V])There was excellent agreement between published citrate measurements and our predictions. Kinetic modeling showed that the plasma citrate concentration of patients with normal citrate body clearance was no more than 1 mmol/L during common RCA-CRRT. The model predicted that when the single pass fractional extraction of citrate on the artificial kidney was above 66％, systemic steady citrate concentration would be among the safe range even in patients of impaired body metabolism of citrate.Conclusions The citrate kinetic model of RCA-CRRT can predict the risk of systemic citrate accumulation and provide the basis for designing the safe RCA-protocols for the patients with impaired body clearance of citrate.     

浅析《神应经》的学术价值

《神应经》是明代针灸学家陈会所著,其记载的内容对后世针灸发展影响深远,其理念深受道家医学影响,遵循天人相应观念,在取穴、配穴及补泻手法三方面皆有建树。在取穴方面,强调穴位定位的精准,主张一穴一法,注重揣穴,倡导适时使用"同身寸"和"折量之法";在配穴方面,灵活使用前后配穴法、本经配穴法、表里经配穴法等配穴法;在补泻方面,提出针刺须以人体左右分补泻,并首创先泻后补手法,丰富了针灸手法的多样性。