近年来,肿瘤已成为继心血管疾病后人类的第二大健康杀手,新型抗肿瘤药物的研发应用已大大提高了肿瘤患者的生存率.恶性肿瘤的发生、发展与治疗过程中常伴随肾损伤,可因肿瘤本身、肿瘤代谢紊乱及肿瘤治疗措施所致;同时,CKD患者特别是透析患者的肿瘤发生风险较普通人群高,合并肿瘤的继发CKD患者生存率降低.肾功能水平与肿瘤患者的预后密切相关.现对临床上如何评估肿瘤患者的肾功能进行阐述与讨论,以期帮助广大肾科、肿瘤科医师针对肿瘤合并肾损伤患者进行合理评估、及时诊断和早期干预,从而改善其预后.

目的 分析长期行腹膜透析治疗的患者恶性肿瘤发生率及其发生的潜在危险因素.方法 回顾性分析2010年1月-2020年12月海军军医大学第一附属医院收治的819例行维持性腹膜透析治疗的终末期肾病患者的临床资料,总结发生恶性肿瘤患者的临床特征.采用x2检验或Fisher确切概率法进行组间比较分析,多因素logistic回归分析恶性肿瘤发生的危险因素.结果 819例患者中,发生恶性肿瘤32例(3.91％),男25例、女7例,年龄为(68.2±9.9)岁,透析龄为(46.8±20.5)个月,消化道肿瘤患者占比最高(40.63％,13/32).根据尿素清除指数(Kt/V)值将患者分为透析不充分组(180例)和透析充分组(639例),透析不充分组恶性肿瘤发生率为4.44％(8/180),透析充分组恶性肿瘤发生率为3.76％(24/639),两组间差异无统计学意义(P＞0.05).发生恶性肿瘤组的男性患者比例和有肿瘤家族史患者比例均显著高于未发生恶性肿瘤组(P值均＜0.05),年龄显著大于未发生恶性肿瘤组(P＜0.01),透析龄显著长于未发生恶性肿瘤组(P＜0.05),血红蛋白和白蛋白水平均显著低于未发生恶性肿瘤组(P值均＜0.05).多因素logistic回归分析结果显示,男性(OR=3.326,95％CI为1.315～8.792)、透析龄≥5年(OR=1.874,95％CI为1.109～2.672)、恶性肿瘤家族史(OR=3.126,95％CI为1.283～5.278)和白蛋白＜30 g/L(OR=2.014,95％CI为1.168～3.235)是行腹膜透析治疗患者恶性肿瘤发生的独立危险因素(P值均＜0.05).结论 行腹膜透析治疗患者发生恶性肿瘤的独立危险因素有男性、透析龄≥5年、恶性肿瘤家族史和白蛋白＜30 g/L.应加强对高危人群的监测,以早期发现、早期诊断和早期治疗,进而改善患者的预后.

Objective:To investigate the effect of hyperbaric oxygen (HBO) intervention on oxidative damage in human retinal pigment epithelium (RPE) cells cultured in vitro in normoxic and hypoxic states. Methods:The ARPE-19 cells cultured in vitro in normoxic state and the ARPE-19 cells cultured in vitro in hypoxic state (incubated in 200 μmol/L CoCl 2) were randomly divided into control groups (normoxic control group and hypoxic control group) and HBO groups [normoxic HBO group (0.15 MPa HBO group, 0.20 MPa HBO group, 0.25 MPa HBO group) and hypoxic HBO groups (hypoxic state + 0.15 MPa HBO group, hypoxic state + 0.20 MPa HBO group, hypoxic state + 0.25 MPa HBO group)]. Each HBO group was exposed to pure oxygen for 60 and 90 min, respectively, at 24 h intervals, for a total of two exposures. The proliferation viability of RPE cells in each group was measured by microculture tetrazolium assay (MTA); the expression level of 8-hydroxydeoxyguanosine (8-OHdG) in RPE cells was measured by immunocytochemistry (ICC); and the expression level of human 8-hydroxyguanine glycosidase (hOGG1) in RPE cells was measured by Western blotting. Each set of experiments was repeated three times. Results:After 60 min and 90 min of HBO intervention, compared with the normoxic control group, the optical density 570 (OD 570) values of normoxic RPE cells in each normoxic HBO group were decreased ( P<0.01), and continued to decrease with the increase of HBO pressure ( P<0.05); the expression levels of 8-OHdG were increased significantly ( P<0.01), and continued to increase with the increase of HBO pressure ( P<0.05); the expression levels of hOGG1 were increased ( P<0.01), and those in the HBO intervention groups after 60 min HBO intervention were decreased with the increase of HBO pressure ( P<0.05). Compared with the hypoxic control group, the OD 570 values of hypoxic RPE cells in each hypoxic HBO group were increased ( P<0.01), and those in the HBO intervention groups after 60 min HBO intervention were increased with the increase of HBO pressure ( P<0.01); the expression levels of 8-OHdG were decreased significantly (60 min P<0.01, 90 min P<0.05), and those in the HBO intervention groups after 60 min HBO intervention were decreased with the increase of HBO pressure ( P<0.05); the expression levels of hOGG1 were increased significantly ( P<0.01), and continued to increase with the increase of HBO pressure (60 min P<0.05, 90 min P<0.01). Conclusion:HBO exposure can cause oxidative damage of normoxic RPE cells, however, it can ameliorate the oxidative damage of RPE cells caused by hypoxia.

目的 初步探究DDR1对TGF-β1诱导的腹膜间皮细胞间质转化的影响.方法 体外培养人腹膜间皮细胞(HPMCs),并将HPMCs细胞分为:control组(0μg/L TGF-β1处理HPMCs)、NC-siRNA组(HPMCs细胞转染DDR1-siRNA无关片段)、DDR1-siRNA组(HPMCs细胞转染DDR1-siRNA)、TGF-β1组(5μg/L或10μg/L TGF-β1处理HPMCs细胞)、TGF-β1+DDR1-siRNA组(10μg/L TGF-β1处理后的HPMCs细胞转染DDR1-siRNA).CCK-8检测细胞活力;Western blot及免疫荧光检测上皮间质转化(epithelial-mesenchymal transition,EMT)相关蛋白(α-SMA和E-cadherin)表达;RT-PCR和Western blot检测各组DDR1 mRNA和蛋白表达水平.结果 与control组相比,TGF-β1组HPMCs细胞活力、α-SMA表达、DDR1 mRNA和蛋白表达都升高,E-cadherin表达降低(均P<0.05).与NC-siRNA组比较,DDR1-siRNA组DDR1 mRNA和蛋白表达都下降(均P<0.05).与TGF-β1组相比,TGF-β1+DDR1-siRNA组 α-SMA表达下降(P<0.05),E-cadherin表达上升(P<0.05).结论 DDR1可以促进TGF-β1诱导的HPMCs上皮间质转化,加重腹膜间质纤维化的进程.

目的 探讨制作及使用肾性贫血家庭管理手册,以提高腹膜透析患者的红细胞生成素(erythropoietin,EPO)注射达标率.方法 选取2017年1月～12月长海医院肾内科腹膜透析中心100例长期门诊规律随访的腹膜透析患者作为观察对象,根据门诊随访的贫血治疗达标率,了解EPO的用药情况,制作具有专科特色的肾性贫血家庭管理手册. 结果 100例腹膜透析患者在使用该手册9个月后EPO注射达标率、贫血治疗达标率均较干预前明显提高(t/X值分别为35.861,19.837;P值分别为＜0.001,＜0.001),且干预6个月或9个月后EPO注射达标率及贫血治疗达标率均显著高于干预3个月后,差异有统计学意义(x2值分别为4.204,17.195;P值分别为0.040,＜0.001;X2值分别为4.568,6.258;P值分别为0.033,0.012).结论 肾性贫血家庭管理手册给予患者和家属EPO用药提醒和指导,医护人员利用手册对患者进行有效的监督和用药调整,在腹膜透析患者贫血管理中起到了有效的作用,值得广泛推广.

[Abstract] L3 skeletal muscle index (L3 SMI) is an emerging nutritional assessment tool. It has been well documented that L3 SMI can correctly reflect body skeletal muscle mass, and can be used to evaluate the prognosis of sarcopenia, chronic liver disease and many malignant tumors. Moreover, it can also be used to predict some surgical complications. This review sums up the recent advances of L3 SMI in evaluating prognosis of diseases. [Key words] L3 skeletal muscle index; sarcopenia; nutritional assessment; prognosis [Acad J Sec Mil Med Univ, 2019, 40(4): 420-425]

目的 应用Framingham风险评估预测慢性肾脏病(CKD)患者未来10年心血管疾病的患病风险,并对CKD相关危险因素与患者未来10年心血管疾病的患病风险进行相关性分析.方法 选择于2014-2017年在上海长海医院CKD随访门诊长期随访且未进行透析治疗的患者122例,其中男85例、女37例,平均年龄为(61.93±11.65)岁.根据估测的肾小球滤过率(eGFR)进行肾功能不全分期,CKD 2期4例、CKD 3期61例、CKD 4期46例、CKD 5期11例.应用Framingham风险评估预测CKD患者未来10年心血管疾病的患病风险,并根据结果将患者分为低风险组(患病风险＜5％)、中风险组(患病风险为5％～＜10％)和高风险组(患病风险≥10％).比较各组的一般资料和尿蛋白水平,并对CKD相关指标与患者未来10年心血管疾病的患病风险进行相关性分析.结果 随着患者未来10年心血管疾病患病风险的增大,男性患者所占比例逐渐升高(F=24.62,P=0.000)、年龄逐渐增大(F=43.98,P=0.000)、病程逐渐延长(F=12.70,P=0.000),且3组间的差异均有统计学意义(P值均＜0.05).3组间的BMI、收缩压(SBP)的差异均无统计学意义(P值均＞0.05).随着患者未来10年心血管疾病患病风险的增大,尿蛋白/尿肌酐(H=7.024,P=0.030)和尿蛋白定量(H=9.148,P=0.010)显著上升,但两组间比较仅低风险组与高风险组间的差异有统计学意义(P值均＜0.05).CKD伴有高血压(r=-0.156)、糖尿病(r=-0.170),以及尿蛋白/尿肌酐(r=0.160)和尿蛋白定量水平(r=0.166)与患者未来10年心血管疾病患病风险相关(P值均＜0.05);而CKD分期,以及血肌酐、尿素氮、尿酸、血白蛋白、血红蛋白、血钙、血磷、甲状旁腺激素(PTH)水平与CKD患者未来10年心血管疾病患病风险均不相关(P值均＞0.05).结论 CKD患者心血管疾病患病风险普遍偏高,CKD患者未来10年心血管疾病患病风险与其是否伴有高血压、糖尿病和尿蛋白水平相关.在临床工作中应积极治疗蛋白尿,密切关注和随访心血管事件并积极干预.

肠道微生态作为肠黏膜生物屏障的重要组成部分,保护肠道免于病原菌的侵入,辅助营养吸收.肠道微生态失调参与多种慢性疾病,如糖尿病、心血管疾病.近年来一些研究证实肠道微生态和慢性肾病存在联系[1-3],而肠道微生态与糖尿病肾病(DKD)之间的研究较少,因此我们将通过阐述肠道微生态和糖尿病、慢性肾病的关系,探讨肠道微生态与DKD之间的联系,并基于肠道微生态寻找治疗DKD的新方法.

将以微课为基础的翻转课堂引入肾内科临床轮转教学,按照教学大纲和翻转课堂教学实施要求构建课程体系,制作相应微课与翻转课堂教案,应用于住院医师规范化培训、住院医师专科培训和实习医师肾内科临床轮转,并与传统教学模式进行比较.结果显示,翻转课堂适用于临床轮转教学,具有激发轮转医师学习主动性、增强带教医师教学积极性、提高带教质量与效率的优势,有助于实现教学相长.

腹膜透析是终末期肾脏病患者治疗中一项重要技术,其具有保护残余肾功能,价格相对低,操作方便等优点,容易被患者及家属接受,随着PD的体外连接系统的不断完善,腹膜透析相关性腹膜炎的发病率已明显下降,但其仍是腹膜透析患者退出PD及死亡的主要原因[1]. 而引起腹膜透析相关性腹膜炎主要原因是PD交换时污染,表现在无菌操作不规范,操作不当等方面,佩戴口罩是无菌操作中的重要组成部分,是预防腹膜炎简单有效手段之一. 为了解患者在腹膜透析实际操作过程中口罩佩戴的真实情况,笔者对患者操作时的戴口罩情况进行了调查,分析原因,总结经验,以提高患者操作时戴口罩的依从性,从而减少腹膜透析相关性腹膜炎的发病率.

Objective To investigate the risk factors of peritoneal dialysis tube wrapping after dialysis tube placement.Methods A total of 626 patients undergoing conventional peritoneal dialysis tube placement in the department of nephrology of Changhai Hospital between January 2007 and December 2015 were collected in this study.Postoperative omental wrapping led to inadequate drainage in 29 patients (package group),while no omental wrapping happened in the other 597 patients (control group).Logistic regression analysis was used to explore the risk factors of omental wrapping after peritoneal dialysis tube placement.Results In the package group,omental wrappingoccurred in 2 cases on day 1,in 4 cases on day 1 to 5,in 10 cases on day 6 to 10,in 10 cases on day 11 to 15,and in 3 cases on day 15 after tube placement.The body mass index (BMI),height and parathyroid hormone (PTH) levels of package group were significantly lower than those of control group (all P＜0.05).The constituent ratio of patients with constipation and postoperative pain scores of package group were significantly higher than those of control group (both P＜ 0.05).The ambulation time (the first-time ambulation after tube placement) of package group was significantly longer than that of control group (P＜0.05)..Serum potassium,triglyceride and cholesterol levels of package group were significantly higher than those of control group (P ＜ 0.05).But there were no significant differences in terms of the distance between the incision and the symphysis pubis,or the levels of hemoglobin,serum calcium,iron,phosphorus,creatinine,albumin between the two groups (all P＞0.05).Multivariate Logistic regression analysis showed that postoperative pain score (OR =2.311,95％ CI 0.975-5.479),ambulation time (OR =2.192,95％ CI 1.337-3.595) and triglyceride level (OR =2.160,95％ CI 1.427-5.319) were independent risk factors of omental wrapping after peritoneal dialysis (all P ＜ 0.05).Conclusion The omental wrapping mostly occurs within 2 weeks after peritoneal dialysis tube placement.Postoperative pain score,ambulation time and triacylglycerol level are the independent risk factors of omental wrapping.

Objective To study the effect of NaF poisoning on renal cell apoptosis in rats, and the mechanism of apoptosis was investigated from the point of view of anti apoptosis.Methods 48 male SD rats weighing between 80~100 g, the rats were randomly divided into 4 groups: control group, low fluoride group, medium fluoride group and high fluoride group, 12 rats in each group, and deionized water of 0 mg/L, 50 mg/L, 100 mg/L and 200 mg/L NaF respectively, continuous exposure to 120 d.The general state of the rats was observed, the formation of dental fluorosis, weight change and urine fluoride content were measured;preparation of renal cell suspension, the apoptosis rate of renal cells was measured by flow cytometry.Real time fluorescence quantitative RT-PCR and Western blot were used to detect the expression of Bcl-2 and Bax genes in renal tissues.Results 60 d and 120 d in NaF exposure, the weight of high fluoride group rats were significantly lower than the control group (P<0.05).The dental fluorosis incidence, the fluoride content in the urine and renal cell apoptosis rate of the three NaF treatment group were significantly higher than control group (P<0.05).With the increase of sodium fluoride concentration, the expression of Bcl-2 mRNA and protein showed an upward trend, the expression of Bax mRNA and protein showed a downward trend, and the difference was significant (P<0.05).Conclusion NaF can induce apoptosis of renal cells by inhibiting Bcl-2 and promoting the expression of Bax, and with the increase of sodium fluoride concentration, the apoptosis rate increased gradually.

Objective To investigate the phagocytosis and killing ability of macrophage under TGF-β intervention.Methods Using TGF-β intervene phagocytosis and killing assay of activated macrophages in vitro.Phagocytic index of macrophage and the intracellular growth of Cryptococcus neoformans was observed respectively.Nitric oxide (NO) production was detected using the Griess regent kit,and then comparing the changes of NO production in macrophages under the TGF-β intervention.Results The phagocytic index with the treatment of TGF-β decreased by 43.9 ％,significantly lower than control group (P＜ 0.05).While the production of NO increased and the intracellular fungal burden significantly declined under the intervention of TGF-β (P＜0.05).Conclusion Chemotaxis and phagocytosis of activated macrophage were inhibited under the intervention of TGF-β in vitro,but the NO production increased and killing ability enhanced.

临床营养是疾病综合治疗的重要组成部分,对疾病的预防、治疗和康复起着关键的作用.营养治疗甚至是一些疾病,如肥胖、糖尿病、高血压病的首选治疗方法.目前,我校在护理本科生中开设了《临床营养学》并作为一门必修课.然而,未来医疗行业的主力军——五年制临床医学本科生却未开设这门课程.以下我们就五年制医学生中开设临床营养教学的重要性和可行性做一些探讨,并期待《临床营养学》能在五年制医学生中作为必修课开设.教学相长,同时也促进临床营养专业的健康发展.

目的：探讨临时血液透析对腹透患者残余肾功能的影响。方法：追踪随访我院腹透中心2013年1月~2014年1月开始规律腹膜透析的患者，按照规律腹透前有无行临时血液透析治疗分为临时血透组和常规腹透组，分别记录年龄、性别、原发病、体质指数（ body mass index，BMI）、血压、血脂、白蛋白、24 h尿蛋白定量、脑钠肽（ brain natriuretic peptide， BNP）、C反应蛋白（ C-reactive protein，CRP）、全段甲状旁腺激素（ intact parathyroid hormone，iPTH）、腹膜转运特性、残余肾功能（ residual renal function，RRF）、24 h尿量等实验室指标。结果：两组患者年龄、原发病、初始尿量、初始RRF等差异均无统计学意义。规律腹透半年后临时血透组患者24 h尿量及RRF与常规腹透组相比，差异无统计学意义（ P>0．05）；规律腹膜透析1年后临时血透组患者24 h尿量较常规腹透组患者明显下降（945．3±481．6）ml vs（1287±608．9）ml，但差异无统计学意义（P>0．05）。结论：尽管随访1年后临时血液透析组与常规腹透组尿量及RRF差异无统计学意义，但规律腹膜透析前行临时血液透析可能导致腹透患者尿量进一步下降，加速腹透患者残余肾功能的丢失。

茶道养生 茶被誉为中国的“国饮”,在传统文化中占有重要的位置,茶道养生一直传承至今.研究证实,茶叶确实含有与人体健康密切相关的成分,不仅具有提神、清热解暑、消食化痰、去腻减肥、清心除烦、解毒醒酒、生津止渴、降火明目、止泻除湿等作用,还对辐射病、心脑血管病、癌症等疾病有一定的预防功效.茶叶的保健功效之多、作用之广,是其他饮品不可替代的.

目的：：研究腹腔内使用低分子肝素( LMWH)对腹膜透析患者透析效能及安全性的影响。方法：将43例患者随机分为两组,试验组21例,对照组22例。试验组每天往腹透液中加入4000 U LMWH,对照组每天往腹透液中加入等量的生理盐水,治疗持续30 d。治疗结束后,所有患者随访观察1年。结果：与对照组相比,试验组的4 h D/Pcr、4 h D/Purea和4 h D/Palb明显降低；净超滤量( nUF)明显升高；血液中CRP、IL-6、IL-8和TNF-α的浓度均显著降低；血液中IL-4的浓度显著升高；腹透液CA125浓度显著升高。两组的凝血功能、出血相关并发症和腹透感染的发生率均差异无统计学意义(P>0.05)。结论：LMWH可以通过抑制腹腔慢性炎症、腹膜纤维化和保护腹膜间皮细胞,降低腹膜对小分子溶质的通透性,改善腹膜的超滤功能,并减少腹腔蛋白质的丢失。

Nursing students are lack of experiences when they start clinical practice, which leads to the frequent occurrence of nursing adverse events related to nursing students.Reason had put forward Organizational Accident Model, which pointed out that the system or organizational failures underlying the errors account the most for an adverse event,though it is partly caused by personal negligence or unskillfulness.The article analyzed a case of error medication administration relevant to a nursing student by using Reason model, in order to find out the un-derlying environmental and organizational defects and propose some measures avoiding similar events.

Objective The cancer risk of patients with diabetes mellitus who are treated by metformin declines remarkably in comparison to patients receiving other drug therapies.The article was to investigate the relationship between antineopastic activity and fatty acid synthase (FASN) of metformin in human hepatocellular carcinoma cell(HCC) line HepG2. Methods HepG2 cells were treated with various concentrations of metformin( 0, 1, 5, 10, 15 mmol/L) for 24, 48 and 72 h respectively and cell growth was assessed by CCK-8 assay.Positive control(paclitaxel 10μg/mL) and negative control(metformin 0mmol/L) were set up simultaneously.After being treated with doses of metformin(0, 5, 10,15mmol/L) for 72h, protein expression levels of AMPKα、P-AMPKα、FASN、P-mTOR and P-Akt were measured by western blotting analysis and FASN mRNA expression levels were measured by RT-PCR. Results Being treated with vari-ous doses of metformin(1, 5, 10, 15 mmol/L) for 24, 48 and 72 h, the growth of HepG2 cells were inhibited by metformin in dose-dependent and time-dependent manner( P<0.05) .The growth inhibition rate approached 50%after being treated with metformin for 72 h, and the growth inhibition rate were all greater than 50%after being treated with 15 mmol/L of metformin.At 72 h after the treatment of various do-ses of metformin(0, 5, 10, 15 mmol/L) on HepG2 cells, the protein expression of P-AMPK increased with the rise of metformin concentra-tion, while the protein expressions of P-mTOR and FASN decreased as the metformin concentration increased.Compared with negative control group, the protein expression levels of P-AMPKα, P-mTOR and FASN all changed significantly in 10 mmol/L group and 15 mmol/L group(P<0.05).However, there was no significant difference as to the protein expression levels of P-Akt in various metformin concen-trations( P>0.05) .FASN mRNA expression levels decreased significantly in all metformin-treated groups( P<0.05) . Conclusion Met-formin actitiviates AMPK, inhibits mTOR and downregulates FASN, which are implicated in its antineopastic activity on HCC.Although metformin inhibits mTOR activation, it is not involved in Akt upregulation through a negative loop.

心血管疾病不是老年人的专利 很多人认为,只有到年老的时候,才需要注意心血管保护.一项在70万人中展开的调查显示,10年间,脑梗死、脑出血等疾病,在35岁男女人群中,发病率分别增加了136％和220％.心脑血管疾病已不是老年人的专利,心肌梗死、脑出血、脑血栓这些由动脉粥样硬化斑块引发的心脑血管疾病,对于中青年人来说,越来越不陌生了.