目的 探讨维持性血液透析(maintenance hemodialysis,MHD)患者自体动静脉内瘘近吻合口狭窄,数字减影血管造影(digital subtraction angiography,DSA)下经皮腔内血管成形术(percutaneous transluminal angioplasty,PTA)与内瘘血管狭窄段近端重建手术的效果比较.方法 搜集2017年6月至2019年6月在北京医院接受治疗的MHD患者自体动静脉内瘘近吻合口狭窄71例,根据手术方式分为PTA(扩张组)37例及内瘘血管狭窄段近端重建术(手术组)34例.比较两种治疗方法成功率,3个月、6个月及12个月的内瘘通畅率及对血管资源的保护情况.结果 两组性别、年龄、透析龄、内瘘使用时间和糖尿病所占比例比较差异无显著性.扩张组手术成功率100％,其中,3个月内瘘通畅率为97.30％、6个月内瘘通畅率为78.38％,12个月内瘘通畅率为51.35％,所有病例在围术期没有留置中心静脉导管作为透析通路,没有血管的损失.手术组手术成功率100％,其中3个月内瘘通畅率94.12％(χ2=0.443,P=0.506),6个月内瘘通畅率82.35％(χ2=0.177,P=0.674),12个月内瘘通畅率64.71％(χ2=1.295,P=0.255),与扩张组比较差异无显著性.手术组围术期有5例患者留置中心静脉导管作为血液透析通路,血管损失(2.43±0.93)cm.结论 PTA治疗自体动静脉内瘘近吻合口狭窄是有效安全的治疗手段,和同期内瘘重建术相比效果相当.PTA治疗可以减少中心静脉插管率,减轻患者痛苦,更能充分保护血管资源.

急性肾损伤(AKI )是全球范围常见的疾病之一,其发生率及死亡率呈逐年升高趋势.肿瘤患者由于感染、脓毒血症、溶瘤综合征(TLS )、肾脏侵犯及肿瘤相关治疗等因素而导致AKI的发生.AKI进一步延迟患者的住院时间,阻碍患者可选择的肿瘤治疗,最终影响其疗效及预后.目前临床医师对肿瘤相关肾脏损伤缺乏足够认识和重视.本文对肿瘤相关性AKI的危险因素、诊断及常见病因等进行阐述,以期提高临床对此类疾病的认识.

简单来说,临床上留取尿液分两种方式:单次尿和时间段尿(8小时和24小时). 首先,谈谈单次尿.对于单次尿液的留取,排尿时应该遵循清洁中段尿的方法,即适当的清洁尿道口(尤其女性),先排出少量尿液,让尿液适量的冲刷尿道后,开始留取尿液标本,女性应该注意清洁外阴,避免阴道分泌物污染尿液,影响检查结果.单次尿分晨尿和随机尿液,这两种尿液都是一次性留取,但其化验结果有可能相差很大,这是由于尿液的比重很容易受到饮食或饮水的影响所致.由于随机尿液可以是处于任何时间段,因此很容易受到上述因素的影响,从而导致尿液稀释,并影响尿液的化验结果,因此我们更推荐晨尿的方式,或者避免留取尿液前摄人大量的水分.

张老先生最近体检被提示有肾囊肿,即刻慌了神.医生根据诊断告诉他,这是良性囊肿,不用着急. 肾囊肿,也就是肾脏囊性病变,其病因可分为遗传性和非遗传性.非遗传性肾囊肿,按恶性风险程度可分为单纯性肾囊肿和复杂性肾囊肿.在体检超声检查中提示的肾囊肿,往往是单纯性肾囊肿,也是成人肾囊肿中最常见的一种,占肾囊性病的65％～70％.目前认为,单纯性肾囊肿是良性疾病,随着年龄增长,发病率逐年增高.

目的 了解间断静静脉血液滤过(intermittent venovenous hemofiltation,IVVH)预防老年慢性肾衰竭患者对比剂所致急性肾损伤(contrast-induced acute kidney injury,CI-AKI)的应用现状,探讨IVVH对老年慢性肾衰竭患者CI-AKI的预防作用.方法 回顾性分析2014年6月～2015年12月于北京医院心内科行冠状动脉造影检查和/或经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的39例老年(≥60岁)慢性肾衰竭患者相关临床资料.按照PCI术后是否行预防性血液净化措施,将患者分为IVVH组和非IVVH组,比较组间对比剂所致急性肾损伤发生率及相关临床资料.结果39例老年慢性肾衰竭患者,年龄(74.03±7.65)岁;IVVH组18例,非IVVH组21例.18例PCI术后行IVVH慢性肾衰竭患者:高血压肾病8例、糖尿病肾病3例、缺血性肾病2例、其他肾脏病5例;术前血肌酐(188.83±76.68)μmol/L,术前肾小球滤过率评估(estimated glomerular filtration rate,eGFR)(30.89±12.38)ml/(min·1.73d),含碘对比剂用量(176.67±69.11)ml;IVVH参数:血流速(155.56±9.84)ml/min,血滤置换液流速(29.73±6.42)ml/(kg·h),每次超滤量386.72±265.75ml.IVVH组和非IVVH组CI-AKI发生率分别为5.56％、42.86％,组间存在统计学差异(x2=5.252,P=0.022,).结论PCI术后行IVVH可能是降低老年慢性肾衰竭患者CI-AKI发生的有效措施.

目的 通过多频生物电阻抗法(multifrequency bioelectrical impedance analysis,MBIA)评估临床干体质量达标的维持性血液透析(maintenance hemodialysis,MHD)患者理想干体质量达标情况,明确氨基末端前体脑钠肽(N-terminal pro brain natrinuretic peptide,NT-proBNP)对本组患者容量超负荷的诊断价值.方法 选取血液净化中心临床干体质量达标的MHD患者共105例,采用MBIA法完成人体体液成分测定,得到细胞外液量(extracellular Water,ECW)与身体总水量(total body water,TBW)的比值(ECW％),确定理想干体质量是否达标,同时检测透前NT-proBNP,分析ECW％的相关影响因素,通过ROC曲线确定NT-proBNP定性诊断容量超负荷的最佳诊断临界值. 结果 应用MBIA法测定本组患者ECW％,平均值为0.39±0.01,以校正的ECW％应用公式确定本组患者理想干体质量,结果显示在本组患者中仍有51.4％(54/105例)的患者未达到理想干体质量.年龄与ECW％呈正相关关系(r=0.578,P=0.000);性别(r=-0.251,P=0.010)、脱水量(r=-0.226,P=0.020)、各点舒张压(r值分别为0.336、-0.374、-0.281,P值分别为0.000、0.000、0.004)与ECW％呈负相关关系;多元线性回归分析显示年龄是ECW％的独立影响因素(β=0.451,t=4.892,P=0.000).血清NT-proBNP水平与ECW％呈正相关关系(r=0.340,P=0.000).理想干体质量达标组与未达标组的NT-proBNP中位数分别为3321pg/ml和5407pg/ml,差别有显著统计学意义(z=-3.802,P=0.000),经ROC曲线分析显示NT proBNP诊断理想干体质量不达标的曲线下面积为0.715(P=0.000),NT-proBNP浓度在3937pg/ml时具有最高灵敏度(0.704)和特异度(0.627),此截点值可作为理想干体质量定性评定的参考临界值. 结论 年龄及NT-proBNP水平与MHD患者ECW％密切相关,NT-proBNP可以作为定性评价MHD患者容量状态的临床标志物,NT-proBNP截点浓度3937pg/ml可作为临床定性判断是否干体质量达标的参考临界值.

Objective To understand clinical feature of carotid artery disease,and to investigate the relation-ship between 25-hydroxy vitamin D and carotid atherosclerosis in chronic kidney disease (CKD)patients.Methods 80 CKD (2-5ND ) patients were enrolled into this cross-sectional observational study.Serum 25-OH-D3 , 1,25(OH)2 D3 ,the other related clinical biochemical examinations and carotid artery intimal medial thickness (IMT) were measured.According to the result of carotid artery color Doppler ultrasound,the patients were divided into two groups:carotid artery thickening group and carotid artery non-thickening group;further the patients with carotid arter-y thickening were divided into carotid artery plaque group and non-carotid artery plaque group.The possible risk fac-tors for carotid atherosclerosis were analyzed and compared between the two groups.Results In 80 CKD patients,the incidence of carotid artery thickening、carotid artery plaque and arteriostenosis was 63.7% (51 /80 ),45.0%(36 /80),12.5% (36 /80),respectively;in the patients with carotid artery thickening,the incidence of carotid arter-y plaque was 70.6% (36 /51).Age、hypertension、e-GFR、HGB、HCT、CRP、cardiac valves calcification、primary glo-merular disease had statistical difference between carotid artery thickening group and non-thickening group(P <0.01 or 0.05).Multivariate logistic gradual regressive analysis showed that hypertension can enter the regression equation (β=1.67,OR =5.29,P =0.004).Age and RBC count were significantly difference in patients with carotid plaque compared patients without carotid plaque(P <0.05).Conclusion Hypertension is independent risk factor of carotid artery thickening,Age and lowering RBC count probably have an effect on the occurrence of carotid artery thickening and plaque in CKD patients.

Objective To improve standards of diagnosis and therapy for acute focal bacterial nephritis bY comparing the characters of acute focal bacterial nephritis and acute pylonephritis.Methods Thirty-five patients of upper urinary tract infection whoever accepted ultrasonographic and computed tomographic (CT) examinations in Beijing Hospital from January 2007 to January 2013 were studied retrospectively.Eighteen patients were diagnosed as acute focal bacterial nephritis (AFBN) according to CT imaging features,the other 17 patients were diagnosed as acute pyelonephritis (non-AFBN).The clinical feature,laboratory and imaging examination were compared between the two groups.Results Leukocyte count,percentage of neutrophil,fasting blood-glucose,ESR,NAG/Cre of urine,the combination of more than one kind of antibiotics and duration of antibiotic treatment were higher or much more in AFBN group patients than non AFBN patients,the differences between two groups were statistical significance(P ＜ 0.05).Urine microorganism culture was mainly Escherichia coli no matter in AFBN group or non-AFBN group,microorganism species of AFBN patients were more complex than non-AFBN patients.The most common contrast-enhanced CT feature of AFBN included local distribution of inflammatory area,wedge-shaped or unregular-shaped hypodense lesions on bilateral or single kidney,and mass-like hypodense lesions in more severe cases.NAG/CRE of urine was higher in AFBN group patients with bilateral kidney lesions than with single kidney lesions and non AFBN patients.The remission time of AFBN and non-AFBN was (3.4 ± 2.9) d,(3.0 ± 1.8)d respectively.The relapsing rate of AFBN and non-AFBN within half a year was 2/18,2/17,respectively.Conclusions The symptoms of acute focal bacterial nephritis are not specific.Abdominal contrast-Enhanced CT,ESR,leukocyte count,urine NAG/CRE are probably a predictor of AFBN.Antibiotic treatment with appropriate usage and sufficient duration could bring satisfactory outcomes and prognosis in acute focal bacterial nephritis and pyelonephritis patients.

<正>Objective To improve standards of diagnosis and therapy for acute focal bacterial nephritis by comparing the characters of acute focal bacterial nephritis and acute pylonephritis.Methods Thirty-five patients of upper urinary tract infection whoever accepted ultrasongraphic and computed tomographic (CT) examinations in Beijing Hospital from January 2007 to January 2013 were studied retrospectively.Eighteen patients were diagnosed as acute focal bacterial nephritis (AFBN) according to CT imaging features,the other 17 patients were diagnosed as acute

Objective To investigate the preventive effect of continuous quality improvement(CQI) on malnutrition,inflammation,peritoneal dialysis adequacy and cardiovascular events in elderly patients undergoing peritoneal dialysis.Methods A single-center prospective self-controlled study was performed.32 stable elderly patients to undergo continuous ambulatory peritoneal dialysis (CAPD) were included.The continuous quality improvement program was conducted by using the 4-step problem-solving framework called the PDCA cycle (plan,do,check and act).The dialysis adequacy,nutritional status,inflammation and cardiovascular events were analyzed before and after PDCA.Results Compared with before PDCA,the proportion of patients with Kt/V≥1.7 and urea kinetics (Kt/V) level were increased after PDCA [71.8％ vs.93.75％,(1.97±0.36) vs.(2.08±0.33),both P＜ 0.05].Serum levels of albumin (ALB),prealbumin (PAB) and serum carbon dioxide combining power (CO2 CP) were increased after PDCA (all P＜0.05).The proportion of patients with ALB≥40 g/L was increased after PDCA as compared with before PDCA (9.4％ vs.31.3％,P＜0.05).The nutritional variables including mid-arm circumference (MAC),triceps skinfold thickness (TSF),mid arm muscle circumference (MAMC),and lean body mass (LBM),lean body mass percentage (LBM％),normalized protein equivalent of total nitrogen appearance (nPNA),handgrip strength were improved after PDCA (P＜ 0.05).High sensitivity C-reactive protein (hs-CRP) level and the proportion of patients with hs-CRP＞3 mg/L were decreased after PDCA as compared with before PDCA [(8.65±6.22) mg/L vs.(5.37±4.33) mg/L,53.1％ vs.25％,both P＜0.05].The incidence of peritoneal dialysis related peritonitis was reduced obviously from 1 case every 25.4 months to 1 case every 78.1 months after PDCA (P ＜ 0.05).The hospitalization rate due to cardiovascular events was decreased after PDCA as compared with before PDCA (25％ vs.3.13％,P＜0.05).Conclusions CQI may significantly improve the malnutrition,inflammation and dialysis adequacy,and reduce the hospitalization rate due to cardiovascular events in elderly patients undergoing peritoneal dialysis.

Objective To understand the clinical feature of the elderly patients with diabetes during coronary angiography,and analyze the risk factors of contrast-induced nephropathy (CIN).Methods The clinical data of 269 elderly patients who had undergone coronary angiography and percutaneous coronary intervention(PCI) from January 2007 to December 2009 in our hospital were analyzed retrospectively.The patients were divided into two groups:CIN group and non-CIN group.The possible risk factors for CIN,such as glycemic control,diabetic complication,renal function,volume of contrast medium,inflammatory state,therapy of perioperative period,past medical history were analyzed and compared between the two groups. Results In 269 elderly patients with diabetes,the incidence of CIN was 9.3 ％ (25/269).According to estimated glomerular filtration rate (e-GFR),the patients were divided into four subgroup:≥90 ml/min,89-60 ml/min,59-30 ml/min,＜29 ml/min.The incidences of CIN for the subgroups were 2.2％(1/45),4.4％(6/135),17.3％(14/81) and 50 ％ (4/8),respectively.Multivariate logistic gradual regressive analysis showed that loop diuretic use (OR＞ 6.07),preoperative e-GFR(＜60 ml/min) (OR＞3.27),volume of contrast medium (≥200ml) (OR＞3.26),chronic kidney disease(CKD) (OR＞2.80) (P=0.001,0.024,0.015,0.048) were indepen-dent risk factors for CIN (P＜0.05). Conclusions Loop diuretic use,preoperative GFR (＜60 ml/min),volume of contrast medium (≥200 ml) and CKD are independent risk factors of CIN.

Objective To analyze the characteristics of the maintenance hemodialysis(MHD) patients died in this hospital from January 2005 to December 2011,and to investigate the risk factors relating to the death in elderly MHD patients.Methods Retrospective study on MHD patients in the period from January 2005 to December 2011 found 83 death cases that had treated with MHD for more than 3 months.The annual number of death cases and mortality rate were then calculated.These cases were divided into 3 groups:middle age group(<60 years of age),elderly group(60 to 79 years of age),and very elderly group(>80 years of age).Demographic features,diabetes,dialysis age and cause of death were analyzed among the three groups.Results The annual mortality rate in MHD patients from 2005 to 2011 was 11.00%,10.90%,8.30%,8.10%,10.10%,8.70% and 6.34%,respectively.Of the 83 death cases,49 cases were males and 34 cases were females,with the mean age of 71.8?2.0 years(42～94 years).Fourteen cases were in middle age group,46 cases in elderly group,and 23 cases in very elderly group.Sex difference was insignificant among the three groups.Dialysis age was longer in middle age group,and was shorter in elderly group.Diabetic nephropathy was frequently found in elderly group.The causes of death were different.In middle age group,50% cases died of cerebral vascular disease,especially cerebral hemorrhage.In very elderly group,56% cases died of septic shock.In elderly group,death was resulted from various causes,including septic shock,cardiac infarction or heart failure,tumor,malnutrition-inflammation-atherosclerosis syndrome(MIA syndrome) and sudden death(in order of the prevalence rate).Conclusions Most of the death cases in this dialysis center were older than 60 years of age.Diabetes played a role more important than age on the prognosis of MHD patients.Cerebral vascular disease was the major cause of death in middle age patients,and septic shock is the main cause in very elderly patients.The causes leading to death in elderly patients were various,including cardiovascular disease,infection,tumor and MIA syndrome.

目前对造影剂肾病的发病机制还不完全清楚，虽然相关的动物和细胞实验研究较多，但临床研究偏少，认识不充分，而且多数动物实验为了成功建造CIN模型，都预先使用了损害肾脏的药物（如非甾体抗炎药等），因此不能完全模拟临床造影剂肾病的病理生理状态，同时也限制了这些研究结果推广到临床，希望今后能有更科学更严谨的研究关注于此。

Objective To investigate the role of oxidative stress on apoptosis induced by iohexol in human renal tubular epithelial cells(HK-2 cells).Methods The incubated HK-2 cells were divided into four groups:①control group;②iohexol treated group(100mgI/ml);③NAC treated group(10mmol/L);④pre-incubated with NAC and then co-incubated with iohexol group.The cell viability was tested by CCK-8 assay;cell apoptosis was determined by flow cytometry with AnnexinⅤ-FITC/PI double staining.Intracelluar ROS was detected by flow cytometry with DCFH-DA fluorescence staining.The signaling transduction pathways were tested by western blot and immunofluorescence staining.Results Iohexol decreased cell viability to(63±5)%(vs.control group,P<0.01),and increased cell apoptosis to(24.41±0.23)% [vs.control group(0.97±0.28)%,P<0.05].ROS was increased to 1.30-fold compared with control(P<0.05).In NAC and iohexol co-incubated groups,the cell viability was increased to 118 %(vs.iohexol treated group,P<0.05).Apoptosis rate was decreased to 13.46%(vs.iohexol treated group,P<0.05).ROS was decreased 0.93-fold(vs.iohexol treated group,P<0.05).Iohexol induced an increasing of p53 phosphorylation and activity,then an up-regulation of Bax and down-regulation of Bcl-2 protein expression.Iohexol induced a releasing of cytochrome C from mitochondria to cytoplasm,all of which caused a final activation of caspase-3.The expression levels of p53,Bax and caspase-3 were decreased,while Bcl-2 protein expression level was increased by NAC.Conclusions Oxidative stress may play an important role in iohexol-induced apoptosis in HK-2 cells.

Objective To explore the protective effect and mechanism of antioxidant N-acetyl-L-cysteine (NAC)on the cytotoxicity induced by iohexol in HK-2 cells. Methods The incubated HK-2 cells were divided into four groups:control group,iohexol group,NAC group,and NAC+iohexol group(pre-incubated with NAC and then co-incubated with iohexol).The cell viability was tested by CCK-8 assay;cell apoptosis was determined by Hoechst 33342 fluorescence staining and flow cytometry with Annexin V-FITC/PI double staining.Intracelluar ROS waft detected by flow cytometry with DCFH-DA fluorescence staining.The signaling transduction pathways were investigated by Western blotting and immunofluorescence staining. Results Iohexol decreased cell viability,and increased apoptosis in a dose-and time-dependent manner.In iohexol(100 gl/L,6 h)group,ROS was increased by 1.30-fold of control(P＜0.05).In NAC(5,10,15 mmol/L)+iohexol groups,the cell viability was increased by 104%,118%,130%respectively,and iohexol group was 63% (P＜0.05, respectively); apoptosis rate was decreased by 13.51%, 13.46%, 12.23% respectively, and iohexol group was 24.41% (P＜0.05, respectively); ROS was decreased by 1.05-fold, 0.93-fold, 0.86-fold respectively, and iohexol group was 1.3-fold (P＜0.05, respectively).Iohexol induced the increase of p53 phosphorylatian and activity, then up-regulation of Bax and down-regulation of Bcl-2 protein expression. Iohexol induced the release of cytochrome C from mitochondria to cytoplasm, all of which caused final activation of caspase-3. The expression levels of p53, Bax and caspase-3 were decreased, while Bcl-2 protein expression level was increased by NAC. Conclusions Iohexol induces the increase of apeptosis rate and ROS generation in HK-2 cells. NAC attenuates this iohexol-induced cytotoxicity by decreasing intracelluar ROS, which is mairdy through the intrinsic pathway.

脑钠肽(brain natriuretic peptide,BNP)是一种心脏血管神经肽类激素,由日本学者SUDOH等首先在猪脑中发现.BNP广泛分布于人的心、肺、脑、脊髓等组织中,以心脏含量最高,它具有利钠、利尿、舒张血管的作用.本文就BNP与慢性肾脏病(CKD)的关系做一综述.

随着经济发展和人民生活水平的提高,糖尿病已成为我国的常见病和多发病.糖尿病及其并发症所带来的问题对公共卫生事业的危害越来越引起人们的重视.