尿毒症患者发生左心室肥厚的危险性及其相关因素

目的:通过横断面调查了解透析患者发生左心室肥厚(LVH)的危险因素及其与血容量的关系.方法:通过无创性方法(Xitron 4200生物阻抗分析仪)分别测量我院73例血透患者、46例腹膜透析患者透析前后血容量(ECW)变化和心脏形态学改变(超声心动图),并设立18例慢性肾衰竭患者和16个正常人作为对照组.结果:血液透析患者、腹膜透析患者、慢性肾衰竭患者及对照组左心室肥厚的发生率分别为68%、56%、39%和0%,与对照组相比,这些患者的nECW均明显升高(P＜0.001).同时LVH与高血压、nECW、红细胞压积均呈显著相关关系(P＜0.05).结论:透析患者LVH的发生率较高,与高血压、红细胞压积和血容量密切相关.提示容量超负荷是引起透析患者和慢性肾衰竭患者高血压、LVH的关键因素.     

慢性肾衰竭高血压的发病机制及其治疗

慢性肾衰竭和高血压是一对互为因果的病理生理现象，二者常相伴而存在，相互影响而加重。慢性肾衰竭合并的高血压，夜间血压生理性下降趋势丧失。尽管单纯的高血压病所引起的肾小动脉硬化症是否能作为导致终末期肾衰竭的原发病因，仍有不同看法，但大家公认的是，高血压能够加速慢性肾脏疾病肾功能恶化的速度，是导致残肾功能恶化的独立危险因素，而控制高血压能够有效地延缓残肾功能的恶化，高血压也是导致肾衰竭患者心、脑血管疾病发病率和病死率显著高于同年龄非肾衰竭患者的主要罪魁祸首，脑卒中、心衰、心肌梗死、心脏猝死等导致的死亡占终末期肾衰竭患者死亡原因的50％以上。因此，怎样能很好地控制慢性患者的高血压是肾脏病工作者共同关心的临床问题。本文在复习最新文献的基础上．结合临床工作，就慢性肾衰竭高血压的发病机制及其治疗综述如下。     

慢性肾衰竭急剧加重危险因素分析

目的:了解慢性肾衰竭急剧加重因素的发病情况及临床特点.方法:对我院2000年3月～2003年3月收治的61例患者的病因、年龄、基础肾脏病及相关药物等进行分析.结果:在导致慢性肾衰竭急剧加重的因素中,老年组与青壮年组有明显的差异,老年组以肾毒性药物、严重感染及血容量不足等为主要原因,而青壮年组以恶性高血压、原发疾病活动及急性左心衰等常见.61例患者中,8例患者因原发病活动而导致慢性肾衰竭急剧加重(13.11%),9例患者与药物相关(14.75%),常见的药物主要有抗菌素(特别是氨基糖甙类)、血管紧张素转换酶抑制剂(ACEI)及一些含马兜铃酸的中草药等.结论:慢性肾衰竭急剧加重的因素多种多样,老年患者尤其要警惕药物性肾损害、严重感染及血容量不足,青壮年患者积极控制高血压、结缔组织病的活动及急性左心衰对于预防慢性肾衰竭急剧加重具有十分重要的意义.     

难治性高血压患者经皮导管肾动脉交感神经射频消融术的护理

对3例难治性高血压患者行肱动脉穿刺经皮肾交感神经射频消融术,3例患者术后血压控制良好,均无护理并发症发生,其中2例患者降压药物服用种类减少,1例患者术后未服降压药。提出对肱动脉穿刺经皮导管肾动脉交感神经射频消融术患者加强护理干预及术后随访,可有效缓解患者心理压力,减少住院天数,改善预后。     

ACEI在慢性肾衰竭伴交感神经活性亢进患者中的新应用

慢性肾衰竭 (ＣＲＦ)患者常伴有交感神经活性升高 ,其活性可被依那普利抑制 ,而不能被Ｃａ2 拮抗剂抑制〔1〕。以前临床医生常习惯于将血管紧张素转化酶抑制剂 (ＡＣＥＩ)用于治疗肾性高血压 ,通过它减少血管紧张素Ⅱ (ＡｎｇⅡ )的生成而实现降低血压、保护肾脏、延缓ＣＲＦ的发展 ,然而忽视了ＡＣＥＩ对交感神经活性的抑制作用。本文主要就ＣＲＦ患者交感神经活性升高的病理生理机制及ＡＣＥＩ如何降低交感神经活性作一综述。　　 1　ＣＲＦ患者的交感神经高活性状态许多研究发现ＣＲＦ患者交感神经活性较正常人高。早已有文献报道 ,Ｃ…     

交感神经系统与慢性肾脏疾病

慢性肾脏疾病（CKD）日益成为严重的公共卫生问题，绝大多数CKD患者合并高血压，与之密切相关的心血管并发症是终末期肾病患者（ESRD）的主要死因，而这其中的机制十分复杂。近年的研究表明，交感神经兴奋性增高在CKD中有着重要作用，本文就交感神经与CKD作一综述。     

控制血压对慢性肾脏病患者预后的影响

<正>近年来慢性肾脏病(chronic kidney disease,CKD)患病率持续增高,2012年中国流行病学调查结果显示CKD患病率高达10.8%~([1])。2012年一项中国CKD住院患者临床特征及高血压现状研究结果显示我国CKD住院患者最常见的并发症是高血压,约占71.4%,其中15.3%的患者为难治性高血压,而且入院前高血压知晓率为87.8%、治疗率为83.7%、控     

慢性肾衰竭患者的甲状旁腺激素升高与心脏损害关系的探讨

为了研究甲状旁腺激素 (ＰＴＨ)对慢性肾衰竭患者心脏损害的作用 ,我们用放射免疫分析法测定全段ＰＴＨ(ｉＰＴＨ) ,兹将 38例分析结果报道如下。资料与方法1　对象　选择 1999年 2月～ 2 0 0 0年 10月我科的慢性肾衰竭住院患者 38例 ,既往无高血压、心脏瓣膜病及心力衰竭病史 ,近半年来未用过钙剂及维生素Ｄ制剂 ,除外原发性甲状旁腺功能亢进。并依其ｉＰＴＨ值是否增高分为ＳＨＰＴ(ＰＴＨ增高为继发性甲状旁腺功能亢进组 )和ＮＳＨ ＰＴ组 (ＰＴＨ正常为非继发性甲状旁腺功能亢进组 )。 2 0例我院心内科门诊高血压患者 ,经检查排除其他器…     

慢性肾小球肾炎患者恶性高血压的临床特点和预后

目的了解慢性肾小球肾炎患者出现的恶性高血压(MHT)的临床特点及其对肾脏疾病预后的影响。方法分析我科1990～2002年4月收治的肾脏病伴发MHT患者的临床和病理资料。用多元回归进行预后相关因素分析。结果符合诊断的共38例,男女比例3.75∶1;平均年龄(29.5±7.7)岁,皆为慢性肾小球肾炎患者,病因以IgA肾病最多见。这组患者的高血压知晓率75.7%,长期治疗率13.5%,控制率5.4%。其中6例发生急性肾衰竭,16例发生慢性肾衰竭基础上的急性肾衰竭,13例为慢性肾衰竭,3例肾功能正常。经过积极抗高血压治疗后,41.7%患者肾功能好转,需透析者中20%脱离透析。1年肾存活率55%。高血压家族史、最高收缩压(SBP)和舒张压(DBP)水平以及肾脏慢性病变积分是影响短期肾功能好转的不良指标。最高血肌酐水平和肾脏慢性病变积分是决定1年肾脏存活的重要指标。结论在年轻肾小球肾炎患者中发生MHT并不少见,严重影响肾脏预后。经过积极降压治疗部分患者可好转。最高血肌酐水平和肾脏慢性病变积分是决定1年肾脏存活的重要指标。肾性高血压治疗率和血压控制率低可能是这组患者容易发生MHT并导致肾功能快速恶化的重要原因。     

肾性高血压的治疗

高血压是导致终末期肾病的主要原因 ,同时 ,肾功能恶化又进一步加重高血压。 1997年美国肾脏病资料库报告 ,由高血压导致终末期肾病患者数持续增长 ,已占终末期肾病人数的 2 8.5 % [1] ,而有文献统计 ,慢性肾功能不全进展到终末期时 ,80 %～ 90 %的患者出现高血压[2 ] 。肾性高血压的发病机制包括 :①钠和水容量超负荷 ;②肾素%D%D血管紧张素%D%D醛固酮系统活性增高 ;③交感神经活性增高 ;④产生内源性洋地黄样物质 ;⑤前列腺素、缓激肽异常 ;⑥内皮源性舒张因子异常 ;⑦肾单位数量减少等。多项研究表明 ,终末期肾病患者的高血压与心血管…     

慢性肾脏病患者高血压现状的横断面调查

目的 对慢性肾脏病（CKD）患者高血压的发病和治疗情况进行横断面调查。 方法 调查对象为2006年11月至2007年3月本院肾内科门诊就诊的900例CKD患者,男性480例,女性420例,其中维持性透析患者354例（血透228例,腹透126例）。 结果 （1）本组CKD患者高血压患病率为80.2%,其中男性患病率高于女性患者（83.5% 比76.4%,P < 0.01）;维持性透析患者显著高于非透析患者（90.1% 比73.8%,P < 0.01）;血液透析与腹膜透析患者的高血压患病率分别为91.7%和87.3%,差异无统计学意义。（2）高血压治疗率为92.4%,透析患者显著高于非透析患者（95.6% 比89.8%,P < 0.01）。（3）非透析患者高血压控制率（<130/80 mm Hg为标准）为20.4%,而尿蛋白量（24 h）>1 g的未透析患者,其血压控制在125/75 mm Hg以下者仅占8.4%。透析患者高血压控制率（<140/90 mm Hg）显著低于非透析患者（45.2% 比55.5%,P < 0.01）,其中血液透析组高血压控制率显著高于腹膜透析组（49.8% 比36.5%,P < 0.05)。（4）CKD患者高血压患病率随肾功能减退和年龄增长逐渐增高;糖尿病肾病患者的高血压患病率高于原发性肾小球疾病患者。高龄、糖尿病、肥胖、肾功能减退、高脂血症均为CKD高血压发病的危险因素。（5）CKD患者服用1、2、3和4种降压药物及以上者分别为37.2%、37.5%、19.3%和5.9%。单药用药以钙通道阻滞剂(CCB)最多（74.1%）,血管紧张素受体阻滞剂（ARB）和血管紧张素转换酶抑制剂（ACEI）分别为48.4%和25.6%,α、β受体阻滞剂为24.7%。联合用药以CCB联合ACEI或ARB最常用。 结论 CKD患者中高血压患病率很高。年龄、肾功能减退、糖尿病、肥胖是CKD高血压的危险因素。CKD患者高血压的治疗率较高,但控制率较低,透析患者和尿蛋白量较多患者的高血压控制情况更是有待提高。     

Hypertension in renal parenchymal disease: why is it so resistant to treatment?

The association between hypertension and chronic renal disease is well known. The pathogenesis of hypertension in patients with chronic kidney disease (CKD) is complex and multifactorial, which may explain why it is resistant to treatment. The traditional paradigm is that hypertension in CKD is due either to an excess of intravascular volume (volume dependent) or to excessive activation of the renin-angiotensin system in relation to the state of sodium/volume balance (renin-dependent hypertension). This review focuses on the importance of less established mechanisms, such as increased activity of the sympathetic nervous system, increased endothelin production, decreased availability of endothelium-derived vasodilators and structural changes of the arteries, renal ischemia, and sleep apnea.     

慢性肾脏病患者中慢性前列腺炎的发生率及其影响因素

目的：研究慢性肾脏病（CKD）患者中慢性前列腺炎（CP）的发生率及其影响因素。方法：对273例明确病理诊断的CKD男性患者进行前列腺液常规检查，比较不同类型肾脏病、不同年龄段和不同程度蛋白尿、血尿、肾功能对CP发生率的影响。结果：273例CKD患者中91例患者伴有CP，总的发生率33．3％；膜性肾病患者CP发生率最高60．0％，较非IgA肾病的系膜增生性肾小球肾炎（25．5％）、乙肝相关性肾炎（24．2％）及局灶节段肾小球硬化症患者（0％）高（P〈0．05）。IgA肾病（IgAN）患者CP发生率39．7％较非IgA系膜增生性肾小球肾炎患者高（P〈0．05）。随年龄增加CP的发生率升高但是各组间无统计学差别；不同程度蛋白尿、血尿、肾功能组间CP的发生率无差别。结论：CKD是CP的高发人群，随年龄增加CKD患者中CP的发生率有增加的趋势，肾脏病病理类型是影响CP的发生率的主要因素；CP与部分CKD间存在一定的联系。     

Hypertension in children with chronic kidney disease: pathophysiology and management

Arterial hypertension is very common in children with all stages of chronic kidney disease (CKD). While fluid overload and activation of the renin–angiotensin system have long been recognized as crucial pathophysiological pathways, sympathetic hyperactivation, endothelial dysfunction and chronic hyperparathyroidism have more recently been identified as important factors contributing to CKD-associated hypertension. Moreover, several drugs commonly administered in CKD, such as erythropoietin, glucocorticoids and cyclosporine A, independently raise blood pressure in a dose-dependent fashion. Because of the deleterious consequences of hypertension on the progression of renal disease and cardiovascular outcomes, an active screening approach should be adapted in patients with all stages of CKD. Before one starts antihypertensive treatment, non-pharmacological options should be explored. In hemodialysis patients a low salt diet, low dialysate sodium and stricter dialysis towards dry weight can often achieve adequate blood pressure control. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are first-line therapy for patients with proteinuria, due to their additional anti-proteinuric properties. Diuretics are a useful alternative for non-proteinuric patients or as an add-on to renin–angiotensin system blockade. Multiple drug therapy is often needed to maintain blood pressure below the 90th percentile target, but adequate blood pressure control is essential for better renal and cardiovascular long-term outcomes.     

Renal Comorbidity After Solid Organ and Stem Cell Transplantation

After transplantation of solid organs or hematopoietic stem cells, a significant acute decrease in renal function occurs in the majority of patients. Depending on the degree of kidney injury, a large number of patients develop chronic kidney disease (CKD) and some develop end‐stage renal disease requiring renal replacement therapy. The incidence varies depending on the transplanted organ, but important risk factors for the development of CKD are preexisting renal disease, hepatitis C, diabetes, hypertension, age, sex, posttransplant acute kidney injury and thrombotic microangiopathy. This review article focuses on the risk factors of posttransplant chronic kidney disease after organ transplantation, considering the current literature and integrates the incidence and the associated mortality rates of acute and chronic kidney disease. Furthermore, we introduce the RECAST (RE nal C omorbidity A fter S olid organ and hematopoietic stem cell T ransplantation) registry.     

慢性肾脏病患者血压昼夜节律异常的研究

目的 观察慢性肾脏病(CKD)患者24 h血压动态变化，探讨昼夜节律异常与肾功能损害的关系。方法 随机选择本院肾脏科CKD患者236例，高血压科原发性高血压住院患者43例。病例分组:正常对照组(NC)14例；原发性高血压组(EHC)43例；CKD血压正常组(NCKD)130例；CKD伴血压升高组(HCKD)106例。动态血压监测(ABPM)采用携带式的动态血压检测仪，ABP Report Mangement System Version 1.03.03进行数据分析。夜间血压下降率:(白昼平均值-夜间平均值)/白昼平均值，下降率≥10%，称勺型血压；<10%，称非勺型血压。结果 在血压正常的患者中，NCKD组的平均夜间收缩压和舒张压数值均高于NC组[(111.2±10.8)比 (91.6±7.5)，(68.7±9.5) 比 (56.2±4.6)mm Hg，P < 0.05]；而日间收缩压和舒张压无明显差异。在高血压患者中，HCKD组患者夜间收缩压和舒张压数值均高于EHC组[(141.9±16.5) 比(118.6±16.4)， (84.5±10.6)比(73.0±11.1)mm Hg， P < 0.05]。CKD患者无论血压正常或升高，其心率均较其对照组明显加快，尤其是夜间心率无明显下降。NCKD组、HCKD组与NC组、EHC组相比，夜间收缩压和舒张压下降数值较小，尤其是CKD伴血压升高组，呈典型的非勺型血压模式。NC组血压节律消失者占7.14%，EHC组为37.2%，NCKD组为70.0%，HCKD组为81.6%。结论 CKD患者无论血压正常或升高，夜间收缩压和舒张压下降减少或消失，呈典型的非勺型血压；血压昼夜节律异常率明显高于原发性高血压患者。在积极降低血压值的同时，还需降低血压负荷和调整血压昼夜节律，以延缓肾功能恶化。     

RIFLE Criteria and Hepatic Function in the Assessment of Acute Renal Failure in Liver Transplantation

Renal dysfunction in cirrhotic patients is primary related to disturbances of circulatory function, triggered by portal hypertension with chronic intrarenal vasoconstriction and hypoperfusion. Pretransplant renal function is an important factor implicated in the development of acute renal failure (ARF) after liver transplantation (OLT), but other factors mostly related to liver function seem to influence the development of ARF.The Acute Dialysis Quality Initiative workgroup developed the RIFLE classification to define ARF. We sought to evaluate the incidence of ARF among patients undergoing OLT, to evaluate the association of ARF with pre-OLT renal and hepatic functions, and to evaluate the influence of ARF on chronic kidney disease (CKD) at 1 month post-OLT.Clinical, renal, hepatic function, and donor risk index data of 24 patients who underwent deceased donor OLT were collected before transplantation, in the perioperative period and in the first month post-OLT. ARF occurred in 37.5% of patients with 56% developing the R grade and 44% the I grade; no patient showed the F grade.An association was observed between ARF and a higher Model for End-Stage Liver Disease (MELD) score and between ARF and a reduced pre-OLT serum albumin. No association was noted between ARF and other pre-OLT parameters. In cirrhotic patients serum creatinine is a bias for renal function assessment and the Modification of Diet in Renal Disease formula overestimates GFR. Post-OLT CKD was present in 6.7% of patients without ARF and in 44.4% of patients with ARF. The R grade developed more frequently among patients with viral cirrhosis.The association of ARF with MELD and hypoalbuminemia may be the result of a close relationship between renal and hepatic functions among cirrhotic patients. Post-OLT CKD may be the result of unrecognized, preexisting CKD and/or the effects of not fully resolved acute damage to an injured kidney.     

Should we shift toward higher blood pressure targets in patients with chronic kidney disease?

Hypertension is the leading cause of death worldwide and is responsible for a significantly increased burden of cardiovascular events and progression to end-stage kidney disease in patients with chronic kidney disease (CKD). The fundamentals of therapeutics in patients with hypertension and CKD are both the use of specific renal protecting agents and the achievement of tight blood pressure control - i.e., blood pressure values below 130/80 mm Hg. When the evidence underpinning a "tight blood pressure target control" recommendation is analyzed, hypertension guidelines appear to be largely extrapolating to people with CKD the key findings of large trials conducted in the general population and other high cardiovascular risk populations, while renal societies guidelines are primarily influenced by observational data reporting renal outcomes and small-scale randomized studies, and have not always incorporated recent evidence from systematic reviews. In this narrative review, we present existing guidelines and evidence for 2 crucial clinical questions in the management of hypertension of CKD: (i) should we, and by how much should we, lower blood pressure in people with CKD and (ii) are there agents which are specifically beneficial in the CKD population, independent of blood pressure control.     

Monocyte to HDL ratio: a novel marker of resistant hypertension in CKD patients

International Urology and Nephrology - Inflammation, oxidative stress (OS), atherosclerosis and resistant hypertension (RH) are common features of chronic kidney disease (CKD) leading to a higher...