百令和复方α-酮酸片联用对维持性血液透析患者微炎症状态影响的研究

研究表明,维持性血液透析患者均可能存在微炎症状态.微炎症是增加慢性肾衰竭病死率的重要原因.另有研究表明,营养不良的发生发展主要与微炎症状态有关.国内外对微炎症的研究大多停留在对终末期肾衰竭患者微炎症状态的认识和评价指标方面;药物观察微炎症状态变化的研究尚少,尤其是中西药物联合应用对不同透析方式患者微炎症状念影响的临床研究尚未见报道.     

慢性肾衰竭患者C-反应蛋白与营养不良及感染的关系

目的　探讨慢性肾衰竭患者C 反应蛋白 (CRP)与营养不良及感染的关系。方法　将5 1例受检的慢性肾衰竭患者分为感染组和非感染组 ,检测其CRP、白蛋白 (Alb)、前白蛋白 (PA )和血肌酐 (Scr)及胆固醇 (TCH)水平。结果　感染组CRP水平明显高于非感染组 (P <0 .0 1) ,感染组血浆白蛋白、前白蛋白及血浆白蛋白 /血肌酐 (Alb/Scr)比值明显低于非感染组 (P <0 .0 1) ,两组间血肌酐和胆固醇比较差异无显著性 (P >0 .0 5 )。慢性肾衰竭患者CRP水平与血浆白蛋白、前白蛋白水平及血浆白蛋白 /血肌酐比值呈负相关 (P <0 .0 1) ,CRP水平与血肌酐及胆固醇的相关性不显著 (P >0 .0 5 )。结论　慢性肾衰竭患者CRP水平可反映机体营养状况及炎症反应     

终末期肾衰竭患者动脉粥样硬化性心血管疾病的危险因素

终末期肾衰竭(ESRD)患者比一般人群具有更高的临床心血管疾病(CVD)和左室肥大患病率，尤其是接受肾脏替代治疗(RRT)的ESRD患者，高度处于过早死亡的危险。事实上，ESRD患者死于营养不良、炎症和动脉粥样硬化综合征的人数与死于转移性肿瘤的人数相当。引起尿毒症患者CVD发病明显增高的原因尚不完全明了，特别是逆流行病学现象的出现，     

慢性肾衰竭时1α-羟胆骨化醇的对照试验

肾性骨营养不良和继发性甲状旁腺亢进症是重度慢性肾衰竭的常见并发症。维生素D代谢产物1,25—二羟胆骨化醇(1,25-DHCC)能有力地促进肠内钙的吸收。但慢性肾衰竭患者血清1,26-DHCC浓度则减低。本文报道1,25-DHCC的合成制剂1α-羟胆骨化醇(1α-HCC)对24例重度慢性肾衰竭(肾小球滤过率5～25毫升/分)未作透析患者进展性骨疾患的作用。     

高通量血液透析和血液灌流联合血液透析对维持血透患者微炎症状态的影响

维持血液透析的慢性肾衰竭（CRF）患者均存在着慢性微炎症状态,慢性炎症反应可导致肾性贫血、营养不良及动脉粥样硬化的发生,是维持血透患者生活质量降低、死亡率高的主要原因之一,其标志物为C-反应蛋白（CRP）。我们对46例维持血液透析的慢性肾衰竭（CRF）患者分别采取高通量血液透析（HFHD）、血液灌流（HP）联合血液透析（HD）治疗,     

氟伐他汀对慢性肾衰竭维持性血液透析患者微炎症状态的影响

近年研究证实,微炎症状态、心血管疾病、营养不良、动脉粥样硬化是影响维持性血液透析（MHD）患者生活质量和预后的强烈预测因子,且炎症指标是心血管疾病及其死亡除年龄外的惟一预测因素。2006年6月-2008年1月,我们对43例慢性肾衰竭MHD患者应用氟伐他汀治疗,并观察了其对患者微炎症状态的影响。现报告如下。     

血液透析患者动脉粥样硬化与慢性炎症及营养不良的关系

心血管疾病是尿毒症患者的首位死亡原因，而慢性炎症状态、营养不良在尿毒症患者中普遍存在。我们对45例维持性血液透析患者进行了动脉粥样硬化(AS)、炎症指标的测定和营养状况的评估，以探讨尿毒症患者心血管疾病与慢性炎症及营养不良的关系。     

血液透析合并感染49例临床分析

慢性肾衰竭(CRF)血液透析患者感染的发生率高于一般人群,是导致透析患者死亡的主要因素。特别是在透析早期,由于患者贫血和营养不良,感染的发生率更高。探讨CRF患者合并感染的临床特点,有助于提高CRF患者的生存率。我们回顾性分析49例慢性肾衰竭血液透析合并感染患者的临床特点     

血液透析对慢性肾衰竭患者心脏功能的影响

目的了解血液透析对慢性肾衰竭患者心脏结构、功能变化的影响,分析其相关危险因素.方法回顾本院2004年1～12月透析治疗的慢性肾衰竭患者76例,分开始进入血液透析组(40例)和维持性血液透析组(36例),应用彩色超声测定左室形态及功能各项参数,测定透析前血压及各项实验室指标.结果开始进入血液透析组患者,超声心动图显示75%出现左室肥厚(LVH),30%左心室收缩功能障碍;维持性血液透析组55.6%出现LVH,左心室收缩功能正常,两组差异有统计学意义.维持性血液透析组血红蛋白、血钙、血磷、钙磷聚集和血浆白蛋白升高,C反应蛋白降低.结论维持性血液透析后,患者左心室功能改善,可能与贫血、营养不良及炎症反应的纠正有关.     

丹参川芎嗪注射剂对老年慢性肾衰竭患者肾功能和血浆内皮素及D-二聚体的影响

肾脏是人体的重要器官,其基本功能是生成尿液,借以清除体内代谢产物及某些废物与毒素、毒物,一旦其功能丧失,人体内新陈代谢产生的废物与毒素、毒物无法排出.慢性肾衰竭患者多有并发症且预后较差[1],其治疗主要以延缓肾衰竭进展,减缓患者进入终末期肾衰竭的速度为目的[2].本研究拟研究丹参川芎嗪注射剂对老年慢性肾衰竭患者肾功能和血浆内皮素(ET)-1及D-二聚体(DDi)的影响.     

Anesthesia for minimally invasive cardiac surgery

Due to its potential benefits and increased patient satisfaction minimal invasive cardiac surgery (MICS) is rapidly gaining in popularity. These procedures are not without challenges and require careful planning, pre-operative patient assessment and excellent intraoperative communication. Assessment of patient suitability for MICS by a multi-disciplinary team during pre-operative workup is desirable. MICS requires additional skills that many might not consider to be part of the standard cardiac anesthetic toolkit. Anesthetists involved in MICS need not only be highly skilled in performing transesophageal echocardiography (TEE) but need to be proficient in multimodal analgesia, including locoregional or neuroaxial techniques. MICS procedures tend to cause more postoperative pain than standard median sternotomies do, and patients need analgesic management more in keeping with thoracic operations. Ultrasound guided peripheral regional anesthesia techniques like serratus anterior block can offer an advantage over neuroaxial techniques in patients on anti-platelet therapy or anticoagulation with low molecular weight or unfractionated heparin The article reviews the salient points pertaining to pre-operative assessment and suitability, intraoperative process and postoperative management of minimally invasive cardiac procedures in the operating theatre as well as the catheterization lab. Special emphasis is given to anesthetic management and analgesia techniques.     

Cirugía cardiaca pediátrica mínimamente invasiva: experiencia de un centro colombiano cardiovascular

Objective:

During the last decades, cardiac surgery has revolutionized, there is a growing interest in minimizing the physical aggression of surgical procedures, seeking a quick recovery, minimally invasive approaches have been a trend in recent years, with safety and efficacy equivalent to traditional techniques sternotomy. The objective of this study is to compare ­clinical results between pediatric patients with congenital heart disease undergoing minimally invasive surgery versus standard sternotomy.

Methods:

Case-control study, nested in a retrospective cohort. All pediatric patients over 10 kg in weight were included, between 2014 and 2019 who underwent surgical correction of simple congenital heart disease, in a cardiovascular center in Medellin. A case was defined as one that underwent a minimally invasive approach (MICS) and control patients who were approached in a conventional manner (CONV). 122 patients were admitted, with a mean age (MICS: 6, 4-12 vs. CONV: 5, 2-8 years). No differences were found in the baseline characteristics of both groups. No statistically significant difference was documented in infusion times (MICS: 67 min [50-90] vs. CONV: 53 min [42-90]; p = 0.54), nor differences in complications (MICS: 7.4 vs. CONV: 8.8%; p = 0.77). MICS patients had lactate on admission and a shorter ICU stay than controls. ­

Conclusion:

The MICS approach turns out to be a novel, less invasive, safe and efficient technique compared to the conventional surgical approach for the repair of simple congenital heart disease in pediatric patients.Key words: Thoracic surgery, Congenital heart disease, Thoracotomy sternotomy     

Reverse epidemiology: a spurious hypothesis or a hardcore reality?

In maintenance hemodialysis (MHD) patients, associations between demographic, clinical and laboratory values and mortality, including cardiovascular death, are significantly different and, in some cases, in the opposite direction of those derived from the general population. This phenomenon, termed 'reverse epidemiology', is not limited to MHD patients but is also observed in populations that encompass an estimated 20 million Americans including those with an advanced age, heart failure, malignancies, and AIDS. A significant portion of this reversal may be due to the overwhelming effect of the malnutrition-inflammation complex syndrome (MICS). Since two thirds of MHD patients die within 5 years of initiation of dialysis treatment, traditional cardiovascular risk factors such as obesity, hypercholesterolemia and hypertension cannot exert a long-term deleterious impact, and instead, their short-term beneficial effects on MICS provides a survival advantage. In order to improve survival and quality of life in MHD patients, extrapolated ideal norms derived from the general population should be substituted with novel norms obtained from outcome-oriented epidemiologic analyses while accounting for the differential effect of MICS in different case-mix subgroups.     

From less invasive to minimal invasive extracorporeal circulation

Development of minimally invasive cardiac surgery (MICS) served the purpose of performing surgery while avoiding the surgical stress triggered by a full median sternotomy. Minimizing surgical trauma is associated with improved cosmesis and enhanced recovery leading to reduced morbidity. However, it has to be primarily appreciated that the extracorporeal circulation (ECC) stands for the basis of nearly all MICS procedures. With some fundamental modification and advancement in perfusion techniques, the use of ECC has become the enabling technology for the development of MICS. Less invasive cardiopulmonary bypass (CPB) techniques are based on remote cannulation and optimization of perfusion techniques with assisted venous drainage and use of centrifugal pump, so as to facilitate the demanding surgical maneuvers, rather than minimizing the invasiveness of the CPB. This is reflected in the increased duration of CPB required for MICS procedures. Minimal invasive Extracorporeal Circulation (MiECC) represents a major breakthrough in perfusion. It integrates all contemporary technological advancements that facilitate best applying cardiovascular physiology to intraoperative perfusion. Consequently, MiECC use translates to improved end-organ protection and clinical outcome, as evidenced in multiple clinical trials and meta-analyses. MICS performed with MiECC provides the basis for developing a multidisciplinary intraoperative strategy towards a “more physiologic” cardiac surgery by combining small surgical trauma with minimum body’s physiology derangement. Integration of MiECC can advance MICS from non-full sternotomy for selected patients to a “more physiologic” surgery, which represents the real face of modern cardiac surgery in the transcatheter era.     

Chronic renal failure in diabetic patients increases lipid risk factors for atherosclerosis

Diabetic patients are at high risk of cardiovascular disease and the risk is amplified in the presence of nephropathy, which may be partially attributed to modifications in lipoproteins. Moreover, lipoprotein profile may be affected by incipient nephropathy, glomerulopathy, and mild or severe renal failure. The aim of our study was to evaluate whether chronic renal failure (CRF) changes lipoprotein profile and apo A-I urinary excretion in diabetic subjects with glomerulopathy in comparison with non-diabetic subjects with glomerulopathy and CRF. Diabetic (n=25) and non-diabetic (n=10) patients with glomerulopathy and CRF showed significantly higher LDL-cholesterol, non-HDL-cholesterol and HDL-triglyceride levels than diabetic individuals without CRF (n=10). Arylesterase and paraoxonase activities did not show any difference between groups. Apo A-I could not be detected in urine samples from diabetic patients without CRF. All diabetic subjects with glomerulopathy and CRF who presented proteinuria above 6.5 g/24 h showed detectable urinary apo A-I (range=13.1-61.0 mg/24 h). Similarly, all non-diabetic patients with glomerulopathy and CRF who had proteinuria above 8.0 g/24 h also evidenced detectable apo A-I in urine (range=25.6-557.3 mg/24 h). Urinary apo A-I showed positive and significant correlations with urea (r=0.73, p<0.05) and proteinuria (r=0.97, p<0.0001), and a negative correlation with albumin plasma levels (r=-0.68, p<0.05). In conclusion, the presence of CRF in diabetic patients was associated with a more atherogenic lipoprotein profile.     

Wireless capsule endoscopy in the investigation of patients with chronic renal failure and obscure gastrointestinal bleeding （preliminary data）

AIM: To investigate the role of wireless capsule endoscopy (WCE) in detection of small bowel (SB) pathology in patients with chronic renal failure (CRF) and obscure bleeding. METHODS: Consecutive CRF patients with obscure bleeding were prospectively studied. Patients with normal renal function and obscure bleeding, investigated during the same period with WCE, were used for the interpretation of results. RESULTS: Seventeen CRF patients (11 overt, 6 occult bleeding) and 51 patients (33 overt, 18 occult bleeding) with normal renal function were enrolled in this study. Positive SB findings were detected in 70.6% of CRF patients and in 41.2% of non-CRF patients (P < 0.05). SB angiodysplasia was identified in 47% of CRF patients and in 17.6% of non-CRF patients. Univariate logistic regression revealed CRF as a significant predictive factor for angiodysplasia (P < 0.05). Therapeutic measures were undertaken in 66% of the patients with the positive findings. CONCLUSION: According to our preliminary results, SB angiodysplasia was found in an increased prevalence among CRF patients with obscure bleeding. WCE is useful in diagnosis of gastrointestinal pathologies and in planning appropriate therapeutic intervention and, therefore, should be included in the work-up of this group of patients.     

老年肾功能不全患者血浆同型半胱氨酸水平及其影响因素

目的研究老年肾功能不全（CRF）患者血浆同型半胱氨酸（Hcy）水平及其影响因素。方法采用快速高压液相层析法测定82例老年CRF患者和40例正常人的Hcy水平,同时用离子夺获分析法和微离子酶免疫分析法分别检测血浆叶酸（FA）和维生素B12（VitB12）水平。结果CRF患者高Hcy血症（HHcy）发生率高达86.6%,为正常对照组的34.6倍（P〈0.01）;且血浆Hcy的浓度随着血肌酐浓度的升高或内生肌酐清除率（Ccr）的降低而升高,有明显的相关性（P〈0.01）。CRF患者的血浆FA和VitB12与正常对照组均无明显差别,血浆tHcy水平与血浆FA浓度均呈负相关关系。血液透析后血浆Hcy水平较血液透析前下降约36%,但仍显著高于正常对照组（P〈0.01）。透析后20 h回复到透析前水平的76.6%～87.3%,在采用血仿膜和聚砜膜透析的患者之间,血浆tHcy水平无明显差异。结论老年CRF患者普遍存在HHcy血症,并且肾功能损害的程度与Hcy浓度明显相关,但没有明显的FA和VitB12缺乏,CRF时肾脏损害削弱了对Hcy的代谢或清除能力,可能是CRF患者血浆tHcy水平增高的主要原因。     

慢性肾衰竭患者血清脂蛋白（a）变化及其临床意义探讨

目的观察慢性肾衰竭（CRF）患者血清脂蛋白（a）[LP（a）]水平的变化及其与心脑血管疾病的关系。方法回顾分析102例慢性肾衰竭患者的临床及实验室资料,探讨患者血LP（a）水平与心脑血管疾病的关系。结果CRF患者无论透析与否,其血LP（a）水平均较健康对照组显著升高（P〈0．05）,血液透析组（HD组）LP（a）水平升高及高密度脂蛋白（HDL．C）水平下降比非透析组（ND）更明显（P〈0．01）,而HD组与ND组患者血总胆固醇（CHOL）、低密度脂蛋白（LDL-C）、三酰甘油（TG）浓度差异无统计学意义。CRF伴心脑血管疾病患者的血LP（a）水平比无心脑血管疾病患者明显升高（P〈0．05）。结论CRF患者存在严重的脂代谢紊乱,血IJP（a）水平升高可能伴随纤溶功能的低下,可能是CRF患者并发心脑血管疾病的危险因素之一。     

SELECTIVE BILATERAL AND SIMULTANEOUS CATHETERIZATION OF THE INFERIOR PETROSAL SINUS: CRF STIMULATES PROLACTIN SECRETION FROM ACTH-PRODUCING MICROADENOMAS IN CUSHING''S DISEASE

Bilateral, selective and simultaneous catheterization of the inferior petrosal sinus with measurements of ACTH after stimulation with ovine corticotrophin-releasing factor (CRF) is now frequently used to establish the differential diagnosis in patients with Cushing's disease and to determine the side of the microadenoma in the pituitary. To investigate whether CRF has any effect on other pituitary hormones, we also determined prolactin (PRL) concentrations in the samples obtained during this procedure. Fourteen patients under evaluation for Cushing's syndrome and one patient with a hormonally inactive pituitary tumour were catheterized. Baseline PRL levels in the peripheral veins were within the normal range before and after CRF in all patients (3.7-16.0 ng/ml). In 10 patients ACTH- and PRL concentrations lateralized to one side of the pituitary and could both be stimulated by CRF. The gradient of PRL between inferior petrosal sinus and periphery ranged from 7 to 147 ng/ml after CRF. There was no correlation between ACTH and prolactin increase in response to CRF. In three patients with no ACTH-gradient but a positive response to CRF, no tumours could be found during transsphenoidal surgery; they had no PRL-gradient and showed no PRL response to CRF. One patient with the ectopic ACTH syndrome had no ACTH- and no PRL response to CRF. The patient with the inactive pituitary tumour showed a normal ACTH-, but no PRL response to CRF. These data demonstrate for the first time that in normo-prolactinaemic patients with Cushing's disease, in contrast to patients bearing no microadenoma, PRL is secreted in response to CRF.(ABSTRACT TRUNCATED AT 250 WORDS)     

Delay in gastric emptying in patients with chronic renal failure

BACKGROUND: Gastrointestinal (GI) symptoms are common in patients with chronic renal failure (CRF). Delayed gastric emptying might be a possible pathophysiological mechanism. The aims of this study were to evaluate gastric emptying in patients with CRF and to correlate the findings with GI symptoms and evaluate the impact of Helicobacter pylori infection in CRF patients on gastric emptying. METHODS: Thirty-nine patients with CRF (17 F, 22 M) were compared with 131 healthy subjects (74 F, 57 M). A standardized breakfast was given with 20 spherical, radiopaque markers (ROMs). The emptying was followed by fluoroscopy after 4, 5 and 6 h. Gastric emptying was assessed by calculating the individual mean percentual gastric retention of markers, 4 to 6 h after the meal. The perceived severity of GI symptoms was assessed with a validated questionnaire. Because of gender differences in gastric emptying, men and women were compared separately and a percentile of 95 was chosen as the upper reference value. H. pylori infection was assessed using a serological method. RESULTS: Delayed gastric emptying was found in 14 out of 39 (36%) of the CRF patients. There was no relationship between delayed gastric emptying and age, GI symptoms, H. pylori infection or underlying renal disease. However, a higher proportion of patients in peritoneal dialysis demonstrated delayed gastric emptying compared with predialytic patients (6 of 9 versus 2 of 13, P = 0.026). Men with CRF had a higher gastric retention compared with healthy men (16.6 (0-63.3)% versus 0 (0-2.1)%, P < 0.0001), and 10 men with CRF had delayed gastric emptying (P < 0.0001). There was no significant difference in mean gastric retention between women with CRF and healthy women (13.3 (0-55.4)% versus 10.8 (0-30.0)%, P = 0.93), but 4 women with CRF had delayed gastric emptying (P = 0.02). Eighteen of the CRF patients had GI symptoms (6 F, 12 M) and 21 were asymptomatic (11 F, 10 M). There was no difference in mean gastric retention in patients with CRF with and without GI symptoms (M: 13.3 (0-55.0)% versus 47.5 (5.0-65.0)%, P = 0.51, F: 16.6 (0-63.3)% versus 13.3 (0-59.2)%, P = 0.96). Gastric emptying in CRF patients with and without H. pylori infection showed no difference. CONCLUSIONS: Delayed gastric emptying is common in patients with chronic renal failure, particularly in men. The delay was not associated with the presence of GI symptoms, underlying renal disease or H. pylori infection. However, the dialytic status might have an impact on gastric emptying in patients with CRF.