体外循环免疫净化技术多靶点救治妊娠并发急性肾衰竭的研究

探讨“AKIN”标准及病理诊断指导下实施体外循环免疫净化(ECIP)救治妊娠期并发急性肾衰竭(ARF)对预后的影响.(1)观察ECIP干预时机对肾功能延迟恢复发生率、病死率的影响.根据“AKIN”标准分为两组:A组14例(37.84％)在AKI损伤期实施ECIP;B组23例(62.16％)在AKI衰竭期实施ECIP.(...     

连续性肾脏替代治疗介入时机对重症急性肾损伤患者预后影响

目的分析重症急性肾损伤(AKI)行连续性肾脏替代治疗(CRRT)患者临床特点,探讨CRRT介入时机对重症AKI患者预后影响。方法回顾性分析2009年1月1日至2015年12月31日在安徽医科大学第二附属医院重症医学科明确诊断AKI行CRRT患者141例,其中男性89例,女性52例;年龄3~88岁,平均年龄53.93岁。根据改善全球肾脏病预后组织(KDIGO)指南分KDIGO 1、2期和KDIGO 3期两组,比较两组患者一般人口学特征、实验室检查、疾病严重程度及预后情况,并对患者28 d生存率进行Logistic回归分析,从而得出影响重症AKI患者28 d存活率的危险因素。结果基线资料:KDIGO 1期18例,KDIGO 2期32例,KDIGO 3期91例;KDIGO 1、2期血肌酐、尿素氮、尿酸明显低于KDIGO 3期(P<0.001),其余生物化学指标两组间未见明显差异(P>0.05)。两组患者总住院日、重症监护病房(ICU)住院日、合并症(高血压、糖尿病、冠心病、慢性肾脏病)无明显差异(P>0.05)。引起重症AKI诱因组成:脓毒症54例(占38.3%),心脏术后25例(占17.7%),失血性休克22例(占15.6%),为引起AKI诱因的前3位;诱因为心脏术后的KDIGO 1、2期患者明显高于KDIGO 3期(P<0.001)。严重程度和预后比较:KDIGO 1、2期序贯脏器衰竭评估(SOFA)评分、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分低于KDIGO 3期,差异有统计学意义(P<0.05);KDIGO 1、2期28 d生存率(70.0%)明显高于KDIGO 3期(46.1%),差异有统计学意义(P<0.01)。经二分类Logistic回归分析,年龄、是否机械通气、白细胞、血肌酐、白蛋白与生存率无关;高SOFA评分、高APACHEⅡ评分、KDIGO 3期为28 d存活率的独立危险因素;女性、ICU入住时间增加是28 d存活率的保护因素。结论基于KDIGO分期的早期CRRT,有望改善重症AKI患者的预后。     

重度窒息新生儿发生急性肾损伤回顾性分析

目的探讨重度窒息新生儿中急性肾损伤（AKI）的发生情况及其诊断标准的适用性。方法回顾性分析2005年1月至2009年12月于北京大学第一医院住院的重度窒息新生儿。根据2005年急性肾损伤协作网提出的AKI诊断标准（包括尿量标准和SCr标准）,将入选患儿分为AKI组和无AKI组。采集患儿一般资料、围生期资料、肾脏损伤情况、治疗和近期预后情况。结果最终纳入患儿30例,AKI组17例,无AKI组13例。①AKI组10/17例仅符合尿量标准,而不符合SCr升高标准,按AKI分期标准分为1期4例、2期5例、3期1例;7/17例同时符合尿量标准和SCr标准,其中3例按照SCr标准和尿量标准分期相同（均为1期）,1例按照SCr标准分期为2期的患儿符合尿量标准1期,余3例按尿量标准分期高于SCr标准。7/17例有SCr一过性升高（SCr〉133μmol.L-1）,达到急性肾功能衰竭诊断标准。②AKI组和无AKI组平均住院时间分别为（14.7±13.9）和（13.7±9.6）d,两组差异无统计学意义（P=0.83）。AKI组预后不良5/17例（29.4%）,包括死亡1例（同时符合尿量标准和SCr标准）,放弃治疗4例（3例同时符合尿量标准和SCr标准,1例仅符合尿量标准）;无AKI组预后不良2/13例（15.4%）,均为死亡病例（均仅符合尿量标准）,两组差异无统计学意义（P=0.368）。按照SCr升高标准,符合AKI诊断的4/7例（57.1%）患儿预后不良,不符合SCr升高标准的3/23例（13.0%）患儿预后不良,差异有统计学意义（P=0.016）。结论在重度窒息新生儿中存在AKI的病例。SCr升高可能提示预后不良,但由于样本量小,无长期随访资料,目前尚不能评价SCr和尿量是否为诊断新生儿AKI的最适宜指标。     

65例老年慢性肾脏病基础上急性肾损伤的临床观察

目的 分析老年慢性肾脏病基础上急性肾损伤(A/C)的基础疾病、发病诱因及影响预后的危险因素.方法 回顾性分析2005年12月至2009年12月于本院住院治疗的65例老年A/C患者的临床资料,分析A/C患者的基础疾病、发病诱因及影响预后的危险因素.根据治疗后肾功能恢复情况将患者分为2组:肾功能恢复患者和肾功能部分恢复患者合并为肾功能恢复组,肾功能未恢复患者与死亡患者合并为肾功能未恢复组,比较两组患者的少尿持续时间、入院时血清白蛋白水平和最高血清肌酐(Scr)水平.结果 糖尿病肾病是老年A/C患者的主要基础疾病(38.5％,25/65),药物因素(30.8％,20/65)和严重感染(27.7％,l8/65)是老年A/C患者的主要发病诱因.与肾功能恢复组比较,肾功能未恢复组患者少尿持续时间较长[(1 1.5±3.4)d比(4.2±1.8)d,P＜0.05]、入院时血清白蛋白水平较低[(23.6±3.1)g/L比(26.6± 4.5) g/L,P＜0.05],而最高Scr水平较高[(601.2± 142.7) μmol/L比(421.3±107.3) μmol/L,P＜0.05].结论 老年A/C患者应对其基础疾病进行有效治疗,积极消除发痫诱因和控制影响预后的危险因素.     

尿IL-18及NGAL在重症急性胰腺炎患者并发急性肾损伤的早期诊断价值

目的探讨尿IL-18及NGAL对急性重症胰腺炎(SAP)患者合并急性肾损伤(AKI)的早期诊断价值。方法 145例急性胰腺炎(AP)患者分为轻型、重型(MAP、SAP)2组,SAP组分非AKI亚组及AKI亚组,设正常对照组。采用ELISA法测定对照组及AP患者发病后12~18 h尿NGAL、IL-18水平。结果尿IL-18在MAP组高于对照组(P<0.05),SAP组明显高于MAP组(P<0.01);尿NGAL在SAP组的AKI亚组明显高于非AKI亚组(P<0.01)。结论尿IL-18水平可以反应AP炎症的严重程度,尿NGAL可以作为SAP合并AKI早期潜在的标记物。     

SII、NPAR与老年急性ST段抬高型心肌梗死患者短期预后的关系

目的 探讨全身免疫炎症指数(SII)、中性粒细胞计数与白蛋白比值(NPAR)与老年急性ST段抬高型心肌梗死(ASTEMI)患者短期预后的关系.方法 回顾性分析2017年1月至2020年1月我院老年病科和循环科收治的行经皮冠状动脉介入治疗(PCI)的152例老年ASTEMI患者的临床资料.随访6个月,根据患者PCI术后心血管不良事件(MACE)的发生情况,将其分为预后良好组(n=100)和预后不良组(n=52).比较两组患者的年龄、性别、体质量指数(BMI)、吸烟饮酒史、糖尿病史、高血压史、Killip分级等指标.绘制ROC曲线分析SII、NPAR对老年ASTEMI患者短期预后的预测价值;采用多因素Logistic回归分析影响老年ASTEMI患者不良预后的危险因素.结果 两组冠状动脉病变支数、发病至行PCI时间、Killip分级、入院GRACE评分、LVEF、中性粒细胞、淋巴细胞、白蛋白、CK-MB、TnI、SII和NPAR相比,差异有统计学意义(P＜0.05).Pearson相关性分析示,术前SII、NPAR分别与Killip分级、GRACE评分呈正相关(P＜0.05).ROC曲线示,SII、NPAR和两项联合检测预测老年ASTEMI患者预后的AUC分别为0.842、0.807、0.910.多因素Logistic回归分析示,冠状动脉病变支数、Killip分级、GRACE评分、LVEF、SII和NPAR是影响老年ASTEMI患者短期预后的独立危险因素(P＜0.05).结论 术前SII、NPAR升高与ASTEMI老年患者预后不良有关,联合检测SII、NPAR对评估ASTEMI老年患者短期预后有较高临床价值.     

烧伤休克期小儿急性肾损伤的防治

目的 探讨烧伤休克期补液对小儿急性肾损伤（AKI）的影响及联合检测血清肌酐（SCr）、胱抑素C（CysC）、尿微球蛋白及尿酶的临床应用.方法 回顾性分析2010年6月至2013年6月濮阳市油田总医院烧伤整形科收治的严重烧伤患儿116例的病例资料,随机分为传统组（采用传统方案治疗）和改进组（采用改进后方案治疗）进行补液治疗,其中传统组59例,改进组57例.有休克症状的经液体复苏达休克治疗终点指标.烧伤早期1、3、5 d进行SCr、血尿素氮（BUN）、CysC、肾小球滤过率（GFR）及尿a1微球蛋白（a1-MG）、β2微球蛋白（β2-MG）、N-乙酰-B-D-氨基葡萄糖苷酶（NAG）检测,同时依据急性肾损伤网络（AKIN）关于AKI的分级诊断标准（基于RIFLE）评估,所获数据进行样本率、样本均数比较,采用u检验.分析两组液体治疗对AKI的影响程度.结果 补液治疗第1个24 h实际补液总量占公式计算量：59例传统组患儿（108.5±9.3）%,57例改进组患儿（141.7±28.2）%.第2个24 h实际补液总量占公式计算量：59例传统组患儿（104.6±10.3）%, 15例休克期度过不平稳.57例改进组患儿（103.8±9.4）%,7例休克期度过不平稳.发生急性肾损伤：传统组17例（28.8%）,改进组7例（12.3%）,AKI发生率比较差异具有统计学意义（aP＜0.05）.传统组与改进组液体治疗后CysC第1、3天比较差异具有高度统计学意义（P＜0.01）.a1-MG、β2-MG、NAG第1、3、5天比较差异均具有高度统计学意义（P＜0.01）.结论 小儿严重烧伤后及时、快速、充分的液体治疗,尽快纠正休克,可以降低AKI的发生率.动态检测CysC、尿微球蛋白及尿酶准确评估AKI,监测肾小球、肾小管功能,能安全实施个体化补液及综合治疗.     

血清淀粉样蛋白A1、脂蛋白结合指数预测急性冠脉综合征患者病情严重程度及预后的价值

目的 探讨血清淀粉样蛋白A1(SAA1)、脂蛋白结合指数(LCI)对急性冠脉综合征(ACS)患者病情严重程度及预后的评估价值.方法 选取2016年12月至2019年1月我科收治的130例ACS患者作为研究对象(观察组),同时,另选我院体检健康志愿者80例(对照组).比较各组受试者血清SAA1、LCI水平.根据患者出院后6个月是否发生不良心血管事件(MACE)分为预后良好组和预后不良组.采用COX比例风险模型分析影响ACS患者预后的危险因素,采用受试者工作特征曲线(ROC)分析SAA1、LCI对ACS患者短期预后的评估价值.结果 观察组血清SAA1、LCI水平高于对照组,差异有统计学意义(P＜0.05).ACS重度组血清SAA1、LCI水平高于中度组、轻度组,中度组血清SAA1、LCI水平高于轻度组,差异有统计学意义(P＜0.05).预后不良组患者血清SAA1、LCI水平高于预后良好组患者,差异有统计学意义(P＜0.05).COX多因素回归分析结果显示,Genisis评分、SAA1、LCI是影响ACS患者预后的独立危险因素(P＜0.05).ROC曲线显示,SAA1、LCI预测ACS患者短期预后的曲线下面积分别为0.821、0.840.结论 ACS患者血清SAA1、LCI水平明显升高,与患者病情严重程度及短期预后密切相关,且对ACS患者预后评估有一定预测价值.     

冠状动脉旁路移植术后急性肾损伤的危险因素分析

目的 对比冠状动脉旁路移植术(coronary artery bypass grafting,CABG)后急性肾损伤(acute kidney injury,AKI)诊断标志物的表达水平,分析CABG后AKI的危险因素.方法 选取73例CABG患者作为研究对象,以CABG是否发生AKI分组为AKI组与对照组;对比两组患者术后24h血清肌酐(serum creatinine,Scr)、血清尿素氮(serum urea nitrogen,BUN)、尿液胱抑素C(urine cystatin C,Cys C)及肾损伤分子-1(kidney injury molecule-1,KIM-1)的表达水平;以AKI为作因变量,而患者的临床资料作为自变量,分析CABG后AKI的危险因素,并进行多因素及单因素Logistic回归分析,为CABG后AKI的预防策略提供依据.结果 AKI组与对照组术前Scr、BUN、Cys C及KIM-1的表达水平对比,差异均无统计学意义(P ＞0.05);AKI组术后Scr、BUN、Cys C及KIM-1的表达水平均显著高于对照组,两组数据差异具有统计学意义(t分别为3.586、3.728、4.325、3.089,P均小于0.05);单因素Logistic回归分析显示,年龄、高血压、移植血管桥数量、机械通气时间及术后低心排作为CABG后AKI的危险因素;多因素Logistic回归分析显示,年龄、移植血管桥数量及术后低心排作为CABG后AKI的独立危险因素,具有统计学意义(P＜0.05).结论 CABG后应密切监测患者的Scr、BUN、Cys C及KIM-1的表达水平,作为AKI的诊断标志物;年龄、移植血管桥数量及术后低心排作为CABG后AKI的独立危险因素,应严格进行术前评估、降低手术风险、围术期保护及改善肾功能,降低CABG后AKI发生的风险.     

体外循环心脏手术后尿mAlb、β2-m和NAG、KIM-1与急性肾损伤的关系

目的:探讨体外循环心脏手术后尿微量白蛋白(mAlb)、β2-微球蛋白(β2-m)和N-乙酰-β-D-氨基葡萄糖苷酶(NAG)、肾损伤分子-1(KIM-1)与急性肾损伤(AKI)的关系.方法:根据AKI的诊断标准,将91例体外循环心脏手术患者分为AKI组和非AKI组,分别留取术前及术后不同时间点的血液和尿标本,测定尿mA...     

Acute cholangitis and pancreatitis associated with sulindac (clinoril)

A 68-year-old man without previous hepatobiliary or pancreatic disease was admitted after five attacks of nausea, vomiting, abdominal pain and high fever. Laboratory investigations indicated cholestatic liver disease and pancreatitis. For 1.5 years the patient had occasionally been taking a non-steroidal anti-inflammatory drug, sulindac (clinoril, MSD, New York), for osteoarthritis. On suspicion of a drug-associated disease, a rechallenge experiment was performed with sulindac. Five hours after drug administration symptoms recurred. There was a pronounced increase in serum alkaline phosphatase and amylase. A liver biopsy 3 d later showed portal tract inflammatory infiltration and abnormal interlobular bile ducts with degeneration and necrosis of the epithelium and neutrophilic infiltration of the ducts. Sulindac-induced cholangitis has not been described previously. The pathogenetic mechanism is considered to be an immunoallergic idiosyncratic reaction to the active metabolite of sulindac absorbed by the bile duct epithelium. The lesion is apparently reversible.     

血浆ET与ANF在急性胰腺炎早期发病中的作用及意义

目的探讨内皮素(ET)与心钠素(ANF)在急性胰腺炎(AP)早期发病中的作用及临床意义.方法采用放射免疫分析测定急性发病期(24～48)h轻症急性胰腺炎(MAP)35例,重症急性胰腺炎(SAP)17例和正常对照组(NC)30例的血浆内皮素与心钠素的含量.Imrie评分＞3分,APACHE Ⅱ评分≥8分者为SAP.结果SAP患者Imrie评分和APACHE Ⅱ评分明显高于MAP患者(P＜0.05,P＜0.01).SAP患者血浆ET水平(59.20±10.69)pg/ml明显增高,MAP患者血浆ET水平(34.20±9.44)pg/ml明显降低,两组之间比较以及与NC组比较具有非常显著差异(P＜0.001).SAP和MAP患者血浆ANF分别为(155.76±34.24)pg/ml,(181.59±58.15)pg/ml,与NC组(165.51±57.16)pg/ml比较无明显变化(P＞0.05).结论ET可能参与了SAP早期胰腺微循环障碍,对胰腺组织具有内源性损伤作用.提示早期给予拮抗ET或ET-A受体的药物,可能有利于减轻胰腺组织损害,改善胰腺微循环,防止胰腺出血坏死性改变.ANF可能对AP早期的胰腺血循环无明显影响.     

A hybrid form of myeloid/NK-cell acute leukemia and myeloid/NK-cell precursor acute leukemia

Natural killer (NK)-cell leukemia/lymphoma is a rare entity that has been defined only in recent years. In the Revised European-American Lymphoma and World Health Organization classifications, only the mature NK-cell malignancies are included. However, at least 3 types of precursor NK-cell neoplasms have been reported in the literature. These include myeloid/NK-cell acute leukemia, myeloid/NK-cell precursor acute leukemia, and blastic NK-cell lymphoma/leukemia. These leukemias are characterized by the presence of blasts, which express CD56, in the peripheral blood, bone marrow, lymph nodes, and/or extranodal tissues. We report a case that is morphologically consistent with myeloid/NK-cell acute leukemia but immunologically is myeloid/NK-cell precursor acute leukemia. This case is unique in its cutaneous presentation without involvement of the peripheral blood. Extensive flow cytometric studies were performed on the skin biopsy and bone marrow aspirate specimens, which included many markers that had not been tested before in these entities. The clinical implications of these findings are discussed.     

miR-133b has protective effect on rats with acute lung injury caused by severe acute pancreatitis through targeting sp1 gene

Objective: We aimed to investigate the regulatory mechanism of miR-133b and Sp1 in rats with severe acute pancreatitis complicated by acute lung injury. Methods: The rats were divided into normal, NC, model, si-Sp1, miR-133b mimic, miR-133b inhibitor, and miR-133b inhibitor + si-Sp1 group and received different treatments. Results: Compared with normal mice, model mice had a lower miR-133b expression, but higher levels of Sp1 expression, W/D of lung tissue, myeloperoxidase activities, and higher levels of interleukin(IL)-6, tumor necrosis factor (TNF)-α and IL-1β, cell apoptosis rate and Notch-1, and Hes-1, nuclear factor (NF)-κB P65 expressions in lung tissue. Compared with model mice, mice in the si-Sp1 group and the miR-133b mimic group had significantly lower W/D of lung tissue, myeloperoxidase activities, lower levels of IL-6, TNF-α and IL-1β, cell apoptosis rate and Notch-1, Hes-1, and NF-κB P65 expressions in lung tissue. Mice treated by miR-133b inhibitor showed opposite results in all above parameters, which were similar with those in the model group. The negative effects of miR-133b inhibitor could be reversed by the combination use of si-Sp1. Conclusion: Overexpression of miR-133b could inhibit Sp1 expression, thereby improving severe acute pancreatitis in rats and playing a protective role in acute lung injury.     

A case of diffuse infiltrating gastrointestinal stromal tumor of sigmoid colon with perforation

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, and typically present as discrete well‐circumscribed but non‐encapsulated tumor masses. In this report, we describe a case of colonic perforation caused by an unusual form of GIST. A 72‐year‐old Japanese woman presented to the emergency department with acute abdominal pain. Under the provisional diagnosis of sigmoid colon perforation, a laparoscopic sigmoidectomy was performed. Although the tumor mass was undetectable during the preoperative examination, a spindle cell lesion with a diffuse longitudinal growth pattern replacing the muscularis propria was revealed by microscopic examination. The spindle cell lesion was exposed at the perforation, suggesting a causal relationship between the lesion and the perforation. The spindle cell lesion was KIT‐positive and had a mutation in the C‐KIT gene at exon 11. We diagnosed it as diffuse infiltrating GIST. We consider that the lesion would be a cause of the colonic perforation, and emphasize the importance of accurate diagnosis of the lesion by histological, immunohistochemical and genetic examinations.     

小鼠急性缺血-再灌注肾损伤模型的建立及体会

目的观察应用小鼠制备急性缺血-再灌注性肾损伤模型的效果。方法应用微型动脉夹夹闭小鼠双侧肾动脉制备急性缺血-再灌注肾损伤模型,其中两组分别于术后24h和48h后处死观察肾功能及肾脏病理变化,另一组观察其病情及存活情况14天。结果各次造模成功率均达85%以上;术后24h及48h实验组血清肌酐(Scr)和血尿素氮(BUN)水平明显升高,与对照组比较差异有统计学意义(P<0.01);实验组肾脏外观出现典型"大白肾"表现,镜下出现典型急性肾小管坏死表现,并有较多炎症细胞浸润,肾小管组织学评分与对照组比较差异有统计学意义(P均<0.01);实验组在观察期间逐渐出现典型急肾衰竭表现,至14天末,死亡率达91.7%,而对照组全部正常存活。结论应用微型动脉夹夹闭小鼠双侧肾动脉可制备稳定急性缺血-再灌注肾损伤模型,而且成功率较高。     

Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems

Urinary tract infections (UTIs) are common in pregnant women and pose a great therapeutic challenge, since the risk of serious complications in both the mother and her child is high. Pregnancy is a state associated with physiological, structural and functional urinary tract changes which promote ascending infections from the urethra. Unlike the general population, all pregnant women should be screened for bacteriuria with urine culture, and asymptomatic bacteriuria must be treated in every case that is diagnosed, as it is an important risk factor for pyelonephritis in this population. The antibiotic chosen should have a good maternal and fetal safety profile. In this paper, current principles of diagnosis and management of UTI in pregnancy are reviewed, and the main problems and controversies are identified and discussed.