动静脉内瘘术钛轮钉吻合与直接缝合的对比观察

230例慢性肾功能衰竭尿毒症患者行动静脉内瘘术时随机分成二组:钛钉组120例用钛轮钉吻合法;缝合组110例用直接缝合法。半年内观察临床使用效果,结果两种方法临床效果无显著差异。

How albumin administration for cirrhosis impacts on hospital albumin consumption and expenditure

AIM:To assess the impact of guidelines for albumin prescription in an academic hospital,which is a referral center for liver diseases.METHODS:Although randomized trials and guidelines support albumin administration for some complications of cirrhosis,the high cost of albumin greatly limits its use in clinical practice.In 2003,a multidisciplinary panel at Sant'Orsola-Malpighi University Hospital(Bologna,Italy)used a literature-based consensus method to list all the acute and chronic conditions for which albumin is indicated as first-or second-line treatment.Indications in hepatology included prevention of post-paracentesis circulatory dysfunction and renal failure induced by spontaneous bacterial peritonitis,and treatment of hepatorenal syndrome and refractory ascites.Although still debated,albumin administration in refractory ascites is accepted by the Italian health care system.We analyzedalbumin prescription and related costs before and after implementation of the new guidelines.RESULTS:While albumin consumption and costs doubled from 1998 to 2002,they dropped 20%after 2003,and remained stable for the following 6 years.Complications of cirrhosis,namely refractory ascites and paracentesis,represented the predominant indications,followed by major surgery,shock,enteric diseases,and plasmapheresis.Albumin consumption increased significantly after guideline implementation in the liver units,whereas it declined elsewhere in the hospital.Lastly,extra-protocol albumin prescription was estimated as<10%.CONCLUSION:Albumin administration in cirrhosis according to international guidelines does not increase total hospital albumin consumption if its use in settings without evidence of efficacy is avoided.

Hemorrhagic Fever with Renal Syndrome Complicated by Orchitis

Hemorrhagic fever with renal syndrome (HFRS) is a disease caused by viruses of the family Bunyaviridae,genus Hantavirus.HFRS from Dobrava virus (DOBV) is a seldom reported disease in Albania.Clinically HFRS is manifested as mild,moderate,or severe.Therefore,the number of cases of Hantavirus' infection may be underestimated,and should be included in the differential diagnosis of many acute infections,hematologic diseases,acute abdominal diseases and renal diseases complicated by acute renal failure.We report here an atypical presentation of HFRS from Dobrava virus complicated by orchitis with a positive outcome.

Treatment of advanced rectal cancer after renal transplantation

Renal transplantation is a standard procedure for endstage renal disease today. Due to immunosuppressive drugs and increasing survival time after renal transplantation, patients with transplanted kidneys carry an increased risk of developing malignant tumors. In this case report, 3 patients with advanced rectal cancer after renal transplantation for renal failure were treated with anterior resection or abdominoperineal resection plus total mesorectal excision, followed by adjuvant chemotherapy. One patient eventually died of metastasized cancer 31 mo after therapy, although his organ grafts functioned well until his death. The other 2 patients were well during the 8 and 21 mo followup periods after rectal resection. We therefore strongly argue that patients with advanced rectal cancer should receive standard oncology treatment, including operation and adjuvant treatment after renal transplantation. Colorectal cancer screening in such patients appears justified.

Contrast induced nephropathy after percutaneous coronary intervention： risk factors and preventive strategy

Objective To analyze the risk factors and clinical outcome of contrast induced nephropathy （CIN） in patients with coronary artery disease （CAD） after percutaneous coronary intervention （PCI） and discuss its prevention. Methods Fifty-four patients with C1N among 729 patients who received PCI were retrospectively studied and the related risk factors, cardiovascular events and preventive strategy were analyzed. Results C1N was strongly associated with pre-procedure chronic renal failure, diabetes mellitus and large-dose contrast. The incidence of cardiac mortality and major adverse cardiac events 1 year after PCI in CIN group was higher than that in group without CIN. Conclusion Chronic renal failure, diabetes mellitus and dosage of contrast agent were three independent risk factors of CIN. CIN could affect the patients＇ prognosis. A well overall perioperative management of CAD patients following PCI, especially hydration therapy, is the most important strategy for prevention of CIN.

Selection of neuromuscular blocking agents in patients undergoing renal transplantation under general anesthesia

OBJECTIVE: To study the pharmacodynamics of vecuronium,atracurium, mivacurium and rocuronium in patients with end-stage renal failure. METHODS: Forty-six patients with end-stage renal failure scheduled for renal transplantation and 53 patients with normal renal function were given either vecuronium, atracurium, mivacurium or rocuronium. The neuromuscular effects were monitored by the evoked response of the adductor pollicis to train-of-four stimulation of the ulnar nerve. RESULTS: Onset of vecuronium, atracurium and mivacurium occurred faster or tended to be faster in patients with end-stage renal failure, but there was no significant difference in onset by rocuronium between the control patients and renal failure patients. Furthermore, the no-response period, duration of action and recovery of atracurium did not differ between the two groups. There was no significant difference in duration of action or recovery of mivacurium between the two groups, whereas its no-response period was significantly prolonged in the patients with end-stage renal failure. There was no difference in no-response period or duration of action after the initial dose of vecuronium or rocuronium between the two groups. However, no-response period and duration of effect by vecuronium and rocuronium were prolonged with increasing incremental doses in patients with end-stage renal failure. CONCLUSIONS: All four muscle relaxants could be safely used in patients with end-stage renal failure. Onset of the relaxants were, in some cases, accelerated and no-response period of mivacurium was prolonged in patients with end-stage renal failure undergoing dialysis therapy. End-stage renal failure prolonged the no-response period and duration of action of vecuronium and rocuronium after repeated incremental doses, but did not alter those attributed to atracurium.

COL4A3 mutations cause focal segmenta glomerulosclerosis

Focal segmental glomerulosclerosis （FSGS） is a histologically identifiable gtomerular injury often leading to proteinuria and renal failure. To identify its causal genes, whole-exome sequencing and Sanger sequencing were performed on a large Chinese cohort that comprised 40 FSGS families, 50 sporadic FSGS patients, 9 independent autosomal recessive Atport＇s syndrome （ARAS） patients, and 190 ethnically matched healthy controls. Patients with extrarenal manifestations, indicating systemic diseases or other known hereditary renal diseases, were excluded. Heterozygous COL4A3 mutations were identified in five （12.5%） FSGS families and one （2%） sporadic FSGS patient. All identified mutations disrupted highly conserved protein sequences and none of them was found in either public databases or the 190 healthy controls. Of the FSGS patients with heterozygous COL4A3 mutations, segmental thinning of the glomerular base membrane （GBM） was only detected in the patient with electronic microscopy examination results available. Five ARAS patients （55.6%） had homozygous or compound-heterozygous mutations in COL4.43 or COL4A4. Serious changes in the G BM, hearing loss, and ocular abnormalities were found in 100%, 80%, and 40% of the ARAS patients, respectively. Overall, a new sub- group of FSGS patients resulting from heterozygous C01.4A3 mutations was identified. The mutations are relatively frequent in famiUes diagnosed with inherited forms of FSGS. Thus, we suggest screening for C01.4A3 mutations in familial FSGS patients.

Emergency intervention therapy for renal vascular injury

Objective： To evaluate the efficacy and safety of the interventional techniques in the treatment of renal vascular injury. Methods： A total of 16 patients with renal vascular injuries were treated by superselective arterial embolization. The renal injuries resulted from renal biopsy in 7 patients, endovascular intervention in 2, percutaneous puncture and pyelostomy in 2, local resection of renal tumor in 1 and trauma in 4. With regards to clinical manifestations, there was hemorrhagic shock in 8 patients, severe flank pain in 14, and hematuria in 14. CT and ultrasonography confirmed that 15 patients had perirenal hematoma. The embolization was performed with microcoils in 13 and standard stainless steel coils in 3 patients, associated with polyvinyl alcohol particles （PVA） in 9, and gelfoam particles in 6 cases. Results： Renal angiogram revealed arterlovenous fistula in renal parenchyma in 9 cases, pseudoaneurysm in 3 and extravasation of contrast media in 4. The arterial embolization was successful in all 16 cases in a single session. The angiography at the end of therapy showed that abnormal vessels had disappeared without other major intrarenal arterial branch occlusion. In 13 patients with hemodynamical compromise, blood loss-related symptoms were immediately relieved after blood transfusion. In 14 patients with severe flank pain, the pain was progressively relieved. Hematuria ceased in 14 patients 2-14 days after the embolization procedures. The renal function was impaired after the procedure in 6 cases, in which preoperative renal insufficiency was exacerbated in 3 and developed new renal dysfunction in 3, 2 of whom received hemodialysis. The ultrasonography showed that perirenal hematoma was gradually absorbed within 2-6 months after the procedure. All patients were followed up in 6-78 months （mean, 48 months）. Six patients died of primary diseases （5 cases of renal failure and multiple organ failure and l case of malignant tumor）. Ten patients survived without bleeding and further intervention. The deterioration of renal function did not occur and the serum creatinine and blood urea were in normal range. Conclusion： Transcatheter selective renal arterial embolization is a safe and effective method in the treatment of renal vascular injuries.