肾损伤程度等因素对肾损伤治疗方式选择及预后的影响

目的了解肾损伤程度(Sargent分类法)、开放或闭合性`损伤、全身损伤严重程度评分(injuryseverityscore,ISS)、休克等相关因素对手术率及死亡的影响。方法采用设计好的调查表,收集我院1998年至2002年间221例外伤性肾损伤的住院病历资料,应用logistic回归分析肾损伤治疗方式选择和预后的影响因素。结果本组平均年龄31.6岁,男191例(86.4%),女30例(13.5%)。其中闭合性损伤175例(79.2%),开放性损伤46例(20.8%),合并伤101例(45.7%),死亡6例(2.7%)。多因素logistic回归分析的结果显示:是否手术主要与肾损伤程度、损伤原因和休克有关[OR=5.965,95%CI(2.767,12.859);OR=4.667,95%CI(1.725,12.628)和OR=2.547,95%CI(1.684,3.936)]。肾切除与否主要与肾损伤程度有关[OR=11.550,95%CI(4.253,31.366)]。死亡与全身损伤严重程度的ISS评分有关[OR=1.236,95%CI(1.082,1.411)]。结论肾损伤的手术率与肾损伤程度、损伤原因和休克有关,肾损伤程度决定是否术中切肾,死亡则主要与合并伤导致的ISS评分的增高有关。

探讨血液净化在急性肾损伤治疗中的作用

目的分析对急性肾损伤患者使用血液净化的治疗效果。方法收集本院2015年6月~2016年6月内收治的28例急性肾损伤患者,将其进行随机分组,分为对照组和观察组,对照组实施常规治疗,对观察组在常规治疗基础上实施血液净化治疗。结果两组均有一定效果,但观察组小便出现时间明显低于对照组,观察组住院时间明显低于对照组,观察组患肾功能恢复正常时间明显低于对照组,差异均有统计学意义(P<0.05)。结论在对急性肾损伤患者治疗时,使用血液净化方法治疗可明显提升治疗效果,有较高使用价值。

闭合性肾损伤的非手术治疗

目的提高闭合性肾损伤的非手术治疗水平,最大限度地保存具有功能的肾脏。方法回顾分析74例闭合性肾损伤的非手术治疗方法和效果,并结合文献进行讨论。结果71例闭合性肾损伤的非手术治疗效果满意,随访六个月至两年,除1例1年后因肾萎缩无功能行肾切除外,其余病例随访期间无并发症。结论非手术方法治疗闭合性损伤是可行的,非手术治疗是闭合性肾损伤治疗的首选方法。

持续性肾脏替代治疗在急性肾损伤中的应用

急性肾损伤(Acute kidney injury,AKI)是一种涉及多学科的临床常见危重病症,发病率逐年上升,死亡率高。持续性肾脏替代治疗(replacement therapy,RRT)是一种连续、缓慢清除水分和溶质,对脏器起支持作用的血液净化技术。现有证据显示早期RRT介入和AKI患者预后改善相关。高剂量治疗[35 ml/(kg.h)]不能使肾脏替代治疗获益,目前的推荐剂量是20～25 ml/(kg.h)。鉴于AKI病因的多样性,患者年龄、性别、血流动力学等的不同及荟萃分析本身的局限性,仍需进行大规模的RCT,针对不同的AKI原因进行分层随机研究,以进一步确定CRRT治疗的时机、方式、剂量等。

连续性肾脏替代治疗重症急性肾损伤患者的疗效

[目的]探讨连续性肾脏替代治疗(CRRT)重症急性肾损伤(AKI)患者的疗效及对相关指标变化的影响。[方法]92例行CRRT的重症AKI患者,以患者入ICU后28d病死率为主要终点。根据患者预后分为生存组42例和死亡组50例。观察并比较两组疗效及相关指标变化。[结果]生存组住院时间、住ICU时间明显高于死亡组。且差异有显著性(P<0.05)。生存组未恢复率为26.19%(11/42).明显低于死亡组的76.00%(38/50),部分恢复率为47.62%(20/42)明显高于对照组的12.00%(6/50)(P<0.05)。CRRT开始前生存组平均动脉压(MAP)、尿量明显高于死亡组,平均血小板容积(MPV)、红细胞分布宽度(RDW)低于死亡组(P<0.05)。CRRT结束后。生存组MPV、降钙素原(PCT)及胱抑素C(Cys-C)明显低于死亡组,血小板计数(PLT)、尿量明显高于死亡组(P<0.05)。生存组CRRT治疗前后,MPV羞值、尿量明显高于死亡组,Cys-C差值明显低于死亡组(P<0.05)。Logistics多因素四归分析显示,CRRT治疗前MAP、MPV及治疗后Cys-C是影响重症AKI患者预后的独立因素。[结论]重瘟AKI患者接受CRRT,高MAP水平有利于患者预后,MPV水平升高及Cys-C升高可作为患者病死率的独立危险因素。

124例肾脏闭合性损伤诊治体会

分析我院近十年来收治的 12 4例肾脏闭合性损伤患者的临床资料 ,其中肾挫伤 80例、肾裂伤 2 5例、肾碎裂伤 14例、肾蒂伤 4例和严重碎裂伤合并肾蒂伤 1例。病理性肾损伤 6例。作者分析了肾闭合性损伤的原因、临床表现。

前列地尔对糖尿病肾病急性肾衰连续性肾脏替代患者的疗效及氧化应激的影响

【目的】探讨前列地尔对糖尿病肾病(DN)急性肾衰连续性肾脏替代(CRRT)患者的疗效及氧化应激的影响。【方法】104例DN急性肾衰患者,随机分为观察组和对照组。对照组采用CRRT治疗,观察组在对照组的基础上另给予前列地尔治疗。比较两组患者临床疗效,活性氧(ROS)、超氧化物歧化酶(SOD)、8-羟基脱氧鸟嘌呤(8-OHdG)、β2微球蛋白(β2-MG)、尿白蛋白排泄率(UAER)、内皮素1(ET-1)、血管性血友病因子(vWF)水平及不良反应发生情况。【结果】观察组的总有效率高于对照组(P<0.05);治疗后,两组患者ROS、SOD、8-OHdG、UAER、β2-MG、vWF水平较治疗前均降低(P<0.05),且观察组各项指标水平均低于对照组(P<0.05);两组不良反应发生率比较,差异无统计学意义(P>0.05)。【结论】前列地尔用于DN急性肾衰CRRT治疗患者,可以提高临床疗效,减轻患者氧化应激水平,同时可以改善肾功能,对血管内皮具有一定的保护作用。

术前肾损害与心脏介入治疗术后发生AKI关系的研究

目的探讨心脏介入治疗术后并发急性肾损伤（AKI）的肾脏危险因素，以及术前肾损害因素与AKI发生率之间的关系。方法回顾性分析2009年1月-20012年1月间在我院行心脏介入治疗术的成人患者的临床资料。分别统计患者术前及术后48h内血清肌酐（Scr）值、术后48h内尿量，评价有无AKI的发生；采用回归分析等统计学方法研究Scr、尿素氮（BUN）、血尿、蛋白尿，肾脏影像学异常等因素与AKI之间的关系。结果选取的152例成人患者中，心脏介入治疗术后48h内并发AKI有33例（21．7％）；单因素分析发现术前蛋白尿，肾脏体积缩小或弥漫性改变．肾积水，血肌酐、尿素氮浓度增高，eGFR≤90ml·min^-1·（1．73m2）。等因素与AKI的发生明显相关（P〈0．05或0．01）；Logistic回归分析结果显示术前蛋白尿，肾脏体积缩小或弥漫性改变，血肌酐浓度增高为术后并发AKI的独立危险因素。结论蛋白尿，肾脏体积缩小或弥漫性改变．肾积水，血肌酐、尿素氮增高，eGFR≤90ml·min^-1·（1．73m2）^-1是心脏介入治疗术后并发AKI的显著危险因素。其中术前蛋白尿。肾脏体积缩小或弥漫性改变，血肌酐浓度增高为独立危险因素．术前必须谨慎评估风险和认真防治。

Contrast-induced acute kidney injury:A review of practical points

Contrast-induced acute kidney injury(CI-AKI) is oneof the most common causes of AKI in clinical practice.CI-AKI has been found to be strongly associated with morbidity and mortality of the patients.Furthermore,CI-AKI may not be always reversible and it may be associated with the development of chronic kidney disease.Pathophysiology of CI-AKI is not exactly understood and there is no consensus on the preventive strategies.CI-AKI is an active research area thus clinicians should be updated periodically about this topic.In this review,we aimed to discuss the indications of contrastenhanced imaging,types of contrast media and their impact on nephrotoxicity,major pathophysiological mechanisms,risk factors and preventive strategies of CI-AKI and alternative non-contrast-enhanced imaging methods.

How tubular epithelial cells dictate the rate of renal fibrogenesis?

The main threat to a kidney injury, whatever its cause and regardless of whether it is acute or chronic, is the initiation of a process of renal fibrogenesis, since fbrosis can auto-perpetuate and is of high prognostic significance in individual patients. In the clinic, a decrease in glomerular fltration rate correlates better with tubulointerstitial damage than with glomerular injury. Accumulation of the extracellular matrix should not be isolated from other significant cellular changes occurring in the kidney, such as infiltration by infammatory cells, proliferation of myofbroblasts, obliteration of peritubular capillaries and atrophy of tubules. The aim of this review is to focus on tubular epithelial cells （TEC）, which, necessarily involved in the repair process, eventually contribute to accelerating fibrogenesis. In the context of injury, TEC rapidly exhibit phenotypic and functional changes that recall their mesenchymal origin, and produce several growth factors known to activate myofbroblasts. Because they are high-demanding energy cells, TEC will subsequently suffer from the local hypoxia that progressively arises in a microenvironment where the matrix increases and capillaries become rarifed. The combination of hypoxia and metabolic acidosis may induce a vicious cycle of sustained inflammation, at the center of which TEC dictate the rate of renal fbrogenesis.

Acute kidney injury from different poisonous substances

AIM To report our experience of acute kidney injury(AKI) developed after exposure to poisonous substance.METHODS Retrospective study where data was collected from case records of patients coming to this institute during January 1990 to May 2016.This institution is a tertiary care center for renal care in the metropolitan city of Karachi,Pakistan.History of ingested substance,symptoms on presentation,basic laboratory tests on arrival,mode of treatment and outcome were recorded from all patients and are presented here.Patients developing AKI after snake envenomation or scorpion stings are not included in this study.RESULTS During studied period 184 cases of AKI developing after poisoning were seen at our institution.The largest group was from paraphenyline diamine poisoning comprising 135 patients,followed by methanol in 8,organophosphorus compounds in 5,paraquat in 5,copper sulphate in 5,tartaric acid in 4,phenobarbitone in 3 and benzodiazipines,datura,rat killer,fish gall bladder,arsenic,boiler water,ammonium dichromate,acetic acid and herbs with lesser frequency.In 8 patients multiple substances were ingested in combination.Renal replacement therapy was required in 96% of patients.Complete recovery was seen in 72.28% patients,20% died during acute phase of illness.CONCLUSION It is important to report poisonous substances causing vital organ failure to increase awareness among general population as well as health care providers.

Hepatorenal syndrome: Update on diagnosis and treatment

Acute kidney injury(AKI) is a common complication in patients with end-stage liver disease and advanced cirrhosis regardless of the underlying cause. Hepatorenal syndrome(HRS), a functional form of kidney failure, is one of the many possible causes of AKI. HRS is potentially reversible but involves highly complex pathogenetic mechanisms and equally complex clinical and therapeutic management. Once HRS has developed, it has a very poor prognosis. This review focuses on the diagnostic approach to HRS and discusses the therapeutic protocols currently adopted in clinical practice.

Novel biomarkers of acute kidney injury: Evaluation and evidence in urologic surgery

atients undergoing urologic surgery are at risk of acute kidney injury （AKI） and consequently long-term deterioration in renal function. AKI is further associated with signifcantly higher odds of perioperative complications, prolonged hospital stay, higher mortality and costs. Therefore, better awareness and detection of AKI, as well as identifcation of AKI determinants in the urological surgery setting is warranted to pre-empt and mitigate further deterioration of renal function in patients at special risk. New consensus criteria provide precise definitions of diagnosis and description of the severity of AKI. However, they rely on serum creatinine （SCr）, which is known to be an inaccurate marker of early changes in renal function. Therefore, several newurinary and serum biomarkers promise to address the gap associated with the use of SCr. Novel biomarkers may complement SCr measurement or most likely improve the diagnostic accuracy of AKI when used in combinations. However, novel biomarkers have to prove their clinical applicability, accuracy, and cost effectiveness prior to implementation into clinical practice. Most preferably, novel biomarkers should help to positively improve a patient’s long-term renal functional outcomes. The purpose of this review is to discuss currently available biomarkers and to review their clinical evidence within urologic surgery settings.

Hypertensive disorders in pregnancy

Renal injury or failure may occur in the context of pre-gnancy requiring special considerations with regard to fetal and maternal health. The condition of pregnancy itself may be a major factor in such injuries. In addition,for many young women previously known to be healthy, pregnancy may be the frst presentation for routine urine and blood testing which may yield previously subclinical renal disease. As such, pregnancy may add complexity to considerations in the management of renal disease presenting coincidentally requiring knowledge of the physiologic changes and potential renal disorders that may be encountered during pregnancy.

Clinicopathological spectrum of snake bite-induced acute kidney injury from India

AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury(AKI).METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital,Shimla with snake bite-induced AKI from July 2003 to June 2016.Medical records were evaluated for patient's information on demographic,clinical characteristics,complications and outcome.Outcomes of duration of hospital stay,requirement for intensive care unit support,treatment with dialysis,survival and mortality were analyzed.The survival and non survival groups were compared to see the difference in the demographic factors,clinical characteristics,laboratory results,and complications.In patients subjected to kidney biopsy,the findings of histopathological examination of the kidney biopsies were also analyzed.RESULTS One hundred and twenty-one patients were diagnosed with snake bite-induced AKI.Mean age was 42.2 ± 15.1 years and majority(58%) were women.Clinical details were available in 88 patients.The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to30 d.Eighty percent had oliguria and 55% had history of having passed red or brown colored urine.Coagulation defect was seen in 89% patients.The hematological and biochemical laboratory abnormalities were:Anemia(80.7%),leukocytosis(75%),thrombocytopenia(47.7%),hyperkalemia(25%),severe metabolic acidosis(39.8%),hepatic dysfunction(40.9%),hemolysis(85.2%) and rhabdomyolysis(68.2%).Main complications were:Gastrointestinal bleed(12.5%),seizure/encephalopathy(10.2%),hypertension,pneumonia/acute respiratory distress syndrome(ARDS) and disseminated intravascular coagulation(9.1% each),hypotension and multi organ failure(MOF)(4.5% each).Eighty-two percent patients required renal replacement therapy.One hundred and ten(90.9%) patient survived and 11(9.1%) patients died.As compared to the survival group,the white blood cell count(P = 0.023) and bilirubin levels(P = 0.006) were significant higher and albumin levels were significantly lower(0.005) in patients who died.The proportion of patients with pneumonia/ARDS(P = 0.001),seizure/encephalopathy(P = 0.005),MOF(P = 0.05) and need for intensive care unit support(0.001) was significantly higher and duration of hospital stay was significantly shorter(P = 0.012) in patients who died.Kidney biopsy was done in total of 22 patients.Predominant lesion on kidney biopsy was acute tubular necrosis(ATN) in 20(91%) cases.In 11 cases had severe ATN and in other nine(41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis(AIN).One patient only had moderate AIN and one had patchy renal cortical necrosis(RCN).CONCLUSION AKI due to snake bite is severe and a high proportion requires renal replacement therapy.On renal histology ATN and AIN are common,RCN is rare.

Prostatic surgery associated acute kidney injury

Acute kidney injury(AKI) is associated with extended hospital stays,high risks of in-hospital and long-term mortality,and increased risk of incident and progressive chronic kidney disease.Patients with urological diseases are a high-risk group for AKI owing to the coexistence of obstructive uropathy,older age,and preexistent chronic kidney disease.Nonetheless,precise data on the incidence and outcomes of postoperative AKI in urological procedures are lacking.Benign prostatic hyperplasia and prostate cancer are common diagnoses in older men and are frequently treated with surgical procedures.Whereas severe AKI after prostate surgery in general appears to be unusual,AKI associated with transurethral resection of the prostate(TURP) syndrome and with rhabdomyolysis(RM) after radical prostatectomy have been frequently described.The purpose of this review is to discuss the current knowledge regarding the epidemiology,risk factors,outcomes,prevention,and treatment of AKI associated with prostatic surgery.The mechanisms of TURP syndrome and RM following prostatic surgeries will be emphasized.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

Major comorbid disease processes associated with increased incidence of acute kidney injury

Acute kidney injury （AKI） is commonly seen amongst critically ill and hospitalized patients. Individuals with certain co-morbid diseases have an increased risk of developing AKI. Thus, recognizing the co-morbidities that predispose patients to AKI is important in AKI prevention and treatment. Some of the most common co-morbid disease processes that increase the risk of AKI are diabetes, cancer, cardiac surgery and human immunodefciency virus （HIV） acquired immune defciency syndrome （AIDS）. This review article identifies the increased risk of acquiring AKI with given co-morbid diseases. Furthermore, the pathophysiological mechanisms underlying AKI in relation to co-morbid diseases are discussed to understand how the risk of acquiring AKI is increased. This paper reviews the effects of various co-morbid diseases including： Diabetes, cancer, cardiovascular disease and HIV AIDS, which all exhibit a significant increased risk of developing AKI. Amongst these co-morbid diseases, inflammation, the use of nephrotoxic agents, and hypoperfusion to the kidneys have been shown to be major pathological processes that predisposes individuals to AKI. The pathogenesis of kidney injury is complex, however, effective treatment of the co-morbid disease processes may reduce its risk. Therefore, improved management of co-morbid diseases may prevent some of the underlying pathology that contributes to the increased risk of developing AKI.

Prevalence and outcome of acute kidney injury,as defined by the new Kidney Disease Improving Global Outcomes guideline,in very low birth weight infants

AIMTo evaluate the prevalence, risk factors and outcome of acute kidney injury （AKI） in very low birth weight （VLBW） infants. METHODSIn this retrospective study of VLBW infants, we analyzed the prevalence of AKI, as defined by changes in serum creatinine and urine output, associated risk factors and outcomes.RESULTSA total of 293 VLBW infants （mean gestational age 28.7 wk） were included, of whom 109 weighed less than 1000 g at birth. The overall prevalence of AKI was 11.6% （22% in infants with a birth weight under 1000 g and 5.4% those heavier）. A total of 19 （55%） affected infants died, with a mortality rate of 58% in infant less than 1000 g and 50% in those heavier. After adjusting for confounding variables, only necrotizing enterocolitis （NEC） remained associated with AKI, with odds ratio of 4.9 （95%CI： 1.9-18.6）. Blood pressure and glomerular filtration rate （GFR） were not different between affected infants and the others upon discharge from hospital. A normal GFR was documented in all affected infants at one year of age.CONCLUSION Using Kidney Disease Improving Global Outcomes defnition of AKI, it occurred in over 10% of VLBW infants, more commonly in infants with lower birth weight. NEC was an independent associated risk factor. Renal function, as defined by GFR, was normal in all surviving affected infants 10 to 12 mo later.

Dosage of L-arginine Preventing Acute High-dose PDD Nephrotoxicity

Objective： To explore the optimal dose of L-arginine to prevent acute high-dose （HD）-PDD nephrotoxicity. Methods： 128 cases using PDD with the dosage of 100 mg/m^2 within two days （D1, 2） in combination with L-arginine were randomly divided into 3 groups of A, B and C. The dosages of L- arginine in the 3 groups were 5 g/（m^2·d）, 10 g/（m^2·d） and 15 g/（m^2·d）, respectively. Each patient received 2 cycles chemotherapy to form self control： 1 cycle combined with L-arginine, while 1 cycle chemotherapy alone, β2-MG in urine, BUN, Cr and uric acid in blood were detected just 24 h before and after using PDD. The changes of each index in the three groups were observed in the presence or absence, and the therapeutic effects were compared among the three groups. Results： There was no significant difference in BUN, Cr and uric acid in blood before and after chemotherapy in the presence or absence, showing these indexes could not be used as markers of early acute nephrotoxicity. Urine β2-MG values in the presence and absence were 0.9120±0.6618 vs 1.5167±0.7908 （P〈0.05）, 0.5404±0.5810 vs 1.4616±0.8120 （P〈0.01）, 0.4998±0.6210 vs 1.5210±0.7710 （P〈0.01） in the groups A, B and C respectively. The excellent effective rate and total effective rate in groups A, B and C were 40.9% and 59.1%, 68.2% and 90.9%, and 77.5% and 97.5%, respectively. There was significant difference in the excellent effective rate and total effective rate between groups A and B, but not between groups B and C. Conclusion： The optimal dose of L- arginine to prevent acute HD-PDD nephrotoxicity is 10 g/（m^2·d）. Increased dosage can＇t improve the effect accordingly.