5%碳酸氢钠严格控制代谢性酸中毒对活体肾移植患者术后早期肾功能的影响

目的：观察使用5%碳酸氢钠严格控制代谢性酸中毒是否可改善活体肾移植患者术后早期肾功能。方法：选择2019年3月至2020年3月于中国科学技术大学附属第一医院择期行活体肾移植手术的120例尿毒症患者为研究对象,随机分为观察组和对照组。观察组术中根据碱剩余（BE）测量值补充5%碳酸氢钠,维持－3 mmol/L≤BE≤+3 mmol/L。对照组仅在明显代谢性酸中毒（BE≤－10 mmol/L或pH≤7.25）时才补充5%碳酸氢钠。调整分钟通气量,使PaCO2在正常范围内。记录患者麻醉前（T0）、麻醉诱导后10 min（T1）、肾动脉血流开放前（T2）、肾动脉血流开放后5 min（T3）、手术结束时（T4）的血流动力学指标及术中出血量、输液量、手术时间。记录术后1、2、3、7、30 d的肌酐、尿素氮及尿量。结果：与对照组相比,观察组术中5%碳酸氢钠输注量明显增加,去氧肾上腺素使用量明显减少（P<0.05）,对照组无输注5%碳酸氢钠指征;观察组术毕时pH、BE明显大于对照组（P<0.05）。与T0时比较,T3时两组MAP、CVP均明显降低（P<0.05）。观察组术后1、2、3、7 d血肌酐、尿素氮含量明显低于对照组（P<0.05）。观察组术后1、2、3 d尿量明显多于对照组（P<0.05）。结论：活体肾移植术中应用5%碳酸氢钠严格控制代谢性酸中毒可改善术后早期肾功能。     

The Influence of Betulin and Its Derivatives EB5 and ECH147 on the Antioxidant Status of Human Renal Proximal Tubule Epithelial Cells

Betulin and its derivatives, 28-propyne derivative EB5 and 29-diethyl phosphonate analog ECH147, are promising compounds in anti-tumor activity studies. However, their effect on kidney cells has not yet been studied. The study aimed to determine whether betulin and its derivatives—EB5 and ECH147—influence the viability and oxidative status of human renal proximal tubule epithelial cells (RPTECs). The total antioxidant capacity of cells (TEAC), lipid peroxidation product malondialdehyde (MDA) level, and activity of antioxidant enzymes (SOD, CAT, and GPX) were evaluated. Additionally, the mRNA level of genes encoding antioxidant enzymes was assessed. Cisplatin and 5-fluorouracil were used as reference substances. Betulin and its derivatives affected the viability and antioxidant systems of RPTECs. Betulin strongly reduced TEAC in a concentration-dependent manner. All tested compounds caused an increase in MDA levels. The activity of SOD, CAT, and GPX, and the mRNA profiles of genes encoding antioxidant enzymes depended on the tested compound and its concentration. Betulin showed an cisplatin-like effect, indicating its nephrotoxic potential. Betulin derivatives EB5 and ECH147 showed different impacts on the antioxidant system, which gives hope that these compounds will not cause severe consequences for the kidneys in vivo.     

Blood Thiol Redox State in Chronic Kidney Disease

Thiols (sulfhydryl groups) are effective antioxidants that can preserve the correct structure of proteins, and can protect cells and tissues from damage induced by oxidative stress. Abnormal levels of thiols have been measured in the blood of patients with moderate-to-severe chronic kidney disease (CKD) compared to healthy subjects, as well as in end-stage renal disease (ESRD) patients on haemodialysis or peritoneal dialysis. The levels of protein thiols (a measure of the endogenous antioxidant capacity inversely related to protein oxidation) and S-thiolated proteins (mixed disulphides of protein thiols and low molecular mass thiols), and the protein thiolation index (the molar ratio of the S-thiolated proteins to free protein thiols in plasma) have been investigated in the plasma or red blood cells of CKD and ESRD patients as possible biomarkers of oxidative stress. This type of minimally invasive analysis provides valuable information on the redox status of the less-easily accessible tissues and organs, and of the whole organism. This review provides an overview of reversible modifications in protein thiols in the setting of CKD and renal replacement therapy. The evidence suggests that protein thiols, S-thiolated proteins, and the protein thiolation index are promising biomarkers of reversible oxidative stress that could be included in the routine monitoring of CKD and ESRD patients.     

Physical examination of arteriovenous fistula: The influence of professional experience in the detection of complications

Vascular access is one of the leading causes of mobilization of financial resources in health systems for people with chronic kidney disease on hemodialysis. Physical examination of the arteriovenous fistula (AVF) has demonstrated its effectiveness in identifying complications. We decided to evaluate the influence of nurses' professional experience in the detection of complications of the AVF (venous stenosis and steal syndrome). The study took place in eight hemodialysis centers between May and September of 2011 in the north of Portugal. Sample was constituted by registered nurses. The nurses involved in the experiment were divided in two groups: those who had more than 5 years of experience and those who had less than 5 years of experience. Ninety‐two nurses participated in the study: 34 nurses had less than 5 years of professional experience and 58 had more than 5 years of professional experience. In the practices considered by nurses in the detection of venous stenosis, there were no differences observed between the groups (P > 0.05). In steal syndrome, there were no differences observed between the groups in the practices of the nurses in the detection of this complication of the AVF (P > 0.05). We concluded that professional experience does not influence the detection of venous stenosis and steal syndrome.     

晚期肾细胞癌靶向药物治疗后孤立转移灶手术切除的疗效

目的　探讨靶向药物治疗的转移性肾细胞癌患者远处孤立转移病灶行手术切除的疗效。方法　回顾性收集2007年12月至2013年12月在北京协和医院接受靶向药物治疗的126例转移性肾细胞癌患者资料，其中16例对远处孤立转移灶予以手术切除。患者均有明确的肾细胞癌病理诊断，口服靶向药物索拉非尼、舒尼替尼或依维莫司，直至孤立转移灶稳定且评估为可切除。对手术治疗的安全性和远期效果进行评价。结果　接受远处孤立转移灶切除术的16例患者中，男11例，女5例，中位年龄51岁（37~72岁）；其中肾透明细胞癌14例，肾乳头状细胞癌2例；肺转移5例，骨转移2例，肾上腺转移5例，脑转移2例，肝转移1例，腹壁转移1例。患者围术期均恢复良好，无严重并发症发生。术后肿瘤相关症状明显缓解，一般情况有所好转。16例患者1、3、5年生存率分别为75.0%、43.8%和31.3％。无手术相关的死亡。结论　经靶向药物治疗的晚期肾细胞癌患者有远处孤立转移灶时可从手术治疗中获益，取得较长时间生存。。     

The relationship between laboratory-based outcome measures and mortality in end-stage renal disease: A systematic review

Despite data that traditional laboratory-based outcome measures in dialysis are improving over time, population-based data indicate that mortality rates are not improving in parallel. With increased focus on performance measures based on laboratory-based outcomes (e.g., hematocrit, albumin, and parathyroid hormone), less emphasis has been placed on other markers, some of which may be stronger predictors of mortality. We performed a systematic review to interpret the predictive value of laboratory-based outcome measures in dialysis. We identified studies with data regarding the predictive value of laboratory-based outcomes for mortality in dialysis. We calculated the sample size-weighted pooled relative risk of death with dichotomized "high" vs. "low" levels of each measure. We rank-ordered predictors by scaling the pooled relative risk of each measure by its pooled standard deviation. There were 5171 titles, of which 128 (representing 44 laboratory-based outcomes) were selected. Nine were significantly associated with mortality, in order of decreasing scaled effect size: (1) tumor necrosis factor-α, (2) hematocrit, (3) interleukin-6, (4) troponin T, (5) Kt/V_urea, (6) prealbumin, (7) urea reduction ratio, (8) serum albumin, and (9) C-reactive protein. Other oft-cited measures such as calcium phosphate product and parathyroid hormone were not significantly associated with mortality in pooled analysis. Quality improvement efforts to improve traditional laboratory-based outcomes in end-stage renal disease are necessary, but likely insufficient, to improve overall mortality in dialysis. Renewed consideration of cardiovascular, inflammatory, and nutritional markers that are especially strong predictors of mortality may have important implications for risk stratification and targeted therapeutic interventions.     

Role of T‐regulatory cells in the response to hepatitis B vaccine in hemodialysis patients

Human disease elicits a complex array of biological processes that results in long‐term protective immunological memory to infectious agents. Chronic kidney disease is known to impair induction of sustained immunological memory to hepatitis B vaccine (HBVax) antigens. We asked the question: Does end‐stage renal disease promote changes in subtypes of regulatory T (Treg) cells that correlate with diminished amnestic response to HBVax antigen compared to healthy controls? The study design and setting was a prospective observational cohort at a veterans affairs medical center. End‐stage renal disease patients on hemodialysis (HD) were compared with individuals with self‐reported normal kidney function. All subjects received HBVax. Peripheral blood was sampled for assessment for Treg cells pre and post vaccination. CD4+ FOXP3 Treg numbers were similar between HD and healthy subjects during a 14‐day time period post vaccination. HD subjcts had lower anti‐HBSag antibody than CON (control) subjects (330 ± 108.7 vs. 663.1 ± 129.7 IU/mL; P = 0.063). Hemodialysis subjects with resting Tregs higher than the median value in our cohort demonstrated a significantly lower change in HBsAB at 30 days post booster vaccination (P = 0.030). No such relationship was found for the activated Treg subset among HD subjects, or either subset among CON subsets. In our limited comparison study of 11 HD and 8 CON subjects, Treg subsets did not differ between the two groups; but differences in the suppressive Treg numbers in the HD group could explain the altered antibody response to HBVax and is worthy of further study.     

High prevalence of subclinical hypothyroidism and nodular thyroid disease in patients on hemodialysis

Chronic kidney disease has been known to affect thyroid hormone metabolism. Low serum levels of T3 and T4 are the most remarkable laboratorial findings. A high incidence of goiter and nodules on thyroid ultrasonography has been reported in patients with end‐stage renal disease (ESRD). Our objective is to evaluate the prevalence of laboratorial and morphologic alterations in the thyroid gland in a cohort of patients with ESRD on hemodialysis (HD). Sixty‐one patients with ESRD on HD were selected and compared with 43 healthy subjects matched by age, gender, and weight. Patients were submitted to thyroid ultrasonography. T3, free T4 (FT4), thyroid‐stimulating hormone, antithyroglobulin, and antithyroperoxidase antibodies were measured. The mean age of patients with ESRD was 47.4 ± 12.3 and 61% were women. ESRD was mainly caused by hypertensive nephrosclerosis and diabetic nephropathy. Mean thyroid volume, as determined by ultrasonography, was similar in both groups. Patients with ESRD had more hypoechoic nodules when compared with the control group (24.1% vs. 7.9%, P = 0.056). Mean serum FT4 and T3 levels were significantly lower in patients with ESRD, and subclinical hypothyroidism was more prevalent in patients with ESRD (21.82% vs. 7.14% control group, P = 0.04). Titers of antithyroid antibodies were similar in both groups. ESRD was associated with a higher prevalence of subclinical hypothyroidism and lower levels of T3 and FT4. Almost a quarter of patients showed thyroid nodules >10 mm. Periodic ultrasound evaluation and assessment of thyroid function are recommended in patients with ESRD on HD.