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Objective:To investigate the clinical practice of chronic kidney disease-mineral and bone disorder (CKD-MBD) in maintenance hemodialysis patients in Shanghai, and to better understand the changes of clinical practice for CKD-MBD.Methods:Sixty-four hospitals with qualified dialysis center in Shanghai were selected for questionnaire survey as of March 2019. The survey questionnaire included the number of hemodialysis and peritoneal dialysis patients, the implementation of CKD-MBD guidelines, the learning of CKD-MBD guidelines, the detection and distribution of CKD-MBD biochemical indicators, the treatment of hyperphosphatemia, the treatment of secondary heperparathyroidism (SHPT) and renal bone disease, and the concentration of calcium ion in dialysate. The results were compared with previous survey data in 2011.Results:There were sixty-three hospitals included in this study, with 10 168 maintenance hemodialysis patients and 4 610 maintenance peritoneal dialysis patients in Shanghai. 84.1%(53/63) hospitals implemented the guidelines smoothly, which increased by 28.5% compared with the rate (55.6%) of 2011. The successful implementation rates for guidelines in secondary and tertiary hospitals were 83.3%(25/30) and 84.8%(28/33) , which increased by 44.0% and 11.7% respectively (39.3% of secondary hospitals and 73.1% of tertiary hospitals in 2011). All hospitals carried out the detection for serum calcium and phosphorus. The rate for parathyroid hormone (PTH), total alkaline phosphatase (AKP), bone specific alkaline phosphatase (BAP), 25-hydroxy vitamin D[25(OH)D], and other bone metabolism-related biomarkers were 98.4%(62/63), 90.5%(57/63), 19.0%(12/63), 90.5%(57/63) and 42.9%(27/63), respectively; coronary artery CT, lumbar lateral X-ray plain, echocardiography, bone mineral density, and vascular ultrasound were carried out in 68.3%(43/63), 74.6%(47/63), 100.0%(63/63), 68.3%(43/63)and 69.8%(44/63), respectively. Compared with 2011, the proportion of detection for PTH, AKP, BAP, 25(OH)D, coronary artery CT, lumbar lateral film and echocardiography increased by 2.1%, 1.6%, 0.5%, 47.9%, 14.6%, 20.9% and 1.9%, respectively. The proportion of patients with serum phosphorus ranging in 0.80-1.45 mmol/L(KDIGO guideline), serum phosphorus ranging in 0.80-1.78 mmol/L(KDOQI guideline), calcium ranging in 2.10-2.54 mmol/L, and PTH ranging in 150-600 ng/L were 37.0%(3 323/8 969), 50.7%(4 571/9 018), 60.2%(5 568/9 244) and 33.2%(3 018/9 087). Compared with 2011(39.6%, 53.5% and 34.1%), the proportion of patients with ideal serum phosphorus (0.80-1.78 mmol/L) and calcium (2.10-2.54 mmol/L) levels increased by 11.1% and 6.7% respectively, and the proportion with PTH 150-300 ng/L decreased by 0.9%. The proportion of hospitals for using non-calcium phosphate binders (lanthanum carbonate from 1.9% to 87.3% and sevelamer carbonate from 14.8% to 63.5%) and surgical treatment (from 38.9% to 68.3%) for SHPT dramatically increased.Conclusions:Through the availability of medicine increases, and nephrologists gain deeper understanding in management and treatment of CKD-MBD, the detection rate for CKD-MBD indicators and the eligible rate have significantly improved compared with those in 2011. However, the comprehensive management of CKD-MBD in Shanghai still faces great challenges. It is still necessary to further improve eligible rate for serum phosphorus and iPTH, so as to provide more evidences and management strategies for integrated management of end-stage renal disease and prevention of abnormal calcium and phosphorus metabolism in patients.
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Objective To explore the feasibility and clinical significance of individualized formular administration of tacrolimus after renal transplantation based on the CYP3A5 and MDR1 gene polymorphism.Methods Total 129 renal transplantation recipients from Oct.1,2015 to July 30,2016 were included in this study and divided into 2 groups.In experimental group,tacrolimus was administrated by the individualized formula based on CYP3A5 and MDR1 gene polymorphism;in control group,tacrolimus was administrated by doctors' experience based on patient's body weight.The blood trough level of tacrolimus was determined 3 days after administration.The first blood trough level of tacrolimus,plasma creatinine level,acute rejection rate,and necessity for dialysis were compared between two groups.Results The first blood trough levels of tacrolimus in experimental and control groups were 9.24 ± 2.32 and 9.39 ± 3.47μg/L respectively (P＞0.05).The tacrolimus levels of 7 cases in experimental group and 18 cases in control group were not in normal range (P＜0.05).The plasma creatinine level at day 7 after surgery was 157.36 ± 110.55 μg/L in experimental group,and 174.01 ± 130.68μg/L in control group (P＞0.05).Acute rejection was found in both two groups:2 in experimental group and 5 in control group (P ＞ 0.05).There was significant difference in necessity for dialysis between two groups:4 in experimental group and 10 in control group (P＜0.05).Conclusion The individualized formular administration of tacrolimus based on the CYP3A5 and MDR1 gene polymorphism is more feasible and reasonable than experimental administration,which is more easier to come to an appropriate blood level and would benefit the early recovery of renal function.
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Objective To explore the causes of nocturnal hemodialysis (NHD) patient dropout and the risk factors for dropout.Methods We collected the clinical data of patients receiving NHD for more than 3 months,of whom 47 patients dropped out and 64 kept receiving NHD from Feb.2009 to Nov.2016 in Changzheng Hospital of Second Military Medical University.We investigated the general conditions;and we compared the differences of the blood parameters between the two groups when the patients received NHD for the first time and for the last time,including hemoglobin,platelet,albumin,ferritin,serum calcium,serum phosphorus and parathyroid hormone.We also analyzed the risk factors for NHD dropout or for death using Cox regression analysis model.Results Among 111 patients,47 patients had withdrawn from NHD,with their average time for NHD being (31.55±20.30) months,and the causes for dropout included death,transferring to other hospitals,turning to conventional hemodialysis (CHD),renal transplantation and others.Univariate Cox regression analysis showed that hypertensive nephropathy (P=0.007,HR=2.913,95％CI:1.348-6.293) and diabetic nephropathy (P=0.047,HR=2.401,95％CI:1.014-5.685) were risk factors for NHD patient dropout,while chronic nephritis syndrome (P＜0.001,HR=0.095,95％CI 0.046-0.195) was a protective factor;blood albumin (P=0.007,HR=0.904,95％CI:0.840-0.973) and age (P=0.027,HR=1.052,95％CI:1.006-1.101) were risk factors for NHD patient dropout.Multivariate Cox regression analysis showed that albumin level (P=0.007,HR=0.911,95％CI:0.848-0.991) was an independent risk factor for death in NHD patients.Conclusion Hypertensive nephropathy and diabetic nephropathy are the risk factors for NHD patients dropout,while chronic nephritis syndrome was a protective factor.Low serum albumin level is an independent risk faetor for death in NHD patients.
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Objective To compare the difference of mortality risk between patients undergoing nocturnal hemodialysis (NHD) and conventional hemodialysis (CHD) and to explore the related factors of mortality.Methods The study cohort comprised the maintenance hemodialysis patients receiving either NHD (n=111) or CHD (n=722) in Changzheng Hospital of Second Military Medical University from Feb.2009 to Feb.2017.The demographic information,clinical characteristics,survival status,causes of death and laboratory examination indexes were obtained from hemodialysis management system.The urea clearance index (Kt/V),hemoglobin,blood phosphorus concentration and mortality were compared between NHD and CHD patients.The multivariate-adjusted Cox model was used to analyze the mortality risk of all patients.Results Compared with the patients receiving CHD,the proportion of male was more in the NHD group,and the baseline age was younger (P＜0.01) and baseline dialysis vintage was longer (P＜0.01).There was no significant difference in incidences of primary disease and comorbidities,or laboratory examination results.Compared with the CHD group,the levels of Kt/V and hemoglobin in the NHD group were significantly higher (P＜0.01),and the blood phosphorus concentration was significantly lower (P＜0.05).Mortality in the NHD and CHD groups was 3.5 per 100 patients-years and 6.2 per 100 patients-years,respectively.After the adjustment by baseline age,dialysis vintage,gender,and comorbidities,Cox model analysis showed that the mortality risk in the NHD group was lower than in the CHD group (HR=0.67,95％CI:0.39-1.00,P=0.05).Subgroup analysis showed NHD was of more survival benefit for male (P＜0.05),non-diabetic patients (P =0.05) and patients with conventional dialysis vintage ＞3 years (P＜0.05).Conclusion NHD can effectively increase the solute clearance,improve anemia and calcium and phosphate metabolism,and thus reduce the mortality risk of maintenance hemodialysis patients.
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Hemodialysis is one of the main treatment methods for patients with end stage renal disease (ESRD),and conventional hemodialysis (CHD) is the most widely used one.With the development of dialysis technology,the survival time of hemodialysis patients is significantly prolonged,but the mortality remains high.Nocturnal hemodialysis (NHD) was proposed in 1963 as a new type of dialysis,and it has greatly extended time of dialysis as compared with CHD.NHD has advantages in controlling blood pressure and cardiovascular function,correcting anemia,improving calcium and phosphorus metabolism and nutritional status,and enhancing quality of life of hemodialysis patients.
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Objective To compare the differences of dialysis complications and tolerability between nocturnal hemodialysis (NHD) and conventional hemodialysis (CHD) patients.Methods Seventy-two NHD and 72 CHD patients from Changzheng Hospital of Second Military Medical University were enrolled in this study.The clinical data were collected and the postdialysis recovery time was recorded.The complications including intradialytic hypotension,postdialytic fatigue,itching,muscle spasms,dizziness,headache,loss of appetite,nausea,vomiting,and sleep disorders,and the mental pressure and daily life (fear of death,worrying about equipment failure,losing freedom,and failing to work) were all investigated using a questionnaire.Results Patients in the NHD group had significantly shortened postdialysis recovery time (P ＜ 0.01) and significantly less complications (intradialytic hypotension,postdialytic fatigue,itching,dizziness,headache,loss of appetite,nausea and vomiting) than those in the CHD group (P＜0.05,P＜0.01).The number of patients who lost freedom significantly was decreased (P＜0.01),but the number of patients worrying about equipment failure was significantly increased (P＜0.01).Conclusion The NHD patients have less complications associated with hemodialysis than CHD patients,and they also have improved tolerance to maintenance hemodialysis.
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Objective To evaluate the clinical efficacy of retroperitoneal laparoscopic nephroureterectomy (RLNU) combined with transurethral electric coagulation on upper urinary tract urothelial carcinoma (UUTUC).Methods Sixty UUTUC patients were enrolled from Jun.2012 to Apr.2013.The prospective clinical controlled analysis method was adopted in this study.All patients were divided into test group and control group according to the order of admission.Thirty cases (test group) underwent RLNU combined with electric coagulation,and 30 cases (control group) underwent RLNU combined with electric resection.The differences in operation time,blood loss,hospital stay and tumor recurrence rate between the 2 groups were compared.Results All the 60 operations for UUTUC were successful without conversion to open surgery.No intraoperative complications such as great vessels or surrounding organs damage occurred.There were 2 cases loss to follow-up in test group and 3 cases in control group.There were no significant differences in operation time,blood loss,follow-up time,tumor stage and tumor grade between the 2 groups.The hospital stay in the test group was shorter (5.5±2.0 d versus 7.1±2.2 d),the tumor recurrence rate was lower [4％ (1/28) versus 30％ (8/27)],and the differences were significant (P＜0.05).Conclusion Compared with RLNU combined with transurethral electric resection,RLNU combined with electric coagulation has advantages of shorter hospital stay and lower tumor recurrence rate.
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ObjectiveTo investigate the clinical outcome of laparoscopic nephroureterectomy (LUNT) for native upper tract urothelial carcinoma (UC) in renal transplant (RT) recipients.Methods We conducted a retrospective analysis on 1130 RT recipients,and 9 patients (0.8％,9/1130) with native upper tract UC were identified. UC was confirmed pathologically in the 9 patients,including 3 cases of unilateral ureter tumor (2 on the right,and 1 on the left),4 cases of unilateral renal pelvis tumor (2 on the right,2 on the left),1 case of bilateral ureter tumor and 1 case of tumor in the right ureter and left kidney.Females predominated (8/9) in the 9 patients with upper tract UC.The patients with left upper urinary tract cancer underwent LUNT using a retroperitoneal approach with a technique of transurethral circumcision of the ureteral orifice.The patients with right upper urinary tract cancer were subjected to nephroureterctomy with ureterectomy and bladder cuff excision by complete laparascopy through a transperitoneal approach. Immunosuppressive protocol conversion from calcineurin inhibitors to sirolimus was performed on all cases. Results In the 9 patients,11 LUNTs were performed successfully without conversion to open surgery.The follow-up period was from 6 to 48 months. One patient died of lung metastasis at 8th month after tumor excision,and 1 patient displayed ductal cancer of the left breast at 7th month after LNUT.Another seven patients showed no evidence of disease during the follow-up period with normal renal function.ConclusionOur present clinical experience suggested that LNUT for the native upper tract cancer in renal transplant recipients is feasible,safe,and effective.
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Objective To analyze the causes of 652 hospitalizations in the patients with autosomal dominant polycystic kidney disease (ADPKD).Methods The medical records of all ADPKD inpatients in our hospital from January 1,1990 to December 31,2010 were collected.The differences of hospitalization causes in different age,gender and period were analyzed.Results (1)In 652 hospitalizations,the most common cause was lumbar pain (15.2％),followed by cystic bleeding (14.6％),aggravating renal failure (10.1％),dialysis-related problems (9.4％),renal transplant related issues (8.3％),renal replacement therapy for ESRD (8.0％),urinary tract infection (6.4％),end stage renal failure (5.8％),hypertension (4.1％),renal cyst volume enlargement (3.7％),finding polycystic kidney disease (2.1％),urinary lithiasis (1.8％) and others (10.4％).(2)Younger patients were admitted into hospital because of polycystic kidney bleeding and finding PKD.With the increase of patients age,hospitalization due to dialysis-related problems increased,while many middle-aged patients were hospitalized because of back pain.(3)Male patients were admitted into hospital for aggravating renal failure,ESRD,kidney transplantation-related problems and urinary lithiasis,while female patients mainly for lumbar pain,dialysis-related problems and urinary tract infection.(4)The proportion was significantly reduced with time of finding PKD,renal failure and polycystic kidney bleeding,the proportion of renal cysts increasing and aggravating renal failure increased,there was a significant increase in the proportion of patients with hypertension,while a significant decrease in the proportion of patients with uncontrolled hypertension,and the average SBP was also significantly reduced.Conclusions The highest rate of hospitalization of ADPKD patients is in 40 to 60 age group.Cause of admission varies with age and gender,and changes with the change of time.Over the past decade,the proportion of hospitalization due to renal cysts enlargement and renal failure aggravation increased significantly.The incidence of hypertension is higher than that in the first 10 years,but hypertension control rate increases compared with the previous.Prevention should focus on finding the suppression measures of renal cysts enlargement.
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Objective To seauch the ideal management for gross hematuria in autosomal dominant polycystic kidney disease (ADPKD).Methods ADPKD patients who were ever hospitalized and followed up in our department since 1993 were enrolled in the study.Demographic and clinical data were colloected,such as gender,age of gross hematuria,level of renal function,causative factors,management strategies,duration of gross hematuria,blood platelet count,activated partial thromboplastin time,prothrombin time,international normalized ratio,size of kidney cyst and so on.ADPKD patients were divided into different groups according to causative factors or management.The clinical data were compared among groups.Results A total of 905 ADPKD patients were screened,among whom 279 patients ever had gross hematuria (male/female:150/129),One hundred and forty-six patients had integrated therapeutic process records,while only 101patients could provide relevant laboratory examination results.In these 101 patients,gross hematuria was found in any stage of chronic kidney disease (CKD); the average eGFR was (56.4±44.1) mml·min-1 ·(1.73 m2)-1; the duration of gross hematuria was (8.8±8.0) d; no significant difference between male and female in duration of gross hematuria existed [(8.2±7.3) d vs (9.5±8.8) d,P=0.426]; coagulation parameters were all normal.The platelet count was also normal in 91 patients.Duration of gross hematuria among groups divided according to different causative factors was significantly different (P＜0.05).The patients in bed rest group had significantly shorter duration of gross hematuria compared with other groups (P＜0.05).The platelet count,prothromhin time and international normalized ratio were all at similar level in different groups.Conclusions The causative factors in ADPKD patients with gross hematuria should be confirmed as the first step of management strategies.Bed rest is the key point in management.Antifibrinolytic agent is a proper choice in the cases receiving bemostatic drugs.It is unnecessary to use antibiotic agent for prevention.
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Objective To summarize the clinical characteristics and outcome of renal cyst infection in patients with autosomal dominant polycystic kidney disease (ADPKD). Methods Clinical data of 40 ADPKD patients with 43 episodes of renal cyst infection admitted in Shanghai Changzheng Hospital from 1st January 1991 to 31st December 2010 were retrospectively analyzed.Differences of microbiological data and treatments between 1st January 1991 to 31st December 2000 and 1st January 2001 to 31st December 2010 were compared. Results Among 473 identified patients with ADPKD and 662 episodes of hospitalization,40 patients had 43 episodes of renal cyst infection,including 8 definite and 35 likely cases.Microbiological documentation was available for 34 episodes (79.0％),Escherichia coli accounting for 82.4％ of all retrieved bacterial strains.Resistant Escherichia coli to quinolone and certain β-lactamine increased in recent decade.Clinical efficacy of initial antibiotic treatment was noted in 69.8％ of episodes. Antibiotic treatment modification was more frequently required for patients receiving initial monotherapy compared with those receiving combination therapy.In the first ten-year group,initial combination therapy and clinical efficacy were noted in 30.0％ and 60.0％ of episodes respectively,and hospital stay was (20.2±6.7) d.In the second ten-year group,initial combination therapy and clinical efficacy were noted in 61.9％ and 78.2％ of episodes respectively,and hospital stay was (16.3±3.2) d.Large infected cysts (diameter ＞5 cm) frequently required drainage. Conclusions In renal cyst infection,the source of the organisms is often a gram negative enteric organism.Empiric therapy is often initiated with two antibiotics.The drainage of large infected cysts remains the main treatment for cyst infection.
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The education goal of 8-year medical students is to develop both clinical competence and to meet the needs of research and development. After the research ability questionnaires, we consider that these students have requirements the cultivation of research ability. We should formalize, organize the designed research training for them as soon as possible to make them become medical personnel with the ability to adapt to international competition as.
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Clinical practice course during the physical diagnosis studying is very important for the medical undergraduate students. It’s a bridge between the medical basic knowledge and clinical work. Several aspects such as moral education,learning attitude,scientific schedule,mas-tering the basic medical knowledge and physical examination,typical case and communicating skill must be emphasized in the clinical practice course.
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Objective To investigate the effects of antisense Smad2 oligodeoxynudeotides(ODN) on fibronetin(FN) and collagen Ⅳ(ColⅣ) secretion of rat mesangial cells cultured with high glucose, explore the action of Smad2 in the glomerulosclerosis and to find a new method to retard the progress of glomerular fibrosis. Methods 20-mer antisense, sense and random ODNs were designed and synthesized that were phosphorothioate modified to increase stability. The antisense ODN encompassed the ATG of the rat Smad2 gene. ODN was tranferred transiently into rat mesangial cells through liposome. Rat cells were treated with high glucose. mRNA and protein of Smad2 were detected by RT-PCR and cytochemistry. FN and ColⅣ were examined by ELISA. Results Antisense ODN significantly decreased mRNA and protein expression of Smad2 in rat mesangial cells treated with high glucose(P
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Objective To compare the applicability between ARF special severity scoring systems and intensive care unit (ICU) general severity scoring systems on predicting the hospital mortality of critical acute renal failure (ARF) patients. Methods The data of 29 patients with critical ARF were retrospectively analyzed. Two ARF special severity scoring models, acute tubular necrosis individual severity index (ATN-ISI) and Stuivenberg hospital acute renal failure scores (SHARF), and 3 ICU general severity scoring models, Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ), APACHE Ⅲ, Mortality Prediction Model Ⅱ (MPM Ⅱ), were used in the analysis. The receiver operating characteristic (ROC) curves were drawn up to assess the ability of these models in hospital mortality discrimination. Results All severity scores of the patients in survivor group (n=9) were lower than those of the patients in non-survivor group (n=20). There were statistical differentiations in the scores of ATN-ISI, APACHE Ⅱ, MPM Ⅱ-24h, MPM Ⅱ-72h between the survivor group and the non-survivor group (P
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Controlling serum phosphorus levels is critical in patients with renal failure. Currently phosphate-binding agents are widely used to reduce phosphate absorption in patients with endstage renal disease. If possible,serum phosphorus level should be reduced without disturbing calcium homeostasis or increasing accumulation of potentially toxic elements. Aluminum hydroxide and traditional calcium -based phosphate binders are commonly used to control serum phosphorus level. Aluminum hydroxide can effectively lower serum phosphorus level,but aluminum can accumulates in the body and results in toxic effect. Traditional calcium-based phosphate binders tend to promote hypercalcemia and calcium overloading,and accelerate cardiovascular calcification. Therefore aluminum -free and calcium-free phosphate-binding agents have become the focus of study; however,agents like sevelamer hydrochloride and lanthanum carbonate are not widely used due to high price,although they are effective in controlling serum phosphorus level. New generation of phosphate binders,such as colestilan,nicotinic acid and magnesium salt,are cheaper than their previous counterparts,but their long -term effect still needs to be observed. This article summarizes the progress of non-calcium phosphate binders in treatment of end-stage renal diseases,hoping to help clinical drug usage.