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期刊信息/Journal information
中华肾脏病杂志
中华肾脏病杂志

陈香美

月刊

1001-7097

cmaszb@mail.sysu.edu.cn

020-87331532

510089

广东省广州市中山二路74号中山大学北校区期刊大楼

中华肾脏病杂志/Journal Chinese Journal of NephrologyCSCD北大核心CSTPCD
查看更多>>1985年创刊，中国科协主管，中华医学会主办，中山大学附属第一医院承办。本刊是我国内儿科肾脏病学科领域高水平的专业期刊，对促进肾脏病学术交流及发展，起着重要的指导作用。本刊报道我国肾脏病领域领先的科研成果及临床诊疗经验。主要栏目有述评、论著、短篇论著、讲座、综述、临床病理（病例）讨论、病例报告、经验交流、会议纪要、国际学术动态。本刊的办刊宗旨：理论与实践相结合，基础与临床相结合，普及与提高相结合，为培养我国的肾脏病医学人才服务，为我国肾脏病患者的健康服务。读者对象：内科及儿科肾脏病临床和先关科研教学人员。
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    机器学习算法构建急性心肌梗死患者发生急性肾损伤风险预测模型并与传统模型比较

    叶楠祝闯徐丰博程虹...
    175-182页
    查看更多>>摘要：目的 利用机器学习算法建立急性心肌梗死（acute myocardial infarction，AMI）患者发生急性肾损伤（acute kidney injury，AKI）风险预测模型，并与传统Logistic回归模型比较。 方法 该研究为回顾性研究。收集首都医科大学附属北京安贞医院2011年7月至2016年12月AMI患者的人口学、实验室检查、治疗方案和用药情况等资料。AKI诊断标准参照2012年改善全球肾脏病预后组织公布的AKI诊疗指南，入选AMI患者采用单纯随机抽样法将其分为训练集（70%）及内部测试集（30%）。运用SelectFromModel和Lasso回归模型选择重要特征因素为AMI患者发生AKI的预测因素。分别利用Logistic回归模型（模型A）及机器学习算法（模型B）建立AMI患者发生AKI的风险预测模型，DeLong法比较模型A和模型B在测试集中的受试者工作特征曲线（receiver-operating characteristics curve，ROC曲线）下面积（area under the curve，AUC），并选出最佳模型。 结果 共6 014例AMI患者被纳入该研究，年龄（58.4±11.7）岁，男性3 414例（80.5%），AKI 674例（11.2%），训练集4 252例（70.7%），测试集1 762例（29.3%）。SelectFromModel和Lasso回归模型选取的12项临床指标包括心肌梗死次数、ST段抬高型心肌梗死、室性心动过速、Ⅲ度房室传导阻滞、入院时伴失代偿性心力衰竭、入院血肌酐、血尿素氮、肌酸激酶同工酶峰值、使用利尿剂、利尿剂日最大剂量、利尿剂使用天数及使用他汀类药物。Logistic回归模型结果显示，预测测试集AMI患者发生AKI的ROC曲线AUC为0.80（95% CI 0.76～0.84）。机器学习算法模型在测试集中得到的ROC曲线AUC为0.82（95% CI 0.78～0.85）。2种模型ROC曲线AUC比较的差异无统计学意义（Z=0.858，P=0.363），但机器学习算法预测模型ROC曲线AUC略高于传统模型。 结论 基于机器学习算法构建的AMI患者发生AKI的风险预测模型与传统Logistic回归模型的预测效应相似，但机器学习算法模型有更优的趋势，引入机器学习算法模型可能提高预测AMI患者发生AKI风险的能力。 Objective To establish a predictive risk model for acute kidney injury (AKI) in acute myocardial infarction (AMI) patients based on machine learning algorithm and compare with a traditional logistic regression model. Methods It was a retrospective study. The demographic data, laboratory examination, treatment regimen and medication of AMI patients from July 2011 to December 2016 in Beijing Anzhen Hospital, Capital Medical University were collected. The diagnostic criteria of AKI were based on the AKI diagnosis and treatment guidelines published by Kidney Diseases: Improving Global Outcomes in 2012. The selected AMI patients were randomly divided into training set (70%) and internal test set (30%) by simple random sampling. SelectFromModel and Lasso regression models were used to extract clinical parameters as predictors of AKI in AMI patients. Logistic regression model (model A) and machine learning algorithm (model B) were used to establish the risk prediction model of AKI in AMI patients. DeLong method was used to compare the area under the receiver-operating characteristic (ROC) curve (AUC) between model A and model B for selecting the best model. Results A total of 6 014 AMI patients were included in the study, with age of (58.4±11.7) years old and 3 414 males (80.5%). There were 674 patients (11.2%) with AKI. There were 4 252 patients (70.7%) in the training set and 1 762 patients (29.3%) in the test set. The selected twelve clinical parameters by the SelectFromModel and Lasso regression models included the number of myocardial infarctions, ST-segment elevation myocardial infarction, ventricular tachycardia, third degree atrioventricular block, decompensated heart failure at admission, admission serum creatinine, admission blood urea nitrogen, admission peak creatine kinase isoenzyme, diuretics, maximum daily dose of diuretics, days of diuretic use and statins. Logistic regression prediction model showed that AUC for the test set was 0.80 (95% CI 0.76-0.84). The machine learning algorithm model obtained AUC in the test set with 0.82 (95% CI 0.78-0.85).There was no significant difference in AUC between the two models (Z=0.858, P=0.363), and AUC of the machine learning algorithm predictive model was slightly higher than that of the traditional logistic regression model. Conclusions The prediction effect of AKI risk in AMI patients based on machine learning algorithm is similar to that of traditional logistic regression model, and the prediction accuracy of machine learning algorithm is better. The introduction of machine learning algorithm model may improve the ability to predict AKI risk.

    机器学习急性肾损伤心肌梗死预测模型

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    基于临床数据库建立急性肾损伤风险预测列线图模型

    唐填董宁欣武乐濠赵丹...
    183-192页
    查看更多>>摘要：目的 基于大样本临床数据库平台，应用R语言及传统统计学方法构建急性肾损伤（acute kidney injury，AKI）的风险预测列线图模型，同时验证模型的准确性。 方法 该研究为回顾性病例对照研究。筛选临床数据库2021年1月1日至12月31日于同济大学附属同济医院就诊患者中的AKI患者，同时纳入48 h内监测血肌酐但未发生AKI的患者作为对照组。收集患者的人口学、疾病史、手术史、用药史以及实验室检查等资料，以筛选临床上发生AKI的危险因素。首先，采用多因素Logistic回归分析及正向逐步Logistic回归分析筛选危险因素，利用这些危险因素构建列线图模型，同时使用交叉验证、Bootstrap验证和随机拆分样本验证方法进行内部验证，并收集同院后1年（即2022年1月至12月）患者的临床资料进行外部验证，通过受试者工作特征曲线来确定模型的区分度，同时采用校准曲线和决策曲线分别评估准确性和临床净效益。 结果 共有5 671例患者纳入该研究，AKI患者1 884例（33.2%），非AKI患者3 787例（66.7%）。与非AKI组相比，AKI组年龄、手术史比例、肾脏替代治疗比例、高血压比例、糖尿病比例、脑血管意外比例、慢性肾脏病比例、药物使用史比例及死亡比例均较高（均P<0.05）。多因素Logistic回归分析结果显示，AKI发生的独立影响因素为手术史、高血压、脑血管意外、糖尿病、慢性肾脏病、使用利尿剂、使用硝酸甘油、使用抗利尿激素、体温、血肌酐、C反应蛋白、红细胞、白细胞、D-二聚体、肌红蛋白、血红蛋白、血尿素氮、脑钠肽、谷草转氨酶、谷丙转氨酶、三酰甘油、乳酸脱氢酶、总胆红素、活化部分凝血活酶时间、血尿酸和钾离子（均P<0.05）。正向逐步Logistic回归分析最终确定纳入列线图的预测因素，包括慢性肾脏病、高血压、肌红蛋白、血肌酐和血尿素氮（均P<0.05），列线图预测模型的受试者工作特征曲线下面积为0.926（95%CI 0.918～0.933，P<0.001），校准曲线显示列线图校准效果良好（P>0.05），决策曲线显示当列线图模型风险阈值>0.04时，该模型构建在临床上有用。此外，列线图模型在外部验证集预测的受试者工作特征曲线下面积为0.876（95%CI 0.865～0.886），提示列线图模型在外部验证集上有较高的区分度。 结论 预测AKI发生风险的列线图模型成功建立，该模型的建立有助于临床医师及早发现高危AKI患者，及时干预，改善预后。 Objective To construct the risk prediction nomogram model of acute kidney injury (AKI) with R language and traditional statistical methods based on the large sample clinical database, and verify the accuracy of the model. Methods It was a a retrospective case control study. The patients who met the diagnostic criteria of AKI in Tongji Hospital of Tongji University from January 1 to December 31, 2021 were screened in the clinical database, and the patients with monitored serum creatinine within 48 hours but without AKI were included as the control group. The demographic data, disease history, surgical history, medication history and laboratory test data were collected to screen the risk factors of AKI in clinic.Firstly, based on multivariate logistic regression analysis and forward stepwise logistic regression analysis, the selected risk factors were included to construct the nomogram model. At the same time, cross validation, bootstrap validation and randomly split sample validation were used for internal verification, and clinical data of patients in the sane hospital after one year (January to December, 2022) were collected for external verification. The receiver-operating characteristic curve was used to determine the discrimination of the model, and calibration curve and decision curve analysis were carried out to evaluate the accuracy and clinical net benefit, respectively. Results A total of 5 671 patients were enrolled in the study, with 1 884 AKI patients (33.2%) and 3 787 non-AKI patients (66.7%). Compared with non-AKI group, age, and proportions of surgical history, renal replacement therapy, hypertension, diabetes, cerebrovascular accident,chronic kidney disease, drug use histories and mortality in AKI group were all higher (all P<0.05). Multivariate logistic regression analysis showed that the independent influencing factors of AKI were surgical history, hypertension, cerebrovascular accident, diabetes, chronic kidney disease, diuretics, nitroglycerin, antidiuretic hormones, body temperature, serum creatinine, C-reactive protein, red blood cells, white blood cells,D-dimer, myoglobin, hemoglobin, blood urea nitrogen, brain natriuretic peptide, aspartate aminotransferase, alanine aminotransferase, triacylglycerol, lactate dehydrogenase, total bilirubin, activated partial thromboplastin time, blood uric acid and potassium ion (all P<0.05). Finally, the predictive factors in the nomogram were determined by forward stepwise logistic regression analysis, including chronic kidney disease, hypertension, myoglobin, serum creatinine and blood urea nitrogen, and the area under the curve of the prediction nomogram model was 0.926 [95%CI 0.918-0.933, P<0.001]. The calibration curve showed that the calibration effect of nomogram was good (P>0.05). The decision curve showed that when the risk threshold of nomogram model was more than 0.04, the model construction was useful in clinic. In addition, the area under the curve of receiver-operating characteristic curve predicted by nomograph model in external validation set was 0.876 (95%CI 0.865-0.886), which indicated that nomograph model had a high discrimination degree. Conclusion A nomogram model for predicting the occurrence of AKI is established successfully, which is helpful for clinicians to find high-risk AKI patients early, intervene in time and improve the prognosis.

    急性肾损伤列线图危险因素临床数据库风险预测模型

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    肾活检在成人急性肾脏病患者诊断和治疗中的价值

    吕梦茹邬步云卞奥张波...
    193-200页
    查看更多>>摘要：目的 分析成人急性肾脏病（acute kidney disease，AKD）患者接受肾活检前后诊断和治疗方案的变化，探讨肾活检在AKD患者诊断和治疗中的价值。 方法 该研究为单中心回顾性观察性研究，纳入2017年1月1日至2021年12月31日在南京医科大学第一附属医院肾内科接受肾活检的成人AKD患者，收集患者人口学、一般临床、实验室检查、肾活检前后诊断和治疗资料，分析肾活检前临床诊断与肾活检后病理诊断的诊断一致率、肾活检后治疗方案的改变及出血并发症情况。 结果 该研究纳入575例经肾活检诊断的AKD患者，年龄51（36，63）岁，男性359例（62.4%）。其中，急性肾损伤293例（51.0%），合并高血压348例（60.5%），合并糖尿病124例（21.6%）。峰值血肌酐272（190，477）μmol/L，血红蛋白106（86，126）g/L，24 h尿蛋白量2.15（0.79，4.82）g。575例AKD患者中，急性肾小球疾病347例（60.3%），急性间质性肾炎136例（23.7%），血栓性微血管病47例（8.2%），急性肾小管坏死45例（7.8%）。急性肾小球疾病中最常见的是IgA肾病（22.3%，128/575）和抗中性粒细胞胞质抗体相关性肾小球肾炎（12.2%，70/575）。454例（79.0%）患者肾活检前的临床诊断与肾活检后病理诊断相符。肾活检后394例（68.5%）患者调整了激素或免疫抑制剂治疗方案。15例（2.6%）患者发生显著的肾活检后出血，其中12例需输血治疗，1例需手术干预。 结论 21.0%的成人AKD患者的临床诊断与病理诊断不符，68.5%的患者肾活检后改变了治疗方案，2.6%的患者肾活检后出现显著的出血并发症。临床需充分权衡肾活检利弊，作出个体化的决策。 Objective To analyze the changes of diagnosis and treatment before and after renal biopsy in adult patients with acute kidney disease (AKD), and to explore the value of renal biopsy in the diagnosis and treatment of AKD. Methods It was a single-center retrospective observational study. The adult patients with AKD who underwent renal biopsy in the Department of Nephrology of the First Affiliated Hospital of Nanjing Medical University from January 1, 2017 to December 31, 2021 were enrolled. Demographic data, general clinical data, laboratory tests, and diagnosis and treatment data before and after renal biopsy were collected to analyze the concordance rate between clinical and pathological diagnoses, changes in treatment after renal biopsy, and bleeding complication. Results A total of 575 patients diagnosed with AKD by renal biopsy were included in this study, with age of 51 (36, 63) years old and 359 males (62.4%). Among them, there were 293 patients (51.0%) of acute kidney injury, 348 patients (60.5%) of hypertension and 124 patients (21.6%) of diabetes. The peak serum creatinine was 272 (190, 477) μmol/L. The hemoglobin was 106 (86, 126) g/L. The 24-hour urine protein was 2.15 (0.79, 4.82) g. There were 347 patients (60.3%) of acute glomerular diseases, 136 patients (23.7%) of acute interstitial nephritis, 47 patients (8.2%) of thrombotic microangiopathy, and 45 patients (7.8%) of acute tubular necrosis. The most common types of acute glomerular diseases were IgA nephropathy and anti-neutrophil cytoplasmic antibody-associated glomerulonephritis, accounting for 22.3% (128/575) and 12.2% (70/575), respectively. The clinical diagnoses before renal biopsy were consistent with the renal histopathological diagnoses in 454 patients, with an accuracy rate of 79.0%. Following the renal biopsy, the treatment plan involving glucocorticoids or immunosuppressants was adjusted in 394 patients (68.5%). Significant post-biopsy bleeding occurred in 15 patients (2.6%), with 12 patients requiring blood transfusion and 1 patient requiring surgical intervention. Conclusions Twenty-one clinical diagnoses do not match the pathological diagnoses in adult AKD patients, 68.5% of patients have changes in their treatment plans, and 2.6% of patients have significant hemorrhagic complications after renal biopsy. Clinicians need to carefully consider the benefits and risks and make individualized decisions about renal biopsy.

    活组织检查诊断临床方案急性肾脏病

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    术前血清尿酸/白蛋白比值对心脏瓣膜术后急性肾损伤的预测价值

    赵晓茹邵泽华张文雯邓小宇...
    201-208页
    查看更多>>摘要：目的 探讨术前血清尿酸/白蛋白比值（serum uric acid/albumin ratio，sUAR）对心脏瓣膜术后急性肾损伤（acute kidney injury，AKI）的预测价值。 方法 采用回顾性分析方法，收集2021年1月至2021年12月于河南省人民医院心脏中心在体外循环下行心脏瓣膜术的成年患者的临床资料，并计算sUAR。根据术后7 d内是否发生AKI将患者分为AKI组和非AKI组，比较两组之间临床资料的差异。采用多因素Logistic回归模型分析心脏瓣膜术后发生AKI的独立相关因素。采用受试者工作特征曲线（receiver operating characteristic curve，ROC曲线）评价相关指标的预测效能。 结果 共422例行心脏瓣膜术患者入选本研究，其中女性194例（46.0%），高血压141例（33.4%），心房颤动172例（40.8%），年龄57（50，65）岁，sUAR 8.13（6.57，9.54）μmol/g，血红蛋白135（125，145）g/L；AKI组142例，非AKI组280例；心脏瓣膜术后AKI的发生率为33.6%。AKI组年龄、心房颤动比例、基线血肌酐、N端脑利钠肽前体、血尿素、血尿酸、血糖、sUAR均高于非AKI组（均P<0.05），估算肾小球滤过率、淋巴细胞计数、血红蛋白、血清白蛋白均低于非AKI组（均P<0.05）；AKI组患者中位体外循环时间较非AKI组患者略长但差异无统计学意义［159（125，192）min比151（122，193）min，Z=-0.797，P=0.426］，其他指标两组间差异均无统计学意义。多因素Logistic回归分析结果显示，sUAR（OR=1.467，95% CI 1.308～1.645，P<0.001）、年龄（OR=1.045，95% CI 1.020～1.072，P<0.001）、心房颤动（OR=2.520，95% CI 1.580～4.020，P<0.001）、血红蛋白（OR=0.984，95% CI 0.971～0.997，P=0.015）是心脏瓣膜术后发生AKI的独立相关因素。ROC曲线分析结果显示sUAR预测心脏瓣膜术后发生AKI的曲线下面积为0.710（95% CI 0.659～0.760，P<0.001），截断值为7.28 μmol/g，敏感度为85.2%，特异度为45.0%。sUAR联合年龄、血红蛋白、心房颤动预测心脏瓣膜术后发生AKI的曲线下面积为0.780（95%CI 0.734～0.825，P<0.001），敏感度为72.5%，特异度为71.8%。 结论 术前sUAR高是体外循环下心脏瓣膜术后发生AKI的独立危险因素，sUAR对术后发生AKI具有一定预测价值。 Objective To investigate the predictive value of serum uric acid/albumin ratio (sUAR) for acute kidney injury (AKI) after cardiac valve surgery. Methods The clinical data of adult patients undergoing cardiac valve surgery under cardiopulmonary bypass from January 2021 to December 2021 from the Heart Center of Henan Provincial People's Hospital were collected retrospectively, and the sUAR was calculated. All patients were divided into AKI group and non-AKI group according to whether AKI occurred within 7 days after cardiac valve surgery, and the differences of clinical data between the two groups were compared. Multivariate logistic regression model was used to analyze the independent correlation factors of AKI after cardiac valve surgery. The receiver operating characteristic (ROC) curve was used to evaluate the performance of relevant indicators. Results A total of 422 patients were enrolled, including 194 females (46.0%), 141 hypertension patients (33.4%) and 172 atrial fibrillation patients (40.8%). They were 57 (50, 65) years old. Their sUAR was 8.13 (6.57, 9.54) μmol/g, and hemoglobin was 135 (125, 145) g/L. There were 142 cases in AKI group and 280 cases in non-AKI group, and the incidence of AKI after cardiac valve surgery was 33.6%. Age, atrial fibrillation rate, baseline serum creatinine, N terminal pro B type natriuretic peptide, serum urea,serum uric acid, blood glucose and sUAR were higher in the AKI group than those in the non-AKI group (all P<0.05), and estimated glomerular filtration rate, lymphocyte count,hemoglobin and serum albumin were lower in the AKI group than those in the non-AKI group (allP<0.05). The median cardiopulmonary bypass time of patients in the AKI group was slightly longer than that in the non-AKI group, but the difference was not statistically significant [159 (125, 192) minvs. 151 (122, 193) min, Z=-0.797, P=0.426], and there were no statistically significant differences in other indicators between the two groups. The results of multivariate logistic regression analysis showed that sUAR (OR=1.467, 95% CI 1.308-1.645, P<0.001), age (OR=1.045, 95% CI 1.020-1.072, P<0.001), atrial fibrillation (OR=2.520, 95% CI 1.580-4.020, P<0.001), hemoglobin (OR=0.984, 95% CI 0.971-0.997, P=0.015) were the independent correlation factors. ROC curve analysis showed that the area under the curve (AUC) of sUAR predicting AKI after cardiac valve surgery was 0.710 (95% CI 0.659-0.760, P<0.001) with a sensitivity of 85.2% and specificity of 45.0% for the sUAR cut-off point of 7.28 μmol/g. TheAUC for the diagnosis of AKI after cardiac valve surgery was 0.780 (95% CI 0.734-0.825,P<0.001) with a sensitivity of 72.5% and specificity of 71.8% for the combination of sUAR with age, hemoglobin and atrial fibrillation. Conclusions For patients undergoing cardiac valve surgery under cardiopulmonary bypass, preoperative high sUAR is an independent risk factor for postoperative AKI, and sUAR has a certain predictive value for postoperative AKI.

    尿酸血清白蛋白心脏外科手术急性肾损伤心脏瓣膜术

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    白细胞介素-37在糖尿病肾脏疾病患者中的表达及其对CD8 +T细胞杀伤功能的调控作用

    布海霞徐可韩晓静王焕...
    209-220页
    查看更多>>摘要：目的 观察白细胞介素（interleukin，IL）-37在糖尿病肾脏疾病（diabetic kidney disease，DKD）患者中的表达，并评估外源性IL-37对DKD患者CD8+T细胞功能的调控作用。 方法 采用横断面研究方法，纳入20例健康对照者、36例2型糖尿病（diabetes mellitus type 2，T2DM）患者及47例DKD患者。采集外周血，分离血浆和外周血单个核细胞。酶联免疫吸附测定（enzyme-linked immunosorbent assay，ELISA）检测血浆IL-37、可溶型IL-1受体8（IL-1 receptor 8，IL-1R8）水平。流式细胞术检测CD8+T细胞中IL-18受体α链（IL-18 receptor α chain，IL-18Rα）、IL-1R8水平和免疫检查点分子水平。纯化CD8+T细胞，使用重组IL-37刺激培养，与人胚胎肾293（human embryonic kidney 293，HEK293）细胞直接接触或间接接触共培养。ELISA法检测穿孔素（perforin）、颗粒酶B（granzyme B）、干扰素-γ（interferon-γ，IFN-γ）、肿瘤坏死因子-α（tumor necrosis factor-α，TNF-α）水平。通过检测乳酸脱氢酶水平计算靶细胞死亡比例。 结果 DKD患者血浆IL-37水平［（63.42±23.30）ng/L］低于健康对照者［（143.02±50.67）ng/L］和TD2M患者［（87.88±40.62）ng/L］（t=8.848，P<0.001；t=3.456，P<0.001）。血浆IL-37对个体发生T2DM、T2DM患者发生DKD的预测效能较好［曲线下面积分别为0.797（95%CI 0.676～0.917，P<0.001）和0.691（95%CI 0.576～0.807，P=0.003）］。DKD患者血浆IL-37水平与血尿素氮（r=-0.313，P=0.032）和血肌酐水平（r=-0.477，P<0.001）呈负相关，与估算肾小球滤过率呈正相关（r s=0.478，P<0.001）。DKD患者IL-1R8+ CD8+细胞比例显著高于健康对照者和T2DM患者（33.60%±9.47%比16.29%±5.97%、17.13%±4.85%，t=7.545、9.516，均P<0.001），且与空腹血糖、血尿素氮、血肌酐、估算肾小球滤过率无相关性（均P>0.05）。IL-18Rα+ CD8+细胞比例、可溶型IL-1R8水平、免疫检查点分子占CD8+T细胞比例在健康对照者、T2DM患者、DKD患者之间的差异无统计学意义（均P>0.05）。DKD患者CD8+T细胞分泌穿孔素和颗粒酶B水平均显著高于健康对照者［（108.78±12.42）ng/L比（94.60±10.07）ng/L，t=3.096，P=0.005；（261.34±48.79）ng/L比（166.28±30.80）ng/L，t=3.387，P=0.002］和T2DM患者［（108.78±12.42）ng/L比（92.58±14.71）ng/L，t=3.263，P=0.003；（261.34±48.79）ng/L比（170.66±39.24）ng/L，t=2.627，P=0.014］，但CD8+T细胞分泌IFN-γ和TNF-α水平在健康对照者、T2DM患者、DKD患者间的差异无统计学意义（均P>0.05）。在直接接触共培养中，IL-37刺激后CD8+T细胞诱导HEK293细胞死亡比例降低（13.03%±4.97%比17.88%±5.19%，t=2.235，P=0.037），上清中穿孔素［（222.02±25.79）ng/L比（294.30±25.58）ng/L，t=6.603，P<0.001］、颗粒酶B［（416.27±90.24）ng/L比（524.71±115.53）ng/L，t=2.454，P=0.023］、IFN-γ［（23.66±4.20）ng/L比（35.18±8.51）ng/L，t=4.026，P<0.001］和TNF-α［（1.62±0.29）μg/L比（2.09±0.57）μg/L，t=2.302，P=0.034］水平均降低。在间接接触共培养中，CD8+T细胞诱导HEK293细胞死亡比例、穿孔素、颗粒酶B水平在无刺激和IL-37刺激之间的差异均无统计学意义（均P>0.05），但IL-37刺激后上清中IFN-γ［（23.56±6.24）ng/L比（32.56±9.90）ng/L，t=2.550，P=0.019］和TNF-α［（1.41±0.31）μg/L比（2.10±0.44）μg/L，t=4.011，P<0.001］水平降低。 结论 DKD患者外周血IL-37水平降低，外源性IL-37可抑制DKD患者CD8+T细胞的杀伤活性。 Objective To investigate interleukin-37 (IL-37) expression in patients with diabetic kidney disease (DKD), and to assess the regulation of exogenous IL-37 on CD8+ T cell function in DKD patients. Methods A cross-section study was carried out. Twenty healthy controls, thirty-six patients with diabetes mellitus type 2 (T2DM), and forty-seven DKD patients were enrolled in the study. Peripheral blood was collected. Plasma and peripheral blood mononuclear cells were isolated. IL-37 and soluble IL-1 receptor 8 (IL-1R8) levels in the plasma were measured by enzyme-linked immunosorbent assay (ELISA). IL-18 receptor α chain (IL-18Rα), IL-1R8 and immune checkpoint molecules levels in CD8+ T cells were measured by flow cytometry. CD8+ T cells were purified, and were stimulated with recombinant IL-37. CD8+ T cells were co-cultured with HEK293 cells in either direct contact or indirect contact manner. Levels of perforin, granzyme B, interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) were measured by ELISA. The proportion of target cell death was assessed by measuring lactate dehydrogenase level. Results Plasma IL-37 levels in DKD patients [(63.42±23.30) ng/L] were significant lower than those in healthy controls [(143.02±50.67) ng/L] and T2DM patients [(87.88±40.62) ng/L] (t=8.848, P<0.001 t=3.456, P<0.001). Plasma IL-37 level had good predictive values for T2DM in health individuals and for DKD in T2DM patients [the area under the curve was 0.797 (95%CI 0.676-0.917, P<0.001) and 0.691 (95%CI 0.576-0.807, P=0.003), respectively]. Plasma IL-37 level was negatively correlated with urea nitrogen (r=-0.313, P=0.032) and creatinine (r=-0.477, P<0.001), and positively correlated with estimated glomerular filtration rate (eGFR) (r s=0.478, P<0.001) in DKD patients. IL-1R8+ CD8+ cell proportion in DKD patients (33.60%±9.47%) was significantly higher compared to healthy controls (16.29%±5.97%) and T2DM patients (17.13%±4.85%) (t=7.545, 9.516, both P<0.001), but did not correlate with fast blood glucose, urea nitrogen, creatinine, or eGFR (allP>0.05). There were no statistical differences of IL-18Rα+ CD8+ cell proportion, soluble IL-1R8 level, or immune checkpoint molecule proportion in CD8+ T cells among healthy controls, T2DM patients, and DKD patients (all P>0.05). Perforin and granzyme B secretions by CD8+ T cells were significantly elevated in DKD patients compared with healthy controls [(108.78±12.42) ng/L vs. (94.60±10.07) ng/L, t=3.096, P=0.005 (261.34±48.79) ng/L vs. (166.28±30.80) ng/L, t=3.387, P=0.002] and T2DM patients [(108.78±12.42) ng/L vs. (92.58±14.71) ng/L, t=3.263, P=0.003 (261.34±48.79) ng/L vs. (170.66±39.24) ng/L, t=2.627, P=0.014]. There were no significant differences of either IFN-γ or TNF-α secretions by CD8+ T cells among healthy controls, T2DM patients, and DKD patients (all P>0.05). In direct contact co-culture manner, CD8+ T cell-induced HEK293 cell death was down- regulated (13.03%±4.97% vs. 17.88%±5.19%, t=2.235, P=0.037). The levels of perforin [(222.02±25.79) ng/L vs. (294.30±25.58) ng/L, t=6.603, P<0.001], granzyme B [(416.27±90.24) ng/Lvs. (524.71±115.53) ng/L, t=2.454, P=0.023], IFN-γ [(23.66±4.20) ng/L vs. (35.18±8.51) ng/L, t=4.026, P<0.001] and TNF-α [(1.62±0.29) μg/Lvs. (2.09±0.57) μg/L, t=2.302, P=0.034] were also reduced as well. In indirect contact co-culture manner, there were no significant differences of CD8+ T cell-induced HEK293 cell death, perforin, or granzyme B levels between no stimulation and IL-37 stimulation (all P>0.05). IFN-γ and TNF-α levels in the supernatants were reduced in response to IL-37 stimulation [(23.56±6.24) ng/Lvs. (32.56±9.90) ng/L, t=2.550, P=0.019 (1.41±0.31) μg/L vs. (2.10±0.44) μg/L, t=4.011, P<0.001]. Conclusion IL-37 level is reduced in DKD patients.Exogenous IL-37 suppresses the cytotoxicity of CD8+ T cells in DKD patients.

    糖尿病,2型白细胞介素类糖尿病肾病CD8阳性T淋巴细胞白细胞介素⁃37

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    肱动脉结扎处理人工血管动静脉内瘘感染外露并破溃出血1例及文献回顾

    刘倩廖甄楠余宗超胡波...
    221-224页
    查看更多>>摘要：该文报告1例肱动脉结扎处理人工血管动静脉内瘘（arteriovenous graft，AVG）感染合并人工血管外露以及破溃出血的病例。结合本通路中心经验和相关文献回顾，分析该并发症产生的原因及治疗方案，并阐述肱动脉结扎治疗该并发症的可行性及安全性，以期为临床诊治提供参考。 The paper reported a case of brachial artery ligation treatment of arteriovenous graft infection with arteriovenous graft exposure and bleeding. Based on the experience of vascular access center and the review of relevant literature, the causes and treatment options of this complication were analyzed, and the feasibility and safety of brachial artery ligation were elaborated for the treatment of this complication, to provide references for clinical diagnosis and treatment.

    人工血管感染肱动脉动静脉内瘘人工血管外露人工血管破裂肱动脉结扎

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    IgA肾病发病机制的研究进展

    王淦淦郑可李雪梅孙玉玲...
    225-230页
    查看更多>>摘要：IgA肾病（IgA nephropathy，IgAN）是目前全球范围内最常见的原发性肾小球肾炎，20%～40%的患者在诊断后20年内进展为终末期肾病。IgAN的发病机制尚不明确，临床治疗主要以控制病情进展为主，缺乏特异性治疗方案。围绕半乳糖缺乏的IgA1（galactose-deficient IgA1，Gd-IgA1）开展的一系列研究提示IgAN发病涉及多个环节。该文从IgA1的结构特征、IgAN患者体内Gd-IgA1抗体及含Gd-IgA1免疫复合物、Gd-IgA1免疫复合物在肾脏中的沉积、Gd-IgA1免疫复合物沉积对肾脏的损伤、补体在IgAN中的作用、IgA肾病的基因组学及黏膜免疫与IgAN等方面，综述了IgAN发病机制的研究进展，为进一步的研究和临床治疗提供线索和思路。 IgA nephropathy (IgAN) is currently the most common primary glomerulonephritis worldwide, with 20%-40% of patients progressing to end-stage renal disease within 20 years of diagnosis. At present, the pathogenesis of IgAN is not clear, and clinical treatment is mainly to control the progression, without specific treatment plan. A series of studies on galactose-deficient IgA1 (Gd-IgA1) suggest that the pathogenesis of IgAN involves multiple links. This review summarizes the research progress on the pathogenesis of IgAN, covering the structure characteristics of IgA1, Gd-IgA1 antibodies and Gd-IgA1 immune complexes in IgAN patients, the deposition of Gd-IgA1 immune complexes in the kidneys, kidney damage following the deposition of Gd-IgA1 immune complexes, the role of complement in IgAN, the genomics of IgAN, and mucosal immunity in IgAN, providing clues and insights for further research and clinical treatment.

    肾小球肾炎,IgA免疫球蛋白A抗原抗体复合体半乳糖缺乏的IgA1多重打击假说发病机制

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    腹膜功能保护的干预性研究进展

    张孟钦杨志凯董捷彭苗...
    231-236页
    查看更多>>摘要：随着腹膜透析（腹透）时间延长，腹膜将面临多重因素打击而发生结构和功能改变，从而影响腹透效率。目前临床上依然缺乏保护腹膜功能的有效手段。该文回顾近10年来具有腹膜功能保护潜能的措施，包括针对腹透液的治疗策略、对腹膜功能有潜在保护作用的药物，以及远红外线、干细胞移植等在内的非药物治疗，以期为后续相关研究提供指导。 With the prolongation of peritoneal dialysis time, the peritoneum probably confronts structural and functional deterioration due to multiple factors, which will affect the efficiency of peritoneal dialysis. Clinically effective measures to protect peritoneal function are still lacking. This article reviewed studies in the last decade on protection of peritoneal function, which included strategies on dialysis prescription, medicine treatments for protection of peritoneal function, and non-medicine treatments such as far-infrared therapy and stem cell transplantation, to provide guidances for subsequent researches.

    腹膜腹膜透析临床试验腹膜功能保护干预性研究

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    《第28届急性疾病质量倡议工作组共识报告：脓毒症相关急性肾损伤》解读

    刘彩虹赵宇亮付平杨克魁...
    237-244页
    查看更多>>摘要：脓毒症相关急性肾损伤（sepsis associated acute kidney injury，SA-AKI）被定义为脓毒症背景下急性肾损伤（acute kidney injury，AKI）的存在。在遗传易感性的背景下，脓毒症可通过多种机制导致SA-AKI的发生，基于病理生理机制的差异，SA-AKI归属于不同的“内型”，且表现为不同的“亚表型”。生物标志物和预测模型的结合具备早期识别AKI高风险患者和明确SA-AKI“内型”的潜力。容量复苏及血液净化是SA-AKI治疗的优化策略。此外，基于儿童的SA-AKI临床研究值得期待。 Sepsis-associated acute kidney injury (SA-AKI) is defined as the presence of acute kidney injury (AKI) in the context of sepsis. In the setting of genetic susceptibility, sepsis can lead to SA-AKI through various mechanisms. Based on differences in pathophysiological mechanisms, SA-AKI is categorized into different "endotypes" and manifests as distinct "subtypes". The combination of biomarkers and predictive models has the potential to early identify high-risk AKI patients and elucidate SA-AKI "endotypes". Volume resuscitation and blood purification are optimized strategies for SA-AKI treatment. Furthermore, clinical research on SA-AKI in children is promising.

    脓毒症急性肾损伤诊断急性疾病质量倡议专家共识

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    高钾血症管理规范——多科室合作全流程管理模式

    叶智明蔡建芳陈崴程虹...
    245-254页
    查看更多>>摘要：高钾血症是临床常见的离子代谢紊乱之一，国内外指南将血钾高于5.0 mmol/L定义为高钾血症。急性重度高钾血症可引起弛缓性麻痹、致死性心律失常，甚至心脏停搏等严重后果。肾素-血管紧张素-醛固酮系统抑制剂、β受体阻滞剂、保钾利尿剂的应用，低钠高钾饮食以及相关合并症的存在均增加了高钾血症的发生。临床各科室均存在高钾血症风险人群，但缺乏医院多科室合作管理模式。为此，国内多位肾内科、心内科等领域专家讨论高钾血症医院多科室防治模式，制定了院内评估、预警、诊疗及管理规范流程，从而促进各科室更有效地参与院内高钾血症的诊疗以及慢性高钾血症的长期管理，提高全院高钾血症管理质量。 Hyperkalemia is one of the common ion metabolism disorders in clinical practice. Hyperkalemia is defined as serum potassium higher than 5.0 mmol/L according to the guidelines at home and abroad. Acute severe hyperkalemia can cause serious consequences, such as flaccid paralysis, fatal arrhythmia, and even cardiac arrest. The use of renin-angiotensin- aldosterone system inhibitors, β-blockers and diuretics, low-sodium and high-potassium diets, and the presence of related comorbidities increase the occurrence of hyperkalemia. Hyperkalemia risk exist in all clinical departments, but there is a lack of a standardization in the management of multi- department cooperation in hospital. Therefore, a number of domestic nephrology and cardiology department experts have discussed a management model for multi-department cooperation in hyperkalemia, formulating the management standard on hospital evaluation, early warning, diagnosis and treatment, and process. This can promote each department to more effectively participate in nosocomial hyperkalemia diagnosis and treatment, as well as the long-term management of chronic hyperkalemia, improving the quality of hyperkalemia management in hospital.

    高钾血症跨部门合作组织和管理管理信息系统多科室合作全流程管理

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