2015年 · 第31卷第02期

"An unfair health system is the most shocking and inhumane inequality."

Neutrophil gelatinase-associated lipocalin (NGAL) was originally discovered and mainly expressed in activated neutrophils. Subsequently, it was found that a variety of cells, including renal tubules, can secrete NGAL under the action of harmful stimuli. Of most concern is that NGAL levels are closely related to the severity of renal impairment and are considered to be one of the most promising measures for the assessment of early renal impairment.

renal flare in patients with lupus nephritis (LN) is very common, and it is one of the important reasons for the increase of disability and mortality of patients^[1]。 We retrospectively analyzed the clinical data of patients with type IV LN renal recurrence in our center in the past 15 years, summarized the incidence, time of recurrence, clinical manifestations at the time of recurrence, induction therapy and maintenance therapy before and after recurrence, prognosis and risk factors, and strengthened peers' understanding of LN renal recurrence.

The patient, male, 31 years old, was admitted on 2 Mar 2014. Twenty days before admission, the patient had no obvious trigger sensation of right lumbar pain, which showed persistent colic, and no obvious relief after rest, pressing, and changing body position. After 5 days, he developed fever, up to 39℃. The other hospital gave analgesic and symptomatic treatment, but the lumbar pain did not improve significantly. During hospitalization, he developed asymmetric swelling and pain of both lower limbs, and the amount of urine decreased (about 700 ml per day). Then he was referred to the emergency department of our hospital, and the urinary protein was qualitatively>4+. Color ultrasound of lower limb veins: Thrombosis of the right common femoral vein, slowing of venous blood flow in both lower limbs. Lumbar MRI ordinary scan: L5-S1 disc herniation. Physical examination: Height 180 cm, body weight 77 kg, fair skin, sparse beard, inobvious Adam's apple protrusion, mild breast development. Both lower limbs showed asymmetric swelling, obvious on the right side. Heart, lung and abdomen examinations were not special. Auxiliary examination: red blood cells 2.77×10¹²/L, hemoglobin 81 g/L, albumin 21.2 g/L, creatinine 79.0 μ mol/L. The urinary protein was qualitatively 2+, and the 24-h urinary protein amount was 5.77 g. Coagulation routine: prothrombin time 16.2 s, international normalized ratio (INR) 1.44. Anti-neutrophil cytoplasmic antibody (-), complement C3: 0.5460 g/L, C4: 0.0556 g/L, anti-nuclear antibody 1:320, anti-double stranded DNA antibody (-), anti-SSA antibody 2+, anti-SSB antibody (-), anti-cardiolipin antibody 22.850 RU/ml, direct anti-human globulin assay 2+. Luteinizing hormone 50.9 IU/L, follicle stimulating hormone 73.3 IU/L, prolactin 31.19 μ g/L, progesterone<0.03 μ g/L, testosterone 0.24 μ g/L, dehydroepiandrosterone sulfate 0.171 μ mol/L. Color Doppler ultrasound of male reproductive system: bilateral small testicles with uneven changes (right side: 14 mm ×7.0 mm ×10 mm, left side: 15 mm ×7.0 mm ×10 mm). Karyotype analysis of peripheral lymphocytes: 46XY/47XXY.

A 51-year-old female was admitted to hospital due to "fever for more than 2 months and left low back pain for 3 days". The patient developed fever without obvious trigger before 2 months, and the body temperature mostly did not exceed 38℃. It was obvious in the afternoon and evening, accompanied by myalgia of both lower limbs, intermittently accompanied by chills, nasal congestion, runny nose, cough and expectoration. After the local diagnosis of "upper respiratory tract infection" and anti-infective treatment, the cough and expectoration improved, but there was still fever, nasal congestion and runny nose. The diagnosis of "sinusitis with nasal polyps" was repeated, and "nasal polypectomy + multiple sinus openings" was performed. Postoperative pathology showed chronic sinusitis with inflammatory polyp formation. The nasal congestion and runny nose improved after operation, but the fever was still repeated, mostly at 37~39℃. The anti-infective treatment such as "levofloxacin, Tezhixing + Baifule" was given for 2 weeks successively, and the effect was not good. 3 days ago, there was no obvious trigger for distension and pain in the left waist, accompanied by pale complexion, check: WBC 13×10⁹/L, NEUT 84.7%, Hb 50 g/L, PLT 322×10⁹/L, CT showed: parenchymal hemorrhage of both kidneys, subcapsular hemorrhage and accumulation of blood in the left kidney, enlarged spleen, retroperitoneal lymph node enlargement, and peritoneal effusion. After "blood transfusion" and other treatment, he was admitted to our hospital for further diagnosis and treatment. Since the onset of the disease, the spirit is general, the appetite is poor, the sleep is poor, the nocturia is slightly increased, the urine volume is 1500~2500 ml, the stool is dry and knotty, and the body weight is reduced by 7 kg. History of hypertension, nephritis, diabetes is denied. Admission physical examination: T: 38℃, P: 116 beats/min, R: 18 beats/min, BP: 149/93 mmHg. The conjunctiva was pale, the left lower abdomen was slightly tender, the spleen was 2 cm below the costs, and the texture was soft, and the left kidney area was percussive (+), but there was no abnormality. Admission blood test routine showed: WBC 19.1×10⁹/L, NEUT 87.7%, Hb 80 g/L, PLT 392×10⁹/L, Scr 277.0 μ mol/L, BUN 20.5 mmol/L, HCO3^-19.7 mmol/L, Alb 28.0 g/L, ALT 32 U/L, AST 28 U/L, CHOL 3.69 mmol/L, LDH 401 U/L, C₃1.0 g/L and high-sensitivity C-reactive protein (HsCRP) 205.6 mg/L. Urinary routine: PRO trace, urine RBC 30/μ L, urine WBC 58/μ L. PT 17.9 s, Fib 7.66 g/L, APTT 57.6 s, PTA 58%, INR 1.48, D-dimer>20 μ g/ml, RF: 199 IU/ml, ESR: 140 mm/h, ASO 423 IU/ml, HBsAg (-), Four items of lupus, ENA series and ANCA were all negative, coombs' test was negative, G6PD, AFP, CEA and thyroid function were not abnormal, anticardiolipin antibody was negative, urinary osmotic pressure was 377 mOsm/L, bone marrow smear was not abnormal, blood culture, urine culture and bone marrow culture were all negative, and tuberculosis antibody (-) was found. After admission, the patient was treated with "meropenem" for anti-infection, albumin supplementation, transfusion of concentrated red blood cells, fresh frozen plasma, vitamin K1 supplementation, and intravenous infusion of prothrombin complex (Kangshuning). The patient still had fever and his body temperature fluctuated between 39 and 40℃. On the sixth day of admission, he had sudden right low back pain, and blood routine showed WBC 22.1×10⁹/L, NEUT 88.7%, Hb 57 g/L, PLT 342×10⁹/L, B-ultrasound of both kidneys showed: right kidney 114 mm ×80 mm, cortex 11 mm, left kidney 123 mm ×90 mm, cortex 12 mm, perirenal hematoma, and the possibility of active hemorrhage in the right kidney was not ruled out. Abdominal enhanced CT showed: left renal parenchyma and subcapsular hemorrhage, and left renal volume increased significantly; Parenchymal hemorrhage of the right kidney, slightly larger volume of the right kidney; Bilateral perirenal exudation, inflammation. SeeFigure 1。