2015年 · 第31卷第04期

chronic kidney disease-mineral and bone disorder (CKD-MBD) is one of the major complications of chronic kidney disease, according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2009 guidelines^[1]CKD-MBD is defined as: systemic mineral and bone metabolism disorders in patients with chronic kidney disease, manifested by any or more of the following conditions: (1) abnormal metabolism of calcium, phosphorus, parathyroid hormone (PTH) and vitamin D; (2) abnormal bone transformation, mineralization, bone volume, linear bone growth or bone strength; (3) Calcification of blood vessels or other soft tissues. secondary hyperparathyroidism (SHPT), as an important aspect of CKD-MBD, manifests as parathyroid hyperplasia and abnormal secretion of PTH, which causes progressive aggravation of calcium and phosphorus metabolism disorders, skeletal lesions, vascular and soft tissue calcification, etc.

secondary hyperparathyroidism (SHPT) occurs in patients with chronic renal failure due to low calcium, high phosphorus and other factors that stimulate the parathyroid glands to proliferate and secrete excessive parathyroid hormone, resulting in calcium, phosphorus and bone metabolism disorders^[1]Clinical symptoms include bone pain, pruritus, soft tissue and vascular calcification, etc., which seriously affect the quality of life and prognosis of patients. The traditional treatment of SHPT includes medical treatment and surgical resection, but both have certain limitations^[2]。 With the development of minimally invasive technology, microwave ablation (MWA) or radiofrequency ablation for SHPT has been reported. However, due to the high technical difficulty of this method, only a few clinical cases have been reported in China^[2,3]。 The clinical data of 34 patients with SHPT treated with MWA were summarized, and the changes of blood calcium, phosphorus and whole segment parathyroid hormone (iPTH), clinical symptoms and complications were analyzed in the short term after operation.

Autologous arteriovenous fistula dysfunction is the main cause of hospitalization in hemodialysis patients^[1]It is mostly related to venous stenosis and thrombosis at the anastomosis. Studies have found that the histological changes of venous stenosis are characterized by intimal hyperplasia^[2]。 By observing the pathological changes of hyperplasia and hypertrophy veins in hemodialysis patients, the pathogenesis of internal fistula dysfunction of this cause was discussed in this study, so as to provide reference for clinical treatment.

Renal fibrosis and tissue hypoxia are considered to be important factors contributing to the progression of chronic kidney disease (CKD). How to evaluate renal function and renal fibrosis early is very important for the treatment of CKD. At present, there is a lack of clinical non-invasive examination methods with high sensitivity and specificity for early CKD. Diffusion tensor imaging (DTI) helps to detect fibrosis in liver tissue and can distinguish between mild and severe lesions^[1]。 Recent studies have shown that DTI is also a non-invasive method to evaluate kidney disease^[2,3,4]。 In this study, the apparent diffusion coefficient (FA) of renal cortex and renal medulla were compared with the clinical biochemical indexes and histopathological fibrosis scores of CKD patients by 3.0T magnetic resonance imaging, and the clinical application value of DTI in the detection of renal fibrosis and renal function was evaluated.

Patient, female, 51 years old. In March 2008, he received hemodialysis treatment for "chronic kidney disease stage 5" for 10 h weekly. On 9 October 2010, he was seen for "occlusion of internal fistula in left hand". With the consent of the patient and his family, he was placed with a Quinton Permce TH long-term dialysis catheter and returned to the local hospital for treatment. On November 5, 2011 and June 22, 2012, I was hospitalized due to "catheter-related infection". Staphylococcus aureus growth was seen in two cultures. After the disease was controlled, the new Palindrome long-term catheter was replaced in situ due to poor catheter flow. After two more complicated catheter-related infections, the growth of Escherichia coli was seen in culture. Nov 17, 2014 During dialysis, the blood flow of the catheter was not smooth, and urokinase thrombolysis was repeated, but the effect was poor. It is recommended to replace the long-term catheter in situ again.

Patient, male, 51 years old. He was admitted to hospital on September 21, 2014 due to repeated low back pain and foamy urine for 8 years, which was aggravated for more than 1 month. Eight years ago, the patient developed left lumbar swelling and pain without obvious trigger, accompanied by foamy urine. The local hospital examination showed proteinuria, which was relieved after giving traditional Chinese medicine (specifics unknown) and nephritis Shu tablets. One month ago, the aforementioned symptoms recurred without obvious trigger. The local hospital examination showed that blood Alb was 25.3 g/L, urine protein (3+), and Huangkui and Bailing capsules were given, but there was no significant improvement. In order to seek further diagnosis and treatment, I came to our hospital for treatment. Physical examination at admission: no edema in both lower limbs, blood pressure 145/100 mmHg. Laboratory tests: urine protein (3+), quantitative 8.9 g/24 h, microscopic hematuria; Blood Alb 22.9 g/L; total cholesterol 8.71 mmol/L; Hemoglobin 132.0 g/L; Serum creatinine was 90.0 μ mol/L. Blood and urine immune fixation electrophoresis were normal. The bone marrow puncture examination showed no abnormalities. Chest X-ray and abdominal B-ultrasound showed no abnormalities. Tumor markers and anti-neutrophil cytoplasmic antibody (ANCA) tests were negative. The patient has an elder brother with kidney disease (details are unknown). Children's health status: The daughter is positive for hepatitis B antigen. Clinical diagnosis: Nephrotic syndrome, chronic renal failure. Renal biopsy: light microscopy: 2 cortical kidney tissues, 2 out of 15 glomeruli with globular sclerosis. The glomerular volume of the residual cutter is enlarged, the mesangial area is moderately to severely widened, the structure is loose, the mesangial cells proliferate, several mesangial lysis, the capillary loops are open and stiff, a large number of eosinophilic and PAS-positive substances are deposited in the mesangial area and under the endothelium, the segmental loops are fused and expanded, the segmental endothelial cells are swollen and paired, and the cyst wall segments are thickened and stratified. PASM-Masson staining: Diffuse mesangial area, massive deposition of complexes under endothelium, occasionally tubular epithelial cells; Mild chronic tubulointerstitial lesions (about 15%), focal tubular atrophy, basement membrane thickening, small amount of protein tubular pattern in the lumen, focal mononuclear, lymphoid and plasma cell infiltration of the interstitial. Segmental hyaline degeneration of the arterioles and thickening of the intima of the interlobular arteries. Renal tissues were negative for Congo red staining. SeeFigure 1，Figure 2，Figure 3。 Immunofluorescence: IgA (+), IgM (+), C1q (+) and fibronectin (FN) (+) were deposited non-specifically in mesangial region and vascular loop. IgG, C3, C4, HBs, HBc and kappa and lambda light chains were all negative. Fibronectin (2+), granular deposition in the diffuse mesangial region of the glomerulus and vascular loop. SeeFigure 4。 Ultrastructure: Diffuse fusion of the foot process, thinning of the basement membrane, increased mesangial matrix, and deposition of substances with lighter color and non-filamentous structure than dense substances can be seen under the endothelium. The deposited substances squeeze the loop cavity, resulting in narrowing of the loop cavity, some even occlusion, and no electronic dense substances can be seen in the glomerular basement membrane and epithelial side. SeeFigure 5。 Pathological diagnosis: fibronectin glomerulopathy.

Secondary hyperparathyroidism (SHPT) is one of the most common serious complications of chronic kidney disease (CKD). Surgical treatment can be given for drug-refractory SHPT, but postoperative gland residual, graft hyperplasia or missing diseased glands are easy to cause recurrence, and reoperation is traumatic and expensive. In recent years, ultrasound-guided microwave ablation (MWA) in the treatment of SHPT has been gradually applied in clinical practice. The author observed the short-term efficacy of MWA surgery for parathyroid adenoma in 2 patients with SHPT, and the effect was obvious. The report is as follows.