2017年 · 第97卷第20期

Hypertension is a common complication of kidney disease, and it is also the cause of kidney disease and the aggravating factor of disease progression. Hypertension caused by various kidney diseases, called renal hypertension, is divided into renal parenchymal hypertension and renal vascular hypertension. The mechanisms leading to renal hypertension are complex, and factors such as impaired self-regulation, water and sodium retention, activation of renin-angiotensin-aldosterone system, activation of sympathetic nervous system and abnormal function of vasoactive substances in patients with renal disease are all involved in the occurrence and development of renal hypertension. The prevalence and severity of renal hypertension are related to the etiology and stage of chronic kidney disease (CKD). According to the epidemiological survey of renal hypertension in hospitalized CKD patients participated in 61 tertiary hospitals in China, the prevalence of hypertension in non-dialysis CKD patients in China is 44% ~86%, while the prevalence of stage 5 CKD patients is more than 91%^[1]。 Although the awareness and treatment rates of hypertension in CKD patients in China were 85.8% and 81.0%, respectively, blood pressure<140/90 mmHg (1 mmHg =0.133 kPa) The control rate is only 33.1%^[1]。 It can be seen that the current situation of prevention and control of renal hypertension is not optimistic. Hypertension not only aggravates the clinical symptoms and laboratory indicators of kidney disease (such as proteinuria), accelerates the progression of kidney disease, but also increases the occurrence of complications such as heart, brain and peripheral blood vessels, resulting in premature death of patients with kidney disease. Therefore, strengthening the management of renal hypertension is of great significance for delaying the progression and complications of renal disease and improving the prognosis of patients.

The application of oxygen to treat diseases or alleviate disease states is referred to as oxygen therapy for short, and has a history of more than 230 years. Oxygen therapy is the most widely used and widely used treatment in clinic. From intensive rescue in acute and intensive care units (ICU) to long-term home oxygen therapy for chronic respiratory failure, from newborns to the elderly, to hospice care, oxygen therapy accompanies patients almost all their lives, and is closely related to most diseases and clinical disciplines. There should be no doubt about whether treatment methods involving so many disciplines and a large population need to be standardized.

Renal artery stenosis (RAS) can reduce the blood supply of the affected kidney and activate the renin-angiotensin system, resulting in serious complications such as secondary hypertension, ischemic nephropathy, left ventricular dysfunction, etc., which has been widely concerned. RAS is not uncommon, with epidemiological surveys showing a prevalence of about 7% in people 65 years and older^[1]。 The prevalence rate was higher in the at-risk population, reaching 20% in patients with diabetes and hypertension, 25.3% in patients with peripheral vascular disease, 40.8% in patients with end-stage kidney disease, and 54.1% in patients with congestive heart failure^[2]。 Different from atherosclerotic renal stenosis (ARAS) and myofibrous dysplasia (FMD) in Western populations, Takayasu arteritis accounts for a larger proportion of patients in China^[3]。 in view of the high prevalence of RAS and the inconclusive optimal treatment regimen for patients with RAS, a study of cardiovascular outcomes in renal atherosclerotic lesions (CORAL) has been conducted.

Recent American Medical Journal (JAMA) published a thought-provoking clinical research article in which the authors divided critically ill patients requiring oxygen therapy in the intensive care unit (ICU) into a conservative oxygen therapy group [arterial oxygen partial pressure (PaO₂): 70-100 mmHg (1 mmHg =0.133 kPa) or pulse oximetry (SpO₂): 94% to 98%] and the traditional oxygen therapy group [PaO₂>150 mmHg or SpO₂The results showed that the mortality rate of ICU in the conservative oxygen therapy group was significantly lower than that in the traditional oxygen therapy group (11.6% vs 20.2%,P＝0.01)； Moreover, the incidence of shock, liver failure and bacteremia in the conservative oxygen therapy group was lower than that in the traditional oxygen therapy group^[1]。 Analyzing the results of this study, it can be seen that the differences between the two groups are mainly manifested in the fact that the traditional oxygen therapy group is given hyperoxia therapy, maintaining a high level of oxygen partial pressure and hyperoxemia, which leads to an increase in the mortality rate of critically ill patients. Therefore, we have reason to question the impact of hyperoxia on human body, and improper application may even cause harm.

Oxygen therapy plays a very important role in the treatment of various diseases, especially in the rescue of critically ill patients, such as the acute exacerbation of chronic obstructive pulmonary disease (COPD). Oxygen therapy, as a therapeutic means, needs to develop a clear treatment plan when using it, including appropriate inhaled oxygen concentration (FiO₂), continuous oxygen inhalation time and clear oxygen therapy goals. For a long time, there has been great randomness and irregularity in clinical oxygen therapy, and the same is true in the treatment of COPD. Clinicians often have innumerable thoughts on the possible adverse reactions and harms of excessive oxygen therapy, insufficient understanding and attention, and lack necessary assessment and follow-up for the harms of excessive oxygen therapy. During oxygen therapy, there are indefinite prolongation of oxygen therapy time, random or indefinite increase of FiO during treatment₂Or oxygen flow.

Oxygen is an essential substance for maintaining physiological activities and health of the body. In some diseases (such as severe infection, cardiac insufficiency caused by cardiovascular disease, etc.), it is often accompanied by tissue hypoxia or hypoxemia, resulting in a series of adverse consequences. Oxygen therapy by nasal tube or mask inhalation (oxygen therapy for short) can often improve the hypoxic state and partially relieve the symptoms associated with the above diseases. Oxygen therapy is often overused in clinical practice. For patients with cardiovascular diseases such as coronary heart disease and heart failure, regardless of whether there is hypoxemia or not, oxygen therapy or even hyperoxia therapy are often routinely given. However, in recent years, many studies have shown that conventional oxygen therapy for patients with the above diseases has no benefit, and hyperoxia therapy even brings harmful results. Therefore, it is very important to sort out the history and current situation of oxygen therapy for cardiovascular diseases, understand the cardiovascular harm of oxygen therapy, especially hyperoxia therapy, and standardize oxygen therapy in clinical practice.

Oxygen therapy is a commonly used clinical treatment measure, which can improve the disease state caused by hypoxia and save lives for critically ill patients with severe hypoxia. Oxygen therapy also has side effects, mainly manifested as the damage to the body caused by hyperoxia. More and more studies have shown that exposure to high concentration of oxygen and hyperoxemia in the body for a certain time can cause hyperoxia-related pathological damage, aggravate the disease, and even threaten life^[1]。 Combined with relevant research results, the damage and mechanism of hyperoxia to the body are described as follows.

In the more than 200 years of clinical practice of oxygen therapy, almost no one doubted the therapeutic effect of oxygen, but few people thought that oxygen therapy would also have side effects and even be life-threatening. Only the safety of oxygen therapy has attracted clinical attention in recent 20 years, among which the adverse effects and even harms brought by hyperoxia therapy have become a hot spot of attention. A large number of research results, including big data and meta-analysis, have confirmed the harm of high-flow oxygen inhalation and hyperoxemia to health and life, and its mechanism has also been revealed by clinical and animal experiments. Generally speaking, domestic clinical oxygen therapy is basically in a state of no rules. Some basic problems of oxygen therapy, such as indications of oxygen therapy, target blood oxygen saturation of oxygen therapy, differences between different diseases and states of oxygen therapy, and whether oxygen therapy has side effects, are ambiguous. In view of the above situation, the current international oxygen therapy guidelines are briefly introduced as follows, hoping to serve as a reference for our clinical oxygen therapy to guide the standardized implementation of clinical oxygen therapy.

Peking Union Medical College Hospital is a large-scale comprehensive hospital integrating medicine, teaching and research. Clinical teaching has always been one of the three inseparable functions, and teachers are the main undertakers of the teaching work in the hospital. Peking Union Medical College Hospital has accumulated a certain amount of experience in teacher training, formed a relatively complete teacher training system, and continuously developed and innovated in practice^[1]。

The kidney is an important organ to regulate blood pressure. The increase of blood pressure caused by renal parenchymal disease and renal artery disease is called renal hypertension. Hypertension aggravates renal disease and causes renal function to decrease, forming a vicious circle, which leads to high disability and mortality of patients with renal disease. The prevalence of chronic kidney disease (CKD) in China reaches 10.8% with the aging of the population, the change of disease spectrum and the change of lifestyle^[1], meaning 1 in 10 adults suffer from kidney disease. The pathophysiological mechanisms, clinical manifestations and treatment of renal hypertension are different from those of general hypertensive people, which require special attention and specialized research. However, the guidelines widely used internationally are mostly based on general hypertensive population studies. The American Nephrology Foundation published guidelines for the diagnosis and treatment of hypertension in patients with CKD in 2004 and 2012, respectively, but the research evidence comes from Western populations^[2,3]。 Therefore, we organized experts in relevant fields to write this guide, hoping to standardize the diagnosis and treatment of renal hypertension in China, improve the awareness, diagnosis and treatment of renal hypertension, promote the research and development of renal hypertension in China, and improve the prognosis of CKD patients.

A 34-year-old female was admitted to our department for "11 years after IUD placement and 2 months after ectopia". Eleven years ago, the patient placed a round IUD in an external hospital, and then repeatedly experienced dull pain in the lower abdomen, which could be relieved by itself. One year later, the patient was menopaused for 3 months. After abdominal color ultrasound examination, the local hospital considered it as "early pregnancy and IUD fall off", and successfully gave birth to a healthy full-term baby girl. No detailed examination was performed after delivery, and the patient still had repeated abdominal pain. The abdominal pain was mainly around the umbilicus, which could be aggravated and relieved by itself during activity. The patient did not pay attention to it. After that, the patient gave birth once 8 years ago and 6 years ago respectively. Two months ago, the patient was not suitable for treatment in the local hospital because of the lumbosacral region, and an abdominal X-ray showed that "a circular foreign body with a diameter of about 4 cm was seen on the left side of the abdomen" (Figure 1), and then went to the outpatient clinic of our hospital and was admitted to our department. After admission, there were no signs of peritonitis in the abdomen, and abdominal CT examination also found: annular foreign body in the left upper abdomen, suspected to be located in the intestinal lumen of the transverse colon. Preoperative diagnostic considerations: ectopic abdominal cavity of the IUD. One day before the operation, the intestine was fully prepared, and after general anesthesia, the abdominal cavity was successfully explored laparoscopically. No obvious adhesions were found, and no obvious scars were found on the uterine surface. After exploring the left upper abdomen, a ring-shaped foreign body was found on the left side of the middle section of the transverse colon. The foreign body was located in the serous layer of the transverse colon, and the foreign body could not be seen. Laparoscopic removal was difficult, and there was no local adhesion. After locating the foreign body, the pneumoperitoneum was released, and a small 5 cm longitudinal incision was made in the left upper abdomen. Further exploration of the transverse colon found that the ring-shaped foreign body was imprisoned in the intestinal wall. The foreign body was incised 2 cm distal to the intestinal wall where the foreign body was located and entered the intestinal cavity. The foreign body corresponding to the colon mucosa was intact, and the ring body was not exposed. The colon mucosa was incised under direct vision, and a round IUD was completely taken out from the intestinal wall. After the foreign body was removed, the corresponding serous layer of the intestinal wall was intact. A purse suture was made in the serous muscle layer outside the intestinal cavity to properly embed the intestinal wall where the foreign body was located, and the distal intestinal wall incision was routinely sutured. The intestinal function recovered 3 days after operation, the incision healed grade A, and the postoperative recovery was good. There was no complaint of discomfort after 2 years follow-up.

A 55-year-old male was admitted to the Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University on August 14, 2015 due to "increased urine protein for 2 months and edema for more than 1 month". Two months ago, the patient was examined in the local hospital for urine protein + + +, more than one month ago, he developed edema of both lower limbs, and the urine protein was examined 1 day ago for + + + +. Has a history of metallurgical tours and found that blood pressure increased for 4 months. Physical examination showed moderate depressed edema of both lower limbs. Laboratory tests: Urinary protein + + +, serum albumin 21.9 g/L, serum creatinine 70 μ mol/L, total cholesterol 3.29 mmol/L. The 24-h urine protein quantitation was 7.84 g, and the creatinine clearance was 122 ml/min. Serum Rapid Plasma Reactin Circular Card Test (RPR) 1:32 (+); Syphilis-specific antibody (TP-Elisa) positive; Treponema pallidum hemagglutination test (TPHA)>1:160 (+). B-ultrasound: The shape, size and internal echo of both kidneys were normal. Renal biopsy was performed on August 25, 2015. Pathology showed that the glomerular capillary loop was slightly stiff and mildly thickened, most of the glomerular mesangial cells had no obvious proliferation, and there was no obvious increase in mesangial matrix. Immunofluorescence showed that IgG, IgG1, IgG4 and complement C3 were deposited in granular form on the wall of glomerular capillary. Under the electron microscope, small clusters of deposits were scattered under the epithelium, and extensive podocyte fusion was observed. Pathological diagnosis: membranous nephropathy. On September 1, 2015, the patient suffered from sudden left limb weakness. The physical examination showed that the left nasolabial fold was shallow, the proximal muscle strength of the left upper limb was grade 3, the distal muscle strength was grade 4, the left lower limb muscle strength was grade 4, and the right limb muscle strength was grade 5. Magnetic resonance imaging (MRI) showed a large area of fresh infarction in the right frontoparietal lobe; Fresh infarction of the left radiation crown. Lumbar puncture was performed on 14 September, CSF pressure 72 mmH₂O (1 mmH₂O =0.009 8 kPa), CSF test: negative Pane's test, white blood cell count 1×10⁶/L, chlorine 124 mmol/L, glucose 4.8 mmol/L, protein quantification 328 mg/L, TPHA 1:160 (+), RPR negative. During the course of the disease, the patient developed fever and sputum culture showed Streptococcus pneumoniae. Clinical diagnosis: syphilis-associated nephrotic syndrome, neurosyphilis, cerebral infarction, pulmonary infection, hypertension. Symptomatic treatment such as antiplatelet, lipid-lowering, antihypertensive and diuretic were given. Methylprednisolone sodium succinate injection 40 mg/d intravenously for anti-inflammatory treatment (33 days in total), and the dose was reduced to methylprednisolone tablets 32 mg/d on September 30th, and methylprednisolone tablets were reduced to 28 mg/d on October 4th; 2.4 million U of long-acting penicillin injection was administered intramuscularly, once/week, for 4 weeks from August 19th, and 4 million U of penicillin injection, once/6 h, intravenous drip, for 2 weeks from September 19th. After treatment, the 24-h urine protein quantification of patients gradually decreased (Figure 1)。 At the time of discharge, the patient's body temperature was normal, the edema of both lower limbs resolved significantly compared with before, and the left limb was paretic. The 24-h urine protein quantification was 5.92 g, urine protein + +, serum albumin 21.8 g/L, and serum RPR 1:4 (+). Reexamination 2 months after discharge showed serum RPR 1:1 (+), serum albumin 35.0 g/L and urine protein + + +.

The 18th American Annual Conference on Hernia Surgery was held in Cancun, Mexico from March 8 to 11, 2017. This conference attracted nearly 400 hernia surgeons from more than 30 countries and regions around the world.