2016年 · 第55卷第03期

Epidemiological investigation shows that the prevalence of chronic kidney disease in adults in China is as high as 10.8%. How to identify early, make clear diagnosis and carry out individualized treatment is an important factor to improve the prognosis of patients. However, due to the large heterogeneity of kidney disease in individual pathogenesis, it brings great challenges to clinical management. If the concept of "precision medicine" can be integrated into the clinical and scientific research work of modern nephrology based on the physiological pathogenesis of the disease, I believe it will bring greater benefits to patients. Professors Yu Feng, Wang Suxia and Zhao Minghui wrote "Clinicians Should Pay Attention to the Physiological Foundation of Diseases: Starting from the 'Accurate' Classification of Lupus Nephritis", pointing out that patients can benefit the most by taking the physiological background of pathogenesis as the theoretical basis and combining clinical and pathological characteristics to "accurately classify" patients, so as to carry out individualized "precise treatment".

In 2015, President Barack Obama announced a new project in the field of life sciences, the precision medicine initiative, in his State of the Union address, calling on the United States to increase funding for medical research, promote individualized genomics research, formulate individual medical plans for patients with cancer and other diseases based on personal genetic information, give the right people the right treatment at the right time, and continue to lead medicine into a new era. Although the key support projects of the program are in the fields of tumor and health management, its concept can also be extended to other majors in the medical field, that is, the application of modern genetic technology, molecular imaging technology, and bioinformation technology, combined with patients' living environment and clinical data, Achieve accurate disease classification and diagnosis on the basis of disease physiology, and formulate personalized treatment plans.

Pulmonary protective ventilation strategy has become the basic principle in the treatment of severe hypoxia and acute respiratory distress syndrome (ARDS)^[1]Its main purpose is to avoid lung damage caused by excessive pulling of lung tissue by pressure or volume, and thus avoid distant organ damage. In recent years, it is worth noting that more and more studies on ARDS have found that patients with ARDS do not die of severe lung injury and refractory hypoxemia, but of shock and sudden cardiac arrest^[2]。 Therefore, emphasizing only lung protection against lung injury in current mechanical ventilation strategies may be far from sufficient. Clinical medical and scientific research should not only pay attention to the effects of respiratory mechanics on lung, but also the hemodynamic effects of respiratory movement^[3]。 In order to improve the prognosis of patients, we should avoid the injury of circulation caused by mechanical ventilation while opening and protecting the lungs.

Influenza (hereinafter referred to as influenza) is an acute respiratory infectious disease caused by influenza virus (referred to as influenza virus). Because of the variability and unpredictability of influenza virus (mainly influenza A virus), it often causes influenza outbreaks and even causes global pandemics^[1]。 According to statistics, there are about 1 billion influenza cases during the global influenza pandemic every year, 5% ~10% of adults and 20% ~30% of children suffer from influenza, of which 3 million ~5 million are critically ill patients, causing 250,000~500,000 deaths every year. In the past 100 years, human beings have experienced four global influenza pandemics, resulting in 40 to 50 million deaths^[2]。 Children, the elderly, pregnant women and those with chronic underlying diseases are at high risk of severe influenza illness and death^[3]。 In the United States, the number of outpatient visits caused by influenza exceeds 25 million each year, and the cost of antimicrobial drugs and over-the-counter drugs is approximately US$2.27 billion and US$2 billion, respectively. It also leads to more than 20 million employee absences and more than 22 million school absences, imposing a huge burden on society and individuals^[2]。

Recently, the American Diabetes Association (ADA) promulgated the 2015 ADA Diabetes Medical Diagnosis and Treatment Standards (hereinafter referred to as the ADA Guidelines)^[1]The American Society of Endocrinologists (AACE) and the American Society of Endocrinology (ACE) also jointly promulgated the 2015 AACE/ACE Clinical Practice Guidelines for Comprehensive Treatment of Diabetes (hereinafter referred to as the AACE/ACE Guidelines)^[2]。 Learning the important contents of dyslipidemia management in these two guidelines can learn about the new trends of dyslipidemia management in diabetic patients.

Kaposi's sarcoma (KS) is a systemic multiple malignant tumor of vascular origin, which tends to occur on the skin and can involve the internal organs. KS is one of the common opportunistic tumors in AIDS patients. According to statistics, the incidence of KS in AIDS patients is 100,000 times that of the general population, and about 40% of AIDS patients can combine with KS^[1]。 The pathogenesis of KS is complex and diverse, and its prognosis is also affected by many factors. This study retrospectively analyzed the clinical characteristics, treatment plan and survival of 27 patients with AIDS complicated with KS.

At present, it is believed that inflammatory bowel disease (IBD) is an abnormal immune response against their own intestinal flora in susceptible people under the combined action of genetic, environmental and immune factors, which ultimately leads to uncontrollable intestinal inflammatory response^[1]。 Immunoglobulin IgG Fc γ ⅡA receptor (Fc γ RⅡA) is a glycoprotein widely expressed on the surface of immune cell membrane. It can activate and regulate a variety of immune responses when combined with IgG Fc fragment, and plays an important bridge role between humoral immunity and cellular immunity^[2]。 Studies have shown that the expression level and function of human Fc γ RⅡA are affected by its genetic polymorphism^[2,3]。 So far from Japan^[4]South Korea^[5]And part of the Caucasian population^[6]Studies have confirmed that the polymorphism of Fc γ RⅡA gene (FCGR2A) is closely related to the susceptibility to ulcerative colitis (UC), but the relationship between UC and FCGR2A gene polymorphism in Chinese Han nationality is rarely reported. In this study, the alleles and genotype frequencies of five single nucleotide polymorphism (SNP) loci of FCGR2A (rs1801274, rs10800309, rs4657039, rs511278 and rs6696854) were analyzed between UC patients and healthy controls by multiplex SNaPshot technique. By exploring the influence of FCGR2A gene polymorphism on UC susceptibility in Zhejiang Han population, we aimed to provide theoretical basis for further revealing the genetic and immunological pathogenesis of UC.

The patient was a 42-year-old male. In the middle and late July, 2014, I went to another hospital for treatment due to "fever with fatigue". Blood routine showed WBC 8.53×10⁹/L, Hb 51 g/L, PLT 25×10⁹/L, blood biochemistry showed TBil 59.2 μ mol/L, DBil 15.8 μ mol/L, indirect bilirubin (IBil) 38.6 μ mol/L, lactate dehydrogenase (LDH) 1 169 U/L; positive for direct anti-human globulin test (Coombs test) and negative for indirect Coombs test; Bone marrow image: hyperplasia is obviously active, erythroid accounts for 79.2%, and the proportion of erythroid is obviously increased; There were 115 megakaryocytes in the whole film, 50 classified, including 43 granular type, 4 plate-producing type, 3 nude nuclei, and platelets were rare. Evans syndrome and upper respiratory tract infection were considered, and dexamethasone and oral danazol were treated, but the effect was poor. He went to our hospital for treatment on August 1, 2014. The patient had been suffering from chronic hepatitis B for 12 years and was diagnosed with type 2 diabetes for more than half a month. He was treated with short-acting combined with long-acting insulin. Family history is not special. Admission physical examination: arterial oxygen saturation (SaO₂) 92%, body temperature 37.8℃, severe anemia, severe yellowing of the skin, mucosa and sclera of the whole body, slightly thick breathing sounds in both lungs, wet rales can be heard at the base of the lungs, heart rate 108 beats/min, regular rhythm, soft abdomen, no tenderness, rebound pain and abdominal muscle tension, palpable under the costs of the liver (3 cm from the right costal margin), unpalpable under the costs of the spleen, and no edema in both lower limbs. Laboratory tests: Blood routine showed WBC 18.45×10⁹/L, Hb 42 g/L, PLT 10×10⁹/L, reticulocytes 435.6×10⁹/L; Blood biochemistry TBil 69.2 μ mol/L, DBil 16.1 μ mol/L, IBil 53.1 μ mol/L, LDH 1 369 U/L, ALT 15 U/L, AST 24 U/L; Both direct and indirect Coombs tests were positive; Aeromonas hydrophila lysin variant (Flare) detection of paroxysmal nocturnal hemoglobinuria (PNH) clone negative; Antiplatelet antibody IgG (PA-IgG) and IgM were normal; Low folic acid, vitamin B₁₂Ferritin normal; Antinuclear antibody, anticardiolipin antibody, lupus anticoagulant and extractable nuclear antigen (ENA) antibody spectra were all negative; Free T₃1.89 pmol/L, free T₄14.45 pmol/L, thyrotropin (TSH) 0.48 mIU/L, thyroglobulin 0.267 μ g/L, anti-thyroglobulin 130.4 IU/ml, anti-thyroid peroxidase antibody 51.73 IU/ml; Urine routine showed occult blood (+ +) and bilirubin (+); HBV DNA Quantitative negative; Epstein-Barr virus and cytomegalovirus were both negative. Bone marrow image: hyperplasia is extremely active, erythroid accounts for 82.4%, grain-to-red ratio is 0.16:1, mainly middle and late young erythrocytes; About 400 megakaryocytes were seen in the whole film, and 25 were classified, including 1 naive type and 24 granular type, with scattered platelets. Karyotyping: 46, XY [20]. Chest CT: Scattered patchy shadows in the lower lobe of the right lung. Clinical diagnosis: Evans syndrome, upper respiratory tract infection, chronic hepatitis B, type 2 diabetes.

The patient was a 28-year-old female. He was admitted for fever with headache, nausea, vomiting for 20 d, and left limb weakness for 11 d. The patient was diagnosed with peripheral T-cell non-Hodgkin's lymphoma due to skin pigmentation and multiple superficial lymph nodes. In May 2012, he underwent lymph node biopsy to confirm peripheral T-cell non-Hodgkin's lymphoma. He underwent chemotherapy with GDPML regimen (Genze, cisplatin, dexamethasone, methotrexate and peaspartase). During the second course of chemotherapy, he developed skin desquamation, exudation, erythema, and had no obvious gastrointestinal symptoms such as nausea and vomiting. The second course of chemotherapy was followed by vorinostat and dexamethasone. Combined with agranulocytic fever, the highest body temperature was 39℃, accompanied by headache, nausea, and vomiting. After the reduction of vorinostat, the vomiting improved, and the low fever was still 37.5℃. Since September 1, 2012, he has left limb weakness, difficulty in walking, no convulsions, impairment of consciousness, etc. Recent appetite is good, no abdominal pain, diarrhea, etc., and no clear history of unclean diet.

October 2015LancetA nationwide cross-sectional survey of AKI led by the Department of Nephrology, Peking University First Hospital and jointly completed by the "ISN AKF 0 by 25" Chinese Acute Kidney Injury (AKI) Clinical Research Collaborative Group was published [Yang L, Xing GL, Wang L, et al. Acute Kidney Injury in China: a cross-sectional survey. Lancet, 2015, 386 (10002): 1465-1471]. The study found that AKI in China leads to a serious disease burden, and there are serious clinical misdiagnosis and inadequate treatment phenomena.

August 11, 2015Int J Rheum DisThe clinical study "Efficacy and safety of golimumab in combination with methotrexate in the treatment of active rheumatoid arthritis in Chinese adults" led by Professor Zhanguo Li of Peking University People's Hospital was published (Li Z, Zhang F, Kay J, et al. Efficacy and safety results from a Phase 3, randomized, placebo-controlled trial of subcutaneous golimumab in Chinese patients with active rheumatoid arthritis despite methotrexate therapy. Int J Rheum Dis, 2015. PMID: 26259617).

Comprehensive management of diabetes includes education, diet therapy, exercise therapy, drug therapy and self-monitoring. Blood glucose monitoring is the basic means to evaluate the condition of diabetes, and it is also an important bridge for communication and interaction between doctors and patients. At present, clinical blood glucose monitoring can reflect different blood glucose contents such as "dot", "line" and "surface". "Point" refers to capillary blood glucose monitoring using a blood glucose meter [including patient self-blood glucose monitoring (SMBG) and bedside rapid (POCT) blood glucose testing in the hospital], "line" refers to 72 h continuous glucose monitoring using dynamic blood glucose monitoring (CGM), and "face" refers to the detection of glycosylated albumin (GA) reflecting the mean blood glucose level of 2 to 3 weeks and glycosylated hemoglobin (HbA1c) reflecting the mean blood glucose level of 2 to 3 months. The role and positioning of different monitoring methods and indexes in clinic: Capillary blood glucose monitoring is the basic form of blood glucose monitoring, HbA1c is the gold standard reflecting the long-term blood glucose control level, CGM and GA are effective supplements to the above.

hypertrophic pachymeningitis (HP) is a rare disease of the central nervous system characterized by localized or diffuse fibrous thickening of the brain and/or spinal dura mater. According to the site of onset, it can be divided into hypertrophic cranial pachymeningitis (HCP) and hypertrophic spinal pachymeningitis (HSP). According to the etiology, HP can be divided into idiopathic and secondary forms. HSP was first reported by Charcot in 1873, and later Naffziger reported the first case of idiopathic HCP^[1]。 Among the different types of HP, idiopathic HCP is the most common. The diagnosis of idiopathic HP needs to rule out the underlying cause, while the secondary HP has a variety of causes, including infection, autoimmune disease, tumor, trauma, etc^[2]。 MRI shows that there are many diseases that need to be differentiated due to dura thickening, and the causes of secondary HP are diverse, which brings certain challenges to the diagnosis of HP.

The accurate judgment of GFR is of great significance in clinical medicine and clinical research, including the diagnosis and staging of chronic kidney disease (CKD) and acute kidney injury, the evaluation of the rate of renal function deterioration and the effect of intervention therapy, the judgment of the timing and efficacy of renal replacement therapy, the adjustment of drug dose and the evaluation of the safety of auxiliary examination, etc. However, GFR cannot be measured directly, but can only be measured and estimated by exogenous and endogenous markers. The estimation of GFR (eGFR) is based on the measurement of GFR (mGFR) as the reference standard, using the demographic characteristics, serum creatinine (Scr) and other parameters, and using the regression model to establish the eGFR formula. It is simple in application, low in cost, and the formula developed in recent years has good accuracy, so it has become a clinical "first-line" project for evaluating renal function. The evaluation methods of eGFR are summarized as follows.

Chronic kidney disease (CKD) has become a global health problem. According to surveys, the global prevalence of CKD in adults is 10% to 13%, with about 400 million to 600 million CKD patients^[1]。 The total prevalence of CKD in my country is 10.8%, and it is estimated that there are 119.5 million CKD patients in my country^[2]。 Tanner et al.^[3]The estimated GFR (eGFR) ≥60, 45-59 and<45 ml·min^－11.73 m^－2The prevalence of refractory hypertension in patients with CKD was 15.8%, 24.9%, and 33.4%, respectively. Studies have established that better blood pressure control can delay the deterioration of renal function and improve the prognosis of CKD patients^[4]。 CKD combined with refractory hypertension has become an important medical problem, which needs to be solved urgently.

Influenza (hereinafter referred to as influenza) is an acute respiratory infectious disease caused by influenza virus (hereinafter referred to as influenza virus). Due to the volatility and unpredictability of influenza virus (mainly influenza A virus), it often causes influenza outbreaks and even causes global pandemics^[1]。 Every year, 5% to 10% of adults and 20% to 30% of children suffer from influenza, with about 3 million to 5 million seriously ill patients, resulting in about 250,000 to 500,000 deaths^[2]。 Early and effective anti-influenza virus treatment can alleviate the symptoms of influenza, shorten the course of influenza, reduce the complications caused by influenza, shorten the virus clearance time, and may reduce the mortality rate. It has been recommended in the guidelines for influenza diagnosis and treatment in various countries^[3,4,5,6]。 Due to the volatility of influenza, geographical differences in epidemic strains, and the variation in the availability of antiviral drugs from country to country, specific antiviral treatment options should still be selected according to the type and drug resistance characteristics of local influenza viruses.

The concept of vascular cognitive impairment (VCI) was first proposed in 1995^[1]All cognitive impairments associated with cerebrovascular injury (not only stroke)^[2]。 VaMCI refers to mild cognitive impairment syndrome caused by, or associated with, vascular causes^[3], is the transitional phase between normal cognition and dementia^[3,4,5,6,7]。 Although associated with vascular cognitive impairment non-dementia (VCIND)^[5]mild vascular cognitive impairment (mild VCD)^[4]and mild NCD^[7]Different concepts but largely consistent definitions, similar to mild cognitive impairment due to Alzheimer's disease (AD) (AD-MCI)^[8,9,10,11]。

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