2017年 · 第56卷第03期

End-stage kidney disease (ESRD) is an important public health issue globally; Patients with chronic kidney disease (CKD) have progressively decreased renal function and require expensive renal replacement therapy (including hemodialysis, peritoneal dialysis, or kidney transplantation) to sustain life after entering ESRD. A meta-analysis of multiple large-scale observational studies and renal registries worldwide revealed^[1]As of 2010, a total of 2.62 million ESRD patients worldwide received renal replacement therapy; However, at least 2.28 million more ESRD patients have died due to lack of access to renal replacement therapy, particularly in low-income countries in Asia and Africa. The number of ESRD patients receiving renal replacement therapy is expected to rise to 5.44 million worldwide by 2030, with an increase particularly significant in Asia, especially in China^[1]。 A large amount of data also shows that ESRD patients place a heavy burden on the healthcare systems of various countries. Taking the United States as an example, the annual report of the United States Kidney Data System shows that in 2012, all patients who received kidney replacement in the United States, even excluding the cost of drug treatment, still spent as much as $28.6 billion, and it continued to grow. In 2012 alone, it increased by $900 million compared with the previous year. It is estimated that the cost of renal replacement therapy for ESRD patients worldwide was $1.1 trillion over the 10 years from 2001 to 2010^[1]。 Therefore, in order to effectively reduce the pressure brought by the growing ESRD on the medical system, it is necessary to carry out disease prevention and control and crowd management for CKD patients who have not yet entered ESRD, and even high-risk groups of CKD.

Rheumatic immune diseases are a large class of diseases with pain as a common symptom and involving skin, joints, muscles, blood vessels, kidneys, lungs and other organs in the whole body. Autoimmune disorders are often the main cause. Infection, metabolism and environmental factors jointly participate in the pathogenesis, and the clinical manifestation is chronic and recurrent progressive disease. Some rheumatic immune diseases, such AS systemic lupus erythematosus (SLE) and systemic sclerosis, change their appearance, and rheumatoid arthritis (RA) and ankylosing spondylitis (AS) make joints or spines deformed and disabled, thus having a psychological impact; Persistent negative emotions and psychological problems in turn react to the immune system, leading to further aggravation of immune disorders. Functional rheumatism, such as fibromyalgia, has psychological factors directly involved in the onset, so psychosomatic medicine is widely involved in the field of rheumatism and immune diseases. In 1993, an article entitled "Discussion on the Psychosomatic Treatment of Rheumatic Diseases-Investigation Report of Patients and Doctors" was published, suggesting that the concept of psychosomatic medicine has already entered the field of rheumatism.

In 2016,Ann Intern MedPublished an article discussing the relationship between big data and evidence-based medicine (EBM)^[1]The author of this article is Professor Ida Sim of the University of California, San Francisco, and one of the first scholars to advocate the combination of evidence-based medicine and big data to provide the best basis for decision-making. In this article, Professor Ida Sim proposes that big data, as a brand-new way of generating evidence, has developed rapidly in recent years, and the application of big data analysis in medical practice is also becoming more and more widespread. The rapid increase in electronic health record (EHR) data stored in various medical institutions, together with real-time health data (such as heart rate, blood pressure, blood sugar, etc.) collected by various mobile sensors (such as wearable devices and remote monitoring devices), as well as social networks and media data that have opened up new ways to obtain patients' social background, are becoming new sources of clinical diagnosis and treatment decision-making. To understand public attitudes towards HPV vaccination, the traditional approach is to use questionnaires with sample sizes ranging from dozens to thousands. But in the age of big data, it is possible to analyze the publishers of 130 million English-language blogs to understand their positive or negative attitudes towards this vaccination^[2]。 In addition, another classification algorithm based on 2.1 million microblogs can identify microblogging users with depression with 70% accuracy and a positive predictive value of 74%^[3]。 However, the evidence provided by big data has a significant limitation, that is, according to a certain algorithm, it is difficult to identify the authenticity of the results only from the data itself, and the existing bias is impossible to know. Evidence-based medicine attaches importance to minimizing the impact of bias through scientific design, accurate measurement and rigorous implementation of trial data from the beginning. Taking the gout data of the National Rheumatology Data Center (CRDC) as an example, we explore how to improve the quality of medical big data from an evidence-based perspective, reduce and reduce the risk of bias, and provide the best basis for clinical decision-making.

Dizziness or vertigo with neck pain and discomfort is always a challenge in neurology, orthopedics, otology, general practice and rehabilitation departments, and it is also the clinical condition most prone to diagnostic errors. Especially today, with the widespread use of imaging examinations, a large number of patients with dizziness or vertigo are thought to be related to cervical degeneration found by imaging, and are diagnosed as "cervical spondylosis", "vertebrobasilar insufficiency", "posterior circulation ischemia" or "cervical dizziness". In fact, the vast majority of these diagnoses lack reliable diagnostic criteria, and the efficacy of various drugs or surgical treatments lacks scientific verification. However, it is an indisputable fact that it increases the financial and physical and mental burden of patients. With the development of medical science, people have a deep understanding of this kind of situation. Therefore, summarizing the history, clarifying the ideas and standardizing the concepts will be of great significance to improve the level of medical service in this field in China.

2013 American College of Cardiology (ACC) /American Heart Association (AHA) Lipid Guidelines^[1]Many academic organizations at home and abroad have successively released documents to explain their views^[2,3]。 Many guidelines are consensus to build a lipid management framework based on statins. In recent years, the results of some new non-statin clinical studies have challenged the existing concept of lipid management. The following takes non-statin drugs as the starting point to discuss related issues.

The patient was a 37-year-old female who wanted to undergo artificial assisted reproduction. Thyroid function examination at the Second Affiliated Hospital of Xi'an Jiaotong University 2 months before ovulation induction intervention showed that free T₃(FT₃) 5.94 pmol/L (reference value 3.1-6.8 pmol/L), free T₄(FT₄) 21.17 pmol/L (reference value 12-22 pmol/L), total T₃(TT₃) 2.18 pmol/L (reference value 1.15-3.10 pmol/L), total T₄(TT₄) 135.30 pmol/L (reference value 66-181 pmol/L), thyrotropin (TSH) 0.03 mIU/L (reference value 0.27-4.2 mIU/L), thyroid peroxidase antibody (TPOAb) 28.59 IU/ml (reference value 0-34 IU/ml), thyroglobulin antibody (TgAb) 581.90 IU/ml (reference value 0-115 IU/ml), thyroid stimulating receptor antibody (TRAb) 1.29 IU/L (reference value 0-1.75 IU/L). One month before the ovulation induction intervention, the thyroid function was re-examined in the Second Affiliated Hospital of Xi'an Jiaotong University: FT₃5.21 pmol/L, FT₄18.97 pmol/L, TT₃1.82 pmol/L, TT₄119.80 pmol/L, TSH 0.05 mIU/L, TPOAb 12.65 IU/ml, TgAb 572.20 IU/ml, TRAb 0.52 IU/L. After visiting the endocrinology department of the outside hospital, it was shown that TSH increased compared with before, and pregnancy could be performed, so ovulation induction intervention was performed. On the second day of the menstrual cycle, 225 IU of urinary follicle-stimulating hormone for injection and 75 IU of urinary gonadotropin were administered for 4 consecutive days. Cetrorelix acetate 25 mg, urinary follicle stimulating hormone 225 IU and urinary gonadotropin 75 IU were administered on the 6th day of the menstrual cycle for 5 consecutive days. On the 11th day of the menstrual cycle, 25 mg of cetrorelix acetate, 75 IU of urinary gonadotropin and 10 000 IU of human chorionic gonadotropin (β-hCG) were administered to stimulate ovulation, and a total of 4 eggs were obtained. Two weeks later, the patient felt fatigue, palpitation and trembling hands. He was treated for upper respiratory tract infection in the local hospital, but the effect was not good, so he went to the Second Affiliated Hospital of Xi' an Jiaotong University for treatment. History of upper respiratory tract infection in the past 1 month was denied, and history of hyperthyroidism (hyperthyroidism) was denied.

Example 1The patient was a 46-year-old female. He was admitted to hospital on July 19, 2014 due to "intermittent abdominal pain and blood in the stool for 3 days". Three months ago, he was diagnosed with chronic hepatitis C (CHC), genotype 1b, and his autoantibody spectrum was negative. He was given peginterferon α-2a (PEG-IFN α-2a) 180 μ g subcutaneously once a week, combined with ribavirin (RBV) 1 200 mg/d oral antiviral therapy. After 4 weeks, he was re-tested for HCV RNA. At the 13th week of antiviral therapy, the patient developed intermittent left lower abdominal pain and repeated bright red bloody stools, totaling about 200 ml, and was admitted to the hospital with "the cause of gastrointestinal bleeding to be investigated". Had a history of blood transfusions 20 years ago. Deny history of hypertension, diabetes, hyperlipidemia, constipation, etc. Physical examination: Vital signs were normal, cardiopulmonary abnormalities were not present, total abdominal distension, left lower abdominal tenderness (+) and rebound pain (+). Blood routine: white blood cells 10.30×10⁹/L, red blood cells 4.73×10¹²/L, hemoglobin 174 g/L, platelets 55×10⁹/L. Fecal routine: bright red bloody stools, red blood cells full of visual field. Discontinue IFN and RBV, fast water, give fluid rehydration, inhibit pancreatic enzyme and gastric acid secretion, anti-infection and other treatments. However, the symptoms of abdominal pain and blood in the stool were aggravated, the body temperature rose to 38.6 ℃, the heart rate was 122 beats/min, and diffuse peritonitis appeared. Whole abdominal and pelvic spiral CT was performed, which showed diffuse ischemic changes in colon, abdominal and pelvic effusion (Figure 1)。 Fiber-optic colonoscopy was not performed due to concerns about intestinal perforation. The initial diagnosis was ischemic necrotizing enteritis and diffuse peritonitis. Emergency laparotomy was performed 22 hours after admission. During the operation, the ascending colon, transverse colon, descending colon and upper segment of sigmoid colon were obviously dilated, the intestine was hard, congested and edematic, and the serosa was partially ruptured. Subtotal colectomy + ileostomy was performed after communication with family members. The pathology of the surgical specimens showed: chronic inflammation of the intestinal wall with acute inflammation and hemorrhage, obvious submucosa in some areas, many small blood vessels (mainly veins) in the submucosa and serosa, inflammatory cell infiltration in the wall with fibrous necrosis, and obvious thrombotic structure formation in the lumen, considering ischemic bowel disease; Immunohistochemical staining excluded colon cancer (Figure 2)。 The results of stool culture showed normal flora, acid-fast staining was negative, and Clostridium difficile toxin test was negative. The patient did not receive any further antiviral therapy and relapsed after 2 months of follow-up.

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In the article "Clinical Application of Aspirin in Atherosclerotic Cardiovascular Diseases: Interpretation of Chinese Expert Consensus (2016)" published on page 4 of Issue 1 of this journal, 2017, due to negligence in revising the manuscript, the statement of aspirin for primary prevention is wrong, which should be as follows: The new consensus determines the following six categories of suitable aspirin...: (1)...; (2) 10-year risk of ASCVD ≥10%; (3) a diabetic patient; The remaining serial numbers are pushed back in turn. The serial number "(6)" in "(6) Combined atrial fibrillation requires..." published at the same time in "Clinical application of aspirin in atherosclerotic cardiovascular disease: Chinese expert consensus (2016)" (page 72) should be the bullet "·". Corrections are hereby made and sorry for the confusion this has caused to readers.

September 1, 2016 New England Journal of Medicine (N Engl J Med) published the study "Epidemic Trends of Chronic Kidney Disease in China" with the Department of Nephrology, Peking University First Hospital as the first author "[Zhang L, Long J, Jiang W, et al. Trends in Chronic Kidney Disease in China. N Engl J Med, 2016, 375 (9): 905-906]^[1]。 The trend of chronic kidney disease (CKD) disease spectrum in China from 2010 to 2015 was evaluated. Studies have shown that with the increasing prevalence of diabetes in China, diabetes-related chronic kidney disease (DM-CKD) has surpassed glomerulonephritis-related chronic kidney disease (GN-CKD) and become the leading cause of CKD.

Perioperative blood glucose abnormalities mainly include hyperglycemia and hypoglycemia. Perioperative blood glucose abnormalities can increase the mortality of surgical patients, increase the incidence of complications such as infection, wound non-healing and cardiovascular and cerebrovascular events, prolong the postoperative hospital stay, and affect the long-term prognosis^[1,2,3,4,5]。 Diabetic patients are at high risk for perioperative dysglycemia compared to non-diabetic patients^[6,7]。 With the surge in the prevalence of diabetes in China^[8]And shortening of average hospital stay^[9]Good perioperative blood glucose management increasingly depends on the participation and decision-making of the departments and doctors involved. The following will be combined with domestic and foreign clinical guidelines and evidence^{[10,11,12,13,14,15]}To provide support to non-endocrinologists for perioperative glucose management.

The "Maastricht-V Consensus Symposium and the Fifth National Consensus Conference on Helicobacter Pylori Infection Treatment" sponsored by Helicobacter Pylori Group of Gastroenterology Branch of Chinese Medical Association was successfully held in Hangzhou on December 16th, 2016. Professor Yang Yunsheng, Chairman of Gastroenterology Branch of Chinese Medical Association, Professor Chen Minhu, Chairman-designate, and You Suning of the Department of Continuing Education of Chinese Medical Association attended the meeting and delivered speeches. Professor Lu Nonghua, member of the Standing Committee of Gastroenterology Branch of Chinese Medical Association and leader of Helicobacter pylori group, served as the chairman of the meeting. More than 70 experts attended the meeting, including some standing members and members of Gastroenterology Branch and Digestive Endoscopy Branch of Chinese Medical Association, members of Helicobacter pylori group/collaboration group, and representatives of the elderly, children and microecology collaboration group.

calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is a rare syndrome characterized by calcification of the media of the skin or subcutaneous fatty arterioles, intimal proliferation, and thrombosis in the vascular lumen, resulting in ischemia, necrosis and ulcer formation of the affected skin^[1,2]。 1961 Selye et al.^[3]"Coined" the concept of calcification defense, 1969 Rees and Coles^[4]The first case of calcification defense was reported. Since then, the number of case reports and studies about calcification defense has gradually increased. According to whether the onset patient has uremia, it can be divided into uremic calcification defense and non-uremic calcification defense^[5]。 Non-uremic calcification defense often occurs in primary hyperparathyroidism, malignant tumors, autoimmune diseases, diabetes, alcoholic liver disease, etc^[6]At present, there are few research reports, limited evidence, and the clinical manifestations and treatment methods are similar to the uremic calcification defense, so the following mainly explains the uremic calcification defense.

Focal segmental glomerulosclerosis (FSGS) is a common clinical glomerular disease and a common cause of adult nephrotic syndrome (NS). Primary FSGS, also known as idiopathic FSGS, accounts for about 80% of all patients. According to the Colombian classification, FSGS can be divided into five histological subtypes: non-special type, periportal type, cellular type, apical type and collapsed type. Among them, the apical type has a relatively good prognosis, while the cellular type and collapsed type have severe lesions^[1]。 Most patients with FSGS present with proteinuria and microscopic hematuria, and some patients may have NS manifestations. At present, the drugs commonly used in the treatment of FSGS include glucocorticoids (hereinafter referred to as hormones), alkylates and calcineurin inhibitors. Relevant literature shows that FSGS patients are treated with oral prednisone for 4 to 24 months, 28% to 74% of patients can achieve complete remission, and 0 to 50% of patients can achieve partial remission. The average time to get remission is 3 to 4 months, and the maximum time is 8 months. The combination of hormones and immunosuppressants can improve the remission rate to a certain extent^[2]。 Recurrence and hormone resistance after remission of NS are currently the main challenges of traditional medication for FSGS. To improve patient prognosis, rituximab was initiated as a novel drug in the treatment of FSGS. Previously, rituximab was used in lupus nephritis^[3]anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitis kidney damage,^[4]membranous nephropathy^[5]All of them showed good efficacy.

Anemia is one of the important clinical manifestations of chronic kidney disease (CKD), and its incidence increases gradually with the progression of CKD, affecting almost all patients with stage 5 CKD. It is generally believed that the occurrence of renal anemia is caused by a combination of factors, among which absolute or relative deficiency of erythropoietin (EPO) is the most important cause of renal anemia. Other factors, such as iron, folic acid and B vitamin deficiency, infection, inflammation, etc., can also promote the occurrence of anemia. It was found that tissue hypoxia in anemia stimulates the increase of EPO production and promotes erythropoiesis by activating hypoxia-inducible factors (HIFs). This response system is severely impaired in CKD patients. Therefore, pharmacological activation of HIFs may become a new method for the treatment of renal anemia.

amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease involving the anterior horn cells of the spinal cord, the motor nucleus of the brainstem and the pyramidal tract. It can start from the bulb or limb, and clinically manifests as progressive aggravation of muscle atrophy, weakness and pyramidal tract signs. Most patients die of respiratory failure 2 to 3 years after the onset of the disease^[1]。 Generally speaking, the clinical prognosis of ALS patients with bulbar onset is often worse than that of patients with limb onset, and the survival time is mostly less than 24 months^[2,3,4]。 On the contrary, ALS subtypes, such as flail arm syndrome (FAS) and flail leg syndrome (FLS), whose clinical manifestations are limited to a certain spinal cord segment, have a better clinical prognosis^[5]。 However, in recent years, some clinical studies have found that a few patients with bulbar onset can preserve limb function for a relatively long time. Compared with the aforementioned patients with typical bulbar onset of ALS, their prognosis is actually not bad, so it is called "isolated bulbar phenotype of ALS" (IBALS).^[6]。 At present, there are few clinical studies on IBALS patients, and its pathophysiological mechanism is still unclear. The relevant research progress is summarized as follows.

Fibroblast growth factor (FGF) -21 is a member of the FGF family and was first developed by Nishimura et al.^[1]Isolated from mouse embryonic tissue. The encoding gene of human FGF-21 is located on chromosome 19, encoded by 209 amino acids, and has 75% homology with mouse FGF-21. FGF-21 is primarily produced by the liver^[1]。 In addition, fat, skeletal muscle, pancreas and other tissues can also produce small amounts of FGF-21^[2]。 FGF-21 is regulated by nutrient metabolism. Fasting or high-fat diet can increase FGF-21 levels in circulation, liver and fat^[3]。 FGF-21 is regarded as an endocrine hormone, which promotes the uptake of glucose by fat cells and reduces fat accumulation^[4]Improve pancreatic islet beta cell function^[5]Promote energy metabolism and improve insulin sensitivity^[6,7]。 Recent studies have shown that FGF-21 plays an important role in the occurrence and development of metabolic diseases, and shows a specific change trend, so it may be used as a new molecular marker for the diagnosis and prognosis of abnormal glucose metabolism. The correlation between different types of glucose metabolism abnormalities and hypoglycemic drugs and FGF-21 levels is discussed below.

The prevalence of hyperuricemia (HUA) in China has been increasing rapidly during the past decade and this disease has stepped up to the second most common metabolic disease following diabetes mellitus. Different disciplinary panels have developed guidelines and consensus on hyperuricemia and gout in respective fields. However, hyperuricemia has been well illustrated to be related to multiple organ disorders such as kidney injuries, endocrine and metabolic abnormalities, and cardiocerebrovascular diseases etc. A multi-disciplinary expert consensus on hyperuricemia and its related diseases will therefore provide a more comprehensive understanding in the diagnosis and treatment of the diseases. The following manuscript is the first consensus established by a task force including rheumatologists, nephrologists, endocrinologists, cardiologists, neurologists, urologists and traditional Chinese medicine experts. This consensus aims at promoting multi-disciplinary collaboration and providing guidelines in clinical practice for general practitioners, doctors from different disciplines at different levels.

End-stage renal disease (ESRD) is an important public health problem worldwide, and diabetic nephropathy is the main cause of ESRD. Research shows that diabetes in China has gradually spread from urban to rural areas since 1980s; After decades, diabetic nephropathy, which is an important complication of diabetes, also spread from urban to rural areas, and began to show a trend of progression from early stage to middle and late stage in the population. Without intervention, it is expected that the peak of ESRD caused by diabetic nephropathy will occur in China in the next 10 to 20 years, and the impact on China's medical and health system is immeasurable. It can be seen that the disease spectrum of chronic kidney disease in China is changing under the influence of social economy, lifestyle and environment. Reasonable and effective formulation of population management strategies for kidney disease can avoid or reduce the heavy burden caused by a large number of ESRD patients in the future. Professors Zhang Luxia and Zhao Minghui were invited to write a monograph "Attaching importance to the disease spectrum changes and population management strategies of chronic kidney disease in China".