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This paper describes how to apply UpToDate ? system can be applied into the evidence-based teaching of difficult and critical clinical problems of nephrology, combined with the practical case of standardized training for specialists. The treatment difficulties can be put forward by teachers or students, and appropriate terms are selected to search in UpToDate ?. The students are required to learn the content of the searched items, and then give their treatment choices and clarify reasons according to the condition of patients. After that, the instructing doctor will comment on the statements of each training specialist, and give treatment plans. Promotion the application of UpToDate ? system is helpful to improve the teaching quality of the standardized training for specialists.
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Objective To identity whether there is muscle atrophy phenomenon in end-stage kidney disease patients and to detect the level of transcription factor Foxo1 and the activity of ubiquitin-proteasome system.Methods Twenty-two patients in chronic kidney disease (CKD) stage 5 were selected and their mean muscle cross sectional area was measured.mRNA and protein levels of Foxo1,Atrogin-1,MuRF1 in rectus abdominis biopsies obtained from consecutive patients were detected.Control biopsies were obtained from 8 healthy subjects during elective surgery for abdominal wall hernias and 6 subjects during elective surgery for adenomyosis.Results Compared with the control group,cross sectional area of muscle fibers decreased and the transcription and protein levels of Foxo1,Atrogin-1,MuRF1 were upregulated in CKD group(P＜0.05).Protein level of p-Foxo1 decreased in CKD group(P＜0.05).Conclusion There exist muscle atrophy phenomenon in CKD patients,which may associate with the upregulation of Foxo1 and activation of ubiquitin-proteasome system.
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Objective To investigate the expression and distribution of parathyroid hormone (PTH) in renal tissues of early stage chronic kidney disease (CKD),and to elucidate its potential role in renal lesion.Methods Eighty-two patients of early stage CKD (stage 1 and 2) diagnosed as glomerulonephritis (GN) with different pathologic types by renal biopsy in our department between 2009 and 2012 were enrolled in the study.Renal tissues of eight patients with mismatched HLA haplotype or the normal part of renal cancer were chosen as controls.Scr,BUN,serum calcium,phosphorus,PTH and 25(OH)VitD3 were measured.Creatinine clearance (Ccr) was calculated by Cockcroft-Gault (CG)formula.99mTc-DTPA clearance rate was used to detect GFR.Patients were divided into mild,moderate and severe groups according to the renal interstitial extent of inflammatory cells infiltration.Immunohistochemistry was used to observe the expression and distribution of PTH in renal tissues.Image-Pro Plus software was used to calculate A value of PTH in renal tissues and compare the extent of PTH expression.Results The levels of calcium,phosphorus,25(OH)VitD3 and PTH in peripheral blood from GN patients of CKD stage Ⅰ and 2 were normal.PTH had no correlation with the above indexes.PTH expression could be seen in renal tissues of all the GN patients with different pathologic types,and it mainly located in renal tubular,only a few in glomeruli and interstitium.The expression of PTH in renal tissues of GN increased compared with the controls (P ＜ 0.01).Furthermore,PTH expression elevated with the increase of inflammatory cells infiltration in interstitium.However the expression of PTH was not significantly different among different pathologic types of GN.Conclusions In the early stage CKD,PTH expression in patients of GN increases,which occurs earlier as compared to PTH elevation in peripheral blood and the imbalance of minerals and bone metabolism.The intensity of PTH expression is associated with the local inflammation.
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ObjectiveTo investigate the expression and distribution of Toll-like receptor 4 (TLR4) in renal tissue of HBV associated nephropathy (HBV-GN) and its role in the pathogenesis and clinical manifestations of HBV-GN.MethodsRenal tissues were sampled from 48 HBV-GN patients confirmed by renal biopsy and 154 non-HBV-GN patients.The distribution of TLR4 in renal tissue and the relationship between the distribution of TLR4 and HBsAg were detected by immunohistochemistry.Integrating case record,correlations between the expression of TLR4 with clinical parameters including pathology,glomeruli,kidney tubules lesions,renal interstitial inflammatory infiltration and blood serum HBV were analyzed.ResultsTLR4 mainly distributed in the renal tubular epithelial cells and interstitial areas as brownish red and granular,which was in consistent with HBsAg distribution.The TLR4 positive rate and score in HBV-GN group were higher than those in non-HBV-GN group (P ＜ 0.05 ).TLR4 positive score was slightly higher in mesangial proliferative glomerulonephritis group and focal segmental glomerulosclerosis group,which had no significant difference (P ＞ 0.05).Kidney tubules lesions were strongly associated with TLR4 expression (r =0.748,P ＜ 0.001 ) which increased with aggravation of renal interstitial fibrosis ( r =0.569,P ＜0.001 ),tubular atrophy ( r =0.577,P ＜ 0.001 ) and inflammatory cell infiltration ( r =0.684,P ＜0.001 ).No obvious correlation with glomeruli lesions was observed ( r =0.293,P =0.053 ).Negative correlation could be seen between TLR4 and the renal function ( R2 =0.784),systolic blood pressure ( R2 =0.869),high sensitivity C-reactive protein (R2 =0.979) and urinary protein (R2 =0.615 ) by regression analysis.Other clinical parameters had no statistical significances.ConclusionsThe expression of TLR4 is abnormal in the renal tissue of HBV-GN patients,mainly in renal tubular epithelial cells and interstitial,which is consistent with the distribution of HBsAg.Its intensity is closely related with renal interstitial lesions,renal function changes and inflammatory cell infiltration.A speculation,that HBV can promote abnormal expression of TLR4 in renal tissues of HBV-GN which may be involved in the lesion progress of HBV-GN,is made upon our study.
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Objective To investigate the expression of Notch 1 receptor in renal tissues of patients with hepatitis B virus associated-glomerulonephritis (HBV-GN) and its role in the pathogenesis of HBV-GN.Methods A total of 48 patients with HBV-GN confirmed by renal biopsy during 2008-2010 were enrolled in the study.Distribution of Notch1 receptor in renal tissue of HBV-GN was detected by immunohistochemistry and the association between the distribution of Notch1 receptor and HBsAg was examined by double-label immunofluorescence assays.Correlations of Notch1 receptor expression with renal pathology and clinical parameters of HBV-GN were analyzed.Results Notch1 receptor distributed mainly in renal tubular epithelial cells and interstitial area as brownish red granules,and a few expression in glomerulus was also found.The positive score of Notch1 receptor expression in HBV-GN patients was significantly higher as compared to primary glomerulonephritis patients with serum HBsAg positive or negative and normal renal tissue controls.Notch1 receptor expression was more obvious in membrano-proliferative glomerulonephritis (MPGN) and mesangial proliferative nephritis (MsPGN) patients,but there was no significant difference among the different pathology groups.Distribution of Notch1 receptor was consistent with the distribution of HBsAg and its intensity was positively correlated with renal interstitial fibrosis (r=0.473,P=0.001),tubular atrophy (r=0.690,P=0.000),inflammatory cell infiltration (r=0.616,P=0.000).Negative correlation was found between renal function and the intensity of Notch1 receptor (r=-0.393,P=0.006).Conclusions Notch1 receptor expression increases in the renal tissues of HBV-GN patients and distributes mainly in renal tubular epithelial cells and interstitium,which is consistent with the distribution of HBsAg.Its intensity is closely correlated with renal interstitial lesions and renal function.Abnormal expression of Notchl receptor in renal tissue of HBV-GN may be involved in the progress of HBV-GN.
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Objective To observe the change of insulin-like growth factor 1 (IGF-1)before and after glucocorticoid (GC) therapy and to explore the effect of its change on bone metabolism in primary nephrotic syndrome (PNS) patients.Methods A total of 39 PNS patients with mean age of (36.73±12.15) years received GC therapy were selected from January 2008 to August 2009 in our hospital.Serum IGF-1,albumin,calcium,phosphorus,parathormone (PTH),25hydroxy vitamin D3,bone gla protein (BGP),degradation products of C-terminal telopeptides of type I collagen (CTx),24-hour urinary protein excretion and the ratio of urinary calcium to creatinine were measured at five time points-before GC therapy,4 weeks,8 weeks,12 weeks and 24 weeks after the use of GC.BMD was also detected at the same time points.Correlations among indexes were analyzed by Pearson.Results Thirty-six PNS patients fulfilled the follow-up and had complete clinical data,while other 3 patients lost.After GC treatment,serum calcium and 25hydroxy vitamin D3 were significantly increased in a time-dependent manner and were negatively correlated with 24-hour urinary protein excretion (r=-0.749,r=-0.831,P＜0.05,respectively).Serum BGP and IGF-1 were decreased after GC therapy in a time-dependent manner while CTx was significantly increased until week 12 after treatment (P＜0.05).Compared with pre-treatment,BMD of various parts had no significant difference at week 4; BMD of lumbar spine (L1-L4) was significantly decreased until week 8 (P＜0.05); BMD of femoral neck and femoral shaft was significantly decreased at week 24 (P＜0.05).IGF-1 was positively correlated with BGP and BMD (r=0.896,r=0.495,P＜0.05) and negatively correlated with serum CTx (r=-0.697,P＜0.05 ).Conclusions Serum IGF-1 level decreases in a time-dependent manner after GC treatment,which is correlated to BGP,CTx and BMD.Glucocorticoid treatment affects bone metabolism through IGF1 pathway possably in patients with PNS.IGF-1 may be used as a new bone biochemical marker of glucocoritcoid - induced osteoporosis.
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Objective To study the change of serum insulin-like growth factor 1(IGF-1)in primary nephrotic syndrome(PNS)patients and its relationship with bone metabolism, and to investigate the clinical significance of IGF-1 in the mechanism of bone metabolic disorders in PNS patients. Methods A total of 30 PNS patients with chronic kidney disease(CKD)stage 1 and 2 were randomly selected from 2008.1 to 2009.5 in our hospital. Serum IGF-1, albumin, calcium, phosphorus, PTH,25 hydroxy vitamin D3, bone gla protein(BGP), degradation products of C-terminal telopeptides of type I collagen(CTx), 24-hour urinary protein excretion, and ratio of urinary calcium to creatinine(UCa/Cr)were measured. Healthy control group of 61 persons were randomly selected from our medical examination center at the same time. Results Serum levels of calcium, 25 hydroxy vitamin D3 and BGP were significantly lower;CTx and UCa/Cr were significantly higher in PNS patients(P<0.05)as compared to healthy control group. BMD of PNS patients was lower but without significant difference compared with healthy control group[(1.078± 0.090)g/cm2 vs(1.090±0.062)g/cm2, P>0.05]. Serum level of IGF-1 was significantly lower in PNS patients and was positively correlated with BMD and BGP,and negatively correlated with 24-hour urinary protein excretion and CTx. Conclusions Bone metabolic disorder exists in PNS patients with the appearance of decreased bone formation and increased bone absorption.Serum level of IGF-1 has good correlations with bone biochemical markers.which may be used as a new bone biochemical marker of bone metabolism in kidney disease.
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Objective To study the association of bone metabolism with the degree of proteinuria in patients of chronic kidney diseases (CKD). Methods A total of 71 CKD patients diagnosed as primary glomerulopathy were randomly selected from 2008.1-2009.5 in the First People's Hospital of Shanghai. They were classified into three groups according to proteinuria:group A of 25 patients, proteinuria ＜1.0 g/24 h; group B of 16 patients, proteinuria 1.0-＜3.5 g/24 h;group C of 30 patients, proteinuria ≥ 3.5 g/24 h. Fifty-eight healthy persons were selected from our medical examination center at the same time as control. Serum albumin, calcium, phosphorus,PTH, 25 hydroxy vitamin D3, bone gla protein (BGP), degradation products of C-terminal telopeptides of type I collagen (CTx), 24-h urinary protein excretion, and the ratio of urinary calcium to creatinine (UCa/Cr) were measured. Bone mineral density (BMD) was detected by dualenergy X-ray absorptiometry. Results Compared with control group, serum levels of calcium [(2.23±0.08), (2.13±0.09), (2.04±0.06)vs (2.37±0.12)mmol/L], 25-(OH)D3 [(50.19±6.58), (47.78±6.69), (42.42±10.85) vs (56.34±8.34) nmol/L] were significantly lower and UCa/Cr was significantly higher in A, B, C groups respectively (all P＜0.05). In group B and C, BGP was lower [(18.69±7.35), (16.13±5.76) vs (22.88±6.21) μg/L] and CTx was higher [(413.59±114.93),(516.21±314.25) vs (304.53±234.15) ng/L] (all P＜0.05). BMD was lower only in group C [(1.028±0.090) vs (1.090±0.062) g/cm2, P＜0.05]. Pearson analysis showed that 24-h urinary protein excretion was negatively correlated with serum calcium and 25 hydroxy vitamin D3, and positively correlated with UCa/Cr. UCa/Cr was positively correlated with serum CTx and negatively correlated with BGP. 25-(OH) D3 was positively correlated with BGP and negatively correlated with CTx. Conclusion Bone metabolism disorder exists in CKD patients, presenting the decrease of bone formation and the increase of bone resorption, which is associated with as the degree of proteinuria, especially in patients with nephrotic syndrome.