【作者】 何晓峰；

【导师】 刘晓城；

【作者基本信息】 华中科技大学 ， 肾病内科， 2007， 博士

【摘要】 第一部分:胡桃夹综合征合并肾小球肾炎的临床病理分析目的:探讨血尿和/或蛋白尿患者中胡桃夹综合征与肾小球肾炎的相互关系。方法:对39例胡桃夹综合征合并肾小球肾炎患者的临床病理资料进行分析,包括血尿者17例,蛋白尿者4例,血尿合并蛋白尿者18例。所有观察对象均行肾静脉彩超检查。检查运动前后尿常规、尿沉渣红细胞计数和形态,24小时尿蛋白和白蛋白定量,运动后尿补体C3、溶菌酶、视黄醇结合蛋白定量、蛋白电泳等。其中30例患者行肾穿刺活检。结果:39例患者均经彩超检查确诊为胡桃夹综合征,运动前部分患者尿常规正常或为非肾小球性血尿、微量蛋白尿,运动后所有患者均出现不同程度的血尿和/或蛋白尿,大部分患者较运动前加重。行肾穿刺活检的30例患者结果具有多样性,与尿检结果无关联性。全部观察对象均经临床、实验室检查或肾活检确诊为胡桃夹综合征合并肾小球肾炎。结论:胡桃夹综合征可与肾小球肾炎并存。对临床表现为血尿和/或蛋白尿,已确诊为胡桃夹综合征的患者,还应注意是否合并隐匿性或早期、缓解期肾小球疾病,必要时应行肾穿刺活检,以免贻误病情。第二部分:大鼠左肾静脉狭窄致左肾淤血性损伤模型的研究目的:观察大鼠左肾静脉不同程度狭窄所致左肾病变,为实验研究左肾静脉受压状态下肾组织淤血性损伤提供合适的动物模型。方法:采用左肾静脉不全结扎的方法建立大鼠左肾静脉狭窄模型。将大鼠分为4组,假手术组和左肾静脉狭窄1.0mm模型组、0.7mm模型组、0.5mm模型组。术后7周处死动物。尿标本行24小时尿蛋白定量,位相镜检,尿补体C3、溶菌酶、视黄醇结合蛋白及圆盘电泳等检查。肾组织行病理学检查。肾皮质匀浆检测丙二醛含量和超氧化物歧化酶活性。结果:各模型组大鼠尿蛋白排泄量均较假手术组明显增加,增加幅度随狭窄程度的增大而增大。尿位相镜检血尿均为非肾小球性。尿圆盘电泳以低分子蛋白为主要区带,白蛋白所占比例随狭窄程度的增大而增加。病理学检查见0.7mm和0.5mm模型组肾小球系膜区增生,小管、间质炎性细胞浸润和纤维化形成,0.5mm模型组病变程度较重。免疫荧光检查未见特异性免疫复合物沉积。各模型组大鼠左肾皮质MDA含量均显著增高,SOD活性均显著降低,变化幅度随狭窄程度的增大而增大。结论:大鼠左肾静脉狭窄程度为0.7mm时,各项观察指标与胡桃夹综合征患者的临床实际情况最接近,而1.0mm和0.5mm时相对偏轻和偏重,0.7mm模型组可以作为大鼠左肾静脉狭窄致左肾淤血实验研究的合适模型。第三部分:手术治疗改善左肾静脉狭窄大鼠肾组织淤血性损伤的作用目的:探讨手术治疗改善左肾静脉狭窄大鼠肾组织纤维化损伤和氧化应激状况的效果,为临床手术治疗左肾静脉受压综合征提供实验依据。方法:将大鼠分为4组,假手术组、模型7周组、模型12周组和手术治疗组。采用左肾静脉不全结扎的方法建立大鼠左肾静脉狭窄模型,治疗组第7周末解除狭窄,第12周末处死动物。尿标本行24小时尿蛋白定量。肾组织行病理学检查。肾皮质制备匀浆检测丙二醛含量和超氧化物歧化酶活性。RT-PCR法和免疫组化法分别检测肾皮质TGF-β1、PAI-1mRNA和蛋白的表达。结果:模型7周组和模型12周组大鼠尿蛋白排泄量均较假手术组增加,左肾皮质MDA含量显著增高,SOD活性显著降低,左肾皮质TGF-β1、PAI-1mRNA和蛋白的表达增加,出现病理学损伤。其中模型12周组病变程度更重。手术治疗可降低MDA含量,提高SOD的活性,减少TGF-β1与PAI-1mRNA和蛋白的表达,减轻组织病理学损伤。结论:左肾静脉狭窄大鼠肾组织氧自由基生成增多,抗氧化能力下降。促纤维化因子TGF-β1与PAI-1表达水平上调。出现组织纤维化。病变随狭窄时间的延长而加重,手术治疗可改善氧化应激状况,减轻组织纤维化损伤。第四部分:丹参对左肾静脉狭窄大鼠肾脏淤血性损伤的保护作用目的:探讨丹参治疗左肾静脉狭窄大鼠肾脏过氧化损伤和纤维化的效果,为临床药物治疗胡桃夹综合征提供实验依据。方法:将大鼠分为4组,假手术组、模型组、丹参治疗组和手术治疗组。采用左肾静脉不全结扎的方法建立大鼠左肾静脉狭窄模型,术后第7周末开始对丹参治疗组予以丹参灌胃治疗,手术治疗组同时解除狭窄。第12周末处死动物,尿标本行24小时尿蛋白定量。肾组织行病理学检查。肾皮质制备匀浆检测丙二醛含量和超氧化物歧化酶活性。RT-PCR法和免疫组化法分别检测肾皮质TGF-β1、PAI-1mRNA和蛋白的表达。结果:模型组大鼠尿蛋白排泄量较假手术组增加,左肾皮质MDA含量显著增高,SOD活性显著降低,TGF-β1、PAI-1mRNA和蛋白的表达增加,出现病理学损伤。丹参治疗组和手术治疗组MDA含量降低,SOD活性增高,TGF-β1、PAI-1mRNA和蛋白的表达减少,组织病理学损伤减轻。其中手术治疗组改善程度更显著。结论:左肾静脉狭窄大鼠肾脏氧自由基生成增多,抗氧化能力下降,促纤维化因子TGF-β1与PAI-1表达水平上调。出现组织纤维化。丹参可通过清除氧自由基、提高抗氧化能力、减少组织纤维化来保护肾脏。虽然其疗效不如手术治疗显著,但结合胡桃夹综合征病变的实际情况考虑,也不失为一种较好的选择。更多还原

【Abstract】 Section one Clinical and pathological analysis of glomerular nephritis complicated by patients with nutcracker syndromeObjective:To investigate mutual relationship between nutcracker syndrome and glomerular disease of patients with manifestation of hematuria and/or proteinuria. Methods:To analysis clinical and pathological data of 39 patients with nutcracker syndrome complicating glomerular nephritis,including 17 hematuria patients,4 proteinuria patients and 18 hematuria complicating proteinuria patients.All patients accepted ultrasonic examination by Doppler’s method. Urine routine,red blood cell count and phase observation of urinary sediment were examined ante- and post-exercise. 24 hours urinary protein and albumin quantitation were detected,urinary complement 3,lysozyme,retinol binding protein,protein electrophoresis were tested postexercise. Among them,30 patients accepted renal needle biopsy.Results:All patients were diagnosised as nutcracker syndrome. Some patients urinary routine examination were normal or had homogenicity hematuria ,microalbuminuria ante-exercise. All had hematuria and/or proteinuria of different degree postexercise,most of them aggravated after exercise. Renal biopsy of 30 patients manifestated multiformity and had no relevance with urinary examination results. All patients were made a definite diagnosis through clinical,laboratory examination and renal biopsy to be glomerular nephritis complicated by nutcracker syndrome. Conclusions:Nut cracker phenomenon could coexist with glomerular disease. Nutcracker syndrome patients with manifestation of hematuria and/or priteinuria should be noted whether coexisted with delitescence glomerular nephritis or not. in order to avoid affecting patient’s condition adversely,renal needle biopsy should be carried out when needed.Section Two Rats model established for studying congestive damage of renal tissue caused by left renal vein constrictionObjective:To observe the left renal lesions in rats caused by left renal vein constriction of several degree,to provide suitable animal model for studying congestive damage of renal tissue caused by left renal vein compression.Methods: The rat model of left renal vein constriction was established by left renal vein partial deligation operation.SD rats were randomly devided into 4 groups,sham-operation group,left renal vein stenosis 1.0mm model group,0.7mm model group,and 0.5mm model group. All animals were killed at the end of the 7th week. Urine routine,red blood cell phase of urinary sediment,24 hours urinary protein quantitation,urinary complement 3 quantitation,lysozyme quantitation,retinol binding protein quantitation , protein electrophoresis were were all examined. Nephridial tissue was detected pathological changes. Renal cortex was homogenated to detect content of malonaldehyde (MDA) and activity of superoxide dismutase (SOD).Results:Urinary protein excretion increased in 3 model group,and its amplitude increased along with the degree of stegnosis. Urinary red blood cell phase were all homogenicity. Urinary protein electrophoresis showed that the major zone was low molecule protein,proportion of albumin increased along with the degree of stegnosis. Model groups showed nephridial tissue pathological damage of glomerular mesangial region hyperplasia and tubule,interstitium cell infiltration and fibrosis,more stegnosis,more severe.Left renal cortex MDA content elevated,SOD activity reduced significantly in 3 model groups compared to those in sham-operation group,and its amplitude increased along with the degree of stegnosis.Conclusions:When stegnosis at 0.7mm,all observation datas of left renal vein constriction rats appeared to approach the clinical status of nutcracker syndrome patients mostly,while stegnosis at 1.0mm and 0.5mm appeared slight and severe relatively. It seemed that 0.7mm model group would be the most suitable rat model for studying congestive damage of renal tissue caused by left renal vein constriction.Section Three Effect of operation on congestive damage of renal tissue in left renal vein constriction ratsObjective:To explore the curative effect of renal tissue fibrosis and peroxidative condition with operation on left renal vein constriction rats,thus to provide the experimental basis for clinical treating left renal vein entrapment syndrome by operation.Methods:SD rats were randomly devided into 4 groups,sham-operation group,7 weeks model group,12 weeks model group,and operation treating group.The rat model of left renal vein constriction was established by left renal vein partial deligation operation.Rats in treating group were disengage from deligation by operation at the end of the 7th week. After 5 weeks of the second operation,all animals were killed. Urine was collected for 24 hours urinary protein quantitation. Nephridial tissue was detected pathological changes. Renal cortex was homogenated to detect content of malonaldehyde (MDA) and activity of superoxide dismutase (SOD).The expression level of PAI-1,TGF-β1 mRNA and protein was detected by RT-PCR and immunohistochemical method.Results:Urinary protein excretion increased,left renal cortex MDA content elevated,SOD activity reduced significantly and the expression of PAI-1 and TGF-β1 mRNA increased in two model groups compared to those in sham-operation group. Model groups showed nephridial tissue pathological damage.Between two groups,changes in 12 weeks model group were more predominance than 7 week model group. Treating by operation could improve SOD activity,decrease MDA content and decrease the expression of PAI-1 and TGF-β1 mRNA,lessen pathological damage.Conclusions:Left renal vein constriction rats appeared pathological damage and tissue fibrosis. generation of oxygen free radical increased,and ability of anti oxidisity decreased,promoting fibrosis factors as TGF-β1 and PAI-1 expression level appeared up-regulation. Renal lesions aggravated when stegnosis longer. Operation could lighten pathological damage and tissue fibrosis,and improve peroxidative condition.Section Four Effect of salvia miltiorrhiza on congestive damage of renal tissue in left renal vein constriction ratsObjective:To explore the curative effect of renal peroxidative damage and fibrosis with Salvia Miltiorrhiza on left renal vein constriction rats to provide the experimental basis for the clinical therapy with drug of nutcracker syndrome.Methods:SD rats were randomly devided into 4 groups,sham-operation group,model group,salvia miltiorrhiza treating group and operation treating group.The rat model of left renal vein constriction was established by left renal vein partial deligation operation.After 7 weeks,rats in salvia miltiorrhiza treating group begain to be intervened by salvia miltiorrhiza. Rats in treating group were disengage from deligation by operation at the same time. All animals were killed at the end of the 12th week. Urine was collected for 24 hours urinary protein quantitation. Nephridial tissue was detected pathological changes. Renal cortex was homogenated to detect content of malonaldehyde (MDA) and activity of superoxide dismutase (SOD) . The expression level of PAI-1,TGF-β1 mRNA and protein was detected by RT-PCR and immunohistochemical method.Results:Urinary protein excretion increased,left renal cortex MDA content elevated,SOD activity reduced significantly and the expression of PAI-1 and TGF-β1 mRNA increased in model group compared to those in sham-operation group. Model groups showed nephridial tissue pathological damage. Both treating with salvia miltiorrhiza and by operation could improve SOD activity,decrease MDA content and decrease the expression of PAI-1 and TGF-β1 mRNA , lessen pathological damage.Between two groups,curative effects of operation treating group were more predominance than salvia miltiorrhiza treating group.Conclusions:Generation of oxygen free radical in left renal vein constriction rats increased,ability of anti oxidisity decreased,promoting fibrosis factors as TGF-β1 and PAI-1 expression level up-regulated and renal tissue fibrosis increased.Salvia miltiorrhiza has protective effect on left renal vein constriction rats,through blocking the oxygen free radical generation,elevating the ability of anti-oxidisity and decreasing tissue fibrosis. Although the curative effects of salvia miltiorrhiza treating group were not as fine as operation treating group,treating with salvia miltiorrhiza was still a suitable choice.更多还原