【作者】 时博；

【导师】 李士星；

【作者基本信息】 中国医科大学 ， 影像医学与核医学， 2010， 硕士

【摘要】 前言肾积水是小儿泌尿外科较常见的疾病,同时也是在诊断、治疗及预后方面存在争议较多的疾病之一。小儿肾积水最常见的病因是肾盂输尿管连接部狭窄,简称盂管部狭窄(ureteropelvic junction stenosis, UPJS)。中、重度肾积水随病程进展大部分会出现肾盂、肾盏扩张的进行性加重,待扩张的肾盏压迫肾实质达到一定程度后会影响该侧肾脏功能,肾功能损害程度常涉及治疗方法的选择及疗效预测,因此在手术前后探寻一种可以间接反映患侧肾脏功能的有效方法一直是临床研究的热点。肾脏是血流供应丰富的器官,肾内血管阻力情况可以间接反映肾脏功能,有助于了解肾脏的病理状态。超声仪器的不断更新,使彩色多普勒血流显像对血流速度的检测越来越敏感。有研究表明肾内三级血管分支中只有段动脉血流显示率为100%,且肾段动脉血流参数改变可以代表整个肾脏的血流动力学变化。本研究旨在通过单侧肾积水患儿手术前后患侧肾内段动脉阻力指数(resistance index, RI)的变化间接评估肾脏功能恢复情况及手术后的疗效。材料与方法1、研究对象病例组：我院2007年7月—2009年12月共40例接受手术治疗的单侧肾积水患儿,于手术前均进行彩超检查,手术中证实本组患儿患侧肾积水的原因均为UPJS。其中男36例,女4例,年龄1月-14岁,平均年龄4.4岁。正常对照组：60例,其中男52例,女8例,年龄1月-14岁,其中各年龄组各20例。2、仪器及超声检查方法采用PHILIPS公司的IU22三维超声诊断仪进行超声检查,腹部凸阵探头,频率为2-5MHZ。检查时被检查者需适度充盈膀胱,取侧卧位,于肾脏冠状切面适当放大图像,分别取样于肾脏上、中、下部测肾实质厚度(renal parenchyma thickness,RPT),取平均值作为最终测值。显示肾内血管床的血流信号,脉冲多普勒分别取样于肾脏上、中、下部测段动脉RI、测量时取样容积与段动脉长轴平行,于出现3-5个连续相似的血流频谱时进行读数,取平均值作为最终测值。3、统计学方法所有结果均采用SPSS14.0软件进行统计学分析,计量资料用均数±标准差表示,作t检验,单因素方差分析,重复测量方差分析,Pearson相关性分析。(P>0.05为差别无统计学意义,P<0.05为差别有统计学意义,P<0.01为差别有显著统计学意义。)结果1、正常对照组小儿各年龄组间肾脏段动脉RI, RPT有显著差异(P<0.01),随着年龄的增长,段动脉RI逐渐降低,RPT逐渐增厚,两者呈显著负相关。2、不同年龄组间肾积水患儿患侧肾段动脉RI均高于正常对照组,且差别不明显,表明肾积水患儿的患侧肾段动脉RI高低与年龄无关。3、重度肾积水组患儿患侧肾段动脉RI值高于中度肾积水组,即随着肾积水程度的加重,患侧肾段动脉RI不断升高。4、中、重度肾积水术后2个月患侧肾段动脉RI值减低,与术前比较P<0.05,但是分别与术后6个月、1年RI值比较无明显差异,P>0.05,说明肾积水患儿术后2个月患侧肾段动脉RI值明显改善,此后RI值趋于稳定,提示术后2个月肾内血管阻力减低,血液供应增加,有利于肾功能恢复。5、中、重度肾积水患儿RPT术后6个月与术前及术后2个月比较,P<0.01,但与手术后1年比较,P>0.05,说明单侧肾积水患儿手术后6个月患侧RPT有显著的改善；术后中度肾积水组与重度肾积水组RPT比较,P<0.05,提示中度肾积水组患儿手术后RPT明显高于重度组,更接近正常,但重度组恢复速度快。6、肾积水患儿手术前患侧肾内段动脉RI与RPT呈负相关,P<0.05。结论1、本组患儿肾积水程度越重,患侧肾内段动脉RI值越高,因此RI值能够间接反映肾积水的严重程度。2、肾积水患儿接受手术治疗解除梗阻后,患侧肾内段动脉RI值较术前降低,RPT相应增厚,术后2个月时RI值己趋于稳定,手术前后患侧肾内段动脉RI值的变化能够间接提示肾功能的恢复,帮助临床评价手术疗效。更多还原

【Abstract】 IntroductionHydronephrosis is a more common disease in pediatric department of urinary surgery.Also simultaneously it is a disease in diagnosing, treatment and prognosis to exist to dispute. The most commonn cause of pediatric hydronephrosis is the ureteropelvic junction stenosis, to call for short UPJS. Along with pathogenesis’ going,most pelvis and kidney calices of moderate and severe hydronephrosis will appear progressive aggravate. When it begin to oppress the renal parenchyma, the dilated kidney calices influences the side kidney’s function.The extent of kidney impairment oftens involve how to choose treatment method and prognosis curative effect, therefore it is constantly a hot spot in clinical research to explore the effective method to examine the function of diseased kidneys before and after an operation.The kidney is one of the organs in enriching blood. The condition of vascular resistance inside the kidney can not only indirectly reflect the function of the kidney,but also contribute to comprehend pathological state of kidney. With ultrasound instrument’s continuously renewal, it make the color doppler flow imaging more and more sensitive in the examination of the blood speed.There is a research indicating that only segment artery blood may be displayed to 100%, and the change of kidney segment artery blood parameters can represent blood dynamics variety of the whole kidney.This research aims at indirectly evaluating kidney’s function and postoperative curative effect according to the variety of kidney segment artery RI value before or after an operation.Materials and methods1. Investigated objects The case group:40 total unilateral hydronephrosis children in our hospital who had operation treatment respectively during July,2007 and December,2009.A11 of those were proceeded the examination of color doppler ultrasound before the operation.And the cause of hydronephrosis were all ureteropelvic junction stenosis after the operation. This group included male 36, female 4, age one month-14 years old, the average age was 4.4 years old.The normal matched control:60 children, the male was 52, the female was 8, age one month-14 years old, each age group was 20 for each.2. Equipments and Ultrasonography MethodsUltrasonic examination used IU22 3D color ultrasonic scanner of PHILIPS company, with a 2-5 MHz convex array transducer.Diseased children made bladder fill moderately when examined, take a side to lie, enlarged the picture appropriately at the kidney coronal section, respectively sampling the upper pole, middle and anus perineum of the kidney to measure renal parenchyma thickness and take average value as the final measurement value.Display the blood signal of vascular bed inside the kidney, make the pulse doppler ultrasound respectively sampling the upper pole, middle and anus perineum of the kidney to measure segment artery resistance index and take average value as the finally measurement value.When examing,make sampling volume and segment artery major axis parallelism, and appearing 3-5 blood frequency spectrums of continuous likenesses,we began to carry on reading a number.3. Statistics methodsAll results adopt SPSS 14.0 software to carry on a statistics. Measurement data all use average±standard deviation to express, make a t test, one-factor analysis of variance, repeated-measure analysis of variance, pearson correlation analysis.(P>0.05 The difference is not statistically significant,P<0.05 the difference is statistically significant, P<0.01 the difference is notable statistically significant.)Results1. The children in each age group of normal matched controls, the change of kidney segment artery resistance index and renal parenchyma thickness both display significant difference (P<0.01).Along with the growth of age, the segment artery resistance index lowers gradually, renal parenchyma thickness increases thicker gradually, presenting to show significant negative correlation between them.2. The segment artery resistance index of diseased kidney in each age group is higher than that of the normal matched control group,but the difference isn’t significant among different age groups in case group,indicating that the segment artery resistance index of the diseased kidney has nothing to do with the age.3. The segment artery resistance index of diseased kidney in the severe hydronephrosis group is higher than that of midrange hydronephrosis group, namely along with hydronephrosis’aggravating, the segment artery resistance index of the kidney continuously goes up.4. Two months after operation,the segment artery resistance index of diseased kidney is lower than before both in midrange and severe hydronephrosis children,p<0.05,but the difference is not significant when comparing it with that six months、one year after the operation,p>0.05,indicating that the resistance index of diseased kidney of hydronephrosis children will ameliorate significantly within two months after operation.Then the value of resistance index goes stabile,indicating that the resistance of blood vessels decreases within two months after operation and the supplement of blood increases,making for the recovery of the function of diseased kidneys.5. Comparing the renal parenchyma thickness after six months with that before、after two months between midrange and severe hydronephrosis children,p<0.01,while comparing it with that after one year,p>0.05,indicating that the renal parenchyma thickness of diseased kidney ameliorates significantly within six months after the operation;comparing the renal parenchyma thickness of the midrange with that of the severe hydronephrosis,p>0.05,indicating that the renal parenchyma thickness of midrange hydronephrosis group is higher than that of severe group significantly,more approaching the normal value,but the speed of revovery of the severe group is more swift.6. The resistance index and renal parenchyma thickness show negative correlation between them,p<0.05. Conclusion1. In this study,more severer, more higher,the segment artery resistance index of diseased kidney is. We can according to this value indirectly reflect the degree of hydronephrosis.2. When the hydronephrosis children receive the operation to relieve the obstruction of diseased kidney,the segment resistance index of diseased kidney is lower than before,accordingly,the renal parenchyma thickness is thicker. The resistance index goes stable within two months when the operation finished.That indicates the change of the segment arteries resistance index of the diseased kidney can prompt the recovery of kidney function and help the clinical surgeons valuate the cure effect after operation.更多还原