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患者女性,61岁,住院号232578。因慢性肾功能不全13年,维持性血透12年,全身骨痛伴皮肤骚痒5年,头痛头晕渐加重半年,视物不清伴复视一周入院。查体贫血貌。双侧瞳孔等大对光反射正常存在,左眼外展受限。颈软。心脏向左下扩大,心前区可闻及Ⅲ级收缩期杂音。右下肺可闻及少量细湿啰音轮薷≈住K闹×Α⒓≌帕φ#旆?射对称存在,双侧双划征(+),余病理反射(-),脑膜刺激征(一)。查BUN13.9mmol/L,CR372umol/L,Ca2.57mmol/L,P1.96mmol/L,AKP768u/L,全段甲状腺激素(iPTH)370pg/ml。MRI示1.左额叶缺血改变.脑梗死。2.颅板显著增厚。诊断1.慢性肾功能不全尿毒症。2.肾性骨病、颅板异常增厚伴颅神经损伤。入院后在充分透析基础上予以磷结合剂,活性维生素D3及活血脑保护治疗。2周后患者AKP降至429u/L,左眼余视未能纠正,骨痛头痛好转出院。图1、2、3示颅脑轴位SETlWI,颅脑轴位FSET2WI,矢状位SETlWI,颅板松质普遍增厚,以颅盖骨明显,最厚处达1.8cm讨论肾脏是参与机体骨代谢的重要器官之一。肾性骨病指肾功能衰竭后,高磷及由于缺少la羟化酶。维生素D不能有效活化,影响肠道钙吸收及骨代谢而导致的骨病。肾性骨病可发生在肾功能不全的任何阶段,尿素症患者100%有肾性骨病存在,是尿毒症的重要并发症之一。肾性骨病通常分为三类高转化型,低转化型,混合型。本案患者骨痛,皮肤骚痒,高磷,AKP及PTH显著增高,符合高转化型肾性骨病。高转化型肾性骨病常见的病理改变为1.纤维性骨炎表现为骨小梁排列不规则,骨组织失去板层状结构,纤维组织增生致骨小梁及骨髓纤维化。2.骨硬化表现为网状骨骨小梁厚度和数量增加,骨密度增加,最常见于椎骨。但如本例由于肾性骨病导致骨面积大量增加,颅骨异常增厚伴颅神经损伤的未见报道。患者由于颅骨异常增厚,可能影响了头痛结构导致头痛不适,也可由于颅底骨增生,挤压颅神经导致左眼斜视、复视,视力下降。逐见肾功能不全肾性骨病的多样性及危害性。应在肾功能不全早期重视患者骨代谢异常,积极纠正高磷、低钙,酌情补充活性维生素D3,纠正继发性甲状旁腺功能亢进,必要时需手术治疗。最大限度防治肾性骨病的发生、发展,对提高慢性肾衰患者长期生存质量意义重大。
Patient female, 61 years old, hospital number 232578. 13 years due to chronic renal insufficiency, hemodialysis for 12 years, systemic bone pain with itchy skin for 5 years, headache and dizziness gradually increased six months, depending on the material unclear with diplopia week hospitalization. Physical examination anemia appearance. Bilateral pupil and other large light reflex normal existence of left eye abduction limited. Neck soft. Enlarge the heart to the left, precordial area can be heard and Ⅲ systolic murmur. Lower right lung can be heard and a small amount of fine wet rales 薷 住 K 闹 闹 闹 闹 闹 闹 ⒓≌ × ⒓≌ ⒓≌ 旆 旆 injection symmetry exists, bilateral double levy (+), more than the pathological reflexes (-), , Meningeal irritation sign (a). Check BUN13.9mmol / L, CR372umol / L, Ca2.57mmol / L, P1.96mmol / L, AKP768u / L, whole thyroid hormone (iPTH) 370pg / ml. MRI showed a change in left frontal lobe ischemia cerebral infarction. 2 cranial significant thickening. Diagnosis 1. Chronic renal insufficiency uremia. 2. Renal bone disease, abnormal cranial skull with cranial nerve injury. After admission based on adequate dialysis to phosphate binding agent, active vitamin D3 and blood-brain protection treatment. 2 weeks after the patient AKP dropped to 429u / L, left eye Ivory failed to correct, bone pain headache improved discharge. Figures 1, 2, and 3 show SETlWI, FSET2WI and SETlWI in sagittal plane. Thylakoid cranial mass is generally thickened, with a significant calvaria and a thickest 1.8cm. Discussion The kidneys are involved in the body bone One of the important organs of metabolism. Renal osteodystrophy refers to renal failure, high phosphorus and lack of la hydroxylase. Vitamin D can not be effectively activated, affecting the intestinal absorption of calcium and bone metabolism caused by bone disease. Renal osteodystrophy can occur at any stage of renal insufficiency, and 100% of patients with uremia have renal osteodystrophy and is one of the major complication of uremia. Renal osteodystrophy is usually divided into three types of high conversion, low conversion, mixed type. Patients with bone pain, itchy skin, high phosphorus, AKP and PTH was significantly higher, in line with high-conversion type of renal osteodystrophy. High-conversion type of renal osteopathy common pathological changes of 1. Fibrous osteitis showed trabecular irregular arrangement, loss of lamellar bone tissue structure, fibrous tissue hyperplasia caused trabecular bone and fibrosis. 2. Osteosclerosis showed reticular bone trabecular thickness and the number increased, increased bone mineral density, the most common in the vertebra. However, as in this case due to renal bone disease caused by a large increase in bone area, abnormal thickening of the skull with cranial nerve injury has not been reported. Patients with abnormal thickening of the skull may affect the headache caused by discomfort, headache, but also due to skull base hyperplasia, cranial nerve crush caused by left eye strabismus, diplopia, decreased vision. By see the diversity of renal insufficiency and renal disease and the dangers. Should pay attention to early renal dysfunction in patients with abnormal bone metabolism, and actively correct high phosphorus, low calcium, vitamin D3 supplementation, as appropriate, to correct secondary hyperparathyroidism, if necessary, required surgical treatment. To prevent and treat the occurrence and development of renal osteodystrophy to a great extent is of great significance to improve the long-term quality of life of patients with chronic renal failure.