Volume 97  ·  Issue 02  ·  2017

In 1954, American surgeon Murry successfully completed the first kidney transplant in the world, ushering in a new era of organ transplantation. In 1960, Chinese Academician Wu Jieping took the lead in implementing the first human kidney transplantation in China. In the course of more than 60 years of development, many breakthroughs have been made in kidney transplantation at home and abroad, but there are still many fields to be explored in depth by kidney transplantation colleagues. This article summarizes the recent research hotspots of renal transplantation.

To study the expression of membrane HLA-G (mHLA-G) and the receptor immunoglobulin-like transcript 2(ILT2) on lymphocyte and find their association with rejection and cytomegalovirus (CMV) infection after renal transplantation.

A total of 88 cases of renal transplant recipients for the first time from February 2014 to February 2016 were studied in this work. Recipients can be divided into rejection group (n=12) and stable renal function group (n=41) according to whether rejection occurred. Recipients only infected CMV not developed rejection were included in the CMV positive group (n=24). CMV negative group (n=11) including CMV negative recipients once infected CMV.The expression of mHLA-G and ILT2 on lymphocytes were detected by flow cytometry, and the differences among different groups were analyzed.

The data showed that after renal transplantation, T and B lymphocytes mHLA-G expression rate was the lowest in the rejection group (0.42%±0.35%, 0.88%±0.47%), having significant difference with renal function stable group and CMV positive group (all P<0.01). In CMV positive group the expression of mHLA-G on T and B lymphocytes was the highest (1.31%±0.69%, 2.01%±0.91%), having significant difference with rejection group (P<0.001). The expression of mHLA-G on B cell was statistically significantly different between CMV positive group and CMV negative group (P<0.05). There was no significant difference in ILT2 expression on B cell among the four groups (P>0.05). The expression rate of ILT2 on T cells was higher in the CMV positive group (36.91%±14.91%), having significant difference with the other three groups (P<0.01).

Low expression of mHLA-G on T and B lymphocytes may predict rejection after renal transplantation. High expression of mHLA-G and ILT2 on lymphocytes is prone to CMV infection after renal transplantation .

To summarize experiences of rescuing arterial hemorrhage and pseudoaneurysm caused by infection in donation after cardiac death (DCD) kidney transplantation.

A total of 198 consecutive DCD kidney transplantations between 1 June 2013 and 30 July 2016 in the Third Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed. The means of rescuing infective arterial hemorrhage and pseudoaneurysm after operation and their therapeutic effects were summarized.

A total of 5 infective arterial hemorrhage, 2 infective pseudoaneurysm with hemorrhage, and 1 infective pseudoaneurysm developed in 198 DCD kidney transplantation recipients with total morbidity of 4.0%, and the morbidity of fungal infection accounted for 2.5%. One case received open surgical therapy. Two cases were treated with endovascular interventional therapy. Five cases received combined treatments of open surgery and endovascular intervention. Selective antibiotics were used based on drug sensitivity test postoperation. The wound was drained, and the drainage was repeatedly cultured to monitor the pathogen till the results turned to negative. Five patients received graft nephrectomy and were restored to hemodialysis. Two patients were successfully rescued with stable graft function. One case died. The mortality of patient was 1/8. Graft loss rate was 5/8. Both patients with stable graft function were mainly treated by intervention.

Infective arterial hemorrhage and pseudoaneurysm were primary risk factors causing patient/graft death postoperation in DCD kidney transplantation. Endovascular therapy can be used as an effective rescuing method under the circumstance of infection. The measure allows opportunity of successfully rescuing kidney graft and deserves recommendation.

To evaluate pre-and early post-transplantation risk factors for acute rejection(AR) in kidney recipients.

This subgroup analysis of a multi-center registry study was conducted on living-donor kidney transplant recipients in China with 10 years of follow-up. This study analyzed 1 255 recipients including 921 males(73.4%) and with a mean age of (33±10)years. Data from patients were first analyzed with univariate analysis and then multivariate analysis was used for finding out the potential risk factors of AR.

A total of 106(8.4%) patients were suspected with AR after kidney transplantation, while 1 149 patients were considered as non-AR. Multivariable analysis demonstrated a significant influence of recipient age and cold ischemia time(CIT) on the occurrence of AR(OR: 0.956, 95% CI: 0.923-0.990; OR: 1.006, 95% CI: 1.002-1.011, respectively). The frequency of severe infection was significantly higher in the AR group than non-AR group(38.7% vs 10.8%; P<0.000 1). The occurrence of new-onset diabetes mellitus and tumors was similar in the two groups.

Recipient age and CIT are risk factors for AR after living-donor kidney transplantation. Reducing CIT and intensive management of younger recipient could benefit kidney transplant patients.

To investigate the relationship between early-stage renal acute rejection(AR) and the level of Fractalkine in urine, explore the diagnostic and noninvasive monitoring value in early stage after transplantation by measurement of urine Fractalkine.

Urine samples were examined from renal transplant patients between January 2006 and October 2009. A total of 155 patients were enrolled, including 49 with biopsy-proved AR, 58 patients with stable renal function and no abnormal histological findings, 10 patients with subclinical rejection in protocol biopsy, 9 patients with biopsy-proven acute tubular necrosis and 29 patients with biopsy-proven chronic allograft nephropathy. Additionally, urine samples were also collected from 40 healthy controls. Fractalkine was measured in urine samples using a commercial human Fractalkine enzyme-linked immunosorbent assay (ELISA) kit. Immunohistochemistry for Fractalkine expression was performed on biopsies from renal transplant patients with AR and non-AR.

Forty-nine patients with AR excreted urinary Fractalkine at a significantly higher level than levels in patients with stable renal function and healthy controls[(429.1±56.1)vs (94.6±8.4), (84.5±8.9)ng/mmol creatine, both P<0.001]. Patients with AR excreted urinary Fractalkine at a significantly higher level than levels in patients with acute tubular necrosis and chronic allograft nephropathy[(429.1±56.1)vs(133.0±9.8), (183.0±18.9)ng/mmol creatine, bothP<0.001]. Receiver operating characteristic(ROC)curve was constructed to determine the discriminatory power of Fractalkine levels for diagnosis of AR. The area under ROC curve was 0.920(95%CI: 0.875-0.969, P<0.001), which showed that Fractalkine was a suitable marker for the diagnosis of AR. At a cut-off point of 157.5 ng/mmol creatinine, the sensitivity was 83.7% and the specificity was 84.5% (P<0.001). The dynamic level of urinary Fractalkine in AR patients within 3 weeks after transplantation fluctuated above 300 ng/mmol creatine, which is remarkably higher than patients with stable renal function (below 200 ng/mmol creatinine).

As a noninvasive monitoring method, Fractalkine in urine may be a new approach for detection of AR as well as useful to predict response to antirejection therapy. It has good sensitivity and specificity. Besides, measurement of Fractalkine in urine is a simple, inexpensive method for the routine clinical monitoring after kidney transplantation.

To compare the safety and effectiveness between antithymocyte globulin (ATG) and basiliximab in deceased donor renal transplantation within matched groups where paired recipients received graft donations from same donors.

A total of 124 cases of deceased donor kidney transplantation performed at Wuhan Tongji Hospital from January 2013 to November 2015 were retrospectively analyzed. Based upon their induction therapies, the recipients receiving graft donations from same donors were divided into two groups, namely ATG group (n=62) and basiliximab group (n=62). Clinical data were gathered and comparisons were made between the two groups.

Delayed graft function (DGF) implicated less patients in the ATG group (11, 17.7%) compared with basiliximab group (21, 33.9%) (P=0.040). Duration of DGF was also significantly shorter in the ATG group than in the basiliximab group[(14.92±6.23) vs(20.26±7.89)days, P=0.048]. The rates of DGF were 5/18 in the ATG group and 10/15 in the basiliximab group (P=0.025), when subgrouping the patients with elevated risk factors (donor age >50 or a history of hypertension or graft cold ischemia time >24 h) for DGF. The acute rejection rates did not differ between the two groups significantly; comparable one-year graft and patient survival were observed between the ATG and basiliximab groups(all P>0.05).

The duration of DGF and DGF rate after deceased donor renal transplantation is reduced by ATG, when compared with basiliximab. Moreover, in recipients with elevated risk factors for DGF, ATG diminishes DGF incidence significantly.

To research the regulation effects of Krüppel like zinc finger transcription factor 2 (KLF2) on γ-glutamylcysteine synthetase (γ-GCS) in airway epithelial cells of chronic obstructive pulmonary disease (COPD).

(1) Human specimen experiment: lung tissue of pulmonary lobectomy patients with lung cancer with or without COPD was collected from Department of Thoracic Surgery of Hunan Cancer Hospital from December 2008 to December 2009. The patients were divided into COPD group and control group without COPD. The levels of KLF2, γ-GCS mRNA and protein expression in lung tissues were measured by immunohistochemistry and in situ hybridization (ISH). Then, the correlation between KLF2 and γ-GCS mRNA and protein expression levels were analyzed, as well as the correlation between KLF2 or γ-GCS protein and smoking index, percentage of forced expiratory volume in one second to predicted value (FEV ₁%), percentage of forced expiratory volume in one second to forced vital capacity (FVC/FEV₁). (2) Animal experiment: the primary bronchial epithelial cells of rats were extracted by enzyme digestion. After 6 hours of incubation with 10% tobacco smoke extract (TSE), cellular glutathione (GSH) was measured by enzyme linked immunosorbent assay (ELISA) method. The cells were transfected by specific inhibitor of KLF2 through the liposom, which inhibited the protein expression of KLF2. Then, the cells were divided into KB group (blank control group without any treatment), KB+ TSE group (treated with TSE), NC group (control group transfected with miRNA), NC+ TSE group (treated with miRNA and TSE), 92a group (transfected with KLF2 inhibitor), 92a+ TSE group (treated with KLF2 inhibitor transfection and TSE) based in the treatment. After that, the changes of KLF2 and γ-GCS mRNA and protein expression in the cells of each group were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blot method.

(1) Human specimen experiment: The expressions of KLF2 mRNA, protein and γ-GCS mRNA, protein in the lung tissue of COPD patients were strong positive and higher than those in control group (0.32±0.04 vs 0.19±0.03, 0.35±0.05 vs 0.22±0.03; 0.28±0.03 vs 0.16±0.03, 0.31±0.05 vs 0.21±0.03; all P<0.01). Linear correlation analysis showed that KLF2 mRNA and protein were positively correlated with γ-GCS mRNA and protein (r=0.705, 0.722; both P<0.01). The KLF2 and γ-GCS protein were positively correlated with smoking index, FEV₁% and FEV₁/FVC (r=0.552, 0.728, 0.670, and r=0.631, 0.727, 0.657; all P<0.01). (2) Animal experiment: The level of GSH in KB+ TSE group was significantly higher than that in KB group[(28.05±2.04) vs (7.27±0.33) nmol/mg,P<0.01]. The KLF2 mRNA, protein and γ-GCS mRNA, protein in KB+ TSE group (1.715±0.026, 1.842±0.028 and 2.117±0.067, 1.879±0.065) were higher than those in KB group (1.130±0.017, 1.177±0.033 and 1.378±0.053, 1.177±0.042; allP<0.05), and those in 92a group (0.472±0.028, 0.634±0.025 and 0.582±0.025, 0.554±0.021) were significantly lower than those in KB group, NC group (1.047±0.056, 1.092±0.045 and 1.303±0.037, 1.252±0.037), and those in TSE+ 92a group (0.262±0.017, 0.288±0.017 and 0.337±0.022, 0.321±0.022) were significantly lower than those in KB+ TSE group, 92a group and NC+ TSE group (1.576±0.036, 1.646±0.066 and 1.948±0.093, 1.843±0.078) (allP<0.05).

KLF2 exerts antioxidative effect by regulating the expression of γ-GCS in the bronchial epithelial cells of chronic obstructive pulmonary disease.

To investigate the effectiveness and safety of the thoracic paravertebral block(TPVB) in the post postanesthesia care unit(PACU) for patients suffered moderate to severe pain after Video-Assisted Thoracoscopic Surgery(VATS).

78 atients who complained moderate to severe pain on arrival to PACU after VATS were randomly assigned into two groups: thoracic paravertebral block treatment group(P group) and sufentanil treatment group(S group). The VAS Pain score at rest and movement, heart rate, blood pressure, and pulse oximetry 1 hour after treatment and duration of patients staying in the PACU after treatment were recorded. VAS Pain score at rest and on coughing at 8, 24 and 48 hours after treatment were closely monitored. Sufentanil comsumption, patient satisfaction and related complications were also recorded.

A successful TPVB was achieved in all patients in P group without puncture related complications. The VAS pain scores at rest and on coughing 1 hour, 8 hours, 24 hours and 48 hours after treatment in P group were significantly lower than the patients in S group. Systolic blood pressure 1 hour after treatment in P group was also lower than the patients in S group(118mmHg±14mmHg vs 128 mmHg±14 mmHg, P=0.021). SPO2 1 hour after treatment in P group was much higher than the patients in S group(95%±3% vs 92%±4%, P=0.015). The duration of patients staying in the PACU after treatment in both groups were similar. Sufentanil comsumption, rate of vomiting and nausea was significantly less and satisfaction was better in P group than thoses in S group.

In the postanesthesia care unit, TPVB could provide effective and safe analgesia therapy for patients suffered from moderate to severe pain after VATS.

To evaluate the application value of carbon lymph node tracing technique by preoperative endoscopic subserosal injection in laparoscopic radical gastrectomy.

From June 2013 to February 2015, seventy eight patients with gastric cancer were enrolled and randomly divided into trial group and control group. Subserosal injection of carbon nanoparticles around the tumor was performed by preoperative endoscopic subserosal injection one day before the operation in trial group, while the patients routinely underwent laparoscopic gastrectomy in control group. Results of harvested lymph nodes, postoperative complications were compared between the two groups. Carbon nanoparticle-related side effect was also evaluated.

The average number of harvested lymph node in trial group was significantly higher than that in control group (35.5±8.5 vs 29.5±6.5, P<0.05). The rate of overall black-dyed harvested lymph node was 74.7% (1 035/1 386) in trial group, the black-dyed lymph node rate in D1 lymph node was 80.1%, which was significantly higher than that in D2 lymph node (69.8%, χ²=19.38, P<0.01). When comparing the lymph node with and without black-dyed in trial group, the rate of metastasis lymph node was significantly higher in lymph node with black-dyed (17.3% vs 4.0%, χ²=38.67, P<0.01). There was no significant difference in postoperative complications rate between two group (trial group 10.2%; control group 12.8%, χ²=0.00, P>0.05), and no carbon nanoparticle-related side effect was observed.

Given a higher harvested lymph node number and a similar rate of complications, preoperative endoscopic subserosal injection of carbon nanoparticles was safe and feasible.

To discuss the clinical safety and efficacyof endovascular aneurysm repair (EVAR) for aortic pseudoaneurysms.

From October 2008 to October 2015, 13 patients (11male, 2female, with a mean age of 55.6) with aortic pseudoaneurysms treated by EVAR wereenrolled. All the 13 casesunderwentcomputed tomographic arteriography (CTA). The etiology diagnosis withdescendingaortic pseudoaneurysms, infected abdominal aortic pseudoaneurysms, abdominal aortic pseudoaneurysmsin Behcet's syndrome, and uncertain reasons were 4, 4, 4, and 1 case, respectively.

In this group, 14 stentswere planted.All the patients hadno accidents and complications in perioperative period.Twelve patients were successfully followed up, 1 patient died of recurrent abdominal aortic pseudoaneurysmsin Behcet's syndrome, and 1 patient with recurrent infected abdominal aortic pseudoaneurysm wascured by pseudoaneurysm resection and extra-anatomic bypass grafting.

EVAR is a safe and effective option for aortic pseudoaneurysms.

To investigate the effect of exendin-4, a glucagon-like peptide-1 (GLP-1) receptor agonist, on reducing lipid deposition and improving insulin resistance in skeletal muscle and the underlying mechanisms in high-fat diet (HFD)-induced obese mice.

Twelve male C57BL/6J mice were challenged with HFD for 12 weeks to induce obesity and then randomly divided into two groups: exendin-4 group (intraperitoneal injection of 24 nmol·kg^-1·d^-1 exendin-4 for 4 weeks) and HFD group (intraperitoneal injection of normal saline for 4 weeks), with 6 mice in each group. Additional 6 mice were also selected as control group. Body weight, fasting blood glucose were recorded. Serum triglyceride (TG), total cholesterol (TC), insulin and skeletal muscle triglyceride levels were measured by enzyme-linked immunosobent assay (ELISA). Oil red O staining was used for morphologic changes of frozen sections from skeletal muscle. The protein levels of lipid metabolic pathway mediated by AMP-activated protein kinase (AMPK) and insulin signailing pathway were determined by Western blot.

Compared with mice in HFD group, exendin-4 significantly decreased body weight[(37.68±1.80) vs (46.03±5.00) g, P<0.025], fasting blood glucose[(5.40±0.33) vs (7.65±1.92) mmol/L,P<0.025], serum TG[(37.78±7.14) vs (80.76±34.22) mg/dl,P<0.025], TC[(180.13±18.75) vs (217.57±22.52) mg/dl,P<0.025], insulin[(0.58±0.01) vs (1.67±1.23) ng/ml,P<0.025]and skeletal muscle TG levels[(9.84±1.08) vs (19.35±7.44) mg/g,P<0.025]of obese mice. Oil red O staining revealed that exendin-4 alleviated the accumulation of larger lipid droplets in skeletal muscle. The protein expressions of lipolysis and lipid oxidation mediated by AMPK and insulin signailing pathway were up-regulated, and the protein expressions of lipogenesis mediated by AMPK were down-regulated after intervention of exendin-4.

Exendin-4 reduces lipid deposition and insulin resistance in skeletal muscle of HFD-induced obese mice via activating AMPK and up-regulating insulin signailing pathway.

To investigate the role and mechanism of hydrogen sulfide (H₂S) in rats with chronic obstructive pulmonary disease (COPD) related pulmonary vascular remodeling.

Twenty four healthy male Sprague-Dawley rats were randomly divided into 4 groups: control group, cigarette smoke (CS) group, CS+ Sodium hydrosulfide (NaHS) group and CS+ DL-propargylglycine (PPG) group. Rats in control group were fed normally and breathed clear air, and for the rest groups, passive cigarette smoke inhalation method were adopted to establish COPD model. After 8 weeks, the rats in corresponding groups were treated by NaHS or PPG. After 16 weeks, the markers of pulmonary vascular remodeling in all groups were measured. Proliferation marker proliferative cell nuclear antigen (PCNA) and oxidative stress marker 3-neurotrophin (3-NT) in all groups were measured by immunohistochemistry (IHC).

Compared with control group, the airway resistance was increased (0.859±0.283 vs 0.578±0.088, P<0.05) and the pathological scores was much higher in CS group, which suggested that the COPD model was successful. The degree of small resistance pulmonary artery medial wall thickness and full vascular muscularization of CS group were much higher (0.54±0.20 vs 0.37±0.12, 0.39±0.08; 0.61±0.16 vs 0.20±0.12, 0.34±0.13, allP<0.01)than control group and CS+ NaHS group, there was no significant difference between CS+ PPG group and CS group. In accordance with the results of morphometric analysis, the proliferation marker PCNA was more in CS group when compared with control group and CS+ NaHS group (0.27±0.08 vs 0.12±0.06, 0.14±0.06, bothP<0.05), there was no significant difference between CS+ PPG group and CS group. Furthermore, the IHC also showed that 3-NT significantly increased in CS group compared with control group and CS+ NaHS group (0.26±0.08 vs 0.18±0.04, 0.19±0.06, bothP<0.01), there was no significant difference between CS+ PPG group and CS group as well. In addition, the small resistance pulmonary artery medial wall thickness had strong correlation with the expression level of oxidative stress marker 3-NT (r=0.906, P<0.001).

H₂S significantly attenuates cigarette smoke induced COPD related pulmonary vascular remodeling, which could be related to its ability to decrease oxidative stress.

A 35-year-old male was admitted to the Department of Endocrinology of Peking Union Medical College Hospital on April 19, 2016 due to roundness of his face, weight gain for 9 years, and aggravation with fatigue for 1 year. Beginning in 2007, the patient's face became rounded and red, his weight increased from 60 kg to 70 kg within 1 year, and his abdominal circumference increased, which was not paid attention to. In 2008, I developed left abdominal colic, and the B-ultrasound in an outside hospital showed "ureteral calculi". After the stone was discharged in the urine, the abdominal pain was relieved and there was no recurrence. In 2009, abdominal skin lesions occurred, and the local hospital considered "tinea corporis". Oral terbinafine 0.25 g/time, once/d, for a total of 14 days, tinea corporis subsided, but it still appears repeatedly. So far, it has been treated with terbinafol for a total of 4 times (the same as above). In 2010, I accidentally discovered purple lines on the skin on the inner side of both thighs. Loss of libido occurred in 2012. In March 2015, I developed easy drowsiness, obvious fatigue, and no soft paralysis. My weight increased from 70 kg to 80 kg within half a year. I went to a local hospital and my blood pressure was checked at 180/140 mmHg (1 mmHg =0.133 kPa). I was diagnosed with "hypertension". I was given nifedipine controlled-release tablets 30 mg/time, once/d. After 2 months of treatment, my blood pressure was re-checked at 150/110 mmHg. In January 2016, the liver and kidney function and electrolyte were examined in the local hospital, and the circadian rhythm of blood cortisol and adrenocorticotropic hormone (ACTH) disappeared (Table 1)。 Overnight low-dose dexamethasone inhibition test (LDDST): not inhibited (blood cortisol 1 523 nmol/L after administration); Classical high-dose dexemide inhibition test (HDDST): can be inhibited (blood cortisol 25 nmol/L after administration). CT scan of the adrenal gland showed that the bilateral medial and lateral adrenal branches were thickened, and the left medial branch was prominent, with a transverse diameter of about 6 mm. Dynamic enhanced MRI of the pituitary gland showed delayed enhancement of the right pituitary gland. Considering "Cushing's disease, secondary hypertension", lacidipine 4 mg/dose, once/d, metoprolol 50 mg/dose, once/d, and blood pressure was controlled at 135/85 mmHg. He visited our hospital in March 2016. The outpatient blood cortisol (8:00 am) was 1116 nmol/L (normal reference value: 110-615 nmol/L), ACTH (8:00 am) was 17.6 pmol/L (normal reference value: 0-10.1 pmol/L), and 24 h urine free cortisol (24 h UFC) was 3 176 nmol (normal reference value: 34-285.7 nmol). Due to the recurrence of tinea corporis in the abdomen, terbinafine was taken orally from March 25 to April 10, 2016 at the same dose as before, and tinea corporis improved after the medication. Deny history of taking antidepressants, long-term glucocorticoids, cottonseed oil, licorice and other drugs. Personal History: Pet doctor, prolonged X-ray exposure for 10 years, no alcohol consumption. Past history, marriage and childbirth history, and family history are not special.

A 55-year-old female was admitted to the hospital in August 2015 due to "intermittent chest and back pain for 1 month 6 years after aortic dissection". In 2009, the ascending aorta and right hemiarch were replaced in the emergency department due to DeBakey type Ⅰ aortic dissection, and the coronary artery and aortic valve were not involved. The postoperative recovery was good without obvious symptoms, and intermittent chest and back pain began 1 month ago. With a history of hypertension for more than 10 years, blood pressure control can be achieved; Renal insufficiency for 3 years, creatinine up to 190 μ mol/L. Systolic blowing-like murmur can be heard in auscultation of the neck and chest, and pulsatile mass can be palpable in abdominal examination without tenderness. Preoperative CT angiography showed that after aortic dissection, ascending aorta and right hemiarch replacement, two intimal ruptures were seen at the distal anastomosis of the artificial blood vessel in the arch, and the contrast agent entered the false lumen through the ruptures. The maximum diameter of thoracic aortic dissection aneurysm was about 65 mm. The celiac trunk artery, superior mesenteric artery and both renal arteries were all supplied with blood from the true lumen. There were multiple ruptures in the abdominal aorta segment, and the dissection involved bilateral common iliac arteries (Figure 1)。 The patient has a history of surgery in the past, so the anatomy of the arch is complicated, and it is difficult to simply observe the axial position of CT and imagine the spatial relationship of three-dimensional reconstruction images. In order to further understand the anatomy of the lesion, the CT data was processed by software before operation, and the interference information was removed, so that the size and location of the rupture could be clearly seen (Figure 2)。 The patient had no other rupture in the thoracic aorta segment. The symptoms of thoracic and back pain this time were considered to be mainly related to the rupture of the arch, and the dissecting aneurysm was at risk of rupture. After careful measurement and preoperative discussion, it was decided to use ventricular septal occluder combined with coil embolization to repair the rupture, and the abdominal aorta segment was not treated temporarily. Because the rupture location is close to the unnamed artery and the left common carotid artery, in order to determine whether the occluder will affect the blood flow of the branches after placement, a transparent lesion model was made by 3D printing technology before operation, and simulated operation was performed in vitro, which showed that the occluder did not affect the blood flow of the branches (Figure 3)。

A 60-year-old male was admitted with "sudden right upper abdominal pain for 1 d". With a history of hypertension for more than 10 years, oral nifedipine can control blood pressure. Previous history of cerebral infarction without sequelae. Abdominal ultrasonography after admission revealed a solid tumor between the right liver and kidney, approx. 14.6 cm ×12.0 cm ×9.3 cm. Emergency blood test showed hemoglobin (Hb) 53 g/L and hematocrit 16%. Emergency red blood cell transfusion showed that Hb rose to 103 g/L. Partial thromboplastin time was 44.2 s, fibrinogen was 5.36 g/L, and plasma D-dimer was 2.33 μ g/ml. Emergency abdominal CT showed: retroperitoneal adrenal mass rupture and bleeding. Because of the unstable circulation, the patient underwent right subclavian vein puncture and catheterization in the intensive care unit. The puncture was successful, the depth of catheterization was 16 cm, the catheter was sealed with heparin water, and the chest X-ray film was performed. Chest orthographic radiograph showed ectopic central venous catheter (Figure 1), but the infusion was unobstructed, so the central venous catheter was not removed. The patient's vital signs were stable after blood transfusion and fluid rehydration treatment, and temporary conservative treatment was recommended after multi-department consultation. After 2 days of conservative treatment, circulation and Hb were still unstable, and B-ultrasound showed signs of enlargement of retroperitoneal hematoma, and then ultrasound-guided abdominal puncture did not coagulate, so exploratory laparotomy was planned. The patient's blood pressure after entrance was 200/103 mmHg (1 mmHg =0.133 kPa), pulse oxygen saturation (SpO₂) was 88%. The catheter was removed because there was no blood in the right subclavian vein catheter. The patient was given intravenous injections of midazolam 2 mg, etomidate 6 mg, fentanyl 0.15 mg and rocuronium 50 mg for induction of anesthesia and mechanical ventilation after intubation. After induction, right internal jugular vein puncture was performed, the puncture was smooth, and the blood returned smoothly. Subsequently, the guide wire was inserted, but the guide wire was blocked during placement. After the guide wire was removed, the blood drawn was smooth, but the guide wire placement was still not smooth. Subsequently, 7.5 MHz linear ultrasound examination was used, and it was found that the internal jugular vein (about 10 cm long) had uneven echoes, and the lumen of the probe compression could not be completely closed (Figure 2)。 The right internal jugular vein puncture was abandoned, and another upper extremity vein was opened. Intraoperative continuous infusion of propofol, remifentanil and cis-atracurium maintained anesthesia. The operation went smoothly, with about 500 ml of intraoperative bleeding, 400 ml of plasma, 4 U of red blood cells and 100 ml of autologous blood transfusion, and returned to the general surgical intensive care unit (ICU) with tracheal intubation after operation. Postoperative jugular ultrasound diagnosis: right internal jugular vein thrombosis (partial type). Results of the postoperative pathological diagnosis of the patient: malignant neoplasm of the adrenal gland.

The homeostasis of iron in the body is mainly achieved by the coordination of systemic iron homeostasis and intracellular iron homeostasis^[1,2]However, systematic iron homeostasis is closely related to the regulatory axis of hepcidin membrane iron transporter. Iron is an essential mineral in the body, which is involved in a wide range of cellular biological processes such as hemoglobin synthesis, DNA replication and enzyme function regulation^[3]Once the regulation of this axis is impaired, it will inevitably lead to iron metabolism disorders, thus affecting the occurrence and development of many diseases^[4]。 Of course, it can also cause bone mass loss and even cause osteoporosis^[5]。 It can be seen that the occurrence of osteoporosis is inextricably related to the regulation of the function of this axis.

Arterial stenting has been widely used in the treatment of atherosclerotic diseases. With the accumulation of therapeutic experience, the current mainstream stents expose advanced thrombus and cause restenosis problems also attract people's attention, so fully bioabsorbable stents (BRS) have entered the sight of therapists again. Compared with the conventional non-absorbable stent, it has good biocompatibility and bioabsorptivity. After the BRS is implanted in the stenosis site, it can provide effective support in the early stage to ensure the patency of blood vessels. After the stent is absorbed in the later stage, its decomposition products can be absorbed, utilized or discharged by the body, and there is no residual foreign body in the target blood vessel, which can restore the vasomotor function to the greatest extent and leave room for secondary intervention^[1,2,3,4]。