泌尿病-肾内科临床病例分析课件

肾内科-临床病例解析Nephrology-Clinicalcasesuncovered简要病例患者，男性，74岁，因感觉嗜睡就诊。由外院经急诊转入肾科。入院前血生化检查：Na+145mmol/L，K+6.9mmol/L，尿素氮（BUN）29.3mmol/L，肌酐（Scr）686umol/L。既往有前列腺增生病史，无不适主诉。Patientisa74-year-oldmanwhoisreferredurgentlybyhisGPwhosawhimthismorninganddidsomebloodtests.TheresultsofthesetestshavebeencalledthroughtotheGPsurgeryandshow:Na145mmol/L,K6.9mmol/L,Urea29.3mmol/L,Creatinine686μmol/LTheGPlettertellsyouthathehashadbenignprostatichypertrophypreviouslybutisotherwiseusuallyveryfitanduncomplaining.Heattendedthesurgerybecausehe’dbeenfeelinglethargicandundertheweatherforthepastweek.Giventhebloodresults,heiscalledbyhisGPandaskedtourgentlyattendtheMedicalAdmissionsUnit.Hearrivesat5pm,andhisinitialobservationsareunremarkable.接诊该患者后首先需要考虑的临床问题是什么？

高钾血症有没有误差？标本溶血！抽血时止血带压迫时间过长标本处理延迟导致试管内溶血显著的白细胞增多或血小板增多：在这种疾病状态下检测的是血浆（抗凝血的液体成分）而非血清（凝固血的液体成分）钾浓度血液标本正在从输入含钾血液的肢体静脉内抽血假性高钾血症的原因需要行哪些紧急处理以减少高钾血症致心律失常的风险？迅速建立静脉通路立即给患者行心电监护以及时发现心律失常重新急查血钾，立即抽静脉血在动脉血气分析以上检查急查心电图，观察有否高钾心电图表现如果患者的心电图为高钾血症的相关改变，应该不等急查血钾结果就给予紧急降血钾治疗高钾血症的心电图表现T波高尖（TentingofTwaves）PR期延长（ProlongedP-Rinterval）QRS波增宽（WideningofQRScomplex）正弦波（‘Sine’wave）这份心电图结果提供什么信息？QRS波增宽及早期正弦波根据心电图结果需做哪些处理？保护心肌：10%葡萄糖酸钙降血钾：胰岛素-葡萄糖注射液刺激细胞膜的钠钾泵将钾离子转入细胞内体内的总钾没有减少，只是再分布！钾从细胞内转移至血液MovementofK+outofcells1.酸中毒：H+转入细胞内，K+移出

Acidosis:H+transportedintocellsattheexpenseofK+efflux2.细胞死亡，细胞内钾释放如：横纹肌溶解、溶瘤综合征CelldeathcausesreleaseofK+,e.g.rhabdomyolysis,tumourlysissyndrome肾脏排钾减少（远曲小管）

FailureofK+excretionbykidney(distalconvolutedtubules）3.肾衰竭Renalfailure4.醛固酮不足Aldosteronedeficiency5.保钾利尿剂的使用，如螺内酯Potassium-sparingdiuretics6.ACEI、ARB钾摄入过多ExcessintakeofK+fromgut哪些原因能导致高钾血症？高钾血症的处理10%葡萄糖酸钙10ml静脉注射10mL10%calciumgluconate(cardioprotectant)intravenously50%葡萄糖50ml+胰岛素10u

50mL50%dextrose+10uActrapid如果建立静脉通道困难，可予以沙丁胺醇喷雾剂吸入ConsidersalbutamolnebulisersifIVaccessdifficult对于慢性高钾血症建议予以低钾饮食，考虑予以降钾树脂以减少肠道钾的吸收Inchronichyperkalaemia,giveadviceonlow–potassiumdietandconsidercalciumresoniumtopreventGIabsorption停止所有与高钾血症相关的药物，如ACEI、ARB，保钾利尿剂，如应用螺内酯或阿米洛利Stopanydrugsassociatedwithhyperkalaemia,e.g.ACEI,ARB,postassium-sparingdiureticssuchasspironolactoneoramiloride该患者的静脉血气分析示血钾7.7mmol/L，经过静脉注射葡萄糖酸钙及高糖胰岛素后，复查患者的血钾5.9mmol/L，心电图的高钾改变消失，至此，该患者的高钾血症的紧急处理已完成，现在，我们可以详细询问该患者的病史。

Venousbloodgassampleshowedapotassiumof7.7mmol/L.Followingthecalciumgluconateandinsulin-dextrose,arepeatmeasurementshowsthathisK+isnow5.9mmol/L.HisECGchangeshaveresolved.Nowthatyouhavetackledtheimmediateurgentissueofhispotassium,youareabletogetsomemorehistoryfromthepatient.详细的病史询问需要着重了解

哪些内容？

肾功能不全是急性还是慢性？Isthisacuteorchronicrenalfailure?肾功能不全的原因？肾前性（低血压/低血容量），肾性还是肾后性（梗阻性）因素？Whydoeshehaverenalfailure?Apre-renal(hypotension/Hypovolaemia),renalorpost-renal(obstruction)cause?患者是否有提示肾损害的任何症状？Doeshehaveanysymptomsasaresultofhisrenalimpairment?患者的化验检查显示明显的肾损害。病史、体格检查及检查主要针对以下三个方面：Bloodsshowsignificantrenalimpairment.Thehistory,examinationandinvestigationsshouldaimtoanswerthreemainquestions.本例患者是急性还是慢性肾衰，或者慢性肾衰合并急性肾衰？

Isthisacuteorchronicrenalfailure,orperhaps

acute-on-chronicrenalfailure?病史：有无肾脏病史、导致慢性肾脏病的其它疾病（糖尿病、高血压、前列腺增生）

Whetherthepatienthaspastmedicalhistoryofrenaldiseaseorofdiseaseswhichcommonlycausechronickidneydisease(e.g.diabetesmellitus,hypertension,prostaticdisease)近期的肾功能检查

Previousrenalfunction泌尿系统B超

Renalultrasound肾衰的原因是什么？肾后性因素？尿路梗阻占5%-10%，老年患者高达30%。患者有无尿频、夜尿增多、排尿等待及尿流变细等。

Post-renalcause？Obstructionistheunderlyingcauseinaround5–10%ofpatientswithARF.Inelderlymales,upto30%ofcasesofARFmaybeduetourethralobstruction.suchasfrequency,nocturia,terminaldribbling,hesitancyorpoorstream.肾性因素？患者是否有咽喉炎或者易导致感染后肾小球肾炎的感染？患者是否有提示全身性炎症或自身免疫性的疾病？既往有心肌梗死、脑血管疾病及外周血管疾病，提示肾动脉粥样硬化可能？

Renalcause?IsthereahistoryofrecentpharyngitisorinfectionwhichmightprecipitateapostinfectiousGN?Doeshehaveanysymptomssuggestiveofasystemicinflammatory/autoimmunedisease?ApastmedicalhistoryofMI/CVA/PVDincreasestheprobabilityofatheroscleroticrenovasculardisease.肾前性因素？近期是否有呕吐、腹泻等导致血容量减少、低血压等相关疾病

Pre-renalcause?Hashehadanyrecentillnesseswhichmightcausevolumedepletionorhypotension,e.g.vomiting,diarrhoea?家族史(Familyhistory)：遗传性疾病(inheritedcauses)导致CKD，例如APKD、Alport综合征、FSGS，多见于年轻人药物史(Drughistory)：引起CKD（NSAID、CsA、锂制剂）；急性间质性肾炎（PPI、抗生素）吸烟史(Smokinghistory)：患者是否吸烟（与动脉粥样硬化有关）；患者是否酗酒（慢性肝脏疾病、肝衰竭）CauseofAKI患者是否已出现肾衰竭并发症的相关症状？尿毒症症状：恶心，食欲下降、尿毒症脑病（嗜睡、癫痫）

Symptomaticuraemia:nausea,lossofappetite,oruraemicencephalopathy(confusion,drowsiness,fitting).酸中毒：过度通气

Acidosis:PatientsmayhyperventilateinanattempttoblowoffCO2andcompensatefortheirmetabolicacidosis.容量负荷：踝部水肿，肺水肿所致的呼吸困难

Volumeoverload:ankleswelling,pulmonaryoedemacausingshortnessofbreath.贫血(Anemia)高磷血症：继发于甲状旁腺功能亢进，可引起难以忍受的皮肤瘙痒

Hyperphosphataemia:secondarytohyperparathyroidismcancauseverytroublesomeitchiness哪些临床征象提示该患者需要进行急诊透析？肺水肿：可表现低氧血症、呼吸频率加快、双肺可闻及吸气相湿罗音Pulmonaryoedema:asevidencedbyhypoxia,elevatedrespiratoryrateandbibasalcoarseinspiratorycracklesinthechest.严重代谢性酸中毒（Severeacidosis）有症状的尿毒症Symptomaticuraemia:evidencedbypericarditisorencephalopathy药物难以控制的高钾血症Hyperkalaemiarefractorytomedicaltreatmentshouldalsobetreatedwithdialysis.

体检：无血容量不足体征，脉搏90次/分，血压160/90mmHg。心脏听诊无心包摩檫音，但双肺底可闻及吸气末湿罗音。腹部检查，脐下2cm似可触及患者的膀胱。直肠指检可触及患者前列腺明显增大，尚光滑。患者双踝部轻度水肿。

Onexamination,MrJonesisclinicallyeuvolaemicwithapulseof90bpmandaBPof160/90mmHg.Onauscultationofhischest,thereisnopericardialrubbuthedoeshavebibasalcracklesposteriorly.Onexaminationofhisabdomen,hisbladderispalpableat2cmbelowtheumbilicus.Arectalexaminationrevealsasmooth,significantlyenlargedprostate.Hehasmildperipheraloedemainhisankles.Hisadmissionbloodtestsshow:Na145mmol/L,K7.7mmol/L,Urea34mmol/L,Creatinine729μmol/L,CRP8mg/L,Hb12.7g/dL,WBC6.5×109/L,Platelets438×109/L.患者行急诊超声检查，该结果有什么临床意义？超声检查显示患者一侧肾脏大小正常，肾脏积水，排尿后膀胱高度充盈；另一侧肾盂积水，双侧输尿管扩张。提示：下尿路梗阻。Theultrasoundscanshowsakidneyofnormalsize(10-12cm)withsomepreservationofcorticomedullarydifferentiationbutgrosshydronephrosisandafullbladderpostattemptedmicturition.TheotherkidneyisalsohydronephroticonUS,andbothuretersaredilated.Thisissuggestiveofdistalobstruction(i.e.attheleveloftheurethraorbeyond).该患者下一步如何处理？

超声检查提示，AKI可能的原因为尿道流出道梗阻。因此，需置入导尿管。考虑前列腺增生病史，可能需要泌尿外科干预；如不能置入导尿管，则需要由耻骨上经皮膀胱造瘘。需复查肾功能、电解质以确保治疗后高钾血症被解决。HehasanultrasoundscanwhichsuggeststhatthemostlikelycauseofARFisurethraloutflowobstruction.Thereforeaurinarycathetershouldbeinserted.Givenhishistoryofprostaticdisease,thismaynotbeeasyandmayrequireurologyinput.Ifacathetercannotbeplacedperurethrallyduetothesizeofthe置入导尿管解除梗阻后最主要的临床问题是什么？尿管解除梗阻后患者通常出现多尿，归因于暂时性肾小管功能不全Followingtreatmentofurinaryobstructionbyinsertionofacatheter,patientsfrequentlybecomep