1、肾内科肾内科-临床病例解析临床病例解析Nephrology-Clinical cases uncoveredv 患者，男性，患者，男性，74岁，因感觉嗜睡就诊。由外院经急诊转入岁，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：肾科。入院前血生化检查：Na+145mmol/L，K+6.9mmol/L，尿素氮（尿素氮（BUN）29.3mmol/L，肌酐（，肌酐（Scr）686umol/L。既往。既往有前列腺增生病史，无不适主诉。有前列腺增生病史，无不适主诉。v Patient is a 74-year-old man who is referred urgently by his GP
2、who saw him this morning and did some blood tests.The results of these tests have been called through to the GP surgery and show:Na 145 mmol/L,K 6.9 mmol/L,Urea 29.3 mmol/L,Creatinine 686 mol/L The GP letter tells you that he has had benign prostatic hypertrophy previously but is otherwise usually v
3、ery fit and uncomplaining.He attended the surgery because hed been feeling lethargic and under the weather for the past week.Given the blood results,he is called by his GP and asked to urgently attend the Medical Admissions Unit.He arrives at 5pm,and his initial observations are unremarkable.接诊该患者后首
4、先需要考虑接诊该患者后首先需要考虑的临床问题是什么？的临床问题是什么？高钾血症高钾血症v有没有误差？有没有误差？标本溶血！标本溶血！抽血时止血带压迫时间过长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（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假性高钾血症的原因需要行哪些紧急处理以减少
5、高需要行哪些紧急处理以减少高钾血症致心律失常的风险？钾血症致心律失常的风险？v 迅速建立静脉通路迅速建立静脉通路v 立即给患者行心电监护以及时发现心律失常立即给患者行心电监护以及时发现心律失常v 重新急查血钾，立即抽静脉血在动脉血气分析以上检查重新急查血钾，立即抽静脉血在动脉血气分析以上检查v 急查心电图，观察有否高钾心电图表现急查心电图，观察有否高钾心电图表现v 如果患者的心电图为高钾血症的相关改变，应该不等急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高钾血症的心电图表现T T波高尖（波高尖（Tenting
6、 of T waves）PRPR期延长（期延长（Prolonged P-R interval）QRSQRS波增宽（波增宽（Widening of QRS complex）正弦波（正弦波（Sine wave）这份心电图结果提供什么信息？这份心电图结果提供什么信息？QRSQRS波增宽及早期正弦波波增宽及早期正弦波根据心电图结果需做哪些处理？根据心电图结果需做哪些处理？v保护心肌：保护心肌：10%10%葡萄糖酸钙葡萄糖酸钙v降血钾：胰岛素降血钾：胰岛素-葡萄糖注射液葡萄糖注射液刺激细胞膜的钠钾泵将钾离子转入细刺激细胞膜的钠钾泵将钾离子转入细 胞内胞内体内的总钾没有减少，只是再分布！体内的总钾没有减少
7、，只是再分布！钾从细胞内转移至血液钾从细胞内转移至血液 Movement of K+out of cells1.1.酸中毒：酸中毒：H H+转入细胞内，转入细胞内，K K+移出移出 Acidosis:H+transported into cells at the expense of K+efflux2.2.细胞死亡，细胞内钾释放如：横纹肌溶解、溶瘤综合征细胞死亡，细胞内钾释放如：横纹肌溶解、溶瘤综合征Cell death causes release of K+,e.g.rhabdomyolysis,tumour lysis syndrome肾脏排钾减少（远曲小管）肾脏排钾减少（远曲小管）F
8、ailure of K+excretion by kidney(distal convoluted tubules）3.3.肾衰竭肾衰竭 Renal failure4.4.醛固酮不足醛固酮不足 Aldosterone deficiency5.5.保钾利尿剂的使用，如螺内酯保钾利尿剂的使用，如螺内酯 Potassium-sparing diuretics6.6.ACEIACEI、ARBARB钾摄入过多钾摄入过多 Excess intake of K+from gut哪些原因能导致高钾血症？哪些原因能导致高钾血症？高钾血症的处理高钾血症的处理v 1010%葡萄糖酸钙葡萄糖酸钙10ml10ml静脉注
9、射静脉注射 10 mL 10%calcium gluconate(cardioprotectant)intravenouslyv 5050%葡萄糖葡萄糖50ml+50ml+胰岛素胰岛素10u10u 50 mL 50%dextrose+10u Actrapidv 如果建立静脉通道困难，可予以沙丁胺醇喷雾剂吸入如果建立静脉通道困难，可予以沙丁胺醇喷雾剂吸入Consider salbutamol nebulisers if IV access difficultv 对于慢性高钾血症建议予以低钾饮食，考虑予以降钾树脂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以减少肠道钾的吸收
10、In chronic hyperkalaemia,give advice on lowpotassium diet and consider calcium resonium to prevent GI absorptionv 停止所有与高钾血症相关的药物，如停止所有与高钾血症相关的药物，如ACEIACEI、ARBARB，保钾利，保钾利尿剂，如应用螺内酯或阿米洛利尿剂，如应用螺内酯或阿米洛利Stop any drugs associated with hyperkalaemia,e.g.ACEI,ARB,postassium-sparing diuretics such as spironol
11、actone or amiloride 该患者的静脉血气分析示血钾该患者的静脉血气分析示血钾7.7mmol/L，经过静脉注射，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。理已完成，现在，我们可以详细询问该患者的病史。Venous blood gas sample showed a potassium of 7.7 mmol/L.Following the calcium gluc
12、onate and insulin-dextrose,a repeat measurement shows that his K+is now 5.9 mmol/L.His ECG changes have resolved.Now that you have tackled the immediate urgent issue of his potassium,you are able to get some more history from the patient.详细的病史询问需要着重了解详细的病史询问需要着重了解哪些内容？哪些内容？v 肾功能不全是急性还是慢性？肾功能不全是急性还是慢
13、性？Is this acute or chronic renal failure?v 肾功能不全的原因？肾前性（低血压肾功能不全的原因？肾前性（低血压/低血容量），肾性还低血容量），肾性还是肾后性（梗阻性）因素？是肾后性（梗阻性）因素？Why does he have renal failure?A pre-renal(hypotension/Hypovolaemia),renal or post-renal(obstruction)cause?v 患者是否有提示肾损害的任何症状？患者是否有提示肾损害的任何症状？Does he have any symptoms as a result of
14、his renal impairment?患者的化验检查显示明显的肾损害。病史、体格患者的化验检查显示明显的肾损害。病史、体格 检查及检查主要检查及检查主要针对以下三个方面：针对以下三个方面：Bloods show signifi cant renal impairment.The history,examination and investigations should aim to answer three main questions.本例患者是急性还是慢性肾衰，或者慢性肾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？衰合并急性肾衰？Is this acute or chroni
15、c renal failure,or perhapsacute-on-chronic renal failure?v 病史：有无肾脏病史、导致慢性肾脏病的其它疾病（糖尿病史：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）病、高血压、前列腺增生）Whether the patient has past medical history of renal disease or of diseases which commonly cause chronic kidney disease(e.g.diabetes mellitus,hypertension,prostatic d
16、isease)v 近期的肾功能检查近期的肾功能检查 Previous renal functionv 泌尿系统泌尿系统B B超超 Renal ultrasound肾衰的原因是什么？肾衰的原因是什么？v 肾后性因素？尿路梗阻占肾后性因素？尿路梗阻占5%-10%，老年患者高达，老年患者高达30%。患者。患者有无尿频、夜尿增多、排尿等待及尿流变细等。有无尿频、夜尿增多、排尿等待及尿流变细等。Post-renal cause？Obstruction is the underlying cause in around 5 10%of patients with ARF.In elderly males,
17、up to 30%of cases of ARF may be due to urethral obstruction.such as frequency,nocturia,terminal dribbling,hesitancy or poor stream.v 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？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？粥样硬化
18、可能？Renal cause?Is there a history of recent pharyngitis or infection which might precipitate a postinfectious GN?Does he have any symptoms suggestive of a systemic inflammatory/autoimmune disease?A past medical history of MI/CVA/PVD increases the probability of atherosclerotic renovascular disease.v
19、 肾前性因素？近期是否有呕吐、腹泻等导致血容量减少肾前性因素？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、低血压等相关疾病 Pre-renal cause?Has he had any recent illnesses which might cause volume depletion or hypotension,e.g.vomiting,diarrhoea?v 家族史家族史(Family history)：遗传性疾病：遗传性疾病(inherited causes)导致导致CKD，例如，例如APKD、Alport综合征、综合征、FSGS，多见于年轻人，多见于年轻人v 药物史药物
20、史(Drug history)：引起：引起CKD（NSAID、CsA、锂制剂）、锂制剂）；急性间质性肾炎（；急性间质性肾炎（PPI、抗生素）、抗生素）v 吸烟史吸烟史(Smoking history)：患者是否吸烟（与动脉粥样硬化：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）有关）；患者是否酗酒（慢性肝脏疾病、肝衰竭）Cause of AKI患者是否已出现肾衰竭并发症的相关症状？患者是否已出现肾衰竭并发症的相关症状？v 尿毒症症状：恶心，食欲下降、尿毒症脑病（嗜睡、癫痫）尿毒症症状：恶心，食欲下降、尿毒症脑病（嗜睡、癫痫）Symptomatic uraemia:na
21、usea,loss of appetite,or uraemic encephalopathy(confusion,drowsiness,fitting).v 酸中毒：过度通气酸中毒：过度通气 Acidosis:Patients may hyperventilate in an attempt to blow off CO2 and compensate for their metabolic acidosis.v 容量负荷：踝部水肿，肺水肿所致的呼吸困难容量负荷：踝部水肿，肺水肿所致的呼吸困难 Volume overload:ankle swelling,pulmonary oedema c
22、ausing shortness of breath.v 贫血贫血 (Anemia)v 高磷血症：继发于甲状旁腺功能亢进，可引起难以忍受的皮高磷血症：继发于甲状旁腺功能亢进，可引起难以忍受的皮肤瘙痒肤瘙痒 Hyperphosphataemia:secondary to hyperparathyroidism can cause very troublesome itchiness哪些临床征象提示该患者需要进行急诊透析？哪些临床征象提示该患者需要进行急诊透析？v 肺水肿：可表现低氧血症、呼吸频率加快、双肺可闻及肺水肿：可表现低氧血症、呼吸频率加快、双肺可闻及吸气相湿罗音吸气相湿罗音 Pulmon
23、ary oedema:as evidenced by hypoxia,elevated respiratory rate and bibasal coarse inspiratory crackles in the chest.v 严重代谢性酸中毒（严重代谢性酸中毒（Severe acidosis）v 有症状的尿毒症有症状的尿毒症 Symptomatic uraemia:evidenced by pericarditis or encephalopathyv 药物难以控制的高钾血症药物难以控制的高钾血症 Hyperkalaemia refractory to medical treatment
24、 should also be treated with dialysis.体检：体检：无血容量不足体征，脉搏无血容量不足体征，脉搏90次次/分，血压分，血压160/90 mmHg。心脏听诊无心包摩檫音，但双肺底可闻及吸气末。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，脐下湿罗音。腹部检查，脐下2cm似可触及患者的膀胱。直肠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。度水肿。On examination,Mr Jones is clinically euvolaemic with a pul
25、se of 90 bpm and a BP of 160/90 mmHg.On auscultation of his chest,there is no pericardial rub but he does have bibasal crackles posteriorly.On examination of his abdomen,his bladder is palpable at 2cm below the umbilicus.A rectal examination reveals a smooth,significantly enlarged prostate.He has mi
26、ld peripheral oedema in his ankles.His admission blood tests show:Na 145 mmol/L,K 7.7 mmol/L,Urea 34 mmol/L,Creatinine 729mol/L,CRP 8 mg/L,Hb 12.7 g/dL,WBC 6.5 109/L,Platelets 438 109/L.患者行急诊超声检查，该结果有什么临床意义？患者行急诊超声检查，该结果有什么临床意义？超声检查显示患者超声检查显示患者一侧一侧肾脏大小正常，肾脏积水，排尿后膀胱高肾脏大小正常，肾脏积水，排尿后膀胱高度充盈；另一侧肾盂积水，双侧输尿
27、管扩张。提示：下尿路梗阻。度充盈；另一侧肾盂积水，双侧输尿管扩张。提示：下尿路梗阻。The ultrasound scan shows a kidney of normal size(10-12 cm)with some preservation of corticomedullary differentiation but gross hydronephrosis and a full bladder post attempted micturition.The other kidney is also hydronephrotic on US,and both ureters are di
28、lated.This is suggestive of distal obstruction(i.e.at the level of the urethra or beyond).该患者下一步如何处理？该患者下一步如何处理？超声检查提示，超声检查提示，AKIAKI可能的原因为尿道流出道梗阻。因此，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。复查肾功能、电
29、解质以确保治疗后高钾血症被解决。He has an ultrasound scan which suggests that the most likely cause of ARF is urethral outfl ow obstruction.Therefore a urinary catheter should be inserted.Given his history of prostatic disease,this may not be easy and may require urology input.If a catheter cannot be placed peruret
30、hrally due to the size of the置入导尿管解除梗阻后最主要的临床问题是什么？置入导尿管解除梗阻后最主要的临床问题是什么？v 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能不全 Following treatment of urinary obstruction by insertion of a catheter,patients frequently become polyuric due to temporary tubular dysfunction.v 置入导尿管后置入导尿管后8小时，该患者排出
31、小时，该患者排出6L尿，需补充足的液体，防尿，需补充足的液体，防止血容量不足并发肾前性止血容量不足并发肾前性AKI In the 8 hours following catheterisation,Patients passes 6 litres of urine and unless he is placed on an adequate fl uid replacement regimen,he will be at risk of developing pre-renal failure due to intravascular volume depletion.v 多饮水，必要时静脉补
32、液多饮水，必要时静脉补液 His fluid balance should be carefully monitored and he is likely to require intravenous fluids in addition to encouraging increased oral intakev 经置入导尿管导尿以及充分的液体支持治疗后，在随后的经置入导尿管导尿以及充分的液体支持治疗后，在随后的48h复查肾功能迅速恢复，血肌酐复查肾功能迅速恢复，血肌酐150umol/L。泌尿外科会诊后，。泌尿外科会诊后，给予口服盐酸坦索罗辛缓释胶囊（哈乐，选择性给予口服盐酸坦索罗辛缓释胶囊（
33、哈乐，选择性受体阻滞剂受体阻滞剂）治疗。患者）治疗。患者PSA水平较前无变化，水平较前无变化，2周后拔管。周后拔管。v 2年后该患者自觉尿量减少，精神不佳、恶心再次入院，血生年后该患者自觉尿量减少，精神不佳、恶心再次入院，血生化检查化检查Na+135mmol/L，K+5.8mmol/L，BUN 36mmol/L，肌酐，肌酐460umol/L。患者临床上容量正常，体检未触及肿大的膀胱，。患者临床上容量正常，体检未触及肿大的膀胱，但腹股沟可触及肿大的淋巴结，超声检查未显示肾盂积水。但腹股沟可触及肿大的淋巴结，超声检查未显示肾盂积水。患者肾功能不全的原因是什么？患者肾功能不全的原因是什么？v 尿路梗阻尿路梗阻v 盆腔的晚期恶性肿瘤引起功能性尿路梗阻而不出现肾盂盆腔的晚期恶性肿瘤引起功能性尿路梗阻而不出现肾盂积水积水v 核素和核素和CTCT扫描扫描核素扫描显示梗阻，下一步治疗？核素扫描显示梗阻，下一步治疗？v 经皮肾造瘘，尿量增加经皮肾造瘘，尿量增加v 输尿管支架输尿管支架
