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腎臟及泌尿醫學概論

義大醫院腎臟科

洪士元 醫師

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Data presented only for those countries from which relevant information was available. All rates are unadjusted. Incident data from Israel, Jalisco, Japan, Luxembou

rg, Pakistan, the Philippines, & Taiwan are dialysis only.

Worldwide Prevalence of ESRD USRDS (United States Renal Data Systems) 2004

2006 ADR

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Data presented only for those countries from which relevant information was available. All rates are unadjusted. Incident data from Israel, Jalisco, Japan, Luxembou

rg, Pakistan, the Philippines, & Taiwan are dialysis only.

Worldwide Incidence of ESRD USRDS 2004

2006 ADR

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全民健保

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(N = 38709, TSN 2004)

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(N = 8525, TSN 2004)

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大綱 腎臟及泌尿系統的解剖及生理 腎臟的功能 腎泌尿系統的檢查 腎衰竭 尿毒症 腎臟代替療法

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腎臟及泌尿系統的解剖及生理

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Kidney 腎臟 Each kidney is measured roughly 11 x 6 x

2.5cm. The left is somewhat longer, and

narrower, than the right. The weight of the kidney in the adult male

varies from 120 to 170 gm, in the adult female from 115 to 155 gm.

The combined weight of the two kidneys in proportion to that of the body is about 1 to 240.

Schrier. Disease of he kidney. 6 ed.

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腎臟的構造

皮質

髓質Medulla

腎盂輸尿管

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腎臟的構造 每個腎臟由一百萬個微血管球組成，即腎絲球或腎元。

每一個腎元有兩部份 : 腎小球及腎小管 腎臟的功能

血液的淨化器官 -- 清除多餘的廢物及水份 維持身體化學物質的平衡 製造荷爾蒙，如紅血球生長激素及維他命Ｄ

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腎臟的血管構造

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腎皮質的構造

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腎絲球的構造鮑氏囊出腎小動脈

入腎小動脈

亨利氏管近端小管

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Glomerulus 腎絲球

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腎絲球的顯微構造Podocyte, Epithelial cell

Endothelial cell

Mesangial cell

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腎絲球的顯微構造

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腎臟及腎上腺Kidney and Adrenal glands

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Ureter 輸尿管 measures from 25 to 30 cm in length a thick-walled narrow cylindrical tub

e is composed of three coats: fibrous,

muscular, and mucous coats runs downward and medialward in fr

ont of the Psoas major enters the pelvic cavity, finally open

s into the fundus of the bladder

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Urinary bladder 膀胱 Composed of the four coats Mucous coat: tunica mucosa Submucous coat: tela submucosa Muscular coat: tunica muscularis

External layer: fibers arranged in a longitudinal arrangement (Detrusor muscle)

Middle layer: fibers arranged in a circular manner

Internal layer: fibers have a general longitudinal arrangement.

Serous coat: tunica serosa

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Vertical section of bladder wall

Detrusor muscle

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Male Pelvis 男性骨盆腔

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膀胱、攝護腺及尿道

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Male urethra 男性尿道 Presents a double curve in the ordinary rel

axed state of the penis Length varies from 17.5 to 20 cm Divided into three portions

Prostatic: pars prostatica (3cm) Membranous: pars membranacea (shortest) Cavernous: pars cavernosa (15cm)

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導尿管 - Male

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Female urethra 女性尿道 a narrow membranous canal, about 4 cm lon

g placed behind the symphysis pubis, imbedde

d in the anterior wall of the vagina direction obliquely downward and forward slightly curved with the concavity directed for

ward. perforates the fasciae of the urogenital diaph

ragm, and its external orifice is situated directly in front of the vaginal opening and behind the glans clitoridis.

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Female Pelvis 女性骨盆腔

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腎臟的功能

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尿液的產生 全身的血液每分鐘以 1200 CC 的速度不停地通過腎臟

一天 24 小時約過濾 150 公升的水份 產生大約 1.5 公升的尿液，排到膀胱 腎絲球

腎小球 :過濾 --廢棄物 腎小管 :吸收，分泌，再吸收 --水份及電解質

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近曲小管 Proximal convoluted tubule

亨利氏管 Loop of Henle

遠曲小管 Distal convoluted tubule

集尿小管 Collecting duct

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腎臟的功能腎功能正常 清除體內代謝廢物 調節水的平衡 調節電解質的平衡 調節酸鹼的平衡 分泌荷爾蒙

(1) 紅血球生成素 (2) 腎素 (3) 前列腺素 (4) 活性維生素 D3

腎衰竭 尿素氮、肌酸酐上升 →噁心、嘔吐 尿酸上升 →續發性痛風 下肢水腫、臉部浮腫、充血性心衰

竭、肺水腫 低鈉血症、高鉀血症、高磷血症、

低鈣血症→肌肉顫抖、皮膚癢 →續發性副甲狀腺機能亢進 代謝性酸中毒 貧血、高血壓、低鈣血症

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水腫Pitting Edema

體液排出異常

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腎泌尿系統的檢查

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腎泌尿系統檢查 - 1 血液檢查 :

尿素氮 (Blood Urea Nitrogen) 肌酸酐 (Creatinine) 滲透壓 (Osm) 電解質 (Na, K, Cl, Ca. Mg) 酸鹼值 (pH, PCO2, HCO3

-) 肌酸酐清除率 (Creatinine Clearance) 一般尿液檢驗 (Urine routine analysis) 靜脈腎盂攝影 (IVP)

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腎泌尿系統檢查 - 2 超音波 (Echography, Sonography) 尿路動力學檢查 (Cystometry, CMG) 膀胱鏡 (Cystoscopy) 電腦斷層 (Computed Tomography, CT) 血管攝影 (Angiography) 核磁共振掃瞄 (MRI) 核子醫學檢查

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腎功能檢查 尿素氮 (BUN) 5 ~ 20 mg/dl 肌酸酐 (Creatinine) 0.5 ~ 1.5 mg/dl 肌酸酐清除率 CCr (Clearance of creatinine)

Normal : 95~ 120 20 cc/min UCr ×UV / 1440 ×PCr

Example: 24 Hr urine 2880 cc, Cr 1.5 mg/dl, U-Cr 75 mg/dl, CCr = (75 x 2880) / (1440 x 1.5) = 100 ml/min

Estimated CCr (Cockcroft)Male = (140 – Age) ×BW / 72 ×PCrFemale = male CCr ×0.85

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一般尿液檢驗 (一 ) Dipsticks:

a rapid semiquantitative measurement Specific gravity pH Glucose ( 尿糖 ) Ketone Protein ( 蛋白尿 )

Hemoglobin Bilirubin Urobilinogen Nitrites Leukocyte esterase

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一般尿液檢驗 (二 ) Urinary sediments

RBC (Red Blood Cell > 5/HPF: 血尿 ) WBC (White Blood Cell > 8/HPF: 膿尿 ) Epithelial cell Cast (圓柱 ) Crystals (結晶體) Bacteria

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血尿的原因 凝血功能異常 腎臟疾病

各種腎絲球腎炎 -- 如 A 型球蛋白腎炎 遺傳疾病 -- 如家族性血尿症

腎後因素 結石 腫瘤 攝護腺或子宮疾病 尿道感染 -- 如膀胱炎

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泌尿道感染 下泌尿道感染 (lower urinary tract infection)

urethritis, cystitis

上泌尿道感染 (Upper urinary tract infection) acute pyelonephritis, prostatitis, and intrarenal an

d perinephric abscesses

診斷三要素 症狀 -- 頻尿 , 小便疼痛 , 急尿 膿尿 -- 尿液中 WBC > 8 / HPF 菌尿 -- 中段尿細菌培養呈陽性 (Colony >105 /ml)

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泌尿道感染

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泌尿道感染 -- 致病菌 革蘭氏陰性菌

大腸桿菌 (E.coli) Klebsiella Proteus Pseudomonas Serratia

革蘭氏陽性菌 Staphylococcus saprophyticus

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蛋白尿 蛋白尿 : 腎炎的徵兆 Normal: 100 to 150 mg/day ( 10 mg/dl) Methods

Dipstick: more sensitive to albumin Sulfosalicylic acid: all protein

Microalbuminuria ( 微量白蛋白尿 ) urinary albumin excretion (UAE) persistent UAE rate: 20-200 ug/min A predictor of overt DM nephropathy & cardiovascu

lar mortality

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Nephrotic Syndrome腎病症候群

Massive proteinuria Daily protein loss > 3.5 gm/1.73 M2

Hypoalbuminemia Albumin < 3.5 g/dl

Generalized edema Hyperlipidemia.

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Intravenous Pyelograpgy (IVP)

靜脈腎盂攝影

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Renal Echography腎臟超音波檢查

C: cortex, M: medulla, S: renal sinus (pelvis fat)

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電腦斷層 (Computed Tomography, CT)

腎細胞癌 (Renal cell carcinoma)

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膀胱癌 (Bladder cancer)The most common: Transitional cell

carcinoma

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膀胱鏡 (Cystoscopes)

Flexible Video Cystoscope

Rigid and Semirigid

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多囊腎

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多囊腎

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腎衰竭

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腎衰竭 急性腎衰竭(Acute renal failure, ARF)

慢性腎衰竭(Chronic renal failure, CRF)

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急性 or 慢性腎衰竭 ?

History

Symptoms

Laboratory tests

Kidney size

Renal osteodystrophy ( 腎性骨病變 )

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急性腎衰竭 ARF Definition

An abrupt reduction in renal function

Usually, but not always, accompanied

by oliguria

Usually reversible

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Causes of acute renal failure

GRF: Glomerular Filtration Rate 腎絲球過濾速率

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Cases of acute renal failure

Prerenal An adaptive response to effective volume

Renal ( Intrinsic ) A response to cytotoxic insults

Postrenal The passage of urine is blocked

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Indications for dialysis in ARF

Hyperkalemia with EKG changes

Severe fluid overloading with pulmonary edema

Severe metabolic acidosis

Uremic pericarditis

Uremic encephalopathy

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40歲女性血中鉀離子濃度過高 (K=7.0meq/L)

引發心律不整

經心臟電擊術後

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急性肺水腫正常

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肋膜積水 (Pleural Effusion)

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Definition of CRF A progressive deterioration in renal

function for more than 3-6 months

Irreversible

Not always accompanied with oliguria

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慢性腎臟疾病 (CKD)之分期Chronic Kidney Disease

GFR 120 90 60 30 15ml/min/1.73m2

Estimated GFR (Cockcroft) Male = (140–Age) × BW / 72 ×PCrFemale = (140–Age) × BW × 0.85 / 72 ×PCrGRF: Glomerular Filtration Rate 腎絲球過濾速率

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美國成人慢性腎臟病之分期及盛行率

1 腎功能正常 持續性蛋白尿 90 5,900,000 3.3 %

2 輕度腎衰竭 60 ~ 89 5,300,000 3.0 %

3 中度腎衰竭 30 ~ 59 7,600,000 4.3 %

4 重度腎衰竭 15 ~ 29 400,000 0.2 %

5 末期腎病 < 15 372,000 0.1 %

期別 說明 腎絲球濾過率 盛行率 GFR (ml/min/1.73 m2) 個案數 %

總計 19,572,000 10.9 %

4.6 %

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台灣 15 歲以上人口慢性腎臟疾病之盛行率依三高調查血清肌酸酐以 MDRD-S 公式計算 GFR

0 1000 2000 3000 4000

¡Ù90

60~89

30~59

15~29

< 15 8

16

400

2810

3365

Case number

GF

R (

ml/m

in/1

.73

m2)

6.43 %

三高調查 ,2002

以 6.43%推算，全台灣 15歲以上人口， CKD 病人數約 115 萬人

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Approach to CRFCreatinine >1.5 mg/dl azotemia ( 氮血症 )

>2-3 mg/dl chronic parenchymal disease

>4 mg/dl chronic renal failure with

irreversible changes

>6-8 mg/dl uremia, prepare for renal

replacement therapy

>8-10 mg/dl Start renal replacement

therapy

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尿毒症 (Uremia) 腎臟功能失去了約 90% 以上時，身體中的代謝廢物無法排出，產生許多的症狀，稱為尿毒症。

急性或慢性腎衰竭都可引起尿毒症。 習慣上使用尿毒症一詞代表慢性腎衰竭。 檢驗數值 :

肌酸酐濃度 : 正常為 1.5 mg/dl 以下，當達到 6.0 ~ 10.0 以上時，即可能為尿毒症

肌酸酐廓清率 : 正常為 85~110 ml/min ，當低於 5 ~ 15 以下時，即為尿毒症

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尿 毒 症

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尿毒症 主要症狀 :

虛弱、頭暈、噁心、嘔吐、皮膚癢、骨頭酸痛、氣喘 臨床徵候 :

貧血、下肢水腫、酸中毒、心律不整、肺水腫 影響多重器官系統

心臟 ,血管 , 神經 ,腸胃 ,肺 ,血液 ,骨骼 ,內分泌 ,免疫 ,皮膚

影響生化平衡 酸血症 ,高血鉀 ,高血磷 ,低血鈣 ,高血鈉或低血鈉 副甲狀腺亢進 ,腎性骨病變 ...

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腎性骨病變

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Clinical Abnormalities in Uremia Fluid and electrolyte disturbances

Volume, Na, K , P, Ca Metabolic acidosis

Endocrine-metabolic disturbances Secondary

hyperparathyroidism Adynamic osteomalacia Vitamin D-deficient

osteomalacia Carbohydrate intolerance UA, TG, Lp(a) , HDL Protein-calorie malnutrition Infertility and sexual

dysfunction Amyloidosis

Neuromuscular disturbances Sleep disorders, Asterixis,

Neuropathy Restless legs syndrome Dialysis disequilibrium

syndrome Cardiovascular and pulmonary

disturbances Hypertension Congestive heart failure Pericarditis

Dermatological disturbances Gastrointestinal disturbances Hematologic and immunologic

disturbances

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Incident ESRD patients. Rates adjusted for age, gender, & race., USRDS 2004

Incident counts & adjusted ratesby primary diagnosis

糖尿病

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%

TSN Renal Registry 1990~2001

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 20010

10

20

30

40

50

60

Chronic GN

DM Nephropathy

Hypertensive Nephrosclerosis

Chronic Tubulointerstitial Nephritis

17.7% 18.1% 19.0% 19.6% 20.4% 21.1% 21.7% 22.6% 23.1% 23.9% 24.0% 24.3%

Calendar Year

台灣透析病患之原發病因

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腎臟代替療法

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腎臟代替療法 四十年前尿毒症是一個絕症 目前治療尿毒症的方法一 . 血液透析治療 (Hemodialysis)

二 . 腹膜透析治療 (Peritoneal dialysis)

三 . 腎臟移植 (Renal transplantation)

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透析的原理 - 擴散作用

控制因子 濃度差 , 電荷 , 分子大小 , 接觸時間

血液 半透膜 透析液尿素氮

肌酸酐

Lactate or Bicarbonate

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血液透析 血液透析又稱為洗腎。 血液透析是把體內的血液輸送到人工腎臟，人工腎臟裡面有過濾膜，把廢物濾過至透析液中清除。

每週須進行三次血液透析，每一次約需4小時。

因為要把血液輸送到透析器，所以必需建立一個血管通道，稱為動靜脈瘻管。

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動靜脈瘻管

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腹膜透析 腹膜透析又稱為洗肚子。 不需要將血液輸送到人工腎臟，不必打針。 方法是將透析液灌注至腹腔內，廢物經由腹膜排放到透析液內，然後再引流到體外。

必需安放一條導管，即腹膜透析管。 通常每次透析液留置需要 4-6 小時，一天必須進行 4-5次的透析液交換。

腹膜透析的好處是可以在家裡進行，只需要每個月到醫院門診即可。

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腹膜透析系統 Dialysate: PD solution

Access: PD catheter

Semipermeable memb:

peritoneal membrane

Reservoir: peritoneal

cavity

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連續可移動性腹膜透析(CAPD)(CAPD)

CContinuous AAmbulatory PPeritoneal DDialysis

1. 引流 2. 注入

3. 留置

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腎臟移植 就是把別人正常的腎臟移植到體內。

分為屍體腎移植及活體腎移植兩種。

活體移植腎臟的存活率要比屍體移植的高。

腎臟移植成功以後不再需要透析治療。

但必需長期使用抗排斥藥物。

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腎臟移植

移植腎

移植輸尿管 膀胱

腸骨動脈

腸骨靜脈

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Incident dialysis patients & patients receiving a first transplant in the calendar year. All probabilities are adjusted for age, gender, & race; overall probabilities are also adjusted for primary diagnosis.

All ESRD patients, 1996, used as reference cohort.Modality determined on first ESRD service date; excludes patients transplanted or dying during the first 90 days.

Adjusted survival 1993-1997 incident patients, USRDS 2002

2004 ADR

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腎臟代替療法

血液透析

腹膜透析 腎臟移植

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Thank You Very Much !