寡尿

腎臟內科

學習目標PGY UGY

知識

1.寡尿相關的影像檢查

2.腎切片檢查的照護

3.寡尿病人的處理程序

4.透析病人的照護

5.透析相關併發症的防治

知識

1.寡尿、急性腎衰竭及尿毒症的定義

2.寡尿、急性腎衰竭及尿毒症的臨床表現

3.寡尿的病理生理機制

4.寡尿的診斷流程

5.尿毒症的病理生理機制

6.透析的基本原理

7.寡尿相關的實驗室檢查判讀，包括BUN/Cr、Ca、P、電解質、動脈血氣體分析、尿液分析、尿鈉、血清及尿之滲透壓、計算鈉離子之fraction excretion

8. 照會做腎超音波之適應症及判讀

技能

1.寡尿相關的病史詢問

2.寡尿相關的身體檢查

3.放置周邊靜脈留置管

4. 抽取動脈血

5. 導尿

定義

急性腎衰竭(Acute renal failure)在幾小時到幾天內腎功能(腎絲球過濾率)急速下降(常併有含氮廢物增加， 寡尿，電解質和酸鹼異常，且不一定有症狀) 。氮血症(Azotemia)：血中尿素氮(BUN)昇高。

寡尿(Oliguria)：

寡尿的病理生理機制

危險因子 Risk Factors

高危險群病人 High-Risk Setting

腎 臟 Kidneys✱ 腎臟是位於後腹腔的一對器官，呈蠶豆形；約位居第十二胸椎與第三腰椎之間，右腎因上方有肝臟之故，因此比左腎略低一些，每個約150公克。

解剖位置

腎 臟 Kidneys

解剖構造

腎 元 Nephron

腎臟發揮功能的基本單位是『腎元』

腎絲球 — 過濾腎小管 — 再吸收、分泌

顯微構造

腎臟的生理功能功 能 機 制 影 響 成 份

‧ 廢物移除 腎絲球過濾 尿素、肌酸酐

腎小管分泌 尿酸、藥物

‧ 水份及電解質平衡

再吸收及分泌 水、鈉、鉀、氯、鎂、鈣

‧ 酸鹼平衡 氫離子分泌 酸鹼

‧ 血壓調節 鈉排泄調控 胞外液容積

腎素製造 血管阻力

‧ 荷爾蒙調節 維生素D活化 鈣、磷恆定紅血球生成素製造 紅血球量

Probable Causes of Acute Renal Failure/Oliguria Based on the Findings of the History

History Probable causes of acute renal failureReview of systemsPulmonary system

Sinus, upper respiratory or pulmonary symptoms Pulmonary-renal syndrome or vasculitisCardiac system

Symptoms of heart failure Decreased renal perfusionIntravenous drug abuse, prosthetic valve or valvular disease Endocarditis

Gastrointestinal systemDiarrhea, vomiting or poor intake HypovolemiaColicky abdominal pain radiating from flank to groin Urolithiasis

Genitourinary systemSymptoms of benign prostatic hypertrophy Obstruction

Musculoskeletal systemBone pain in the elderly Multiple myeloma or prostate cancerTrauma or prolonged immobilization Rhabdomyolysis (pigment nephropathy)

SkinRash Allergic interstitial nephritis, vasculitis, SLE, atheroemboli or TTP

Constitutional symptomsFever, weight loss, fatigue or anorexia Malignancy or vasculitis

Past medical historyMultiple sclerosis, diabetes mellitus or stroke Neurogenic bladderPast surgical history

Recent surgery or procedure Ischemia, atheroemboli, endocarditis or exposure to contrast agentMedication historyACEI, NSAID, antibiotics or acyclovir (Zovirax) Decreased renal perfusion, ATN or allergic interstitial nephritis

Physical examination Probable causes of acute renal failureVital signs Temperature Possible infection Blood pressure Hypertension: nephrotic syndrome or malignant hypertension

Hypotension: volume depletion or sepsisWeight loss or gain Hypovolemia or hypervolemiaMouth DehydrationJugular veins Hypovolemia or hypervolemiaPulmonary system Signs of congestive heart failureHeart New murmur of endocarditis or signs of congestive heart failureAbdomen Bladder distention suggesting urethral obstructionPelvis Pelvic massRectum Prostate enlargementSkin Rash of interstitial nephritis, purpura of microvascular disease,

livedo reticularis suggestive of atheroembolic disease,or splinter hemorrhages or Osler's nodes of endocarditis

Probable Causes of Acute Renal Failure/Oliguria Based on the Findings of the History

急性腎衰竭Acute renal failure異常及診斷流程

FENa

Urine osmolality

Urine casts

急性腎衰竭的鑑別診斷

Acute Renal Failure(oliguria)

Pre-RenalAzotemia

Post-Renal(含Intratubular obstruction)

Ischemia (Renal hypoperfusion)

Acute Tubular Necrosis(ATN)

Nephrotoxin

IntrinsicCauses

Acute GNInterstitialNephritis

Acute on CRF

Vascular

急性腎衰竭與寡尿的診斷流程

急性腎衰竭之診斷

相關檢驗及檢查

寡尿性急性腎衰竭相關實驗檢查

BUN、CreatinineEletrolyte (Na+,K+,Cl+,Ca2+,P2+,Mg2+)Blood and urine osmalityABG (metabolic acidosis)Urine routine (RBC,WBC,Spgr)Spot urine (FeNa)Abdominal sonography (obstruction or

structure problem)

腎衰竭與寡尿的影像檢查 Plain film:stone, kidney contour Ultrasonogrpahy:size, hydronephrosis, kidney size, parenchyma CT scan:stone, malignancy, thrombosis Magnetic resonance imaging Intravenous urogram (pyelogram) :stone Others: Renal arteriography, Renal venography, Radionuclide

studies, Voiding cystourethrogram, Retrograde or anterograde pyelography