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成人慢性肾脏病治疗概述

Author
Mark Rosenberg, MD
Section Editor
Gary C Curhan, MD, ScD
Deputy Editor
Alice M Sheridan, MD
Translators
李超, 主治医师

引言

所有肾脏病患者(不管是急性还是慢性)，都应通过血清肌酐估计肾小球滤过率(glomerular filtration rate, GFR)以评估肾功能。临床上通过肾小球滤过率评估肾脏受损的程度、追踪疾病进程及评价疗效。必须尽可能尝试获得具体的诊断。该过程的第一步就是要仔细进行尿液分析，寻找是否出现蛋白尿、血尿和细胞管型。进一步评估可能包括蛋白尿定量、肾脏超声、转诊至肾脏专科医生和肾活检。肾功能快速减退[如尿白蛋白/肌酐比值升高(>300mg/g)或者出现尿红细胞管型]尤其需要转诊至肾脏专科。 (参见“肾功能的评估”和“急性肾损伤(急性肾衰竭)或慢性肾脏病患者的诊断方法”和“Urinalysis in the diagnosis of kidney disease”)

有关慢性肾脏病(chronic kidney disease, CKD)患者治疗的一般问题的概述(包括延缓肾病进展的方法)见此专题。有关特殊肾脏病的特定治疗，将在相关专题中单独讨论。

肾脏病的自然病程

肾脏的初始损伤可能导致一系列临床表现，包括从无症状血尿到需要透析的肾衰竭。许多患者可以完全恢复，只有轻微的或没有后遗症。例如，儿童链球菌感染后肾小球肾炎最常出现长期预后良好。相比之下，某些疾病患者(例如狼疮性肾炎患者)则会经历肾实质的反复和慢性损伤，导致持久性破坏。此外，一些原发疾病无活动性或已治愈的患者，因血流动力学和其他机制，肾功能可能仍会发生进行性损害。

除了个体间疾病的活动性存在差异外，这些不同的表现，部分程度上由肾脏对损伤如何应答导致。肾脏能够通过增加残余正常肾单位的滤过率，以适应损伤，这一过程称之为适应性高滤过。因此，轻度肾功能不全的患者，其血清肌酐浓度通常正常或接近正常。另外各种稳态机制(大多发生在肾小管内)使得血清钠、钾、钙、磷的浓度及体内总水量也维持在正常范围内，特别是在轻到中度肾功能不全患者中。 (参见“肾功能的评估”)

尽管适应性高滤过机制在最初是有益的，但似乎会对残余肾单位的肾小球造成长期损伤，表现为蛋白尿和进行性的肾衰竭。这一过程可能是原发疾病并非活动性或治愈的患者发生肾衰竭的原因[1]。采用有助于阻断这一过程的措施[例如采用血管紧张素转换酶(angiotensin converting enzyme, ACE)抑制剂或血管紧张素Ⅱ受体阻断药(angiotensin Ⅱ receptor blocker, ARB)进行降压治疗]可能延缓疾病进展，甚至保护肾功能。如果这些措施有效，那么在肾脏出现大量不可逆瘢痕之前开始应用可能获益最大。 (参见“慢性肾脏病的继发性因素及进展”)

                                        

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Literature review current through: 2017-06 . | This topic last updated: 2016-02-24.
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