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结核病中的肾病

Authors
Vernon M Pais, Jr, MD
Jodie Dionne-Odom, MD
Section Editors
C Fordham von Reyn, MD
Gary C Curhan, MD, ScD
Deputy Editors
Elinor L Baron, MD, DTMH
Alice M Sheridan, MD

引言

结核病(tuberculosis, TB)会通过一系列机制导致肾功能障碍，包括肾脏和下尿路的直接感染、肾小管间质性肾炎、肾小球性肾炎、继发性淀粉样变性和梗阻性尿路病。相关不良反应包括肺部病变诱导抗利尿激素分泌失调综合征(syndrome of inappropriate antidiuretic hormone secretion, SIADH)所致的轻度低钠血症和抗分枝杆菌药物诱导的肾毒性。

结核性泌尿道感染

泌尿生殖系统结核是肺外结核病的一种常见形式；据估计4%-20%具有肺部感染的个体会出现泌尿生殖系统受累，且主要是在发展中国家[1,2]。泌尿生殖系统结核在男性中比在女性中更常见。原发于肺部的结核杆菌感染血行播散可以导致肾脏受累，后期再活动的结核病或粟粒性结核也可以发生肾脏感染。25%-62%的粟粒性结核患者伴随有肾脏病变[3]。 (参见“肺外结核和粟粒性结核的临床表现、诊断及治疗”和“肺外结核与粟粒性结核的流行病学与病理学”)

分枝杆菌播散会导致肉芽肿靠近肾小球形成。这些病变有可能随着纤维化而愈合而不会出现明显的肾脏病。或者，肉芽肿有可能干酪化并破裂进入管腔；这可在初次感染后长达30年才发生。之后结核杆菌可以进入肾髓质间质组织，导致肉芽肿形成和进行性肾髓质损伤[4,5]。肾乳头的破坏可以导致形成肾盏溃疡或脓肿。集合系统受累可能会导致纤维性瘢痕和狭窄。

临床表现 — 泌尿生殖系统结核通常起病隐匿，表现为不适和下尿路症状，包括尿痛和肉眼血尿[4-6]。肾绞痛这一表现并不常见。由于肾小球肉芽肿破裂的发生与其他部位的疾病活动度无关，因此全身性症状(如发热、体重减轻)相对罕见[4,7]。一些患者无症状，仅会被偶然发现脓尿和/或镜下血尿。

脓尿和/或镜下血尿见于90%以上的病例[4]。一般不会见到大量蛋白尿和细胞管型，且血浆肌酐浓度通常正常。可发生输尿管狭窄并且可能因此导致梗阻性尿路病[7,8]。结核病还可以导致慢性附睾炎或前列腺炎，遇到对抗菌治疗无效的病例应考虑这些病。在结核病累及男性精囊和射精管以及女性输卵管的情况下，可以发生不育[1]。伴有终末期肾病的泌尿生殖系统结核的晚期表现是不可逆的[9]。

            

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Literature review current through: 2017-06 . | This topic last updated: 2017-05-02.
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