UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

肾衰竭患者的尿量和残余肾功能

Author
Anthony Bleyer, MD, MS
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD

引言

虽然终末期肾病(end-stage kidney disease, ESRD)患者的肾小球滤过率(glomerular filtration rate, GFR)很低，但可有数量不等的尿量，从少尿至尿量正常、甚至高于正常水平。之所以出现这样的结果，是因为尿量不是由GFR单独决定，也取决于GFR和肾小管重吸收率之间的差异。比如，如果一位晚期急性或慢性肾衰竭患者的GFR为5L/d(正常水平为140-180L/d)，倘若只有3.5L尿液被重吸收，那患者每日尿量依旧可以维持在1.5L。

以前一直认为在这种情况下，肾小管损伤影响了重吸收钠和水的能力，从而有助于维持足够的尿量。但是，血容量扩张(由于初期钠潴留)和尿素渗透性利尿(由于每日尿素负荷由较少的有功能肾单位排出)，似乎更有可能在尿量的维持中扮演更重要的角色，溶质吸收也是尿素渗透性利尿的部分原因[1-3]。

相比之下，在晚期肾病时，水摄入量[一般通过改变抗利尿激素(antidiuretic hormone, ADH)的分泌水平决定尿量]在调节尿量方面只有相对很小的作用。这些患者既不能正常稀释也不能正常浓缩尿液，尿渗透压可从最低200mosmol/kg至最高300mosmol/kg不等，而正常人尿渗透压是50-1200mosmol/kg[3,4]。ADH抵抗的净效应是：水摄入量的变化影响ADH的释放，但后者最终对尿量的影响极微[4]。

残余肾功能的临床重要性

ESRD患者残余肾功能的丧失有重要的临床表现。包括对容量控制和患者生存的不良影响[5-7]。

●尽管开始维持透析的患者可能仅存4-5mL/min的GFR，但这对清除潜在尿毒症毒素足以产生很大帮助，因为与血液透析患者一周12小时的血液透析不同，肾脏的滤过是连续的[8]。

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-04-08.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Yeh BP, Tomko DJ, Stacy WK, et al. Factors influencing sodium and water excretion in uremic man. Kidney Int 1975; 7:103.
  2. Danovitch GM, Bourgoignie J, Bricker NS. Reversibility of the "salt-losing" tendency of chronic renal failure. N Engl J Med 1977; 296:14.
  3. Feinfeld DA, Danovitch GM. Factors affecting urine volume in chronic renal failure. Am J Kidney Dis 1987; 10:231.
  4. Tannen RL, Regal EM, Dunn MJ, Schrier RW. Vasopressin-resistant hyposthenuria in advanced chronic renal disease. N Engl J Med 1969; 280:1135.
  5. Bargman JM, Golper TA. The importance of residual renal function for patients on dialysis. Nephrol Dial Transplant 2005; 20:671.
  6. Wang AY, Lai KN. The importance of residual renal function in dialysis patients. Kidney Int 2006; 69:1726.
  7. Bragg-Gresham JL, Fissell RB, Mason NA, et al. Diuretic use, residual renal function, and mortality among hemodialysis patients in the Dialysis Outcomes and Practice Pattern Study (DOPPS). Am J Kidney Dis 2007; 49:426.
  8. Rottembourg J. Residual renal function and recovery of renal function in patients treated by CAPD. Kidney Int Suppl 1993; 40:S106.
  9. Suda T, Hiroshige K, Ohta T, et al. The contribution of residual renal function to overall nutritional status in chronic haemodialysis patients. Nephrol Dial Transplant 2000; 15:396.
  10. Shemin D, Bostom AG, Laliberty P, Dworkin LD. Residual renal function and mortality risk in hemodialysis patients. Am J Kidney Dis 2001; 38:85.
  11. Termorshuizen F, Dekker FW, van Manen JG, et al. Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol 2004; 15:1061.
  12. Szeto CC, Wong TY, Chow KM, et al. Are peritoneal dialysis patients with and without residual renal function equivalent for survival study? Insight from a retrospective review of the cause of death. Nephrol Dial Transplant 2003; 18:977.
  13. Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced cardiac injury: determinants and associated outcomes. Clin J Am Soc Nephrol 2009; 4:914.
  14. Krediet RT, Zweers MM, van Westrhenen R, et al. What can we do to preserve the peritoneum? Perit Dial Int 2003; 23 Suppl 2:S14.
  15. Bargman JM, Thorpe KE, Churchill DN, CANUSA Peritoneal Dialysis Study Group. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 2001; 12:2158.
  16. Lysaght MJ, Vonesh EF, Gotch F, et al. The influence of dialysis treatment modality on the decline of remaining renal function. ASAIO Trans 1991; 37:598.
  17. Moist LM, Port FK, Orzol SM, et al. Predictors of loss of residual renal function among new dialysis patients. J Am Soc Nephrol 2000; 11:556.
  18. Misra M, Vonesh E, Van Stone JC, et al. Effect of cause and time of dropout on the residual GFR: a comparative analysis of the decline of GFR on dialysis. Kidney Int 2001; 59:754.
  19. Jansen MA, Hart AA, Korevaar JC, et al. Predictors of the rate of decline of residual renal function in incident dialysis patients. Kidney Int 2002; 62:1046.
  20. Lameire N, Van Biesen W. The impact of residual renal function on the adequacy of peritoneal dialysis. Perit Dial Int 1997; 17 Suppl 2:S102.
  21. McKane W, Chandna SM, Tattersall JE, et al. Identical decline of residual renal function in high-flux biocompatible hemodialysis and CAPD. Kidney Int 2002; 61:256.
  22. Gunal AI, Kirciman E, Guler M, et al. Should the preservation of residual renal function cost volume overload and its consequence left ventricular hypertrophy in new hemodialysis patients? Ren Fail 2004; 26:405.
  23. Ogata K. Clinicopathological study of kidneys from patients on chronic dialysis. Kidney Int 1990; 37:1333.
  24. McCarthy JT, Jenson BM, Squillace DP, Williams AW. Improved preservation of residual renal function in chronic hemodialysis patients using polysulfone dialyzers. Am J Kidney Dis 1997; 29:576.
  25. Caramelo C, Alcázar R, Gallar P, et al. Choice of dialysis membrane does not influence the outcome of residual renal function in haemodialysis patients. Nephrol Dial Transplant 1994; 9:675.
  26. Lang SM, Bergner A, Töpfer M, Schiffl H. Preservation of residual renal function in dialysis patients: effects of dialysis-technique-related factors. Perit Dial Int 2001; 21:52.
  27. Hakim RM, Wingard RL, Husni L, et al. The effect of membrane biocompatibility on plasma beta 2-microglobulin levels in chronic hemodialysis patients. J Am Soc Nephrol 1996; 7:472.
  28. Hartmann J, Fricke H, Schiffl H. Biocompatible membranes preserve residual renal function in patients undergoing regular hemodialysis. Am J Kidney Dis 1997; 30:366.
  29. Schiffl H, Lang SM, Fischer R. Ultrapure dialysis fluid slows loss of residual renal function in new dialysis patients. Nephrol Dial Transplant 2002; 17:1814.
  30. Daugirdas JT, Greene T, Rocco MV, et al. Effect of frequent hemodialysis on residual kidney function. Kidney Int 2013; 83:949.
  31. Obi Y, Streja E, Rhee CM, et al. Incremental Hemodialysis, Residual Kidney Function, and Mortality Risk in Incident Dialysis Patients: A Cohort Study. Am J Kidney Dis 2016; 68:256.
  32. Hiroshige K, Yuu K, Soejima M, et al. Rapid decline of residual renal function in patients on automated peritoneal dialysis. Perit Dial Int 1996; 16:307.
  33. Hufnagel G, Michel C, Queffeulou G, et al. The influence of automated peritoneal dialysis on the decrease in residual renal function. Nephrol Dial Transplant 1999; 14:1224.
  34. Holley JL, Aslam N, Bernardini J, et al. The influence of demographic factors and modality on loss of residual renal function in incident peritoneal dialysis patients. Perit Dial Int 2001; 21:302.
  35. Rabindranath KS, Adams J, Ali TZ, et al. Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis for end-stage renal disease. Cochrane Database Syst Rev 2007; :CD006515.
  36. Michels WM, Verduijn M, Grootendorst DC, et al. Decline in residual renal function in automated compared with continuous ambulatory peritoneal dialysis. Clin J Am Soc Nephrol 2011; 6:537.
  37. Cnossen TT, Usvyat L, Kotanko P, et al. Comparison of outcomes on continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis: results from a USA database. Perit Dial Int 2011; 31:679.
  38. Kim JK, Kim YS, Song YR, et al. Excessive Weight Gain during the First Year of Peritoneal Dialysis Is Associated with Inflammation, Diabetes Mellitus, and a Rapid Decrease in Residual Renal Function. PLoS One 2015; 10:e0139033.
  39. Chang TI, Kang EW, Kim HW, et al. Low Serum Bicarbonate Predicts Residual Renal Function Loss in Peritoneal Dialysis Patients. Medicine (Baltimore) 2015; 94:e1276.
  40. Medcalf JF, Harris KP, Walls J. Role of diuretics in the preservation of residual renal function in patients on continuous ambulatory peritoneal dialysis. Kidney Int 2001; 59:1128.
  41. van Olden RW, van Meyel JJ, Gerlag PG. Acute and long-term effects of therapy with high-dose furosemide in chronic hemodialysis patients. Am J Nephrol 1992; 12:351.
  42. Li PK, Chow KM, Wong TY, et al. Effects of an angiotensin-converting enzyme inhibitor on residual renal function in patients receiving peritoneal dialysis. A randomized, controlled study. Ann Intern Med 2003; 139:105.
  43. Suzuki H, Kanno Y, Sugahara S, et al. Effects of an angiotensin II receptor blocker, valsartan, on residual renal function in patients on CAPD. Am J Kidney Dis 2004; 43:1056.
  44. K/DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 2006; 47(Supp 4):S1.
  45. Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
  46. Ha IS, Yap HK, Munarriz RL, et al. Risk factors for loss of residual renal function in children treated with chronic peritoneal dialysis. Kidney Int 2015; 88:605.
  47. Kim S, Oh J, Kim S, et al. Benefits of biocompatible PD fluid for preservation of residual renal function in incident CAPD patients: a 1-year study. Nephrol Dial Transplant 2009; 24:2899.
  48. Fan SL, Pile T, Punzalan S, et al. Randomized controlled study of biocompatible peritoneal dialysis solutions: effect on residual renal function. Kidney Int 2008; 73:200.
  49. Szeto CC, Chow KM, Lam CW, et al. Clinical biocompatibility of a neutral peritoneal dialysis solution with minimal glucose-degradation products--a 1-year randomized control trial. Nephrol Dial Transplant 2007; 22:552.
  50. Kim S, Oh KH, Oh J, et al. Biocompatible peritoneal dialysis solution preserves residual renal function. Am J Nephrol 2012; 36:305.
  51. Johnson DW, Brown FG, Clarke M, et al. Effects of biocompatible versus standard fluid on peritoneal dialysis outcomes. J Am Soc Nephrol 2012; 23:1097.
  52. Wang J, Zhu N, Yuan W. Effect of neutral pH and low-glucose degradation product-containing peritoneal dialysis solution on residual renal function in peritoneal dialysis patients: a meta-analysis. Nephron 2015; 129:155.
  53. Baker RJ, Senior H, Clemenger M, Brown EA. Empirical aminoglycosides for peritonitis do not affect residual renal function. Am J Kidney Dis 2003; 41:670.
  54. Badve SV, Hawley CM, McDonald SP, et al. Use of aminoglycosides for peritoneal dialysis-associated peritonitis does not affect residual renal function. Nephrol Dial Transplant 2012; 27:381.
  55. Lui SL, Cheng SW, Ng F, et al. Cefazolin plus netilmicin versus cefazolin plus ceftazidime for treating CAPD peritonitis: effect on residual renal function. Kidney Int 2005; 68:2375.
  56. Moranne O, Willoteaux S, Pagniez D, et al. Effect of iodinated contrast agents on residual renal function in PD patients. Nephrol Dial Transplant 2006; 21:1040.
  57. Dittrich E, Puttinger H, Schillinger M, et al. Effect of radio contrast media on residual renal function in peritoneal dialysis patients--a prospective study. Nephrol Dial Transplant 2006; 21:1334.
  58. Janousek R, Krajina A, Peregrin JH, et al. Effect of intravascular iodinated contrast media on natural course of end-stage renal disease progression in hemodialysis patients: a prospective study. Cardiovasc Intervent Radiol 2010; 33:61.
  59. Feldman L, Shani M, Efrati S, et al. N-acetylcysteine improves residual renal function in peritoneal dialysis patients: a pilot study. Perit Dial Int 2011; 31:545.
  60. Park JT, Kim DK, Chang TI, et al. Uric acid is associated with the rate of residual renal function decline in peritoneal dialysis patients. Nephrol Dial Transplant 2009; 24:3520.
  61. Shin SK, Noh H, Kang SW, et al. Risk factors influencing the decline of residual renal function in continuous ambulatory peritoneal dialysis patients. Perit Dial Int 1999; 19:138.
  62. Tian SL, Tian XK, Han QF, et al. Presence of peripheral arterial disease predicts loss of residual renal function in incident CAPD patients. Perit Dial Int 2012; 32:67.
  63. Singhal MK, Bhaskaran S, Vidgen E, et al. Rate of decline of residual renal function in patients on continuous peritoneal dialysis and factors affecting it. Perit Dial Int 2000; 20:429.
  64. Perl J, Bargman JM. The importance of residual kidney function for patients on dialysis: a critical review. Am J Kidney Dis 2009; 53:1068.
  65. Madar H, Korzets A, Ori Y, et al. Residual renal function in peritoneal dialysis after renal transplant failure. Perit Dial Int 2010; 30:470.