<link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/css/video-js.min.css?v=1"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/base.css?v=5"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/index.css?v=35"><link rel="stylesheet" href="https://ysz-web.yxj.org.cn/live/dist/static/base/index.css?ysz_v=2.0"><script src="https://studioyszimg.yxj.org.cn/js/dsbridge.js?v=13" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/dsBridge/main.js?v=26" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/base/fun.js?ysz_v=3" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/js/nativeToWeb.js?v=1" type="text/javascript"></script><div id="ysz-header" style="margin:0;overflow:hidden;"><h1 style="font-size:24px;line-height:1.8;color:#333333;word-wrap:break-word;">避免IgA肾病快速进展为尿毒症,这3个错误别再犯!</h1><h2 style="font-size:16px;color:#999999;word-wrap:break-word;"><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">2022-05-18</em><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">原创:医学界肾病频道</em></h2></div><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">一个41岁的小老板,3年前检查发现,尿蛋白定量1.8g/d(正常<0.15g/d),血肌酐略有升高,为170µmol/L,没有贫血,经肾穿刺确诊为局灶增生性IgA肾病,在我院住院。</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED981A3E5934B39853.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; visibility: visible ; width: 556px ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图1:患者检查单<br/></span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED99616905548F6A05.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; visibility: visible ; width: 556px ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图2:患者检查单</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED9A85DCDD7425F4AE.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 556px ; visibility: visible ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图3:患者检查单</span></section><section><br/></section><section><section><section><section><section><section><section><section></section></section></section></section></section><section><section><section><section><section></section></section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">病情刚稳定,患者就开始“放飞自我”</span></p></section></section></section></section></section></section><p><br/></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA肾病患者的尿蛋白定量超过1g/d,并且肾功能已经下降,根据诊疗指南,在这种情况下,患者应该使用激素或者联合免疫抑制剂治疗,同时使用沙坦类(或者普利类)降压药治疗。<br/></span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">但是,患者拒绝使用激素,也拒绝用免疫抑制剂,无论我们怎么做工作也不听,只同意使用降压药治疗。最后,我们给他用缬沙坦+苯磺酸氨氯地平治疗。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">出院半年后复查,病情还算稳定。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">这下可好,患者就开始“放飞自我”,把医生的话放在一边。降压药基本上也停了,可能想起来就吃一片苯磺酸氨氯地平,不再用缬沙坦。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">饮食无节制,酒更是没停过。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">出院一年后又复查一次,病情也还稳定,见图4-5。</span></section><section><br/></section><section></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED9B9FFD1F3898F229.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 556px ; visibility: visible ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图4:患者1年后的复查检查单</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED9C9F8EE8305DD944.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 556px ; visibility: visible ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图5:患者1年后的复查检查单</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者以为万事大吉了,此后再也没复查。<br/></span></section><section><br/></section><section><section><section><section><section><section><section><section></section></section></section></section></section><section><section><section><section><section></section></section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">放纵自己后,3年就进展到了尿毒症期</span></p></section></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者自觉疲乏无力,下肢水肿,恶心,没有食欲,这种情况持续了一周,于是来我院复查,你猜怎么着?</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">检查发现,患者血压160/100mmHg,血肌酐1800µmol/L,血红蛋白62g/L,而且有严重的代谢性酸中毒,已经进展到尿毒症期了,同时合并有严重的肾性贫血、心衰等,见图6-8。</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED9DBF3E263F416632.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 556px ; visibility: visible ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图6:患者检查单</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img img_loading" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4ED9F1128D304B2DC70.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; border: 1px solid rgb(238, 237, 235); background-size: 22px ; background-position: center center ; background-repeat: no-repeat ; height: 278.487px ; width: 556px ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图7:患者检查单</span></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1A30180D4EDA07205710AEC9EBD.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 556px ; visibility: visible ;"/></section><section style="text-align: center;"><span style="line-height: 28px; color: rgb(136, 136, 136); font-size: 13px;">图8:患者检查单</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者3年就发展到尿毒症,真的太可惜了!<br/></span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">那么你知道IgA肾病有哪些特点吗?还有,为什么我说他太可惜了?</span></section><section><br/></section><section><section><section><section><section><section><section><section></section></section></section></section></section><section><section><section><section><section></section></section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">什么是IgA肾病?</span></p></section></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA是一种免疫球蛋白,主要分布在呼吸道黏膜、消化道黏膜和尿道黏膜等。免疫球蛋白相当于人体的“军队”,而IgA类似于“边防军”,主要负责人体防御的第一道防线。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">呼吸道、消化道、尿道等部位反复的感染,比如慢性扁桃体炎等,IgA就和细菌等“入侵者”同归于尽,形成大量含有IgA的感染复合物。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">感染复合物随血液循环流到肾脏,因复合物的分子量较大,无法通过肾小球的滤过膜而沉积在那里,人体的免疫系统在清除这些复合物的同时,误伤了肾小球滤过膜。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">所以,呼吸道、肠道、尿道等黏膜反复炎症可诱发IgA肾病。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">激素以及免疫抑制剂可以抑制这种损伤,保护未受到损伤的肾小球免于伤害。这就是为什么IgA肾病患者要使用激素或者免疫抑制剂。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA肾病是我国最常见的一种肾小球肾炎,也是目前我国尿毒症的主要原因,因为相比其他类型的肾小球肾炎,IgA肾病的进展比较快,容易发展到肾衰、尿毒症,所以IgA肾病患者一定要积极治疗。据统计,大约20%的IgA肾病患者在10年内发展为慢性肾衰竭。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA肾病多发于年轻人,常于呼吸道感染、肠道感染或者尿路感染后发病,主要表现为血尿、蛋白尿、高血压等,大约40%~50%患者表现为发作性肉眼血尿。最终需要肾穿刺进行确诊。</span></section><section><br/></section><section><section><section><section><section><section><section><section></section></section></section></section></section><section><section><section><section><section></section></section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">IgA肾病如何治疗?</span></p></section></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA肾病的治疗措施包括:抑制免疫、严格控制血压、减低蛋白尿、延缓肾脏病进展等。</span></section><section><br/></section><section><section><section><section><section style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">抑制免疫:</span></strong></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">由于自身免疫是导致肾损害的主要原因,所以IgA肾病常需要免疫抑制治疗。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">一般建议,尿蛋白定量≥1g/d,或者病理检查出现新月体,就应该使用激素治疗。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">激素的使用剂量为泼尼松1mg/kg/d,或者甲泼尼龙以0.8mg/kg/d,足量治疗一个月后剂量递减,总疗程6~12个月。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">积极使用激素治疗,可延缓IgA肾病的进展。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">根据相关诊疗指南,肾功能不全的IgA肾病患者,如果血肌酐为130~260µmol/L,且病理以活动性病变为主,应使用糖皮质激素+环磷酰胺治疗。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">患者3年前的病情符合这种情况,但是他拒绝使用激素和免疫抑制剂。</span></section><section><br/></section><section><section><section><section><section style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">严格控制血压、降尿蛋白治疗:</span></strong></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA肾病以及其他慢性肾脏病大多会出现高血压,我们称肾性高血压。控制血压是各种肾脏病最核心的治疗措施之一,应贯穿于肾病治疗始终。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">指南明确要求,将慢性肾脏病的血压控制在130/80mmHg以下,首选沙坦类或者普利类降压药。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">降压治疗既可抑制高血压对肾小球的损伤,又可显著延缓肾病进展,而且普利类或者沙坦类降压药还具有明确的降尿蛋白作用。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">此外,多数患者需服用2种或多种药物来控制血压,常联合的药物有长效钙拮抗剂,以及利尿剂、β-受体阻滞剂和其他降压药等。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">大剂量使用沙坦类或者普利类降压药,积极的控制血压,可延缓IgA肾病进展。</span></section><section><br/></section><section><section><section><section><section style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">消肿:</span></strong></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">给予噻嗪类利尿剂或者袢利尿剂,可排除患者体内多余液体,有助于控制血压,与沙坦或普利类降压药联合使用,可增加降压疗效。</span></section><section><br/></section><section><section><section><section><section style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">抗感染:</span></strong></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">对同时存在的细菌感染,可使用抗菌素抗感染治疗。</span></section><section><br/></section><section><section><section><section><section style="text-align: justify;"><strong><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">饮食控制:</span></strong></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">肾功能下降的患者,建议采用低盐低脂优质低蛋白饮食,以减轻肾脏负担,延缓肾病进展。</span></section><section><br/></section><section><section><section><section><section><section><section><section></section></section></section></section></section><section><section><section><section><section></section></section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">一意孤行,终食苦果!</span></p></section></section></section></section></section></section><p><br/></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">IgA肾病尽管相对较重、进展较快,但却是可控的。如果治疗及时得当,只有极少数IgA肾病患者会发展到尿毒症。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">但是,医生给这位患者制定的治疗措施,他几乎都没有执行。</span></section><section><br/></section><section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">1、拒绝使用激素和免疫抑制剂;</span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);"><br/></span></p><p style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">2、没有监测和控制血压;</span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;"><br/></span></p><p style="text-align: justify;"><span style="color: rgb(0, 0, 0); font-size: 16px;">3、缺乏自我管理,饮食不控制,没有定期复查。</span><br/></p></section></section></section></section><p><br/></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">这三大失误是患者发展到肾衰的最主要原因。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">而如果做得好,这些都是完全可以避免的。疏忽大意,放任疾病的发展,让他不得不吞下苦果。</span></section><section><br/></section><section><section><section><section><section><section><section><section></section></section></section></section></section><section><section><section><section><section></section></section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">肾内科大夫想说的话</span></p></section></section></section></section></section></section><p><br/></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">这个病例看似是一个偶然现象,但却是许多人,普遍存在的健康误区。</span></section><p><br/></p><section><section><section><section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">1、不信任医生:总是对医生的建议持怀疑态度,到最后受害的还是自己。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">2、“妖魔化”激素:临床上经常遇到这样的情况,一说用激素,患者便一口回绝。激素的确有许多副作用,但激素的作用任何药都不能取代。其实,患者应该心里有把秤,是激素的副作用大,还是疾病的危害大?并且,医生使用激素,都是严格依据指南和大数据调查结果,规范给药的。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">3、急功近利:浮躁的社会,许多人急功近利,反映在疾病治疗上,就是总幻想有某一种神奇的“秘方、偏方、特效药”,可以药到病除,一劳永逸,而忽视对疾病的长期控制和自我管理。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">慢性病都需要终身控制和医患双方的共同管理,哪有“根治”的好事。</span></section></section></section></section></section><p><br/></p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">定期体检早发现,根据规范正规治疗,不要再误导自己!</span></section><!--auditorInfo-->

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