泌尿系结核并发慢性肾脏病的临床分析(附三例报告)

doi:10.3969/j.issn.2095-3755.2017.03.000

摘要/Abstract

摘要： 目的探讨泌尿系结核并发慢性肾脏病的诊治，为早期精准诊断治疗泌尿系结核提供思路。方法搜集2016年1月至2016年12月沈阳市胸科医院（沈阳市第十人民医院）收治的3例泌尿系结核并发慢性肾脏病患者的临床资料，3例患者均为农民，年龄分别为52、53和67岁。对3例患者的就诊史，各项相关检查及治疗史进行分析。结果 3例患者的确诊延误时间达5～10年。临床症状和体征：例1主要以“尿频、尿急、夜尿增多”为主；例2“肉眼血尿、尿失禁”明显；例3则以“发热、乏力”症状就医。3例均有长时间多次泌尿系感染或前列腺疾病的误诊误治史。例1和例2患者均有并发肺结核的影像学改变，但无相关临床表现。例1表现为无菌性脓尿、蛋白尿，尿液Xpert MTB/RIF结核分枝杆菌检测、DNA扩增定性检测、结核分枝杆菌快速培养(BACTEC MGIT 960)及结核分枝杆菌抗原MPB64测定均阳性。例2表现为严重血尿，尿液涂片、培养等细菌学检查均阴性。例3呈酸性尿改变，尿液涂片、培养等细菌学检查均阴性。例1行肾脏CT平扫，提示双肾多发空洞，一侧肾损伤并发对侧肾盂积液及输尿管扩张。例2行泌尿系统增强CT扫描，显示一侧肾毁损，对侧肾盂肾盏及输尿管全程扩张积液，膀胱挛缩伴膀胱壁弥漫性增厚。例3行肾脏MRI检查：双肾见多发囊状信号影，右肾萎缩，左肾实质变薄。例1通过尿液Xpert MTB/RIF检测阳性确诊；例2右肾切除术后病理检测确诊；例3通过泌尿系统MRI检查而临床诊断。本组的例1和例3患者已进入慢性肾脏病5期，抗结核用药选用了一线抗结核药物异烟肼、利福平及二线氟喹诺酮类药物中的莫西沙星，同时辅助血液透析替代治疗；例1因尿酸处正常值范围，加用了吡嗪酰胺。例2为慢性肾脏病3期泌尿系结核患者，选择了异烟肼、利福喷丁、吡嗪酰胺化疗方案。随访6个月至1年，3例患者均有效控制病情，目前病情平稳。结论泌尿系结核长期延误诊断易造成肾脏毁损并发慢性肾脏病，应引起泌尿科及结核科医生的重视。

Abstract: Objective To investigate the diagnosis and treatment of urinary tuberculosis complicated with chronic kidney disease and provide guides for the accurate treatment of urinary tuberculosis. Methods To collect the clinical data of three patients suffered urinary tuberculosis complicated with chronic kidney disease hospitalized from Jan.2016 to Dec.2016 in tuberculosis department of the Tenth People’s Hospital ,Shenyang. the history of medicationand treatment was analyzed in three patients who were farmers Results The 3 cases was delayed diagnosis from 5 to 10 years. Case 1 mainly presented with "urinary frequency, urgency, nocturia"; Case 2 had symptoms of" hematuria, urinary incontinence"; Case 3 with "fever, weak". All 3 patients had a long misdiagnosed history as other urinary tract bacteria infections or prostate disease and accepted an unfavorable treatment Cases 1 and 2 had imaging changes of pulmonary tuberculosis, but no symptom. Case 1 showed sterile pyuria, proteinuria, Xpert Mtb / RIF test, DNA amplification qualitative test, Mycobacterium tuberculosis rapid liquid culture (BACTEC MGIT 960) and Mycobacterium tuberculosis antigen MPB64 test in their urine specimen were all positive. Case 2 showed severe hematuria, urine tuberculosis-related test were negative. Case 3 had a acidic urine changes, urine tuberculosis-related examination was negative. The case 1’ showed bilateral multiple renal cavitation on his renal CT, unilateral kidney destruction，contralateral ureterohydronephrosis and extension. In Case 2 ,his CTU showed unilateral kidney damage, contralateral ureterohydronephrosis, contracted bladder presents with diffuse thickening of the bladder wall。 The feature of renal MRI in Case 3 was right autonephrectomy，bilateral multiple renal cavitation ,left renal parenchyma thinning. The three patients were diagnosed by urine Xpert Mtb / RIF positive test in case 1,’ histopathology of a sample obtained through renal surgery in Case 2; MRI imaging in Case 3, respectively. Two patients selected first-line drugs（isoniazid, rifampicin）and second-line fluoroquinolone（Moxisfloxacin）because of the chronic kidney disease stage 5, and hemodialysis alternative therapy., case 1 selected the same regiman but added pyrazinamide due to the normal range of uric acid. Case 2 suffered with urinary TB with chronic kidney disease stage 3, regimen of isoniazid, rifapentine, pyrazinamidewas selected. Followed up from 6 months to 1 year, 3 cases was stable. Conclusion Long-term diagnosis delay of urinary tuberculosis can easily lead to kidney damage,which should be noticed by urology doctors and tuberculosis doctors

陈禹,李桂琴. 泌尿系结核并发慢性肾脏病的临床分析(附三例报告)[J]. 结核病与肺部健康杂志, 2017, 6(3): 222-228. doi: 10.3969/j.issn.2095-3755.2017.03.000

CHEN Yu,LI Gui-qin. The analysis of diagnosis and treatment on urinary tuberculosis complicated with chronic kidney disease(3 cases report)[J]. Journal of Tuberculosis and Lung Health, 2017, 6(3): 222-228. doi: 10.3969/j.issn.2095-3755.2017.03.000

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