如何诊治与预防结石？

h2span style="font-size: 16px;"如何诊治与预防结石？/spanbr//h2divpspan style="font-size: 16px;"尿石症是临床的常见疾病。研究表明，我国部分地区尿石症发病率为4.9%-9.8%，且处于逐年上升的状态，临床上泌尿系结石以草酸钙结石为常见。/span/ppspan style="font-size: 16px;"尿石症的复发率较高，尿石症患者往往迫切的需要得到临床医生的帮助。br//span/ppspan style="font-size: 16px;"在临床上接诊尿石症患者时，首先应对患者进行结石成分分析，然后进行代谢评估，据评估结果选择治疗方式。/span/psectionbr//sectionsectionsectionsectionsectionpspan style="font-size: 16px;"如何诊断尿石症？/span/p/section/section/section/sectionsectionsectionbr//sectionpspan style="font-size: 16px;"尿石症是临床的常见疾病。研究表明，我国部分地区尿石症发病率为4.9%-9.8%，且处于逐年上升的状态，临床上泌尿系结石以草酸钙结石为常见。/span/ppspan style="font-size: 16px;"尿石症的复发率较高，尿石症患者往往迫切的需要得到临床医生的帮助。br//span/ppspan style="font-size: 16px;"在临床上接诊尿石症患者时，首先应对患者进行结石成分分析，然后进行代谢评估，据评估结果选择治疗方式。/span/psectionspan style="font-size: 16px;"尿石症诊断四大要素：br//span/sectionsectionspan style="font-size: 16px;"1、结石本身的诊断：包括其部位、性质、形状、大小和数目；/span/sectionsectionspan style="font-size: 16px;"2、结石并发症诊断：尿路感染、尿路梗阻、肾绞痛及肾功能损害；/span/sectionsectionspan style="font-size: 16px;"3、结石性质的诊断：结石成分病理；/span/sectionsectionspan style="font-size: 16px;"4、结石病因的诊断：局部性尿路畸形；全身性代谢异常、基因诊断。/span/section/sectionsectionsectionsectionsectionsectionpbr//p/section/section/sectionsectionsectionpspan style="font-size: 16px;"结石成分分析/span/p/section/section/section/sectionsectionsectionsectionsectionsectionpbr//p/section/section/sectionsectionsectionpspan style="font-size: 16px;"尿石症的病因/span/p/section/section/section/sectionsectionsectionsectionpspan style="font-size: 16px;"高钙尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"指尿钙排泄量＞5mmol200mg/24h。/span/sectionsectionspan style="font-size: 16px;"1、吸收性高钙尿：/span/sectionsectionspan style="font-size: 16px;"I型非饮食依赖型：严重，无论摄钙量多少，高钙尿持续存在/span/sectionsectionspan style="font-size: 16px;"II型饮食依赖型：只在摄钙量多时尿钙才升高，反之则降低/span/sectionsectionspan style="font-size: 16px;"III肾漏磷型：由于肾磷阈低而使肾漏磷/span/sectionsectionspan style="font-size: 16px;"2、肾性高钙尿肾漏钙：肾小管的钙重吸收功能缺陷导致发病。/span/sectionsectionspan style="font-size: 16px;"3、重吸收性高钙尿：甲状旁腺机能亢进导致发病。br//span/section/sectionsectionsection/section/sectionsectionsectionsectionpspan style="font-size: 16px;"高草酸尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"指尿草酸排泄量＞0.5mmol45mg/24h。 /span/sectionsectionspan style="font-size: 16px;"1、原发性先天性高草酸尿：由常染色体隐性遗传，肝脏内源合成草酸增加导致发病，以尿酸排泄量重度升高，＞100mg/24h为特点，可能会有父母近亲结婚、儿童期发病、肾钙化、肾功能衰竭等病史。/span/sectionsectionspan style="font-size: 16px;"I型：丙氨酸-乙醛酸转氨酶AGT/span/sectionsectionspan style="font-size: 16px;"II型：乙醛还原酶GR或羟基丙酮酸还原酶HPR/span/sectionsectionspan style="font-size: 16px;"III型：4-羟基-2-酮戊二酸醛缩酶HOGA1/span/sectionsectionspan style="font-size: 16px;"2、继发性肠源性高草酸尿：因肠道疾病或肠短路综合征，肠道外源吸收草酸增加导致发病。br//span/sectionsectionspan style="font-size: 16px;"其发病与肠道疾病造成未吸收的脂肪增多，与钙结合后皂化作用使游离草酸的吸收率增加、多余的胆盐使肠道对草酸的通透性增高及草酸菌数量减少导致肠内草酸的降解减少有关。/span/sectionsectionspan style="font-size: 16px;"3、特发性轻度代谢性高草酸尿：病因不明，推测与细胞膜的磷酸化功能障碍有关，其特点为尿草酸排泄轻度升高，约为45-60mg/24h。/span/section/sectionsectionsection/section/sectionsectionsectionsectionpspan style="font-size: 16px;"高尿酸尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"指尿尿酸排泄量＞4.0mmol/24h。  /span/sectionsectionspan style="font-size: 16px;"因蛋白摄入过多和/或体内尿酸合成过多导致发病，其特点为高尿酸性草酸钙结石HUCN。/span/section/sectionsectionsection/section/sectionsectionsectionsectionsectionpspan style="font-size: 16px;"低枸橼酸尿/span/p/sectionsectionbr//section/section/section/sectionsectionsectionspan style="font-size: 16px;"指枸橼酸尿排泄量320mg/24h。/span/sectionsectionspan style="font-size: 16px;"其发病机制为抑制因子及络合因子。/span/sectionsectionspan style="font-size: 16px;"单纯由尿枸橼酸过低引起的结石只占10%，其余的多合并其他各种代谢紊乱。/span/section/sectionsectionsection/section/sectionsectionsectionsectionpspan style="font-size: 16px;"低镁尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"指尿镁排泄量＜3.0mmol/24h。/span/sectionsectionspan style="font-size: 16px;"因脂肪泻镁与肠道内脂肪形成“镁皂”，影响其吸收和/或镁摄入过少如长期禁食导致发病。/span/sectionsectionspan style="font-size: 16px;"镁是结晶抑制因子之一，降低时可造成尿中草酸钙形成。/span/section/sectionsectionsectionsectionsectionsectionpbr//p/section/section/sectionsectionsectionpspan style="font-size: 16px;"尿石症的评估/span/p/section/section/section/sectionsectionsectionsectionpspan style="font-size: 16px;"简化评估法/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"简化评估法适用于所有结石患者。/span/sectionsectionspan style="font-size: 16px;"1、影像检查：包括KUB、US、CT等。/span/sectionsectionspan style="font-size: 16px;"影像学检查的主要目的是对结石性质进行初步定性及作出经验性判断。/span/sectionsectionspan style="font-size: 16px;"2、常规检验：包括血常规、尿常规、血生化、电解质等。/span/sectionsectionspan style="font-size: 16px;"常规检验的目的主要是诊断或排除重要的结石病因：/span/sectionsectionspan style="font-size: 16px;"血钾↓：提示肾小管性酸中毒/span/sectionsectionspan style="font-size: 16px;"血钙↑：提示甲状旁腺机能亢进/span/sectionsectionspan style="font-size: 16px;"血尿酸↑：提示痛风及血症" 高尿酸血症/span/sectionsectionspan style="font-size: 16px;"血细胞过度异常：提示血液病/span/sectionsectionspan style="font-size: 16px;"3、结石分析：结石红外光谱自动分析系统。/span/sectionsectionspan style="font-size: 16px;"结石分析的目的主要是据结石分析结果提供结石病因诊断和预防建议。/span/section/sectionsectionsection/section/sectionsectionsectionsectionpspan style="font-size: 16px;"评估法/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"评估的主要目的是进一步诊断各种代谢紊乱如高钙尿、高草酸尿、高尿酸尿、低枸橼酸尿等以及据具体病因进行个体化防治。/span/sectionsectionspan style="font-size: 16px;"1、简化评估/span/sectionsectionspan style="font-size: 16px;"2、甲状旁腺素PTH/span/sectionsectionspan style="font-size: 16px;"3、24h尿分析/span/section/sectionsectionsection/section/sectionsectionsectionsectionpspan style="font-size: 16px;"特殊评估方法/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"1、钙负荷试验：用于区分高钙尿的亚型/span/sectionsectionspan style="font-size: 16px;"2、氯化铵试验/span/sectionsectionspan style="font-size: 16px;"3、基因检测：用于确诊原发性高草酸尿等/span/section/sectionsectionsectionsectionsectionsectionpbr//p/section/section/sectionsectionsectionpspan style="font-size: 16px;"尿石症的治疗/span/p/section/section/section/sectionsectionsectionsectionpspan style="font-size: 16px;"吸收性、肾性高钙尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"双氢克尿噻可以增加远端肾小管对钙的重吸收，从而降低尿钙的排泄，适用于中、重度高钙尿，尿钙8mmol/24h的患者。用药过程中注意补钾，可与枸橼酸钾合用。/span/section/sectionsectionsectionsectionpspan style="font-size: 16px;"重吸收性高钙尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"重吸收性高钙尿多由原发性甲状旁腺机能亢进导致发病，因此治疗手段可选择甲状旁腺切除。/span/section/sectionsectionsectionsectionpspan style="font-size: 16px;"原发性高草酸尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"原发性高草酸尿患者可使用维生素B6使尿中草酸排泄量达正常40mg/24h。/span/sectionsectionspan style="font-size: 16px;"对于双肾钙化已发展为肾功能衰竭者，可选择肝肾联合移植，正常肝脏可使乙醛酸代谢正常，同时可预防移植肾再形成结石。/span/section/sectionsectionsectionsectionpspan style="font-size: 16px;"继发性高草酸尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"钙离子能结合肠道中的游离草酸，减少草酸的肠吸收，从而降低其在尿中的排泄，而枸橼酸盐是草酸钙结晶的抑制因子和络合因子，因此继发性高草酸尿可使用枸橼酸钙，药物剂量应随尿钙而定。/span/section/sectionsectionsectionsectionpspan style="font-size: 16px;"高尿酸尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"别嘌呤醇可通过抑制黄嘌呤转化酶来阻止次黄嘌呤向黄嘌呤及尿酸的转化，从而减少尿酸的产生，适用于血尿酸＞8mg/dl，尿尿酸＞800mg/d的高尿酸尿患者。/span/section/sectionsectionsectionsectionpspan style="font-size: 16px;"低枸橼酸尿/span/p/sectionsectionbr//section/section/sectionsectionsectionspan style="font-size: 16px;"枸橼酸钾可抑制因子增加尿中枸橼酸盐排泄，亦可络合因子与钙结合，形成枸橼酸钙，间接降低尿中草酸钙的饱和度，且血液碱化可降低骨骼脱钙，减少尿钙排泄，适用于尿枸橼酸排泄量＜2.5mmol320mg/24h或轻度高尿钙5-8mmol/24h且普通饮食不能将尿钙排泄降至5mmol/24h以下的低枸橼酸尿患者。/span/section/sectionsectionsectionsectionsectionsectionpbr//p/section/section/sectionsectionsectionpspan style="font-size: 16px;"如何预防尿石症？/span/p/section/section/section/sectionsectionsectionspan style="font-size: 16px;"1、注意摄钙平衡。/span/sectionsectionspan style="font-size: 16px;"我国的摄钙量为800mg/日，一般居民的平均摄入量为309mg/日。/span/sectionsectionspan style="font-size: 16px;"限钙量：轻度限钙为800mg/日，中度限钙为600mg/日II型吸收性高钙尿，重度限钙为400mg/日。/span/sectionsectionspan style="font-size: 16px;"2、限制草酸的摄入。/span/sectionsectionspan style="font-size: 16px;"忌食大黄、芒果、菠菜、芝麻等，同时限食巧克力、茶叶、坚果包括花生、杏仁、核桃等等。/span/sectionsectionspan style="font-size: 16px;"3、限制蛋白的摄入。/span/sectionsectionspan style="font-size: 16px;"蛋白是高钙尿的“推动力”，限食蛋白可以降低尿钙排泄量，同时也可减少尿酸形成，食用量为生肉或鱼80g/日。/span/sectionsectionspan style="font-size: 16px;"4、限制钠盐的摄入。/span/sectionsectionspan style="font-size: 16px;"尿中钠离子的排泄与钙离子呈正相关，每日钠离子摄入量应低于2g。/span/section/section/divpbr//p