中山医学大学肾脏科.doc

中山醫學大學腎臟科 醫學生 Orientation 2007-12-07 Update (簡易版)一. Meeting(1.) Morning meeting : W3, 4 7:30AM9F衛教中心 / 會議室 (Clerk/Intern/Resident 請於前一天跟病房CR確認Case,新舊病歷皆需帶)(2.) Case conference by Dr. 林智廣 : W21:00PM4705 會議室 (請Resident跟 Dr. 林 確認預討論Case)(3.) Case conference by Dr. 吳勝文 : W23:00PM10F 會議室(Clerk/Intern請準備一位Case , 不一定要是腎臟科的)(4.) Journal meeting : 每W4下午 4: 00PM10F會議室(5.) 腎臟科基礎教學 : 每W5 下午 4: 00PM10F會議室(6.) 臨床病理討論及教學 : 每月第二個禮拜四 3: 00PM 10F會議室(7.) 腎臟科/泌尿科/放射科聯合討論 : 每W5 8:00 AM 1F 放射科(7.) Bedside teaching and 門診教學 : as schedule 二. 次分科病房見習課程時間表 : 見附件一三. 學習重點(1.) Edema/proteiuria/hematuria/urinalysis判讀(2.) Hyper/hyponatremia(3.) Hyper/hypokalemia (4.) Metabolic/respiratory acidosis/alkalosis ( ABG 判讀)(5.) Acute renal failure(6.) Chronic renal failure (esp diabetic nephropathy)(7.) Glomerular disease (Nephrotic syndrome and nephritic syndrome)(8.) Tubular disorders and tubulointerstitial disorders (9.) Vascular injury to kidney (10.) Replacement therapy of renal failure (A.) Dialysis therapy (hemodialysis and peritoneal dialysis ) (B.) Renal transplantation(11.) Nephrolithiasis (12.) Urinary tract infection and pyelonephritis (13.) Urinary tract obstruction腎臟內科學習指引綱要(Part I) Approach to the patient with renal disease(一) 尿液分析1. 如何判讀Dipstick各項結果？(protein, blood, sugar, pH, 比重, .等)，當Dipstick protein與Sulfosalicylic acid test兩者有差異時，代表什麼意義？2. 如何分辨glomerular或nonglomerular hematuria？3. 各類casts代表的意義如何？(二) 腎功能評估4. 測定glomerular filtration rate (GFR)的方法有那幾種？它的意義如何？ 那些因素會影響GFR的測定？5. 血液BUN / Creatinine正常比值約多少？那些狀況會造成比值上升或下降？(三) 影像學檢查6. 腎臟超音波檢查有那些功用(適用時機)？超音波強度與腎臟大小判讀的意義如何？7. Intravenous pyelograply (IVP)有那些功用？那些病人較可能發生contrast-induced nephropathy ?(四) 腎臟穿刺檢查8. 什麼是腎臟穿刺的適應症和禁忌？它可能造成什麼併發症？(Part II) 體液、電解質和酸鹼平衡9.Osmolality如何估計？如何Approach hyponatremia的病人？10. SIADH的原因和診斷要點是什麼？如何治療？11. 如何區分renal loss或extrarenal loss的hypokalemia？hypokalemia的治療準則如何？(如何估計補充量？如何給予？)12. Hyperkalemia的EKG變化如何？如何緊急處理嚴重病例？13. Anion gap是指什麼？正常範圍約多少？如何利用anion gap作metabolic acidosis的鑑別診斷？什麼情況才須補充NaHCO314. 如何利用volume status和urine chloride level來作metabolic alkalosis鑑別診斷？15. Hypercalcemia常見的原因有那些？intact parathyroid hormone (iPTH)及PTH-related protein (PTHrP)的診斷意義如何？16. Hypophosphatemia對全身各器官產生那些危害？(例如中樞神經、神經肌肉、血液、腎臟等)(Part III) Clinical Nephrology(一) 腎衰竭17.如何利用FeNa和urinary indices來作急性腎衰竭的鑑別診斷？18.那些狀況會使慢性腎衰竭病人產生急性惡化，須儘早矯治？19.那些措施可減緩GFR下降的速度？20.需要接受緊急透析的適應症(indications)有那些？21. Hemodialysis (HD)與continuous ambulatory peritoneal dialysis (CAPD)各有何優缺點？兩種透析式各有何併發症？22. CAPD腹膜炎如何診斷？其治療原則如何？23. 尿毒症病人發生congestive heart failure或pulmonary edema時如何診斷和治療？24. 那些常用藥物在腎臟衰竭病人身上須減量？25. 腎臟移植術前如何準備(HLA typing, Donor的選擇)?26. 腎臟移植的抗排斥藥物治療的種類和機轉如何?(二) 腎絲球病變27. Nephrotic syndrome (腎病症候群)的定義如何？請列舉其常見的發生原因？(依原發性或繼發性來區分)28. 那些腎絲球腎炎其血清補體有下降現象？29. IgA nephropathy的臨床和病理特徵如何？那些因素表示預後較差？30. 糖尿病腎病變的stage如何區分？那些措施可減緩它的progression？31. Lupus nephritis的WHO分類如何？那個分類預後最差？(三) 腎間質小管病變、腎血管病變等32.急性腎小管間質炎的臨床特點如何？導致此病的常見藥物有那些？33.Complicated urinary tract infections有那些特色？34. Autosomal dominant polycystic kidney disease(ADPKD)會造成那些併發症？影響其預後的因素有那些？35. 對懷疑患有繼發性高血壓病人需要安排那些檢查？利用captopril screening test診斷renal artery stenosis的criteria如何？四. 病房工作要點(1.) 住院常規 (A.) CBC, BUN, Cre, Na, K, GPT, Ac sugar (or DC, Alb, TP, Ca, P, UA, .) (B.) Urinalysis (C.) Chest X-ray ( or KUB) (D.) 12 lead ECG (E.) Record body weight or urine output or input (F.) Inspect and review the necessity of current drugs and the correlation with diagnosis every day (G.) Set therapeutic goal and preparation for discharge (2.)個別疾病常規 (A.) Acute renal failure - survey medical history, drug history, family history, .- Exclude post-renal etiology by physical exam, KUB, urinary catheterization or renal echo- Check FENa, urine-osmo or urine-Na to differentiate pre-renal and intrinsic etiology - correct precipitated factors and keep adequate urine output by diuretics if needed ( hydration may be needed but cautiously in oligouric or anuric patient(B.) Chronic renal failure or end stage renal stage - collect 24-H urine for Ccr and daily urine protein - check HbsAg, anti-HCV, anti-HIV, VDRL, intact-PTH, ferritin, Fe, TIBC, Mg, Ca, P, ABG ( esp for dialysis) - renal echo - EPO for anemia after correction of iron deficiency if existence - CaCO3/VitD3(Macolol or Alfarol) for hypocalcemia and Ulcerin for hyperphosphotemia(C.) Electrolyte imbalance - collect serum/urine biochemistry (serum/urine osmolarity, Na, K, Cl, 24 hour urine K, or ABG) before therapy as possible according to individual disease - follow electrolyte daily till stabilization or normalization (D.) Nephrotic syndrome or glomerulonephritis - collect 24-H urine for Ccr and daily urine protein - check ANA, C3, C4, IgG/A/M, HbsAg, anti-HCV, anti-HIV, Alb, TP, TG/Chol(NPO at least 8 hours), or ANCA if needed - perform serum/urine electrophoresis and immunoelectrophoresis(E.) Work-up for renal biopsy (a.) Prepare for renal biopsy - check coagulation status including platelet, PT, APTT, and bleeding time - survey any absolute or relative contraindication for renal biopsy - explain the risk/配合事項 to the patient and family - DDAVP 4amp IVD or analgesic( ex Demerol IM ) before biopsy if needed (b.) Post biopsy - bed rest and wound compression strictly and check vital sign as order - follow urinalysis and renal echo the next day(F.) Renal transplantation - Three combined therapy : Tacrolimus(FK506)/cyclosporine, Mycophenolate(Cellcept), and steroid ; (+ Baktar) - check body weight and urine output daily - check Cre level and drug level ( FK506 and C2 level) if deteriorated renal function, drug interaction, or adjustment of dosage of immunosuppressive drugs - survey precipitated factors of deteriorated graft kidney function - Rescue therapy : MTP and ATG 五. 醫學生需注意/ 完成事項(1.) 依照resident 分配完成primary care patient 的 general history, progress note(2.) 完成morning meeting, Bedside teaching and 門診教學記錄(3.) 查房及meeting要準時出現,且查房時要主動向attending報告病人情況/data(4.) 請實習醫師詳實記錄Special chart上的Lab data results，包括門診及急診data(5.) 幫忙通知下一梯醫學生提前找ward CR報到Classification and Major Causes of Acute Renal Failure (ARF)PRERENAL ARFI. HypovolemiaA. Hemorrhage, burns, dehydrationB. Gastrointestinal fluid loss: vomiting, surgical drainage, diarrheaC. Renal fluid loss: diuretics, osmotic diuresis (e.g., diabetes mellitus), hypoadrenalismD. Sequestration in extravascular space: pancreatitis, peritonitis, trauma, burns, severe hypoalbuminemiaII. Low cardiac outputA. Diseases of myocardium, valves, and pericardium; arrhythmias; tamponadeB. Other: pulmonary hypertension, massive pulmonary embolus, positive pressure mechanical ventilationIII. Altered renal systemic vascular resistance ratioA. Systemic vasodilatation: sepsis, antihypertensives, afterload reducers, anesthesia, anaphylaxisB. Renal vasoconstriction: hypercalcemia, norepinephrine, epinephrine, cyclosporine, tacrolimus, amphotericin BC. Cirrhosis with ascites (hepatorenal syndrome)IV. Renal hypoperfusion with impairment of renal autoregulatory responsesCyclooxygenase inhibitors, angiotensin-converting enzyme inhibitorsV. Hyperviscosity syndrome (rare)Multiple myeloma, macroglobulinemia, polycythemiaINTRINSIC RENAL ARFI. Renovascular obstruction (bilateral or unilateral in the setting of one functioning kidney)A. Renal artery obstruction: atherosclerotic plaque, thrombosis, embolism, dissecting aneurysm, vasculitisB. Renal vein obstruction: thrombosis, compressionII. Disease of glomeruli or renal microvasculatureA. Glomerulonephritis and vasculitisB. Hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, toxemia of pregnancy, accelerated hypertension, radiation nephritis, systemic lupus erythematosus, sclerodermaIII. Acute tubular necrosisA. Ischemia: as for prerenal ARF (hypovolemia, low cardiac output, renal vasoconstriction, systemic vasodilatation), obstetric complications (abruptio placentae, postpartum hemorrhage)B. Toxins1. Exogenous: radiocontrast, cyclosporine, antibiotics (e.g., aminoglycosides), chemotherapy (e.g., cisplatin), organic solvents (e.g., ethylene glycol), acetaminophen, illegal abortifacients2. Endogenous: rhabdomyolysis, hemolysis, uric acid, oxalate, plasma cell dyscrasia (e.g., myeloma)IV. Interstitial nephritisA. Allergic: antibiotics (e.g., -lactams, sulfonamides, trimethoprim, rifampicin), nonsteroidal anti-inflammatory agents, diuretics, captoprilB. Infection: bacterial (e.g., acute pyelonephritis, leptospirosis), viral (e.g., cytomegalovirus), fungal (e.g., candidiasis)C. Infiltration: lymphoma, leukemia, sarcoidosisD. IdiopathicV. Intratubular deposition and obstructionMyeloma proteins, uric acid, oxalate, acyclovir, methotrexate, sulphonamidesVI. Renal allograft rejectionPOSTRENAL ARF (OBSTRUCTION)I. UretericCalculi, blood clot, sloughed papillae, cancer, external compression (e.g., retroperitoneal fibrosis)II. Bladder neckNeurogenic bladder, prostatic hypertrophy, calculi, cancer, blood clotIII. UrethraStricture, congenital valve, phimosisUrine Diagnostic Indices in Differentiation of Prerenal versus Intrinsic Renal ARFTypical Findings in ARF Diagnostic IndexPrerenalIntrinsic RenalFractional excretion of sodium (%)a1Urine sodium concentration (mm