三聚氰胺所致婴幼儿尿路结石的综合治疗分析

目的 总结含三聚氰胺配方奶粉所致婴幼儿尿路结石的治疗手段及疗效.方法 有三鹿奶粉喂养史尿路结石患儿228例.男165例,女63例,年龄4个月～3岁.平均11个月.双肾结石144例.单侧肾结石54例.结石直径0.5～2.5 cm;双侧输尿管结石合并中重度肾积水8例.一侧输尿管结石合并中重度肾积水7例,结石直径0.4～lI 1 cm;膀胱结石合并尿潴留5例,尿道结石合并尿潴留10例,结石直径O.5～1.3 cm.患儿均经B超、CT检查确诊.分4组:①肾功能衰竭组15例(6.6%),少尿5～10 d 2例、无尿1～5 d 13例,实验室检查BUN平均32一mmol/I,SCr平均750μmol/L.13例采用经尿道输尿管镜下碎石、碱性药物溶石、双J管置入术,术后碱性药物溶石治疗;2例在B超引导下行经皮肾穿刺造瘘引流术、肾盂内间歇性碱性药物灌洗溶石.②输尿管结石合并中重度肾积水15例,行输尿管镜下碎石清石、双J管置入术及碱性药物溶石治疗.③膀胱、尿道结石合并急性尿潴留15例,采用经尿道输尿管镜下第三代碎石清石系统碎石清石.④单纯肾结石183例,采用碱性药物治疗1～8周.其中113例口服碳酸氢钠片0.15 g,2次/d;23例口服柠檬酸氢钾钠2.4 g/d;47例口服10%柠檬酸钾溶液,5 m1,3次/d.61例经碱性药物治疗＞8周疗效差者行ESWL及碳酸氢钠注射液溶石治疗,尿pH＞7.5时停药.对有肾功能损害患儿每天复查肾功、电解质直至正常.228例患儿随访1～3个月.统计数据采用SPSS 13.0软件分析.结果 组①患儿术后12～24 h内即出现多尿,多尿期持续24～72 h.尿量800～2500 ml/24 h,术后48～96 h尿量逐渐恢复正常,术后1～5 d BuN及SCr均恢复正常,1～2周4例肾、输尿管结石基本排净,2～4周15例结石全部排净.组②患儿治疗后1～2周结石完全排净.组③患儿经微创手术均一次性清除结石,立即恢复正常排尿,3 d后复查B超,膀胱、尿道内均无残余结石.组④经碳酸氢钠治疗组结石2周排净4例,4周排净18例,13周排净15例,8周后结石明显变小变淡34例,结石无明显变化42例;口服柠檬酸氧钾钠治疗组结石1周排净4例,2周排净7例,4周排净10例,6周排净2例;口服10%柠檬酸钾溶液组结石1周排净3例.2周排净5例,4周排净16例,8周排净11例,8周后结石明显变小变淡8例,结石无变化4例.柠檬酸盐治疗组与碳酸氢钠治疗组疗效比较差异有统计学意义(P-O.001),柠檬酸盐组内比较差异无统计学意义(P=0.372).61例患儿行ESWL及继续碱性药物溶石治疗患儿1～6周结石排净49例,结石缩小8例,无明显变化4例.结论 三聚氰胺所致婴幼儿尿路结石早期以内科观察治疗为主,发生急性肾功能衰竭、输尿管中重度积水及下尿路急性梗阻时应以外科干预为主,解除梗阻、保护肾功能、恢复正常排尿.治疗后期,结石特点发生变化,单纯碱性药物治疗无效者应采用ESWL治疗.

Comprehensive therapy of the infant urinary calculus induced by melamine

Objective To explore the comprehensive therapy of infants with urinary calculus induced by melamine.Methods Clinical data of 228 infants(aged from 4 months to 3 years,mean age 11 months)with urinary calculus induced by melamine were analyzed. Bilateral renal calculi were found in 144 cases and one-side renal calculus in 54 cases,of which the diameter ranged from 0.5-2.5 cm.Ureteral calculi with moderate to severe hydronephrosis were found in 15 cases,of which the diameter ranged from 0.4-1.1 cm. Bladder calculi with urinary retention were found in 5 cases and urethral calculi with urinary retention in 10 cases,of which the diameter ranged from 0.5-1.3 cm. All the urinary calculi were confirmed by B-uhrasound examination and CT. Group 1 : Of the 15 cases with acute renal failure, 13 underwent shattering and dissolving renal and ureternal calculus by pelvis clysis with alkalinity drug, detaining double J tubes through ureteroscope. After operation, these patients were treated with alkalinity drugs. Two cases were treated by percutaneous nephrostomy guided by B ultrasound and underwent shattering and dissolving renal calculus by intermittent pelvis clysis with alkinity drug. Group 2:15 cases of ureteral calculus with serious nephrohydrops underwent shattering and detaining double J tubes through ureteroscope, then treated with alkalinity drug. Group 3:15 cases of infant bladder and urethral caleus with acute urinary retention were treated by EMS through ureterscope per urethra. Group 4: The rest 183 cases without urinary obstruction received 1-8 week'surine alkalization therapy. Among them, 113 cases received sodium bicarbonate 0.15 g twice per day,23 cases received potassium sodium hydrogen citrate 2.4g/d, and 47 cases received 10% potassium citrate solution 5 ml 3 times per day. Sixty-one cases who were of no effect with alkalinity drug were treated by extracorporeal shock wave lithotripsy (ESWL) and dissolving calculus with sodium bicarbonate. During treatment with alkalinity drug, urine Ph was observed by urine analysis once per day.When it exceeded 7.5, alkalinity drug. Was withdrawn. All the patients were followed up for 1 to 3 months. Statistical analysis was done with the SPSS 13.0 software. ResultsHyperdiuresis emerged 12-24 h after operation in group 1. The duration of hyperdiuresis was 24-72 h with the urine volume of 800-2500 ml/24h. Urine volume revived gradually 48--96h after operation while serum BUN and Cr revived 1-5 d after operation. Four cases with renal and ureteral calculus became almost stone-free in 1-2 weeks and 14 cases became completely stone-free in 2-4 weeks after operation. Patients of group 2 became completely stone-free in 1-2 weeks. Patients of group 3 were cured by one EMS session through ureterscope per urethra and smooth urination was seen immediately after operation. No retained calculus in the bladder and urethra was found by B ultrasound 3 days later. In the sodium bicarbonate group, 4 cases became completely stone-free in 2 weeks, 18 cases in 4 weeks, 15cases in 13 weeks. The stones lessened and faded in 34 cases and had no changes in 42 cases. In the potassiun sodium hydrogen citrate group, 4 cases became completely stone-free in 1 weeks, 7 cases in 2 weeks, 10 cases in 4 weeks, 2 cases in 6 weeks. In the potassium citrate group, 3 cases became completely stone-free in 1 weeks, 5 cases in 2 weeks, 16 cases in 4 weeks, 11 cases in 8 weeks. The stones lessened and faded in 8 cases in 8 weeks and had no changes in 4 cases. The efficacy of the sodium bicarbonate group was significantly different with the efficacy of the citrate group (P=0. 001). No significant difference was found between the potassium sodium hydrogen citrate group and the potassium citrate solution group(P=0. 372). ConclusionsConservative treatment should be employed mainly in the earlier stage for the infant urinary calculus induced by melamine . When the diagnosis of acute renal failure, moderate to severe hydronephrosis and acute lower urinary tract obstruction are established, surgical intervention should be the main method to relieve obstruction, protect renal function and resume normal rnicturition. With the development of the characteristics of the stones later,the oral dissolution therapy with alkalirtity drug could not dissolve the calculi and ESWL should be employed.