不典型肾结核的诊断治疗

目的探讨不典型肾结核诊断与治疗。方法回顾性分析2003年1月-2010年7月12例肾结核住院患者的临床资料。患者尿常规异常9例(75%);腰痛3例(25%);尿频8例(66.7%)。尿沉渣检查抗酸杆菌9例中阳性2例(22.2%);静脉尿路造影11例,患肾不显影7例(63.6%),提示肾结核2例(18.2%);逆行尿路造影7例,提示肾结核1例(14.3%);CT确诊8例(66.7%)。确诊肾结核后,12例患者中7例行手术治疗,5例行药物治疗。药物治疗患者中3例采用异烟肼、利福平加盐酸乙胺丁醇治疗,疗程为9个月;2例加用吡嗪酰胺,疗程为1年。手术治疗7例患者于抗结核治疗2周后行肾切除术,术后行抗结核治疗1～1.5年。治疗结束后随访尿查结核分枝杆菌6个月。结果异烟肼、利福平加盐酸乙胺丁醇药物治疗组3例中1例在9个月后复查时患肾损伤严重,行肾切除,另2例患者以及加用比嗪酰胺2例药物抗结核治疗后,活动性病灶消失,连续半年尿中未找见结核分枝杆菌。行肾切除手术的7例患者术中2例肾萎缩,5例患肾体积增大,均伴有不同程度肾积脓;肾切除术后病理均确诊为肾结核,合并输尿管结核2例,输尿管慢性炎症4例。7例手术患者术后行抗结核治疗,治疗结束后尿中均未找见结核分枝杆菌,影像学检查也未发现新发病灶。结论临床症状不典型及起病隐匿是导致肾结核延误诊疗的重要原因。彩色多普勒超声、静脉肾盂造影、逆行尿路造影是主要的检查方法,CT对肾结核的诊断具有重要价值。手术治疗上多以患肾切除为主。

Diagnosis and Treatment of Non-typical Renal Tuberculosis

Objective To explore the diagnosis and treatment of non-typical renal tuberculosis.Methods We retrospectively analyzed the clinical data of 12 patients with renal tuberculosis treated between January 2003 and July 2010.Among them,there were nine(75%) cases of abnormal routine urinalysis,three(25%) cases of lumbago,and eight(66.7%) cases of urinary frequency.Acid-fast stains of urinary sediment showed that there were two(22.2%) positive cases in the nine cases with abnormal routine urinalysis.Among the 11 patients undergoing intravenous urinary imaging,seven(63.6%) had invisible kidney,and the results indicated renal tuberculosis in two(18.2%) patients.Seven patients underwent retrograde urography which indicated renal tuberculosis in two patients.CT diagnosed renal tuberculosis in eight(66.7%) patients.After the disease was confirmed,seven patients underwent surgery,and five others accepted drug therapy.In the five patients with drug therapy,three had isoniazid,rifampicin,and ethambutol hydrochloride for nine months,and two had the three above-mentioned medicines added with pyrazinamide for one year.The seven surgery patients underwent nephrectomy two weeks after treatment of tuberculosis,and later accepted anti-tuberculosis treatment for 1 to 1.5 years.M.tuberculosis was detected in the six-month follow-up after the treatment.Results One of the three patients treated with isoniazid,rifampicin,and ethambutol hydrochloride had severe renal damage during re-examination,and underwent nephrectomy.The other two patients and two other patients treated with the three above-mentioned medicines added with pyrazinamide turned to be tuberculosis-negative stably as the active focuses of the disease disappeared and no M.tuberculosis was found for half a year.Among the seven nephrectomy patients,two had renal atrophy and five had kidney enlargement,and all of them were accompanied with various degrees of pyonephrosis.Pathological findings confirmed that the seven patients all had renal tuberculosis including two accompanied with ureter tuberculosis and four accompanied with chronic ureteritis.After anti-tuberculosis treatment,no M.tuberculosis was found in the seven patients,and no new disease focus was found,either.Conclusions The reason for delaying diagnosis and treatment of renal tuberculosis is that the patients lack specific clinical symptoms and the onset of the disease is not clear.Ultrasonography,intravenous urography(IVU),and retrograde urography(RU) are the main diagnostic methods,and CT has significant value among these methods.Nephrectomy is the major method of operation.