慢性腎臟病與急性腎衰竭

作者：李隆志

「醫生，我的腎臟壞了是不是要洗腎?」，「醫師，我的腎臟會不會好起來?」

這是我當腎臟科醫師十幾年來最常聽到的兩個問題，也是花最多時間解釋的問題之一。首先，要回答這個問題，必須先了解"慢性腎臟病"與"急性腎損傷"的定義。


慢性腎臟病(Chronic Kidney Disease, CKD)

顧名思義，腎臟是慢慢的壞掉的。K-DIGO將慢性腎臟病定義為腎臟受損已達三個月以上。腎臟在我們體內，看不到摸不到，那什麼可以是代表腎臟受損呢? 答案就是"腎絲球過濾率"(Glomerular Filtration Rate, GFR)下降及"蛋白尿"的產生，這兩者可以預測腎臟病的預後。

圖一、摘自台灣腎臟病臨床治療指引

K-DIGO將腎絲球過濾率分為五期，第一期:> 90、第二期:89-60、第三期:59-30、第四期: 29-15、第五期: <15，通常進入第五期後期產生尿毒的症狀(如噁心、嘔吐、全身癢)，就會需要接受透析治療。

一般而言，慢性腎臟病是不容易變好的。因為腎臟細胞受損後，部分細胞會死亡，腎絲球會硬化及間質纖維化。在臨床上比較會有貧血症及高磷，在影像上會看到腎臟萎縮。因此我們只能以飲食以及控制三高(血壓、血糖、血脂肪)來緩解腎功能的惡化。一旦有尿毒的症狀，需要透析(就是洗腎!)來治療，一開始尿還多時，還可以透析劑量少一些；一旦尿量減少了，便不容易再脫離洗腎了!


急性腎損傷(Acute Kidney Injury, AKI)

腎臟功能在幾天或幾星期內急速惡化，可能原因包括心臟衰竭、肝臟衰竭、藥物、顯影劑等等。臨床上貧血及高血磷較輕微。通常把造成急性腎損傷的因素移走，腎臟是有機會恢復的!

急性腎損傷也有分期，一般是以血清肌酸酐(serum creatinine)上升倍數或是尿液的多寡來分期，分級越高，表示傷害越嚴重。

圖二、急性腎損傷的分級

若是不幸腎功能惡化太嚴重，造成寡尿、高血鉀、肺積水、代謝性酸中毒或是尿毒症狀時，醫師也會介入透析治療，病人在急性期過後，是有可能會恢復的!但恢復的多寡，取決於病患年紀、腎衰竭前的腎功能、是否及時解決傷害的原因。但凡走過必留下痕跡，急性腎損傷久了之後也可能會進入慢性腎臟病，需要長期的追蹤照護!

個人簡歷

Name：李隆志 ,  Li/Lung-Chih

Specialist: 1.慢性腎臟病照護 2.代謝性腎臟病:糖尿病腎病變、腎性高血壓 3.急性腎衰竭 4.電解質異常 5.血液透析、腹膜透析 研究領域: 代謝性腎臟病 血脂異常 急慢性腎衰竭 血管鈣化
Education：1994-2001, Doctor of Medicne, Chang-Gung Medical University, Taiwan, R.O.C.
Post-Graduate Education：2009-2013, Division of Medicine, University College London, London, UK, Ph.D.

Post-Graduate Training:
1. 2000-2001 Internship, Chang Gung Memorial Hospital, Taipei, Taiwan
2. 2001-2004 Residency, Kaohsiung Chang Gung Memorial Hospital, Taiwan
3. 2004-2006 Fellowship, Division of Nephrology, Kaohsiung Chang Gung Memorial
Hospital, Taiwan
4. 2006-present  Attending, Division of Nephrology, Kaohsiung Chang Gung Memorial
Hospital, Taiwan

Publications

1. Lung-Chih Lee, King-Kwan Lam*, Chien-Te Lee, Jin-Bor Chen, Tzu-Hsien Tsai, Shun-Chen  Huang. ‘Full house’ proloferative glomerulonephritis: an     unreported presentation of subacute infective endocarditis. Journal of Nephrology 2007; 20:745-9
2. Lung-Chih Lee, Chien-Te Lee*, Shang-Chih Laio, Kao-Tai Hsu, King-Kwan Lam, Jin-Bor Chen, Feng-Rong Chuang, Yu-Shu Chien, Chih-Hsiung Lee, Ben-Chung     Cheng, Chien-Hsing Wu. Peritoneal transport, residual renal function, and chronic inflammation in peritoneal dialysis patients. Acta Nephrologica 2008;  22(2): 105-10
3.  Jin-Bor Chen, Tsu-Kung Lin, Chia-Wei Liou, Shang-Chih Liao*, Lung-Chih Lee, Pei-Wen Wang, Mao-Meng Tiao. Correlation of oxidative stress biomarkers and     peritoneal urea clearance with mitochondrial DNA copy number in continuous ambulatory peritoneal dialysis patients.  American journal of nephrology 2008; 28(5): 853-9
4. Chung-Yao Hsu, Chien-Te Lee*, Yue-Joe Lee, Tiao-Lai Hung, Ching-Yi Yu, Lung-Chih Lee, King-Kwan Lam, Yu-Shu Chien, Feng-Rong Chuang, Kao-Tai Hsu. Better     sleep quality and less daytime symptoms in patients on evening hemodialysis: a questionnaire-based study. Artificial organs, 2008; 32(9):711-6
5. Chien-Te Lee*, Yu-Che Tsai, Hwee-Yeong Ng, Wen-Chin Lee, Lung-Chih Lee, Terry Ting-Yu Chiou, Shang-Chih Liao, Kao-Tai Hsu. Association between C-reactive     protein and biomarkers of bone and mineral metabolism in choric hemodialysis patients: a cross-sectional study. Journal of renal nutrition, 2009; 19(3): 220-7 
6. Chien-Yu Su, Lung-Chih Lee, Chien-Hao Lai, Yi-Hsi Wang, Yu-Kun Yang, Hwee-Yeong Ng, Wen-Chin Lee, Yu-Che Tsai, Feng-Rong Chuang, and Chien-Te Lee*.     Successful Treatment of Bilateral Emphysematous Pyelonephritisin a Uremic Patient without ephrectomy. Renal failure, 2009; 31(2): 167-70 
7. Yi-Chun Wang, Wen-Chin Lee, Shang-Chih Liao, Lung-Chih Lee, Yu-Jen Su, Chien-Te Lee, Jin-Bor Chen*. Mitochondrial DNA copy number correlates with     oxidative stress and predicts mortality in nondiabetic hemodialysis patients. Journal of nephrology, 2011; 24(03):351-358. 
8. Lung-Chih Li, Zac Varghese, John F. Moorhead, Chien-Te Lee, Jin-Bor Chen, and Xiong Z. Ruan*. Cross-talk between TLR4-MyD88-NF-B and SCAP-SREBP2     pathways. American journal of physiology-heart and circulatory physiology, 2013; 304: H874-H884. 
9. Chao Zhou, Han Lei, Yaxi Chen, Qing Liu, Lung-Chih Li, John F. Moorhead, Zac Varghese, Xiong Z Ruan*.  Enhanced SCAP Glycosylation by Inflammation     Induces acrophage Foam Cell Formation. PLoS One, 2013; 8(10): e75650. 
10. Yaxi Chen, Halcyon Ku, Lei Zhao, David C Wheeler, Lung-Chih Li, Qing Li, Zac Varghese, John F. Moorhead, Stephen H. Powis, Ailong Huang, and Xiong Z.     Ruan*. Inflammatory stress induces statin resistance by disrupting HMGCoA reductase feedback regulation. Arteriosclerosis thrombosis and vascular     biology. 2014; 34(2):365-76. 
11. Wen-Chin Lee, Lung-Chih Li, Jin-Bor Chen, Hsueh-Wei Chang*. Indoxyl sulfate-induced oxidative stress, mitochondrial dysfunction and impaired biogenesis     are partly protected by vitamin C and N-acetylcysteine. The Scientific World Journal. 2014: 620826
12. Lung-Chih Li, Yueh-Ting Lee, Yi-Wei Lee, Chia-An Chou, and Chien-Te Lee. Aortic Arch Calcification Predicts the Renal Function Progression in Patients     with Stage 3 to 5 Chronic Kidney Disease. BIOMED RESEARCH INTERNATIONAL, 2015:131263.
13. Chia-An Chou, Hwee-Yeong Ng, Wei-Hung Kuo, Terry Ting-Yu Chiou, Sung- Nan Pei, Lung-Chih Li, Yueh-Ting Lee and Chien-Te Lee. Rosiglitazone attenuates     indoxyl sulfate-induced endothelial dysfunction.CLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY.
14. Yueh-Ting Lee, Hwee-Yeong Ng,Terry Ting-Yu Chiu, Lung-Chih Li, Sung-Nan Pei, Wei-Hung Kuo, Chien-Te Lee (2015, Dec). Association of bone-derived     biomarkers with vascular calcification in chronic hemodialysis patients. Clinica Chimica Acta, 452: 38-43.
15. Ying Liu, Ben-Chung Cheng,Wen-Chin Lee, Lung-Chih Li, Chih-Hsiung Lee, Wen Xiu Chang, Jin-Bor Chen. Serum Potassium Profile and Associated Factors in     Incident Peritoneal Dialysis Patients. Kidney Blood Press Res 2016;41:545-551.
16. Jin-Gang Zhua, Ben-Chung Cheng, Wen-Chin Lee, Lung-Chih Li, Chih-Hsiung Lee, Gang Long, Jin-Bor Chen. Serum Alkaline Phosphatase Levels are Not     Associated with Increased Death Risk in Prevalent Hemodialysis Patients: 5-Year Experience in a Single Hemodialysis Center. Kidney Blood Press Res     2016;41:498-506
17. Lung-Chih Li, Chien-Ning Hsu*, Chih-Che Lin, Yu-Fan Cheng, Tsung-Hui Hu, Ding-Wei Chen, Chih-Hsiung Lee, Toshiaki Nakano, and Chao-Long Chen (2017, Apr).     Proteinuria and Baseline Renal Function Predict Mortality and Renal Outcomes after Sirolimus Therapy in Liver Transplantation Recipients. BMC     Gastroenterology, 17(1):58
18. Wei-Yu Chen, Lung-Chih Li, Jenq-Lin Yang (2017, Apr). Emerging Roles of IL-33/ST2 Axis in Renal Diseases. International Journal of Molecular Sciences.  18(4):783
19. Wei-Yu Chen, Jenq-Lin Yang, Yi-Hsiu Wu, Lung-Chih Li, Ru-Fang Li, Ya-Ting Chang, Lo-Hsin Dai, Wan-Chen Wang1 and Ya-Jen Chang. IL-33/ST2 axis mediates hyperplasia of intrarenal urothelium in obstructive renal injury. Experimental & Molecular Medicine. 50:36
20.  Lung-Chih Li, Jenq-Lin Yang, Wen-Chin Lee, Jin-Bor Chen, Chien-Te Lee, Pei-Wen Wang, Zac Vaghese, and Wei-Yu Chen*(2018, Sep). Palmitate aggravates     proteinuria-induced cell death and inflammation via CD36-inflammasome axis in the proximal tubular cells of obese mice. Am J Physiology Renal Physiol. 315: F1720-31
21. Kai-Fan Tsai, Lung-Chih Li*, Chien-Ning Hsu, Chih-Che Lin, Yu-Hung Lin,Yu-Fan Cheng, Chih-Chi Wang, and Chao-Long Chen. Effects of Conversion from      Calcineurin Inhibitors to Sirolimus or Everolimus on Renal Function and Possible Mechanisms in Liver transplant Recipients. J Clin Pharmacol. 2019; 59    (3):326-334

Honor &/or Awards：

1. Travel award for 2016 Annual Congress of International Liver Transplantation Society.  
2. Best abstract for 2015 International Symposium on Lipid and Tissue Injury.
3. The runner up to best poster presentation at UCL graduation student day 2013.