Ramanathan R, Kumar A, Kapoor R, Bhandari M
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
Br J Urol. 1998 Feb;81(2):199-205. doi: 10.1046/j.1464-410x.1998.00500.x.
To assess the effect of the relief of obstruction on the ultimate function of the affected renal unit in urinary tuberculosis, and to identify predictors of functional recoverability.
Of a total of 82 patients with urinary tuberculosis presenting over 7 years, 38 with evidence of upper tract obstruction were analysed. All patients were assessed with pre-operative excretory urography, urinary mycobacterial cultures and serum chemistry. Patients with subnormally functioning kidneys were assessed with baseline renal scans. Preliminary intervention in the form of JJ stenting or percutaneous nephrostomy (PCN) was carried out in patients with reasonable renal function. Function was reassessed after 4 weeks to detect evidence of improvement and factors which could affect the outcome were determined.
Thirty-eight patients had documented upper tract obstruction, of whom six had bilateral obstruction (total of 44 renal units). Ten renal units were not functioning at presentation, with a mean (SD) glomerular filtration rate (GFR) of 3.0 (5.73) mL/min, and no preliminary intervention was performed. In the remaining 34, preliminary intervention was carried out before definitive surgery (JJ stenting in 14, PCN in 15 and PCN followed by antegrade JJ stenting in five); 21 of these renal units were salvaged but 13 were lost despite overcoming the obstruction. Three of the 13 units deteriorated from having acceptable pre-treatment GFRs to becoming non-functional. Good renal cortical thickness, a low grade of renal involvement (Semb 1 or 2), the presence of more distal disease in the form of ureteric stricture and a GFR of > 15 mL/min were good predictors of renal recovery after diversion.
The loss of some renal units seems inevitable in patients with urinary tuberculosis, despite advances in chemotherapy. Having pre-operative predictors of renal recovery may ensure optimal patient selection, thereby reducing the number of procedures and economic burden on the patient who does not require intervention.
评估解除梗阻对肾结核受累肾单位最终功能的影响，并确定功能恢复的预测因素。
在7年多时间里共收治82例肾结核患者，其中38例有上尿路梗阻证据，对其进行分析。所有患者术前行排泄性尿路造影、尿结核菌培养及血清化学检查。肾功能异常的患者行基线肾扫描。肾功能尚可的患者采用双J管支架置入术或经皮肾造瘘术（PCN）进行初步干预。4周后重新评估功能，以检测改善迹象，并确定可能影响结果的因素。
38例患者有记录的上尿路梗阻，其中6例为双侧梗阻（共44个肾单位）。10个肾单位就诊时无功能，平均（标准差）肾小球滤过率（GFR）为3.0（5.73）mL/分钟，未进行初步干预。其余34个肾单位在确定性手术前进行了初步干预（14例行双J管支架置入术，15例行PCN，5例行PCN后行顺行双J管支架置入术）；其中21个肾单位得以挽救，但13个肾单位尽管梗阻解除仍丧失功能。13个肾单位中有3个从治疗前可接受的GFR恶化至无功能。肾皮质厚度良好、肾受累程度低（Semb 1或2级）、存在输尿管狭窄等更远处病变以及GFR>15 mL/分钟是引流后肾功能恢复的良好预测因素。
尽管化疗有进展，但肾结核患者中一些肾单位的丧失似乎不可避免。术前有肾功能恢复的预测因素可确保最佳的患者选择，从而减少不必要干预患者的手术次数和经济负担。
