332.4 📋 章末速記 Summary

332.4.1 🔑 一句話總結

腎臟功能六大：排泄廢物 + 體液電解質 + 酸鹼 + 血壓 (RAAS) + 內分泌 (EPO, calcitriol, renin) + 葡萄糖新生；GFR 為核心 — eGFR (CKD-EPI 2021 race-free preferred) + cystatin C (muscle mass independent) + Cockcroft-Gault (drug dosing)；UACR A1/A2/A3 分類；主要 presentations：AKI (rapid Cr ↑) + CKD (eGFR < 60 OR damage ≥ 3 mo) + nephrotic syndrome (> 3.5 g/24h + hypoalbuminemia + edema + hyperlipidemia) + nephritic syndrome (hematuria + RBC casts + HTN + AKI) + UTI + stones + obstruction；urinalysis = dipstick + sediment + casts (muddy brown ATN, RBC GN, WBC AIN/pyelo, waxy chronic, fatty nephrotic)；electrolyte disorders + anion gap MUDPILES；2024 重要新概念：CKD-EPI 2021 race-free、APOL1 nephropathy、SGLT2i + finerenone + GLP-1 RA for CKD。

332.4.2 💊 治療精要

  • diagnostic workup：UA + UACR + eGFR + electrolytes + imaging (US first-line)
  • nephrotic / nephritic：immunology (ANA, dsDNA, complement, ANCA, anti-GBM, hepatitis, HIV, free light chains, cryoglobulins) + renal biopsy
  • AKI：urine output + sediment + Na excretion + imaging for obstruction
  • CKD：staging G1-G5 + albuminuria + cause + complications (anemia, MBD, CV)
  • electrolytes：specific protocols per disorder

332.4.3 🎯 盧醫師的考前提醒

  1. eGFR CKD-EPI 2021 race-free preferred (ASN/NKF endorsement, 取消 race coefficient)；cystatin C 在 muscle wasting / athletes / elderly 更準
  2. UACR 分類：A1 < 30、A2 30-300 (microalbuminuria)、A3 > 300 (macroalbuminuria)；nephrotic-range > 3500 mg/g 或 > 3.5 g/24h
  3. nephrotic vs nephritic 鑑別：nephrotic = 大量 proteinuria + hypoalbuminemia + edema + hyperlipidemia；nephritic = hematuria + RBC casts + HTN + 可能 AKI
  4. 6 種 urine casts 經典關聯：hyaline (normal)、RBC (glomerular GN)、WBC (pyelonephritis or AIN)、granular muddy brown (ATN classic)、waxy (chronic disease)、fatty (oval fat bodies — nephrotic)
  5. anion gap MUDPILES：Methanol、Uremia、DKA、Paraldehyde、Iron + INH、Lactic acidosis、Ethylene glycol、Salicylates
  6. renal anatomy + nephron 結構：glomerulus + Bowman + PCT + LoH + DCT + CD；filtration barrier = fenestrated endothelium + GBM + podocyte slit diaphragm (nephrin + podocin)
  7. filtration fraction = GFR/RBF ~ 20%；GFR autoregulation via myogenic + tubuloglomerular feedback (macula densa Cl- sensing)
  8. electrolyte disorders 主要重點：hyponatremia (SIADH 最常見住院)、hyperkalemia (AKI/CKD + ACE/ARB/MRA)、hypocalcemia (CKD + vit D 不足 + hypoPTH)、hypophosphatemia (refeeding + alcoholism)
  9. APOL1 risk genotype (G1, G2) 在 African ancestry：↑ FSGS、HIV-AN、lupus nephritis、HTN nephropathy；inaxaplin 為 targeted therapy 試驗中
  10. 2024 CKD therapies revolution：SGLT2i (dapagliflozin, empagliflozin) + finerenone (non-steroidal MRA, FIDELIO/FIGARO) + GLP-1 RA (semaglutide FLOW) — beyond DM nephroprotection