臺灣博碩士論文加值系統

腎衰竭為動物臨床上常見疾病之一。當有腎衰竭發生時，即表示有75%以上的腎元失去正常生理功能，進而導致代謝廢物的累積，液體、電解質與酸鹼的不平衡。雖然急性腎衰竭導致的腎臟損傷是可逆性的，但急性腎衰竭在不同治療方式下（如傳統輸液療法、腹膜透析與血液透析療法），仍有30-83%的致死率。另一方面，中央途徑的血管通路（如中央靜脈導管）可用以輸液治療與多次採血，但由於導管相關感染（catheter-related infection）的情形，往往限制這類導管的使用並導致血管通路的喪失。本研究的實驗目的主要分為兩部分，第一部份為收集急性腎衰竭動物的基本資料、出現臨床症狀、伴隨疾病與臨床病理學、尿液學和血液氣體分析的結果，調查影響急性腎衰竭犬貓的相關預後因子。於2000年一月至2006年十二月間，共有1,339個犬隻病例與241個貓隻病例因腎衰竭就診於中興大學獸醫獸醫教學醫院。腎衰竭之年盛行率與致死率在犬隻分別為4-10%與49-59%，在貓隻則為2-10%與33-62%。在判定為急性腎衰竭的動物中（501為犬隻、69為貓隻），犬貓整體致死率分別為81.2%與65.2%。調查結果顯示在犬隻若住院天數 ≦ 5天、就診時體溫 ≦ 37.4℃、氮血症較嚴重（BUN ＞ 100.0 mg/dL、creatinine ＞ 6.0 mg/dL）、血中磷離子（＞ 10.0 mg/dL）與鈣磷乘積（＞ 60.0 mg2/dL2）較高和出現蛋白尿（＞ 25.0 mg/dL）者，會有較高的致死率，然而在貓隻，僅發現住院天數（≦ 4天）與就診時體溫 ≦ 37.6℃者，會影響貓隻的存活率。本研究另一部份為將中央靜脈導管放置於8隻健康犬隻之頸靜脈內，進行6天的實驗期，期間由導管周圍皮膚、導管中心內外圍、導管於皮下與尖端的部分進行採樣，並採集血液進行微生物培養，評估中央靜脈導管相關感染的情形。結果顯示並無發現任何導管相關感染的現象。不過在導管放置後第三天與第六天，由導管周圍皮膚與導管中心外圍所分離到的菌株中，以革蘭氏陽性菌佔多數，特別是Bacillus sp.( 37.5% )、Staphylococcus epidermidis ( 25.0% )與Micrococcus luteus ( 25.0% )，且這些菌株對多數抗生素皆具敏感性，以penicillin、cefazolin、chloramphenicol與enrofloxacin等抗生素敏感性較佳。由本研究可知，在患有急性腎衰竭的犬隻，若就診時呈現較嚴重的氮血症與電解質不平衡時，會有較差的預後。另外，中央靜脈導管未來可安全應用於腎衰竭的動物上，作為長期輸液與採血途徑，並進行中央靜脈壓的監控。

Renal failure is one of the most common diseases in practice and contributes to retention of metabolic toxins and derangement of electrolyte balance. Although renal damage resulting from acute renal failure (ARF) is reversible, the mortality rates of ARF following different treatments were determined between 30-83%. Vascular access of central line such as central venous catheter (CVC) allows for reliable fluid therapy, the key in treating ARF and frequent blood sampling. However, catheter-related infection significantly limits the use of catheters and causes vascular access loss. The purpose of this study was to access the prognostic indicators associated with ARF for small animals in central Taiwan. In addition, we evaluated the catheter-related infection induced by using CVC in dogs. A total of 1,339 dogs and 241 cats with renal failure were admitted to Veterinary Medicine Teaching Hospital of NCHU from January 2000 to December 2006. The yearly prevalence of renal failure in dogs and cats was 5-10% and 2-10%, respectively. Among 501 dogs and 69 cats with ARF, the mortality rates were 81.2% and 65.2%, respectively. The clinical parameters such as hospitalized day (≦ 5 day), body temperature (≦ 37.4℃), the magnitude of azotemia (BUN ＞ 100.0 mg/dL, creatinine ＞ 6.0 mg/dL), the concentrations of serum phosphorus(＞ 10.0 mg/dL) and calcium × phosphorus product (＞ 60.0 mg2/dL2), and severity of proteinuria(＞ 25.0 mg/dL) at initial presentation were identified to be associated with high mortality in dogs, while in cats, only hospitalized day (≦ 4 day) and body temperature (≦ 37.6℃) at initial presentation were identified to be associated with mortality. The application of CVC was performed to eight health adult dogs in a period of 6-day-experment. Skin of insertion site and external surface of catheter hub were cultured for bacteria. Blood cultures were obtained through the distal part of catheter before catheter removal. The results of the culture indicated that gram-positive bacteria were mostly isolated from skin of insertion site and external surface of catheter hub on the 3rd and 6th day after CVC insertion, especially for Bacillus sp. (37.5%), Staphylococcus epidermidis (25.0%), and Micrococcus luteus (25.0%), which were susceptible to penicillin, cefazolin, chloramphenicol and enrofloxacin. In conclusions, canine ARF with severe azotemia and electrolytes disorders is significantly associated with poor outcome. The application of CVC in small animals with renal failure would be safe for a long-term fluid therapy and central venous pressure monitoring in the future.

中文摘要 ...................................................................................................................... i
英文摘要 ..................................................................................................................... ii
目次 ............................................................................................................................ iii
表次 .......................................................................................................................... viii
圖次 .............................................................................................................................. x
第一章 序言 ................................................................................................................ 1
第二章 文獻探討.......................................................................................................... 2
第一節 急性腎衰竭 .......................................................................................... 2
第二節 引起犬貓急性腎衰竭之常見病因 ...................................................... 3
一、 感染 ...................................................................................................... 3
(一) 鉤端螺旋體感染（Leptospirosis） …...…........................................ 3
(二) 焦蟲感染（Babesiosis） ................................................................... 3
(三) 萊姆病（Lyme disease） ................................................................... 4
二、 腎毒性藥物 .......................................................................................... 4
(一) 胺基配醣體類藥物（Aminoglycoside） .......................................... 4
(二) Amphotericin B ................................................................................. 5
(三) Cisplatin ............................................................................................ 5
(四) NSAID（non-steroidal anti-inflammatory drugs） ........................... 5
(五) ACE（angiotensin-converting enzyme）inhibitors ............................ 5
(六) Vitamin D中毒 ................................................................................ 5
三、 中毒 ...................................................................................................... 6
(一) Ethylene glycol ................................................................................. 6
(二) 百合（Lily）........................................................................................ 6
(三) 葡萄與葡萄乾（grape and raisin） ................................................... 6
四、 其他 ...................................................................................................... 7
第三節 急性腎衰竭之診斷 .............................................................................. 7
一、 病史 ...................................................................................................... 7
二、 理學檢查 .............................................................................................. 7
三、 臨床症狀 .............................................................................................. 7
(一) 胃腸道系統 ...................................................................................... 7
(二) 泌尿系統 .......................................................................................... 8
(三) 心血管與呼吸系統 .......................................................................... 8
(四) 神經肌肉系統 .................................................................................. 8
四、 實驗室檢查 .......................................................................................... 8
五、 影像學檢查 .......................................................................................... 9
六、 腎臟生檢 .............................................................................................. 9
七、 早期偵測腎臟傷害與腎臟疾病 .......................................................... 9
(一) 排尿量 .............................................................................................. 9
(二) 尿中酵素 ........................................................................................ 10
(三) 蛋白尿 ............................................................................................ 10
第四節 慢性腎衰竭 ........................................................................................ 10
一、 造成慢性腎衰竭之病因 ........................................................................ 11
二、 慢性腎衰竭之診斷與併發症 ................................................................ 11
(一) 病史與理學檢查 ............................................................................ 11
(二) 臨床症狀 ........................................................................................ 11
1. 胃腸道系統 .................................................................................. 11
2. 泌尿系統 ...................................................................................... 12
3. 心血管與呼吸系統 ...................................................................... 12
4. 神經肌肉系統 .............................................................................. 13
5. 眼睛 .............................................................................................. 13
6. 皮膚與皮毛 .................................................................................. 13
(三) 實驗室檢查 .................................................................................... 13
1. 酸血症 .......................................................................................... 13
2. 貧血 .............................................................................................. 14
3. 高血磷症 ...................................................................................... 14
4. 繼發性副甲狀腺功能亢進 .......................................................... 14
5. 低血鉀症 ...................................................................................... 14
6. 蛋白尿 .......................................................................................... 15
第五節 腎衰竭之區別診斷 ............................................................................ 15
一、 區別急性與慢性腎衰竭 ........................................................................ 15
二、 區別腎前性與腎性腎衰竭 .................................................................... 16
三、 其他區別急性與慢性腎衰竭的方法 .................................................... 16
第六節 腎衰竭之治療 .................................................................................... 17
一、 傳統療法 ................................................................................................ 17
(一) 利尿 ................................................................................................ 17
(二) 離子不平衡的矯正 ........................................................................ 18
(三) 酸鹼不平衡的控制 ........................................................................ 19
二、 腎取代性治療 ........................................................................................ 19
(一) 透析治療時機與適應症 ................................................................ 19
(二) 腹膜透析 ........................................................................................ 20
1. 原理與方法 .................................................................................. 20
2. 禁忌 .............................................................................................. 20
3. 治療程序 ...................................................................................... 20
4. 併發症 .......................................................................................... 20
(三) 血液透析 ........................................................................................ 21
1. 原理與方法 .................................................................................. 21
2. 血液透析治療時機與適應症 ...................................................... 21
3. 治療程序 ...................................................................................... 21
（1） 建立血管通路 ........................................................................ 21
（2） 透析 ........................................................................................ 22
（3） 肝素（heparin）的使用 ............................................................ 22
（4） 透析導管的維持 .................................................................... 22
4. 併發症 .......................................................................................... 23
（1） 透析導管功能不足 ................................................................ 23
（2） 低血壓 .................................................................................... 23
（3） 神經系統併發症 .................................................................... 23
（4） 呼吸系統併發症 .................................................................... 24
（5） 白血球與血小板減少和貧血 .............................................. 24
（6） 氨基酸流失 ............................................................................ 25
(四) 血液透析導管常見之併發症 ........................................................ 25
1. 埋置導管引發感染的比例 .......................................................... 26
2. 埋置導管引發感染的來源 .......................................................... 26
3. 埋置導管導致感染的診斷 .......................................................... 27
（1） 需移除導管的診斷方法 ........................................................ 27
（2） 不需移除導管的診斷方式 .................................................... 28
a. 定量血液培養 ...................................................................... 28
b. 導管中心（hub）、導管離開處與導管位於皮下部分1 cm處的培養 .................................................................................. 28
c. 定性血液培養（qualitative blood cultures） ......................... 28
d. 導管腔內刷術（endoluminal brush） .................................... 29
（3） 其他快速診斷方法 ................................................................ 29
4. 埋置導管導致感染的治療 .......................................................... 29
5. 埋置導管導致感染的菌叢相 ...................................................... 30
6. 抗生素敏感性試驗 ...................................................................... 31
(五) 腎臟移植 ........................................................................................ 33
三、 飲食療法 ................................................................................................ 34
第七節 腎衰竭之預後評估 ............................................................................ 34
一、 急性腎衰竭之預後評估 ........................................................................ 34
二、 慢性腎衰竭之預後評估 ........................................................................ 36
第三章 材料與方法 .................................................................................................. 38
第一節 腎衰竭病例之收集 ............................................................................ 38
一、 腎衰竭病例收集來源 ............................................................................ 38
二、 腎衰竭病例收集標準與記錄 ................................................................ 38
三、 急性腎性腎衰竭相關預後因子調查 .................................................... 39
第二節 中央靜脈導管之相關感染評估 ........................................................ 39
一、 動物與分組 ............................................................................................ 39
二、 儀器及其相關試劑與器材 .................................................................... 39
(一) 雙腔中央靜脈導管套組 ................................................................ 39
(二) 外科用器械 .................................................................................... 39
(三) 藥品 ................................................................................................ 40
三、 實驗設計與流程 .................................................................................... 40
四、 中央靜脈導管的放置 ............................................................................ 40
五、 中央靜脈導管之細菌分離 .................................................................... 41
(一) 細菌分離 ........................................................................................ 41
1. 導管管腔內外圍與輸液內容物之採樣、培養步驟和導管周圍皮膚處之總菌數檢測 ...................................................................... 41
2. 定性血液培養步驟 ...................................................................... 42
3. 半定量與定量培養 ...................................................................... 43
(二) 細菌鑑定 ........................................................................................ 43
1. 細菌型態學 .................................................................................. 43
2. Biolog鑑定系統 .......................................................................... 43
3. 聚合酶鍊鎖反應 .......................................................................... 44
（1） 材料 ........................................................................................ 44
（2） 核酸萃取 ................................................................................ 45
（3） 16S rRNA增幅之引子 .......................................................... 45
（4） PCR反應 ................................................................................ 45
（5） PCR產物確認 ........................................................................ 45
（6） PCR產物純化 ........................................................................ 46
（7） PCR產物定序 ........................................................................ 46
(三) 菌株保存 ........................................................................................ 46
(四) 抗生素敏感性試驗 ........................................................................ 46
第三節 統計分析 ............................................................................................ 47
第四章 結果 .............................................................................................................. 48
第一節 腎衰竭之流行病學調查 .................................................................... 48
一、 不分類型之腎衰竭調查 ........................................................................ 48
二、 腎前性、腎性與腎後性腎衰竭之調查 .................................................. 54
第二節 急性腎性腎衰竭犬貓之基本資料 .................................................... 55
第三節 急性腎性腎衰竭犬貓之臨床症狀、伴隨疾病與治療方式 .............. 57
一、 急性腎性腎衰竭犬貓出現之臨床症狀 .............................................. 57
二、 急性腎性腎衰竭犬貓之伴隨疾病與治療方式 .................................. 59
第四節 急性腎性腎衰竭犬貓之臨床病理學檢查與尿液學檢查結果 ….... 60
一、 急性腎性腎衰竭犬貓之臨床病理學檢查結果 ….............................. 60
二、 急性腎性腎衰竭犬貓之尿液學檢查結果 .......................................... 63
第五節 急性腎性腎衰竭犬貓之相關預後因子 ............................................ 65
第六節 中央靜脈導管之細菌分離與鑑定 .................................................... 74
第七節 抗生素敏感性試驗 ............................................................................ 80
第五章 討論 .............................................................................................................. 83
第一節 腎衰竭之流行病學調查 .................................................................... 83
第二節 急性腎衰竭犬貓之臨床症狀、伴隨疾病與治療方式 ...................... 85
一、 急性腎衰竭犬貓之臨床症狀 ................................................................ 85
二、 急性腎衰竭犬貓之伴隨疾病 ................................................................ 86
三、 急性腎衰竭犬貓之治療 ........................................................................ 86
第三節 急性腎性腎衰竭犬貓之臨床病理學檢查與尿液學檢查結果 ........ 87
一、 急性腎性腎衰竭犬貓之臨床病理學檢查 ............................................ 87
二、 急性腎性腎衰竭犬貓之尿液學檢查 .................................................... 87
第四節 急性腎性腎衰竭犬貓之相關預後因子 ............................................ 88
第五節 中央靜脈導管之細菌分離與鑑定 .................................................... 91
第六節 抗生素敏感性試驗 ............................................................................ 93
第六章 總結 .............................................................................................................. 95
參考文獻 .................................................................................................................... 96

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