胸部X光診斷肺炎有時候不容易看出來

在祕密花園看到的, 連結裡面有連續的CT可以看.
.

70-year-old male with proven COVID-19. Imaging reveals bilateral areas of peripheral ground-glass opacity.

https://bit.ly/2WhZNwY
Case contributed by Dr Fabio Macori.

腎臟尿酸結石治療

避免腎臟發生尿酸結石的方法有三種

鹼化尿液

增加水分補充

減少尿酸生成

TREATMENT

Because alkalinization of the urine with medical therapy can lead to dissolution of pure uric acid stones, more invasive procedures (such as extracorporeal shock wave lithotripsy) are usually not required. The three treatments options to prevent recurrent uric acid nephrolithiasis include [3]:

●Alkalinization of the urine

●Increased fluid intake

●Reduction of uric acid production with reduced purine intake and xanthine oxidase inhibitors

尿酸腎結石病患都應該鹼化尿液及增加水分補充

Urinary alkalinization and increased fluid intake should be prescribed to almost all patients with uric acid stones. The indications for xanthine oxidase inhibitors to reduce uric acid production depend upon whether uric acid stones are recurrent despite alkalinization or when alkalinization cannot be used and also upon the presence or absence of gout:

Xanthine Oxidase  inhibitor  主要用於鹼化尿液和補充水分治療無效的病患, 尿酸生成過多 (每天超過 1000 mg) 的病患, 鹼化尿液和補充水分可能無效, 但尿酸排泄在正常範圍內的病患,  xanthine oxidase inhibitor 仍有效

●Recurrent uric acid stones – Xanthine oxidase inhibitors are usually reserved for patients who continue to have stones despite urinary alkalinization and a prescribed higher fluid intake. Recurrent uric acid stone formation despite urinary alkalinization and increased hydration usually occurs in patients with high urinary uric acid excretion (exceeding 1000 mg/day [6 mmol/day]). However, xanthine oxidase inhibitor therapy is warranted in recurrent uric acid stone formers even if urinary uric acid excretion is in the reference range.

●Patients with gout – Patients with uric acid stones who also have recurrent or tophaceous gouty arthritis should be treated with a xanthine oxidase inhibitor for long-term control of gouty manifestations; the primary indication in such patients is gout and not necessarily the prevention of kidney stones (see "Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout"). Urate-lowering therapy for gout with uricosuric agents is not indicated as first-line therapy in gouty stone formers to prevent stone recurrence, as this will not lead to a long-term change in the amount of uric acid in the urine.

In a patient with a history of uric acid stones and gout but ≤1 flare of gouty arthritis per year, there may be no specific indication for xanthine oxidase inhibitor therapy. Rather, urinary alkalinization and increased hydration are the initial treatment option in such patients. If, however, the patient prefers a medication that could reduce both gout flare frequency and recurrence of uric acid stones, we would agree to prescribe treatment with a xanthine oxidase inhibitor (along with increased hydration but not necessarily urinary alkalinization).

Urinary alkalinization — The effect of increasing the urine pH on uric acid solubility can be appreciated from the Henderson-Hasselbalch equation for the relationship between soluble urate and insoluble uric acid, where 5.35 is functionally the pKa for this reaction under conditions existing in urine [31]:

pH = 5.35 + log ([urate] ÷ [uric acid])

At a urine pH of 6.75, more than 90 percent of the total urinary uric acid will be the more soluble urate salt, thereby minimizing the risk of uric acid precipitation.

There are no randomized trials that have evaluated the efficacy of urinary alkalinization on recurrence or dissolution of uric acid stones. However, alkalinization is associated with a remarkable reduction in recurrent stone episodes in observational studies. As an example, the mean rate of recurrent uric acid stones among 18 patients was reduced from 1.2 to 0.01 stones per patient per year with long-term treatment with potassium citrate [32]. Alkalinization can also dissolve existing uric acid calculi, as demonstrated in eight patients with recurrent uric acid stones who underwent serial ultrasound examinations after initiating potassium citrate or potassium bicarbonate [33].

鹼化尿液過度可能會造成磷酸鈣結石, 所以維持尿液 pH 6.5~7 即可, pH 超過 7 以上, 效果並沒有更好.
另外, 也不需要持續維持鹼化尿液, 一天一次或兩天一次, 將尿液pH提升超過 6.5 以上, 就可以預防尿酸結石產生. (不用 24 小時)

Alkalinization therapy should target a urine pH between 6.5 and 7. Achieving a urine pH higher than 7 will provide little if any further benefit on uric acid stone formation and may increase the risk of calcium phosphate stone formation (figure 1). An alkaline urine pH may not need to be maintained at all times since raising the urine pH to at least 6.5 once per day or every other day may prevent uric acid stone formation [34].

可給予重碳酸鉀 或檸檬酸鉀, 可將已經出現的腎結石溶解, 也可以預防腎結石生成, 使用鉀鹽比鈉鹽好. 因為檸檬酸鈉或重碳酸鈉會增加鈣的排泄(經腎臟), 在某些病患會引起鈣結石. 

應建議病患在家自己測尿液pH

Either potassium bicarbonate or potassium citrate can be given, with the typical dose being 40 to 80 mEq/day (table 2) [3,32]. This regimen can dissolve preexisting pure uric acid stones and prevent the formation of new stones. Alkalinization with potassium salts is preferable since the sodium load with sodium citrate or sodium bicarbonate may increase calcium excretion and promote the formation of calcium stones in some patients [32]. Patients should be instructed to check their urine pH at home; this will help guide the amount of alkali required.

飽和脂肪酸與反式脂肪會增加血中膽固醇濃度

國健署-膽固醇
cholesterol 膽固醇
high density lipoprotein 高密度膽固醇

low density lipoprotein 低密度膽固醇
食物中的飽和脂肪酸以及反式脂肪對膽固醇影響較大. 這兩類是身體合成膽固醇原料.

體檢報告上看到的膽固醇，其實不是膽固醇，而是「脂蛋白」

影響血液中膽固醇含量最大的因素是吃進去的『飽和脂肪酸』，而不是『膽固醇』。

我們體內膽固醇約有70-80%是內生性膽固醇，是自己身體從肝臟或小腸細胞合成的膽固醇，而剩餘的20-30％才是來自於飲食中，其中最主要引起膽固醇的是飽和脂肪酸，因此我們應該要更注意飽和脂肪酸的攝取，例如：五花肉、培根、奶精、烹調用豬油等。

107年最新版的「每日飲食指南」也將蛋白質食物來源的順序調整為豆>魚>蛋>肉類，因此適量吃海鮮與雞蛋是沒有問題的！

糖在體內會轉變成三酸甘油脂, 也會增加血中膽固醇濃度

飲食控制降低膽固醇效果有限, 通常需要藥物控制. 

食物的成分, 即使膽固醇含量低, 但飽和脂肪酸過高, 仍會增加血中膽固醇濃度, 例如奶精

反式脂肪酸, 會增加低密度膽固醇LDL濃度, 減少高密度膽固醇HDL濃度, 而 LDL

2015~2020 年最新美國飲食指南指出：「取消膽固醇攝取上限」。原因在 於飲食僅佔膽固醇生合成中 2~3 成的影響因素。許多報告發現飲食中的飽和及 反式脂肪酸會導致更多膽固醇生成且不易代謝。因此減少富含飽和及反式脂肪 的食物來源，例如高脂肉品(培根、熱狗等)、冰淇淋、奶精、使用棕櫚油或椰 子油或氫化植物油製作的餅乾、糕點等，對於降低膽固醇是首要之道。

DM病患應該多久回診一次

控制不佳的一個月回診一次
控制良好的三個月回診一次

開始胰島素注射, 或改變胰島素劑量, 每天回診一次
改變口服治療藥物, 每周回診一次

正常成人血糖值與糖尿病患血糖控制目標

糖尿病臨床照護指引摘要
降血脂的首要目標是降低 LDL.
慢性腎病的血壓要控制低一點
空腹血糖 80-130
飯後兩小時血糖 80-160

正常人, 飯前(空腹)血糖 < 110, 睡前血糖< 120
DM患者, 依照美國糖尿病學會建議, 制訂血糖控制目標：飯前血 糖介於 80-120 毫克/毫升，睡前血糖 100-140 毫克/毫升
Target of blood glucose
飯前血糖(空腹血糖)
睡前血糖

低血糖 HYPOGLYCEMIA

美國糖尿病學會ADA

Classification of hypoglycemia
Level 1 <70
Level 2 < 54
Level 3 神智改變或活動變差 A severe event characterized by altered mental and/or physical status requiring assistance

血糖<70建議給予GLUCOSE葡萄糖 15-20g
血糖<54如果無法口服碳水化合物, 可考慮給予昇糖素, 昇糖素並不限制醫護人員才能使用. 家人或學校人員或病患的照顧者都可以給.

6.10 Glucagon should be prescribed for all individuals at increased risk of level 2 hypoglycemia, defined as blood glucose <54 mg/dL (3.0 mmol/L), so it is available should it be needed. Caregivers, school personnel, or family members of these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. E



Glucagon 昇糖素
The use of glucagon is indicated for the treatment of hypoglycemia in people unable or unwilling to consume carbohydrates by mouth. Those in close contact with, or having custodial care of, people with hypoglycemia-prone diabetes (family members, roommates, school personnel, child care providers, correctional institution staff, or coworkers) should be instructed on the use of glucagon kits, including where the kit is and when and how to administer glucagon. An individual does not need to be a health care professional to safely administer glucagon. Care should be taken to ensure that glucagon kits are not expired.

「糖尿病及初期慢性腎臟病照護整合方案」定期檢驗項目及處置建議

2026-08-08 16:47

之前在這篇放入太多網路上腎臟病相關連結. 有點雜亂. 所以另開一篇筆記.比較容易閱讀

筆記: 給一般民眾的慢性腎臟病相關的網路資料

「全民健康保險初期慢性腎臟病醫療給付改善方案」已經在 111年（2022年） 起正式整併並升級為 「糖尿病及初期慢性腎臟病照護整合方案」

（納入健保醫療費用支付標準第八部第二章）115-04-01 生效

這篇本來是初期慢性腎臟病品質提升計畫裡面的建議
是給醫護人員參考的. 不是給一般民眾的. 

下面列出例行的檢查檢驗項目

 

慢性腎病定期檢驗項目及處置建議

GFR<30 轉介至腎臟科

GFR 30-44 每三個月測一次GFR. 每 3-6 個月測一次電解質. bicarbonate, hemoglobin. Ca. P/ parathyroid hormine. albumin. 體重. 

GFR 45-60 如果有非糖尿病引起的腎病變, 例如T1DM<10年. 腎臟超音波檢查異常. 難治療之高血壓, 快速GFR下降. 尿液沉渣檢查異常. 轉介至腎臟科

  考慮治療藥物是否需降低劑量

  每六個月測一次GFR

  每年測一次電解質. bicarbonate, hemoglobin. Ca. P/ parathyroid hormine. albumin. 體重. 

  確認vitamin D 足夠

  考慮骨密度檢查

  轉介營養師諮詢

全部病患, 每年測 Cr. urine protein. 血鉀. 

健保署-糖尿病及初期慢性腎臟病照護整合方案(支付標準第八部第二章)

裡面有四個主題. 點進各個主題可下載pdf檔案

全民健康保險醫療服務給付項目及支付標準第八部品質支付服務

第二章糖尿病及初期慢性腎臟病照護整合方案─初期慢性腎臟病

（Early CKD）問答集

即使過去膽固醇正常仍須檢驗 LDL

29.收案的 CKD 患者即使膽 固醇正常，無高血脂症的 診斷碼，仍需於第一年檢 查3次 LDL-C，隔年起一 年兩次 LDL-C 嗎？ 

1.依照本章規定符合收案條件之病人，依照慢性腎臟病指引提 供3-6個月的必要檢查，UPCR或糖尿病人 UACR、血清肌酸酐 等檢查屬於本章之必要檢查，每次維護個案追蹤資料必需填報。 

2.LDL 為本章必要檢查，檢查頻率至少每年(當年)一次。 （LDL 當年度至少要上傳1次，不限時間） 

3.為減少重複檢查，照護就醫日前後3個月之檢查數據均可採計。

年度診療項目

之前沒例行做尿生化檢查. 僅6個月測 urine Cr + urine microalbumin. 

之前沒有例行做心電圖. 心電圖屬於選擇性檢查. 非必要性

過去沒有 CKD 患者. 以下情況仍建議定期檢查血中肌酸酐值及尿液(UPCR 或 UACR)

最近高血壓的作比較多. DM本來就會測. 長期服用藥物沒有標示哪一種藥. 或許長期吃安眠藥的也可算? 長期食用中草藥的. 平常不會特地去問. 

2.高危險群: 

(A)高血壓、高血糖患者 

(B)長期服用藥物者 

(C)心血管疾病人者 

(D)結構性腎小管異常，腎結石或攝護腺腫大者 

(E)洗腎家族史或家族性腎疾病 

(F)潛在影響腎功能之系統性疾病(如 SLE) 

(G)長期食用中草藥者 

(H)隨機性血尿或尿蛋白 

(I)年齡六十五歲以上