睡眠呼吸暂停综合征是临床上的常见病,近年来发病率逐渐上升,发病年龄也在提前。过去病人的年龄大都在50岁以上,现在的病人以30-45岁为多,而且并发症的发生也提前了。临床上经常遇到一些患者,因睡眠呼吸暂停综合征导致多发性脑梗塞、高血压心脏病和冠心病心肌梗塞,造成劳动力丧失,生活难以自理,生活质量下降,给家庭和社会带来沉重的负担。尚无并发症的病人如不积极治疗,5-10年以后将有可能出现严重的并发症。一旦出现并发症,治疗则更加困难,即使可以治疗原发病——睡眠呼吸暂停综合征,多数并发症也难以逆转,成为痼疾缠身。
睡眠呼吸暂停综合征引起的肾脏损害,由于临床表现比较隐匿,大多数人首先考虑是肾脏本身的疾病和常见病如高血压肾损害,甚至有些人根本就不相信睡眠呼吸暂停综合征可以造成肾脏损害,因此常不被重视,大多在造成严重肾脏损害后才开始治疗。
睡眠呼吸暂停综合征可以合并蛋白尿或肾病综合征。国外有学者报道,阻塞性睡眠呼吸暂停综合征出现蛋白尿的发生率高达64%,合并大量蛋白尿和肾病综合征的也有大量报道。我院共诊治5例睡眠呼吸暂停综合征合并严重肾损害患者,睡眠呼吸暂停综合征得到治疗后,尿蛋白也有所下降。
大多数学者认为,睡眠呼吸暂停综合征合并蛋白尿,是由于睡眠呼吸暂停综合征引发反复缺氧、高碳酸血症,导致肺动脉高压,右心房压力和中心静脉压增高,肾静脉压力和肾小球毛细血管静水压升高,从而使肾小球基底膜的结构发生(可逆性)改变,结果蛋白质经基底膜“漏出”,产生蛋白尿。睡眠呼吸暂停综合征引发肾功能损害的原因是由于患者上气道关闭,胸腔负压增高,右心回流增加,缺氧肺血管收缩,右心负荷加大,导致右心房扩张,刺激心房利钠因子分泌增加,肾近端肾小管钠重吸收率降低,尿渗透压和肾小管浓缩功能降低。
睡眠呼吸暂停综合征合并肾损害的临床表现为夜尿增多和浮肿,严重者可出现肾功能不全的一系列表现。但许多病人的肾损害症状常被其他疾病的症状掩盖,因而经常被误诊。睡眠呼吸暂停综合征合并肾损害的病理变化较轻,表现为肾小球增大,少量局灶性硬化。因此睡眠呼吸暂停综合征合并蛋白尿在早期是功能性的,为可逆性蛋白尿,随着睡眠呼吸暂停综合征的治疗好转或痊愈,蛋白尿可减少或消失,临床症状也可以好转或消失。有人报道,睡眠呼吸暂停综合征病人尿量、尿钠和尿氯排泄率明显高于正常人。此外,睡眠呼吸暂停综合征还可以影响肾内分泌功能,如促红细胞生成素和影响钙磷代谢的维生素D的合成障碍。
治疗睡眠呼吸暂停综合征合并肾损害,首先应治疗原发病。目前多采用以经鼻面罩无创性呼吸机治疗为主的综合治疗方法。根据睡眠呼吸暂停综合征的类型、严重程度、病人的年龄、上呼吸道的情况和并发症的轻重等选择不同的治疗方案。大多数病人通过的治疗,肾损害可以完全恢复。当自己或家属因肥胖打鼾出现呼吸暂停时,应及时到医院就诊,通过夜间多导睡眠图检查确定是否患有睡眠呼吸暂停综合征,了解睡眠呼吸暂停综合征的类型和轻重。一旦确诊,特别是中重度睡眠呼吸暂停综合征的病人和夜尿多的病人,应详细检查肾脏的情况,如尿常规、24小时尿蛋白定量和肾功能检查,必要时行肾穿刺活组织检查。对于合并肾功能不全的病人,除治疗睡眠呼吸暂停综合外,应积极治疗肾功能不全,保护残存的肾功能。
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