原创 痛风诊断的最新推荐指南
2020年01月04日 【健康号】 韩光明

痛风是大家比较熟悉的一种常见的炎症性关节炎,其发病机理是由于长期存在的高尿酸血症导致的关节及其他组织单钠尿酸盐(MSU)结晶的沉积而引起的炎症发作。痛风被称为最常见的关节炎是因为它的患病率非常高,根据流行病学数据,在欧洲人口的患病率为0.9-2.5%,在美国人口的患病率为3.9%,在南极-太平洋地区人口的患病率超过6%。

根据单钠尿酸盐(MSU)结晶沉积的自然过程,疾病可分为下列三期:无症状的MSU结晶沉积期;MSU结晶沉积伴有痛风急性发作期;慢性痛风性关节炎和痛风石形成期。

尽管痛风的发病原因比较明确,治疗也有非常有效的手段,然而在过去的十几年间,其预后并没十分改善,是因为痛风经常被误诊误治。鉴于此,欧洲抗风湿病联盟(ELAR)在风湿界最著名的期刊(Ann Rheum Dis 2020,79(1):31-38)又更新了建立在循证医学基础之上针对痛风诊断的八条最新推荐指南。在这里翻译成中文供大家参考。
 
推荐一:推荐在每一个怀疑患有痛风病人的关节液或痛风石抽取标本中查找单钠尿酸盐(MSU)结晶的证据,因为找到MSU结晶可以明确诊断痛风。(Search for crystals in SF or tophus aspirates is recommended in every person with suspected gout, because demonstration of MSU crystals allows a definitive diagnosis of gout.)
 
推荐二:在成年人中,如果初步诊断为任何哪一种急性关节炎都应该考虑到痛风的可能。如果关节液查找单钠尿酸盐(MSU)结晶的方法不可行,以下患者的特征及疾病发作的特点也支持临床痛风的诊断:(1)脚(尤其是第一跖趾关节)或踝关节的单关节发病;(2)以前同样的急性关节炎发作史;(3)急剧发作的严重疼痛和肿胀(最严重在24小时内);(4)受影响关节皮肤发红;(5)男性;(6)有相关的心血管疾病和高尿酸血症。这些疾病的特征高度提示痛风,但对诊断痛风并不特异。(Gout should be considered in the diagnosis of any acute arthritis in an adult. When SF analysis is not feasible, a clinical diagnosis of gout is supported by the following suggestive features: monoarticular involvement of a foot (especially the first MTP) or ankle joint; previous similar acute arthritis episodes; rapid onset of severe pain and swelling (at its worst in <24 hours); erythema; male gender and associated cardiovascular diseases and hyperuricaemia. These features are highly suggestive but not specific for gout.)
 
推荐三:对未明确诊断的炎症性关节炎所有患者都强烈推荐进行关节液抽取标本的单钠尿酸盐(MSU)结晶检查。(It is strongly recommended that synovial fluid aspiration and examination for crystals is undertaken in any patient with undiagnosed inflammatory arthritis.)
 
推荐四:痛风的诊断不应当建立在患者仅仅存在高尿酸血症的基础上。(The diagnosis of gout should not be made on the presence of hyperuricaemia alone.)
 
推荐五:当根据临床表现诊断痛风不十分肯定,单钠尿酸盐(MSU)结晶检查条件又不允许时, 患者应该通过影像学的方法来查找单钠尿酸盐(MSU)结晶沉积直接证据和任何替代诊断的特征。(When a clinical diagnosis of gout is uncertain and crystal identification is not possible, patients should be investigated by imaging to search for MSU crystal deposition and features of any alternative diagnosis.)

 推荐六:平片放射线检查是用于查找单钠尿酸盐(MSU)结晶沉积引起关节影像学改变证据的,对于诊断痛风的急性发作价值有限。而超声检查通过检测临床检查不能发现的痛风石或软骨表面的双轨征(对于关节中尿酸盐的沉积非常特异)对于怀疑痛风急性发作的患者或慢性痛风性关节炎患者的明确诊断非常有帮助。(Plain radiographs are indicated to search for imaging evidence of MSU crystal deposition but have limited value for the diagnosis of gout flare. Ultrasound scanning can be more helpful in establishing a diagnosis in patients with suspected gout flare or chronic gouty arthritis by detection of tophi not evident on clinical examination, or a double contour sign at cartilage surfaces, which is highly specific for urate deposits in joints.)
 
推荐七:对于每一个有痛风的患者都应该筛查一下慢性高尿酸血症的风险因素,特别是:慢性肾脏疾病;超重;药物引起(包括利尿剂,小剂量阿司匹林,环孢素,他克莫司);饮用过多的酒精(特别是啤酒和烈性酒),无糖汽水,肉和海产品。( Risk factors for chronic hyperuricaemia should be searched for in every person with gout, specifically: chronic kidney disease; overweight, medications (including diuretics, low-dose aspirin, cyclosporine, tacrolimus); consumption of excess alcohol (particularly beer and spirits), non-diet sodas, meat and shellfish.)
 
推荐八:推荐对于存在并发症的痛风患者应进行系统性的健康评估,这些并发症包括肥胖,肾功能受损,高血压,缺血性心脏病,心力衰竭,糖尿病和血脂异常。(Systematic assessment for the presence of associated comorbidities in people with gout is recommended, including obesity, renal impairment, hypertension, ischaemic heart disease, heart failure, diabetes and dyslipidaemia.)
 
参考文献:
Richette, P., Doherty, M., Pascual, E., et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Annals of the Rheumatic Diseases Ann Rheum Dis 2020, 79(1): 31-38.

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韩光明
主任医师
擅长红斑狼疮、硬皮病、皮肌炎、嗜酸性筋膜炎、白塞病、大动脉炎、巨细胞动脉炎、肉芽肿性血管炎... 更多
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