核实记录：尿酸、肾结石与胆囊结石
核实日期：2026-09-18。全书 523 → 528 条。第 6 节 17 → 20、第 16 节 7 → 9。
起因是 issue #16：读者建议开一节讲三高、尿酸、肾结石、胆结石，并提供了《DK 家庭医生常见病诊疗手册》《肥胖密码》两本书的网盘链接。
处理方式是不新开节，只补空白条目，理由见本文第三部分。
一、逐条核对到的原文
| 来源 | 核对到的原文 / 数据 | 用在哪 |
|---|---|---|
| Borghi L, Meschi T, Amato F, et al. (1996). Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol 155(3):839-843, doi:10.1016/s0022-5347(01)66321-3（PMID 8583588，Europe PMC 摘要全文） | 「During followup recurrences were noted within 5 years in 12 of 99 group 1 patients and in 27 of 100 group 2 patients (p = 0.008). The average interval for recurrences was 38.7 +/- 13.2 months in group 1 and 25.1 +/- 16.4 months in group 2 (p = 0.016).」基线尿量：「men with calcium oxalate stones 1,057 +/- 238 ml./24 hours versus normal men 1,401 +/- 562 ml./24 hours, p < 0.0001 and women calcium oxalate stones 990 +/- 230 ml./24 hours versus normal women 1,239 +/- 440 ml./24 hours, p < 0.001」。分组说明：「Followup in group 1 only involved a high intake of water without any dietetic change, while followup in group 2 did not involve any treatment.」 | 第 16 节第 8 条 |
| NICE guideline NG118《Renal and ureteric stones: assessment and management》第 1.8.1 条，https://www.nice.org.uk/guidance/ng118/chapter/Recommendations（直连可取全文） | 「adults to drink 2.5 to 3 litres of water per day, and children and young people (depending on their age) 1 to 2 litres」「adding fresh lemon juice to drinking water」「avoiding carbonated drinks」「adults to have a daily salt intake of no more than 6 g」「not restricting daily calcium intake, but maintaining a normal calcium intake of 700 to 1,200 mg for adults, and 350 to 1,000 mg per day for children and young people」 | 第 16 节第 8 条、第 6 节第 20 条 |
| Borghi L, Schianchi T, Meschi T, et al. (2002). Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. NEJM 346(2):77-84, doi:10.1056/NEJMoa010369（PMID 11784873） | 「At five years, 12 of the 60 men on the normal-calcium, low-animal-protein, low-salt diet and 23 of the 60 men on the low-calcium diet had had relapses. The unadjusted relative risk of a recurrence for the group on the first diet, as compared with the group on the second diet, was 0.49 (95 percent confidence interval, 0.24 to 0.98; P=0.04).」「urinary oxalate excretion increased in the men on the low-calcium diet (by an average of 5.4 mg per day) but decreased in those on the normal-calcium, low-animal-protein, low-salt diet (by an average of 7.2 mg per day)」。干预定义：正常钙 30 mmol/日、动物蛋白 52 g/日、氯化钠 50 mmol/日；对照低钙 10 mmol/日 | 第 6 节第 20 条 |
| Doherty M, Jenkins W, Richardson H, et al. (2018). Lancet 392(10156):1403-1412, doi:10.1016/S0140-6736(18)32158-5（PMID 30343856） | 「517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care.」「More patients receiving nurse-led care had serum urate concentrations less than 360 μmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42–4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years.」次要终点原文列为「flare frequency in year 2, presence of tophi, quality of life」 | 第 16 节第 9 条 |
| Abhishek A, Jenkins W, La-Crette J, et al. (2020). Rheumatology 59(3):575-579, doi:10.1093/rheumatology/kez333（PMID 31410473） | 「A total of 438 participants of NGTT-II were sent a questionnaire... Completed questionnaires were returned by 82% of participants.」「self-reported fewer flares in the previous 12 months [median (inter-quartile range) 0 (0–0) vs 1 (0–3), P < 0.001]」「were more likely to be taking urate-lowering treatment [adjusted relative risk (95% CI) 1.19 (1.09, 1.30)]」 | 第 16 节第 9 条 |
| FitzGerald JD, Dalbeth N, Mikuls T, et al. (2020). 2020 ACR Guideline for the Management of Gout. Arthritis Care Res 72(6):744-760, doi:10.1002/acr.24180（PMC10563586 网页版全文逐字核对） | 强推荐部分：「initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage ≥3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD)...; and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3–6 months was strongly recommended.」表 1「For patients with frequent gout flares (≥2/year), we strongly recommend initiating ULT over no ULT.」 | 第 16 节第 9 条 |
| 同上，表 1 及脚注 † | 「For patients with asymptomatic hyperuricemia (SU >6.8 mg/dl with no prior gout flares or subcutaneous tophi), we conditionally recommend against initiating any pharmacologic ULT (allopurinol, febuxostat, probenecid) over initiation of pharmacologic ULT.」证据确定性「High †」，脚注：「There is randomized clinical trial data to support the benefit that ULT lowers the proportion of patients who develop incident gout. However, based on the attributable risk, 24 patients would need to be treated for 3 years to prevent a single (incident) gout flare leading to the recommendation against initiating ULT in this patient group.」例外行：「For patients experiencing their first flare and CKD stage ≥3, SU >9 mg/dl, or urolithiasis, we conditionally recommend initiating ULT.」 | 第 6 节第 18 条 |
| 同上，Allopurinol 小节 | 「Testing for the HLA–B5801 allele prior to starting allopurinol is conditionally recommended for patients of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and for African American patients...」「The prevalence of HLA–B5801 is highest among persons of Han Chinese, Korean, and Thai descent (7.4%), lower among African Americans (3.8%), and even lower among whites and Hispanics (0.7% each). ... Asian and African American patients taking allopurinol both have a 3-fold increased risk of AHS compared with white patients taking allopurinol」 | 第 16 节第 9 条、第 6 节第 18 条 |
| 同上，停药段 | 「In a single case series where ULT was withheld in patients in clinical remission with years of well-controlled SU concentrations prior to cessation, only 13% of patients (27 of 211) whose SU concentration remained at <7 mg/dl while not receiving ULT had no flares during a 5-year follow-up period.」 | 第 16 节第 9 条 |
| 同上，表 7 及 Alcohol 段 | 生活方式推荐全部为 conditional、证据 Low 或 Very low。「SU levels among patients who limited or abstained from alcohol were 1.6 mg/dl lower compared with patients who did not do so」「a unit of beer raised SU concentrations by 0.16 mg/dl. The effects of a healthy diet, Mediterranean diet, or Dietary Approaches to Stop Hypertension (DASH) diet were even smaller」 | 第 16 节第 9 条 |
| Badve SV, Pascoe EM, Tiku A, et al. (2020). Effects of Allopurinol on the Progression of Chronic Kidney Disease（CKD-FIX）. NEJM 382(26):2504-2513, doi:10.1056/NEJMoa1915833 | 「The change in eGFR did not differ significantly between the allopurinol group and the placebo group (−3.33 ml per minute per 1.73 m2 per year [95% CI, −4.11 to −2.55] and −3.23 [−3.98 to −2.47], respectively; mean difference, −0.10 [95% CI, −1.18 to 0.97]; P = 0.85). Serious adverse events were reported in 84 of 182 patients (46%) in the allopurinol group and in 79 of 181 patients (44%) in the placebo group.」人群为「stage 3 or 4 chronic kidney disease and no history of gout」，363 人进入主要终点分析 | 第 6 节第 18 条 |
| Doria A, Galecki AT, Spino C, et al. (2020). Serum Urate Lowering with Allopurinol and Kidney Function in Type 1 Diabetes（PERL）. NEJM 382(26):2493-2503, doi:10.1056/NEJMoa1916624 | 「A total of 267 patients were assigned to receive allopurinol and 263 to receive placebo.」「the mean serum urate level decreased from 6.1 to 3.9 mg per deciliter with allopurinol」「the between-group difference in the mean iohexol-based GFR was 0.001 ml per minute per 1.73 m2 (95% CI, −1.9 to 1.9; P = 0.99)」「The mean urinary albumin excretion rate after washout was 40% (95% CI, 0 to 80) higher with allopurinol than with placebo.」 | 第 6 节第 18 条 |
| Festi D, Reggiani ML, Attili AF, et al. (2010). J Gastroenterol Hepatol 25(4):719-724, doi:10.1111/j.1440-1746.2009.06146.x（PMID 20492328） | 「A total of 11 229 subjects... At ultrasonography, GS were present in 856 subjects (7.1%). ... At enrollment, 580 (73.1%) patients were asymptomatic... GS patients were followed up for a mean period of 8.7 years... At the end of the follow up, of the asymptomatic subjects, 453 (78.1%) remained asymptomatic; 61 (10.5%) developed mild symptoms and 66 (11.4%) developed severe symptoms. ... A total of 189 cholecystectomies were performed: 41.3% on asymptomatic patients...」结论「Expectant management still represents a valid therapeutic approach in the majority of patients.」 | 第 6 节第 19 条 |
| McSherry CK, Ferstenberg H, Calhoun WF, et al. (1985). Ann Surg 202(1):59-63, doi:10.1097/00000658-198507000-00009（PMID 4015212） | 「The natural history of gallstone disease in 691 patients, followed for a mean ± SD duration of 78 ± 61.6 months... the other 135 (19.5%) patients were asymptomatic. ... Only 10% of asymptomatic patients followed for 58 ± 50.2 months (median 46.3 months) developed symptoms of biliary calculi, and seven per cent required operations. There were 50 deaths in this series of 691 patients, 25 in the symptomatic group, and 25 in the asymptomatic. Only two of these deaths were biliary tract related, and both were in the symptomatic group. This study suggests that patients with silent stones do not need to be operated on prior to the development of symptoms.」 | 第 6 节第 19 条 |
| NICE guideline CG188《Gallstone disease: diagnosis and management》，https://www.nice.org.uk/guidance/cg188/chapter/Recommendations（直连可取全文） | 第 1.2.1 条「Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms.」第 1.3.1 条「Offer bile duct clearance and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones.」 | 第 6 节第 19 条 |
二、收益量级怎么定的
| 条目 | 口径 | 量级 | 依据 |
|---|---|---|---|
| 16-8 多喝水防结石复发 | 死亡率（健康终点） | 大 | 机械套：5 年复发 27.0% → 12.1%，相对降幅 55%，≥20% |
| 16-9 痛风达标治疗 | 死亡率（健康终点） | 大 | 机械套：达标率 30% → 95%，RR 3.18；发作频率、痛风石均改善 |
| 6-18 无症状高尿酸不吃药 | 死亡率 | 小 | 机械套：两项 RCT 的肾脏终点均为阴性，无降幅可算；获益只有「治 24 人 3 年防 1 次发作」这一个替代终点，按「只有替代终点 = 小」 |
| 6-19 无症状胆囊结石不切 | 死亡率 | 中 | 判断，非机械套：收益栏里没有可比的相对降幅，只有自然史比例（78% 一直无症状）。避免的是一次全麻手术和住院，比第 6 节其他「少买一瓶保健品」的条目重，但不到「避免刑责/万元级」那一档，定中 |
| 6-20 结石后不戒钙 | 死亡率（健康终点） | 大 | 机械套：RR 0.49，相对降幅 51%，≥20% |
三、为什么不新开一节
issue 建议的是「医学方面的现代常见病例处理办法」章节。没有采纳，三条理由：
- 体裁不兼容。本书每条要回答「花掉什么、换回什么」，是决策指南；诊疗手册回答的是「怎么诊断、用哪个药、剂量多少」，读者本来就做不了这个主，写了也不该照做，既没法按现有规则机械套收益量级，风险还实打实。
- 三高已经铺开，再开一节会大面积重复。量血压与吃药达标在第 1 节第 7 条，35 岁后超重查空腹血糖在第 1 节第 8 条，降压药他汀的依从性在第 2 节第 8 条（带 A 级效应量），低钠盐、含糖饮料、BMI、运动在第 2 节多条，慢病依从、12 周长期处方、异地慢特病结算、糖尿病并发症筛查是第 16 节整节，分级诊疗见第 24 节。
- 真正的空白只有尿酸、肾结石、胆囊结石——全仓库搜下来这三样此前只在别的条目备注里被捎带提过。这次补的就是这三样。
四、未采用的来源
| 来源 | 不采用的理由 |
|---|---|
| 《DK 家庭医生常见病诊疗手册（第五版）》 | 科普转述，不是原始文献或官方机构报告，按仓库引用规则不可引 |
| 《肥胖密码：少吃多动，为何还不瘦》（Jason Fung, The Obesity Code） | 核心主张（肥胖由胰岛素而非能量平衡驱动）与等能量对照喂养研究冲突，属有争议的畅销书，不作为来源 |
| issue 里的坚果云网盘链接 | 整本书的网盘分享，版权状态不明；本书第 9、11 节自己在写版权红线，不在正文或记录里引用该链接 |
五、未取得
| 想找的 | 结果 | 处理 |
|---|---|---|
| EASL《Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones》(2016) 全文 | journal-of-hepatology.eu 直连 403，无头 Chrome 只拿到 7 KB 壳页；easl.eu 的 PDF 连接被重置 | 改用 NICE CG188，已逐字核对，条目不受影响 |
| AUA《Medical Management of Kidney Stones》2026 版 Part I/II 全文 | J Urol 付费，摘要中无具体饮水量数字；auanet.org 指南页 404 | 改用 NICE NG118，已逐字核对 |
| 国家卫健委《成人高尿酸血症与痛风食养指南（2024 年版）》 | 国务院政策文件库按 searchfield=title 检索无命中；nhc.gov.cn 全站恒 412 |
未引用。条目只用已逐字核对的 ACR 指南与 RCT |
| 中国腹腔镜胆囊切除的官方费用统计 | 未找到可逐字核对的官方按病种费用数据 | 第 6 节第 19 条不写金额，口径按死亡率（健康终点）走，量级用判断，见第二部分 |