血尿蛋白尿鑒別定ppt課件

1、血尿、蛋白尿的診斷血尿、蛋白尿的診斷和鑒別診斷和鑒別診斷北京協(xié)和醫(yī)院腎內科北京協(xié)和醫(yī)院腎內科陳麗萌陳麗萌內 容w血尿的診斷與鑒別血尿的診斷與鑒別w蛋白尿的診斷與鑒別蛋白尿的診斷與鑒別w血尿、蛋白尿血尿、蛋白尿-腎小球疾病的診斷與鑒別腎小球疾病的診斷與鑒別血尿的診斷思緒血尿的診斷思緒w確定能否是真性血尿確定能否是真性血尿w判別出血部位判別出血部位w確定病變性質確定病變性質顏顏 色色正常時：無色廓清正常時：無色廓清-淡黃色淡黃色-琥珀色琥珀色病理情況：病理情況：近于無色：尿液稀釋、尿崩癥近于無色：尿液稀釋、尿崩癥深黃色：膽紅素尿濃茶樣尿藥物、食物深黃色：膽紅素尿濃茶樣尿藥物、食物 醬油色：血紅蛋白

2、尿醬油色：血紅蛋白尿(酸性酸性)ARF乳白色：乳白色： 乳糜尿、膿細胞尿乳糜尿、膿細胞尿紅紅 色：色： 血尿、血紅蛋白尿、肌紅蛋白尿血尿、血紅蛋白尿、肌紅蛋白尿 藥物藥物 (聯苯胺實驗聯苯胺實驗試紙法檢測：潛試紙法檢測：潛 血血w原理：試紙法原理：試紙法 Hb有類過氧化物酶作用有類過氧化物酶作用 催化分解過氧化物催化分解過氧化物-鄰鄰聯甲苯胺氧化變色聯甲苯胺氧化變色 假陽性假陽性假陰性假陰性 血紅蛋白血紅蛋白尿尿 肌紅蛋白肌紅蛋白尿尿 尿中尿中強氧化劑強氧化劑 脫水脫水還原劑還原劑尿尿 pH降低降低試紙預先暴露試紙預先暴露 在空氣中在空氣中試紙法的局限性：試紙法的局限性：血尿的定義血尿的定義w

3、尿沉渣尿沉渣 AddisAddis計數，計數，12h12h紅細胞超越紅細胞超越5050萬萬 每高倍視野每高倍視野HPHP超越超越3 3個紅細胞個紅細胞w尿檢陽性是血尿嗎？尿檢陽性是血尿嗎？確定能否是真性血尿確定能否是真性血尿w標本的可靠性標本的可靠性-污染污染 月經、子宮、陰道出血鑒別月經、子宮、陰道出血鑒別 容器、化驗容器、化驗w尿標本搜集的留意尿標本搜集的留意 晨尿晨尿 清潔中段尿清潔中段尿 防止生殖道的污染防止生殖道的污染 1小時內送檢小時內送檢-冰箱冰箱 血尿的診斷步驟血尿的診斷步驟w確定能否是真性血尿確定能否是真性血尿w判別出血部位判別出血部位w確定病變性質確定病變性質判別出血的部位

4、判別出血的部位1 1w按照血尿和排尿先后的按照血尿和排尿先后的關系進展分析通常根關系進展分析通常根據尿三杯實驗來判別：據尿三杯實驗來判別：w初血尿：尿道病變初血尿：尿道病變 w終末血尿：膀胱頸終末血尿：膀胱頸部和三角區(qū)或后尿道病部和三角區(qū)或后尿道病變變w全程血尿：上尿道全程血尿：上尿道或膀胱或膀胱判別出血的部位判別出血的部位2 2相差顯微鏡檢查紅細胞形狀：相差顯微鏡檢查紅細胞形狀：均一性均一性不均一不均一性性腎單位血尿腎單位血尿w穿過病變腎小球基底膜時受損穿過病變腎小球基底膜時受損w經過腎小管時遭到管腔內經過腎小管時遭到管腔內:w 浸透壓、浸透壓、PH值、代謝物質值、代謝物質(脂肪酸脂肪酸/溶

5、血卵磷溶血卵磷脂及膽酸脂及膽酸)w大小、外形改動大小、外形改動+同時合并紅細胞管型同時合并紅細胞管型=腎單位來源腎單位來源w例外例外:腎創(chuàng)傷、活檢、堵塞、腎皮質壞死、腎創(chuàng)傷、活檢、堵塞、腎皮質壞死、 猛烈運動也可有紅細胞管型猛烈運動也可有紅細胞管型判別出血的部位判別出血的部位3 3w微粒容積自動分析儀微粒容積自動分析儀10501001502001050100150200105010015020010501001502001050100150200血紅細胞容積分布曲線非腎小球源性血尿腎小球源性血尿腎小球源性血尿混合性血尿血尿的診斷步驟血尿的診斷步驟w確定能否是真性血尿確定能否是真性血尿w判別出血

6、部位判別出血部位w確定病變性質確定病變性質確定病變性質確定病變性質1 1血尿的病因血尿的病因泌尿生殖系統(tǒng)疾病泌尿生殖系統(tǒng)疾病全身性疾病全身性疾病尿路臨近器官疾病尿路臨近器官疾病其他緣由其他緣由2%98%1.腎單位來源腎單位來源(內科性內科性): 原發(fā)、繼發(fā)、家族性原發(fā)、繼發(fā)、家族性2.非腎單位來源非腎單位來源(外科性外科性): 腫瘤、外傷、結石、畸形、血管等腫瘤、外傷、結石、畸形、血管等泌尿生殖系統(tǒng)疾病泌尿生殖系統(tǒng)疾病內科性血尿查什麼內科性血尿查什麼?內科性血尿內科性血尿w蛋白定量蛋白定量w管型管型w腎功能腎功能w腎活檢腎活檢w細菌學檢查細菌學檢查外科性血尿查什麼外科性血尿查什麼?外科性血尿外

7、科性血尿1. 1. 尿零落細胞尿零落細胞2. 2. 影像學影像學: : 腹部平片腹部平片 超聲波檢查超聲波檢查 CT/MRI CT/MRI 3. 3. 介入檢查介入檢查: : 膀胱鏡檢查膀胱鏡檢查 靜脈腎盂造影靜脈腎盂造影( (排泄性尿路造影排泄性尿路造影) ) 逆行尿路造影逆行尿路造影 腎動脈及腎靜脈造影腎動脈及腎靜脈造影4. 4.鈣負荷實驗鈣負荷實驗: : 尿鈣尿鈣4mg/kg.24h,4mg/kg.24h,尿鈣尿鈣/ /肌酐肌酐0.210.21胡桃夾子景象胡桃夾子景象w腸系膜上動脈壓迫腸系膜上動脈壓迫左腎靜脈致左腎回左腎靜脈致左腎回流妨礙，淤血；從流妨礙，淤血；從而引起血尿而引起血尿w多

8、發(fā)生于兒童，成多發(fā)生于兒童，成年后腸系膜上動脈年后腸系膜上動脈壓迫解除病癥消逝壓迫解除病癥消逝腸系膜上動脈腸系膜上動脈左腎靜脈左腎靜脈內 容w血尿的診斷與鑒別血尿的診斷與鑒別w蛋白尿的診斷與鑒別蛋白尿的診斷與鑒別w血尿、蛋白尿血尿、蛋白尿-腎小球疾病的診斷與鑒別腎小球疾病的診斷與鑒別正常尿蛋白正常尿蛋白w150mg/24hw組成: 60%濾過血漿蛋白 40%白蛋白, 15%免疫蛋白w 5%其他血漿蛋白w 40% Tamm-Horsfall蛋白失去大小選擇性屏障失去大小選擇性屏障實際上實際上GBM濾過孔孔徑加大，長度縮短濾過孔孔徑加大，長度縮短單位面積單位面積GBM上孔密度添加上孔密度添加以上兩

9、項均有以上兩項均有失去電荷選擇性屏障失去電荷選擇性屏障GBM失去帶陰電荷的分子失去帶陰電荷的分子(糖蛋白分解添加糖蛋白分解添加/合合成減少成減少) 帶陽電荷的分子中陰電荷帶陽電荷的分子中陰電荷以上兩項均有以上兩項均有蛋白尿的機理蛋白尿的機理腎小球濾過屏障腎小球濾過屏障腎小球濾過膜：內皮細胞基底膜上皮細胞系膜組織多種生理功能：參與免疫及腎小球炎癥反響病理情況下致腎小球硬化蛋白尿的分類和特點蛋白尿的分類和特點w腎小球性蛋白尿腎小球性蛋白尿 腎小球濾過屏障損害腎小球濾過屏障損害 2.0 g/24 h2.0 g/24 h 大、中、小分子大、中、小分子w腎小管性蛋白尿腎小管性蛋白尿 腎小管對正常濾過蛋白

10、的重吸收妨礙腎小管對正常濾過蛋白的重吸收妨礙 2.0g/24 h 2.0g/24 h，小分子，小分子w溢出性蛋白尿溢出性蛋白尿 血漿中某種蛋白質濃度過高，經正常或異常腎小球血漿中某種蛋白質濃度過高，經正?；虍惓ＤI小球濾出濾出w分泌性蛋白尿分泌性蛋白尿 遠端小管分泌：遠端小管分泌：Tamm-HorsfallTamm-Horsfall蛋白蛋白尿診斷方法蛋白蛋白尿診斷方法及及診斷思緒診斷思緒w能否蛋白尿？尿常規(guī)能否蛋白尿？尿常規(guī)w繼續(xù)性？一過性：繼續(xù)性？一過性： 多見于少量蛋白尿多見于少量蛋白尿trace to 2+ proteinw定量：定量： 24小時尿蛋白定量小時尿蛋白定量 2gw定性：定性：

11、 SDS-PAGEw定位定位 ？內 容w血尿的診斷與鑒別血尿的診斷與鑒別w蛋白尿的診斷與鑒別蛋白尿的診斷與鑒別w血尿、蛋白尿的診斷與鑒別診斷血尿、蛋白尿的診斷與鑒別診斷診斷層次1.血尿、蛋白尿血尿、蛋白尿-臨床診斷臨床診斷2.腎功能腎功能3.病因病因:繼發(fā)腎病繼發(fā)腎病?原發(fā)腎病原發(fā)腎病4.病理病理5.并發(fā)癥并發(fā)癥診斷方法及程序診斷方法及程序w病史病史w體格檢查體格檢查w實驗室檢查實驗室檢查w特殊檢查特殊檢查w隨訪隨訪w排除假性血尿排除假性血尿w血凝塊血凝塊 血尿中混血凝塊常提示非腎小球疾患出血血尿中混血凝塊常提示非腎小球疾患出血w血尿與全身疾病及呼吸道感染的時間關系血尿與全身疾病及呼吸道感染的

12、時間關系wPSGN：感染后：感染后1014天出現血尿天出現血尿wIgAN： 幾乎同時發(fā)生，普通不超越幾乎同時發(fā)生，普通不超越3天。天。w家族史家族史:耳聾、血尿、腎衰耳聾、血尿、腎衰w血尿伴隨病癥血尿伴隨病癥w腎絞痛腎絞痛w尿路刺激癥尿路刺激癥w水腫、高血壓及全身其他病癥等水腫、高血壓及全身其他病癥等病史病史-血尿血尿Onset when began with conditions identified around the initial presentation, i.e., drug ingestion record of previous urinalyses precipitatio

13、n/palliation identification of triggering agents infectious, drugs, foods, chemicals, vaccinations helps to identify acquired forms of tubulointerstitial proteinuria 蛋白尿蛋白尿-問診問診quality associated with hematuria severity ： pathologic if associated with hematuria or Nephrotic Syndrome likely to be a p

14、rimary GN unlikely to be benign etiology or secondary GN timing acute vs acute-on-chronic intermittent vs persistent duration of proteinuria associated symptoms past medical history functional inquiry Specific Entities helps to differentiate acute GN from chronic GN identify overload proteinuria cau

15、ses 1. History of Presenting Illness1. History of Presenting Illnessat the end of the history, one should be able to discern: 1. benign vs pathologic proteinuria (if pathologic then) 2. glomerular vs tubulointerstitial proteinuria (if glomerular then) 3. hereditary vs non-hereditary (if non-heredita

16、ry then) 4. acute GN vs chronic GN (if chronic then) 5. primary GN vs secondary GN 6. nephrotic vs non-nephrotic proteinuria 7. proteinuria with or without hematuriauria 病史病史w功能性功能性w病理性病理性 腎小球性腎小球性 腎小管、間質性腎小管、間質性 溢出性溢出性 分泌性分泌性隱匿性腎炎綜合征隱匿性腎炎綜合征急性腎炎綜合征急性腎炎綜合征慢性腎炎綜合征慢性腎炎綜合征急進性腎炎綜合征急進性腎炎綜合征腎病綜合征腎病綜合征2. F

17、amily History2. Family Historyhelps to differentiate hereditary from non-hereditary : 1. Proteinuria family members must have had previous urinalysis to ascertain this 2. Renal Disease Polycystic Kidney Disease Nephrotic Syndrome, Fanconi Disease renal dialysis kidney transplantation 3. Others：heari

18、ng/ocular impairment (Alport Syndrome) PE? Lab? More information3 Physical Examination3 Physical Examination1. Vitals hypertension, fever 2. O/E edema, skin paleness or jaundice, rashes external genitalia外生殖器外生殖器 joints for signs of arthritis-red, warm, or swollen abdomen: masses or tenderness. C V

19、A t e n d e r n e s s enlarged kidneys. length and weight and plot on growth chart.Glomerular Proteinuriapresents in 1 of 3 ways: 1. Isolated Proteinuria 2. Proteinuria + Hematuria 3. Nephrotic Syndrome edema, hypoalbuminemia, hyperlipidemia 進一步檢查w1.血尿、蛋白尿血尿、蛋白尿w2.腎功能腎功能w3.病因病因:繼發(fā)腎病繼發(fā)腎病?原發(fā)腎病原發(fā)腎病w4.病

20、理病理:腎活檢腎活檢w5.并發(fā)癥并發(fā)癥病因診斷繼發(fā)繼發(fā): 感染相關感染相關 免疫相關免疫相關 腫瘤相關腫瘤相關/淀粉樣變淀粉樣變/MM 代謝性病代謝性病原發(fā)性腎病原發(fā)性腎病病理診斷w腎活檢的順應癥和忌諱癥腎活檢的順應癥和忌諱癥w穿刺方法穿刺方法w常見的病理類型常見的病理類型w常見的病理改動常見的病理改動隨隨 訪訪w無病癥血尿患者無病癥血尿患者w每半年一次尿液分析和細胞學檢查每半年一次尿液分析和細胞學檢查w每兩年一次膀胱鏡和靜脈腎盂造影每兩年一次膀胱鏡和靜脈腎盂造影w假設血尿反復發(fā)作，隨訪期至少假設血尿反復發(fā)作，隨訪期至少3 3年年CASE 1wA four year-old African A

21、merican male is brought to your office after his parents noticed that his urine appeared dark brown or coke 焦碳colored. Important questions to ask in your History 1wHas there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? wHas there been any recent URI symptoms or sore th

22、roat? wHas there been any type of skin rashes or sores? wAny abdominal pain or colicky pain? wAre the stools loose or bloody? Important questions to ask in your History 25. Has there been any recent trauma? 6. Has there been any joint pains or swellings? 7. Is there any history of sickle cell diseas

23、e or trait?8. Is there any family history of renal disease,transplants, or dialysis? 9.Is there a family history of hearing deficits? 10.What medications does the child take? wAccording to the parents, the child was treated with Bacitracin桿菌肽 2 weeks ago for impetigo膿皰病 on the legs and arms? Physica

24、l Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examinationSevere dehydrationPeripheral edema, Cardiovascular system Myocardial infarctionAtrial fibrillationHypertension AbdomenBruit Genitourinary system Enlarged prostate P

25、himosis （包莖）（包莖）Meatal stenosis（尿道狹窄）（尿道狹窄）Renal vein thrombosisNephrotic syndrome vasculitisRenal artery embolus or thrombus Renal artery embolus or thrombusGlomerulosclerosis with or without proteinuria Arteriovenous fistulaUrinary tract infectionUrinary tract infection Urinary tract infectionwThe

26、 patients examination was normal except for a blood pressure of 125/90 and some mild periorbital edema. 擬診：最能夠？擬診：最能夠？ 其次？其次？擬診：能夠擬診：能夠wpost streptococcal acute glomerular nephritis(PSAGN) 急性鏈球菌感染后腎炎secondary to a nephrogenic strain of streptococcus pyogenes wcausing impetigo 2 weeks ago w進一步檢查證明？進一

27、步檢查證明？進一步檢查證明進一步檢查證明wASOwanti-DNAse B titerswBUN and Creatininewcomplement levels.治療治療-有助于診斷有助于診斷wThe child should be monitored closely paying attention ：w blood pressure, wdaily weights,w urine output and po input. 預期結果預期結果wThe red blood urine ：w C3 complement ：w預后：預期結果預期結果wThe urine may continue t

28、o contain red blood cells for many months wthe C3 complement usually returns to normal levels in 6-8 weeks. wMost of the PSAGN patients recover completelyCommon causes of hematuria in childrenwUrinary tract infection. Diagnosed by symptoms of burning and frequency and a positive urine culture on a p

29、roperly collected specimen wFamilial benign hematuria- usually asymptomatic and may have minimal proteinuria. At times the hematuria may be gross. wHypercalcuria- usually asymptomatic and may be microscopic or gross hematuria. Do a spot urine and measure the Ca/Creatinine ratio. Age related. 19 mo.-6 years is 0.42(95%) wTransient- no etiology established. wHSP- hematuria may precede the rash Common Causes of Gross HematuriawLocal irritation or trauma to the perineal area wReanl trauma secondary to blunt abdomi