腎功能檢查1課件

RenalFunctionTest

腎功能檢查p349KidneydiseasesUrinetests:urinalysisandothersCheapandconvenient;ForscreeningandfollowingRenalbiopsyRenalfunctionsGlomerulus:filtrationTubule:reabsorptionandacidificationImagingExaminationImmunologicaltestWhenandforWhatKidneydiseasesorinjuriesOverallcheckupKidneyfunctionassessmentwithotherdiseasesDiabetesmellitusHypertensionShockorextensiveburnAuto-immunologicaldiseasesDrugtoxicityFUNCTIONSOFKIDNEYExcretemetabolicproducts/wastesKeepthebalanceofwater,acid-baseandelectrolyteEndocrinefunction:EPO(erythropoietin):RBCproduct1,25(OH)2D3:Calciumandphosphorusrenin:boodpressureregulationRelatedconcepts急性腎衰AFR腎前性Pre-renal：休克早期、大面積燒傷、脫水等功能性腎性renal：器質(zhì)性腎小管上皮細(xì)胞壞死腎臟本身：腎小球腎炎、腎盂腎炎、狼瘡腎炎腎動(dòng)脈血栓、栓塞腎后性postrenal：結(jié)石、腫瘤、前列腺肥大等尿路梗阻Stagesforrenalfailure：代償期compensatorystage失代償期decompensatorystage:

氮質(zhì)血癥Azotemia：血中尿素氮BUN或肌酐sCR超出正常范圍腎性腎前性腎后性衰竭期Failurestage尿毒癥期UremiaStage：綜合癥候群，“尿潴留在血中”而引起的中毒RelatedconceptsRelatedconceptsCommonsymptomsofAFR少尿期oliguriastage：Oliguriaoranuria,Hematuria,ProteinuriaandsomekindsofcastsWaterintoxicationHyperpotassemiaMetabolicacidosisAzotemia多尿期polyuriastage恢復(fù)期recoverystageTestsofglomerularfunction

腎小球功能檢查——腎小球?yàn)V過功能Renalbloodflow：1200-1400ml/min，占20%-25%心血流量Crudeurine：即腎小球?yàn)V過液,120-160ml/min影響因素：renalbloodfloweffectivefiltrationpressureFiltrationareamembranepermeabilityGlomerularFiltrationEndogenousCreatinine肌酐內(nèi)源性肌酐外源性肌酐肌肉活動(dòng)中肌酸代謝產(chǎn)物來自于魚類、肉類等食物和咖啡、茶等飲料EndogenousCreatinineClearanceRate,CcrDefinition：Ccristhevolumeofbloodplasmawithcreatininethatisclearedbykidneysperunittime.即：單位時(shí)間內(nèi),腎臟可全部清除多少毫升血漿中的內(nèi)生肌酐計(jì)算公式：Normalvalue：80-120ml/minClinicalSignificancePathologicaldecreaseSensitiveforkidneyinjuryGFR<50%時(shí)Ccr≈50ml/minEstimatethestageofrenalfailurecompensatory：>50ml/mindecompensatory：20-50ml/minfailure：10-19ml/minuremia：<10ml/minFortreatment30-40:limitedproteindiets

diuretic<30diuretic:notavailable<10replacementtherapyPhysiologiccal：relatedwithsports,diets,age……SerumCreatinine,Scr血肌酐測定肌肉活動(dòng)穩(wěn)定、外源性肌酐來源不變的情況下，Scr濃度主要取決于腎小球的濾過能力。NormalValue:SerumorPlasmaCr:male:53-106μmol/Lfemale:44-97μmol/LClinicalSignificanceofScrincreaseGlomerularFiltrationInjuryChronicrenalfailureCompensatorystage:Scr<178μmol/LDecompensatorystage:Scr>178μmol/LFailurestage:Scr>445μmol/LClinicalSignificanceofScrincreaseDifferentialdiagnosisofprerenalandrenalazotemiaPrerenaloliguria:Scr<200μmol/LRenaloliguria:Scr>200μmol/LClinicalSignificanceExcessiveintakeofproteinandproteolysis:Highproteindiet，Highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismClinicalSignificanceRenaldamage:AcuterenalfailureCompensatoryClinicalSignificanceRenaldamage:ChronicrenalfailureCompensatorystage:BUN<9mmol/LDecompensatorystage:BUN>9mmol/LFailurestage:BUN>20mmol/LExcessiveintakeofproteinandproteolysis:

highproteindiet，highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismStageofkidneyimpairement

CcrScrBUN（ml/min)(umol/L)(mmol/L)Compensatorystage80-51<178<9Decompensatorystage50-20178～4459～20Renalfailure19-10445-70720-28.6end-stagerenalfailure

<10>707>28.6(uremia)Expressedinallnucleatedcells,encodedbyhousekeepinggeneCanbedetectedinallbodyfluidAlmostfiltratedthroughglomeruluscompletely,reabsorbedbytubulusandthendegradedConcentrationinserumorplasmaisdeterminedbyGFR。NormalValue：0.6-2.5mg/LCystatinC胱氨酸蛋白酶抑制劑C優(yōu)點(diǎn)Highspecificity：不受炎癥反應(yīng)、惡性腫瘤、肌肉、性別以及年齡的影響。Highsensitivity：與GFR相關(guān)性優(yōu)于Ccr，相當(dāng)于菊粉清除率檢測結(jié)果OperatedeasilyTestsoftubularfunction

腎小管功能檢查Testsofproximaltubularfunction

近端腎小管功能檢測Urineβ2-microglobulin,β2-MGFreelyfiltratedbyglomeruliAlmostreabsorbedbytubulescompletelyThresholdofreabsorption:5mg/LNormalvalue:Urine：<0.3mg/LClinicalSignificanceGFR：Serumβ2-MG↑:moresensitivethanScrwhenCcr<80ml/minReabsorptionfunctionofproximaltubules：

bloodβ2-MG<5mg/L,urineβ2-MGincreaseAcuteandchronicpyelonephritisClinicalSignificanceEvaluationfortransplantkidneyfunctionurineβ2-MG↑↑，impliedgraftrejeciton排異時(shí)血β2-MG增高先于Ccr，測定β2-MG有助于診斷尚處于亞臨床期的腎排異反應(yīng)。腎移植雖有少尿，但血β2-MG下降者提示預(yù)后良好。惡性腫瘤、炎性疾病（肝炎、類風(fēng)濕關(guān)節(jié)炎等）Testsofdistalnephronfunction

遠(yuǎn)端腎單位（遠(yuǎn)端小管和集合管）功能檢測Mosenthal’stest(renalconcentrationfunction)Alsoas:Circadianurinespecificgravity(SG)testNormalintake(water<500-600ml),noextrawaterEmptybladderat8aminthemorningDetectthevolumeandSGoftheurineevery2hoursfrom10amto8pm,andmorningurineofnextdayNormalValuesvolume：24htotalvolume:1000～2000ml；12hovernighturine:<750ml；volumeratioofdaytimeandovernight

:>3～4∶1SGspecificgravity：1.015-1.025highest>1.018thegapofthehighestandthelowest>0.009ClinicalSignificanceImpairmentindistaltubules：Earlystage：overnighturine>750ml,Day/overnight↓,SGisnormalSevereimpairment:polyuria，overnighturine↑SG↓Failure：polyuria、SG:1.010~1.012Diabetesinsipidus尿崩癥:Totalurine>4L，SG<1.006Urinevolume↓SG↑：renalconcentrationfunction:normalbloodvolume↓orGF↓Urineosmol尿滲量AssesstheabilityofkidneystodiluteorconcentrateurineandidentifyADHabnormalitiesNormalvalue:Urineosmol:600-1000mOsm/kgH2O800mOsm/kgH2OPlasmaosmol:275-305mOsm/kgH2O300mOsm/kgH2O

Uosm/Posm=3~4.5:1判斷尿濃縮功能1.Uosm=300mOsm/kgH2O:Isosthenuria等滲尿2.Uosm《300mOsm/kgH2O低滲尿3.Uosm<600mOsm/kgH2O:尿濃縮功能障礙UrineosmolNormalvalue:Plasmaosmol:275-305mOsm/kgH2O

平均300mOsm/kgH2O

Urineosmol:600-1000mOsm/kgH2O

平均800mOsm/kgH2OUosm/Posm=3~4.5:1Uosm<600mOsm/kgH2O,腎小管濃縮功能障礙Uosm=300mOsm/kgH2O，等滲尿ClinicalsignificanceIncrease:dehydration,Addison'sdisease,diarrhea,diabetesmellitus,hyperglycemia,hypernatremiacirrhosisDecrease:overhydration,aldosteronism,diabetesinsipidus,hyponatremia,hypocalcemiaDifferentialdiagnosisofoliguriacauses一次性尿滲透量檢測用于鑒別腎性和腎前性少尿Renaloliguria:腎前性少尿

Uosm<350mOsm/kgH2OPrerenaloliguria:腎性少尿

Uosm>