腎功能檢查七年制

時間安排周次日期授課內(nèi)容授課教師19月11日緒論血液學檢查（一）孟曉慧29月18日血液學檢查（二）孟曉慧39月25日血栓與止血檢查鐘寧410月9日骨髓細胞學檢查鐘寧510月16日骨髓細胞學檢查鐘寧610月23日尿液檢查王謙810月30日腎功能檢查、腦脊液、漿膜腔積液陸楠911月6日臨床生物化學檢查（一）張義1011月13日肝功能檢查、糞便檢查陸楠1111月20日臨床生物化學檢查（二）張義1211月27日臨床免疫學檢查王傳新1312月4日臨床病原學檢查孫恩華AssessmentofRenalFunction

腎功能檢查實驗診斷學,2nded.王鴻利.人民衛(wèi)生出版社.

p199KidneyDiseasesUrinalysis:CheapandconvenientForscreeningandfollowingCasePresentation1Boy,9yearsold,admittedasanemergencywithpuffinessoftheface,eyesandtrunk.Aweekpreviouslyhehadcomplainedofasorethroat.Onexamination,hehadamildfever(38.1°C)andhypertension(BP170/110).Hewasanaemic(Hb107g/l)withanormalwhite-cellcountanddifferentiation.Urinalysis:proteinuria,oliguria,haematuriaandredcellcast.CasePresentation266-year-oldmanHistoryHypertensiononmedicationsfor12yearsHighbloodsugarsformorethan5years,notbeentoldasdiabetesHisgrandmotherwasondialysisforherCRFHeworriesabouthisrenalfunctionQuestionsIsthepatientatriskforrenalfunctioninjuried?Whatelseshouldwemeasure?Howshouldwetreathim?RenalFunctionsAssessmentKidneyDiseasesUrinalysisRenalfunctiontestOthertests:ImmunologicalTestImagingExaminationRenalBiopsyStructureofKidney腎單位集合管腎小體腎小管腎小球腎小囊近曲小管遠曲小管髓袢Glomerularfunctionassessment

腎小球功能檢查StructureandFunctionGFR:thevolumeoffluidfilteredfromtheglomerularcapillariesintotheBowman'scapsuleperunittime120-160ml/minTestsofGlomerularFunctionSerumCreatinine(sCr)&Serumurea(SU)CreatinineClearanceRate,CcrCystatinCMicroalbumin(MA)、Transferrinuria(TRU)、uricacid、urineIg……SerumCreatinine(sCr)CreatinineEndogenousawasteproductproducedbymusclemetabolismComefromfoods,suchasmeat,fish,etc.ExogenousSerumCreatinine(sCr)Asmallmolecule,filtratedbyglomerularcompletely,andnotreabsorbedbytubulesCr:riseifthefilteringofthekidneyisdeficientNormalValue:SerumCr:male:53-106μmol/L(0.6-1.2mg/dl)female:44-97μmol/L(0.5-1.1mg/dl)單位換算：mg/dl=88.5umol/LClinicalSignificanceofsCrincreaseGlomerularFiltrationInjury(male)Stage1(Normalfunction):53-106μmol/LStage2(Compensatorystage):<177μmol/L(2mg/dl)Stage3(pensatorystage):>178μmol/LStage4(Failurestage):>445μmol/L(5mg/dl)Stage5(Uremia):>707μmol/L(8mg/dl)ClinicalSignificanceofsCrincreaseriseonlywithmarkeddamagetonephronsfiltrationAcuteKidneyInjuryDefinitionIncreaseinSCrby≥0.3mg/dl(≥26.5μmol/l)within48hours;orIncreaseinSCrto≥1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;orUrinevolume＜0.5ml/kg/hfor6hours.Serumurea(SU)alsonamedasBUNInfluencefactorsProteinintakeProteindegradationLiverfunctionGlomerularfiltrationNormalvalue:Adults:3.2-7.1mmol/LChildrenorinfants:1.8-6.5mmol/LClinicalSignificanceofSURenaldamage:ChronicrenalfailureCompensatorystage:SU<9mmol/Lpensatorystage:SU>9mmol/LFailurestage:SU>20mmol/LUremia:SU>28.6mmol/LAcuterenaldiseaseClinicalSignificancePhysical:↑：highproteindiet↓：pregnancyPre-renal:Highfever,Shock,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma……Congestiveheartfailure,renalhypertensionPost-renal:ObstructioninurinarytractBUN/sCrratioNormalratio:10-15:1>20:1dehydration,GIhemorrhage<10:1lowproteindietOverhydrationsevereliverdiseaseCreatinineClearanceRate,CcrDefinition：Ccristhevolumeofbloodplasmawithcreatininethatisclearedbykidneysperunittime.即：單位時間內(nèi),腎臟可全部清除多少毫升血漿中的肌酐Normalvalue：80-120ml/min·1.73m2eGFR:ClinicalSignificanceofCcrPhysiological：relatedwithsports,diets,age……PathologicaldecreaseMoreSensitivethansCrforkidneyinjuryGFR<50%時Ccr≈50ml/minClinicalSignificance(FromKDIGO2012ClinicalPracticeGuidelinefortheEvaluationandManagementofChronicKidneyDisease)FortreatmentStage2:observation,controlofbloodpressureStage3a(45-59ml/min):limitedproteindietstreatmentofcomplication,diureticStage3b(30-44ml/min):somediureticisnotavailableStage4:combinetreatmentplanningforend-stagefailureStage5(end-stagefailure):replacementtherapytransplantationordialysisClinicalSignificanceExpressedinallnucleatedcells,encodedbyhousekeepinggeneLowmolecularweight,FiltratedfreelythroughglomerulusConcentrationinserumorplasmaisdeterminedbyGFRCystatinC(胱抑素C)CystatinCbetterthancreatinineinpredictingCystatinCbetterthancreatinineinpredicting優(yōu)點Highsensitivity：betterthanCcrHighspecificity：notinfluencedbyacutephasereaction,activities,genderandage,etal.Usedwidely:forrenaltransplantationstatusformonitoringGFRinnephrotoxicdrugtherapyforacuteandchronickidneydiseasesincludingadiabeticnephropathyOperatedeasilyTestsoftubularfunction

腎小管功能檢查Functionofrenaltubular重吸收：水、電介質(zhì)、小分子蛋白葡萄糖、氨基酸腎單位集合管腎小體腎小管腎小球腎小囊近端小管遠端小管髓袢Testsofproximaltubularfunction

近端腎小管功能檢測TestsofProximaltubularFunctionα1-microglobulinβ2-microglobulinRetinol-bindingprotein,RBPN-acetyl-β-D-glucosaminidase,

N-NAGFractionofurinenatriumexcretion,FeNaβ2-microglobulin,β2-MGPresentonallnucleatedcells,especiallyonlymphocytes,andstableinbloodSmallprotein,freelyfiltratedbyglomeruliAlmostreabsorbedbytubulescompletelyThresholdofre-absorption:5mg/LNormalvalue:Urine：<0.3mg/LClinicalSignificanceofβ2-MGSerumβ2-MG↑：GFR↓:whenCcr<80ml/min，moresensitivethanScr惡性腫瘤、炎性疾?。ǜ窝?、類風濕關節(jié)炎等）Reabsorptionfunctionofproximaltubules：urineβ2-MGincrease(bloodβ2-MG<5mg/L)AcuteandchronicpyelonephritisDrugortoxininducedtubularnecrosisClinicalSignificanceEvaluationfortransplantkidneyfunctionUrineβ2-MG↑↑，impliedgraftrejectionserumβ2-MG:helpforsub-clinicalrejectionofgrafts注：腎移植雖有少尿，但血β2-MG下降者提示預后良好。Retinal-bindingprotein,RBP視黃醇結(jié)合蛋白Canbedetectedwidely,inallbodyfluidFreelyfiltratedbyglomeruli,almostreabsorbedbytubulescompletely,anddegeneratedintoaminoacidsOnlyalittlewasexcretedwithurineNormal:0.11±0.07mg/LClinicalSignificanceBloodRBP:Increase:glomerularfunction

HigherspecificityandsensitivitythanScrDecrease:liverfunction,malnutritionUrineRBP:tubularfunctionmorespecific:similarsensitivewithβ2-MGbetterstabilityN-acetyl-β-D-glucosaminidase(NAG)N-乙酰-β-D-氨基葡萄糖苷酶widelydistributedlysosomalhydrolasenotfilteredattheglomerulusLocatedpredominantlyintherenalproximaltubulesExcretedinlowamountsinurineClinicalSignificanceUrineNAGincrease:exocytosisprocessoftubularcellsToxicacutetubularinjuries:lead,aminoglycosideantibiotics,nephrotoxicdrugs,anti-cancerdrugs(cisplatin……)Acuterejection:UpperUrinaryinfectionFractionofurinenatriumexcretion,FeNaNatrium:freelyfiltratedthroughglomeruliand99%wasreabsorbedbyproximaltubulesNormalvalues:FeNa:<1%ClinicalSignificancePre-renal：鈉攝入過多或血容量下降尿鈉↑同時伴有血鈉↑Reabsorptiondamage:急性腎小管壞死尿鈉↑，但血鈉不高DifferentialdiagnosisofazotemiaPrerenal:FeNa<1%Renal:（腎小管性）

FeNa>1%Functionofrenaltubular腎單位集合管腎小體腎小管腎小球腎小囊近端小管遠端小管髓袢尿液稀釋、濃縮遠端腎單位Testsofdistalnephronfunction

遠端腎單位（遠端小管和集合管）功能檢測Mosenthal’stest(renalconcentrationfunction)Alsoas:Circadianurinespecificgravity(SG)testClassical&oldNormalintake(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:Totalurine>4L，SG<1.006Urinevolume↓SG↑

：

renalconcentrationfunction:normal