內(nèi)科學(xué)教學(xué)課件：英文班泌尿系統(tǒng)疾病-總論

Chapter1

GeneralIntroduction

BasicstructureofkidneyLocationBasicstructureofkidneyLocation:towsidesofspinalcolumnbehindperitoneumLiftkidney:upperpoleT11lowpoleL2Rightkidney:neartheliverupperpoleT12lowpoleL3Length10.5-11.5cmWidth5-7.2cmThickness2-3cmBasicstructureofkidneyConstitute

kidneyunitjuxtaglomerularcomplexrenalinterstitiumbloodvesselnervusBasicstructureofkidneyKidneyunitBasicstructureofkidneyKidneyunitrenalcorpuscle:glomerulusrenalcapsulerenaltubule:proximaltubule thinsegmentdistaltubuleconnectingtubuleBasicstructureofkidneyStructureofglomerulusBasicstructureofkidneyStructureofglomerulus:

endotheliumcellglomerularbasementmembranepodocyte/footcellBasicstructureofkidneyfootcell

sticktoGBMbypodocyticprocessstenopaicholeisclosedbystenopaicmembraneBasicstructureofkidneyglomerularbasementmembrane(GBM):

1.middlelevel:compactlayersialoprotein2.strataexternumandendothecium:tectoriumheparansulfateanion3.Ⅳcollagenprotein:basicstructurefillinglaminin,fibronectionGBMfunction

maintainnormalstructuretiredjacentcellconstitutefiltrationbarrierconstitutefiltrationbarrier

size/molecular

barrier:limitpassingofbigmolecularchargebarrie:restrictfilterofnegativechargemateriala臟層上皮細(xì)胞bGBMc內(nèi)皮細(xì)胞d系膜e副系膜PhysiologicalfunctionofkidneyExcretionofmetabolite

Regulationofwaterelectrolytes&acid-basebalance

MaintainingthestablenessofinternalenvironmentGlomerularfilterfunctionMainformofmetabolitesexcretionwhichincludeurea,creatine,hippuricacid,benzoicacid,amine&uricacid2.GFR

indicateifthefilterfunctionisnormalornot,whichisdeterminedbyhydrostaticpressure,colloidosmoticpressure,areaoffiltermembrane&filterfractionofcapillary。腎小球?yàn)V過(guò)功能Reabsorption&secretionfunctionofrenaltubuleCrudeurine(electrolytecomponentsaresimilarwithplasma)→180L/d;

Urinevolume→1500ml/d(99%isreabsorbed);

Reabsorption&secretionarecontrolledbyrenaltubule→makewater-electrolytebalance.腎小管重吸收和分泌功能近端小管是重吸收的主要部位，葡萄糖、氨基酸全部被重吸收，排泄有機(jī)酸、尿酸、造影劑、抗生素。髓袢細(xì)段的尿液濃縮起重要作用。遠(yuǎn)端小管調(diào)節(jié)終尿成分的主要場(chǎng)所，重吸收Na，排出K及分泌H、NH4。Endocrinefunctionofkidney①vasoactivehormones→actsonkidney→regulatephysiologicallyhemodynamics&water-saltmetabolism→includesrenin、angiotensin、prostategroup、kininsystem②non-vasoactivehormones→actsonwholebody→includes

1α—hydroxylase&erythropoietinExaminationofkidneydiseaseUrinalysis1、proteinuria

urineprotein>150mg/d,qualitativeanalysis(+),urineprotein/creatinine>200mg/g→proteinuriaurineprotein>30~300mg/d→minimalurineproteinClassificationofproteinuriaReasons:(1)Physiologic

proteinuria①functional～②positional～(2)Glomerularproteinuria

：

selective～nonselective～

Classificationofproteinuria(3)tubuleproteinuria

:proteinreabsorptiondefectofproximaltubule→β2－microglobulin、lysozymeinurine;≤2g/d.(4)overflowproteinuria:abnormalprotein(Hb/myoglobin/lightchainproteinofmultiplemyeloma)oflowmolecularweight↑Urinalysis2hematuriagrossµscopic～。新鮮尿離心沉渣每高倍視野紅細(xì)胞超過(guò)３個(gè)，稱(chēng)為鏡下血尿。尿外觀呈洗肉水樣、血樣、醬油樣或有血凝塊時(shí)，稱(chēng)肉眼血尿。尿液檢查尿液檢查鑒別腎小球源性血尿：a新鮮尿沉渣鏡檢

變形紅細(xì)胞為腎小球源性;原因:GBM斷裂,紅細(xì)胞通過(guò)受血管內(nèi)壓力擠出受損,其后通過(guò)腎小管各段時(shí)受滲透壓變化和PH作用,呈現(xiàn)變形紅細(xì)胞血尿，紅細(xì)胞體積表小、破裂。均一形態(tài)正常紅細(xì)胞尿?yàn)榉悄I小球源性尿液檢查鑒別腎小球源性血尿b尿紅細(xì)胞容積分布曲線腎小球源性血尿呈非對(duì)稱(chēng)曲線，其峰值紅細(xì)胞容積小于靜脈峰值紅細(xì)胞容積非腎小球源性血尿呈對(duì)稱(chēng)曲線，其峰值紅細(xì)胞容積大于靜脈峰值50100150200a50100150200b5010015020050100150200c50100150200d尿液檢查3.cylinderuria：castinurine→proteincoagulationintubule→cell/manygranularcasts&proteinuriaappearinthemeantimeismeaningfulinclinic原因：1、腎小球或腎小管性疾病

2、炎癥、藥物刺激使粘蛋白分泌少而形成尿液檢查4leucocyturia、pyuria、bacteriurialeucocyturia

：pyuria→>5WBC/HPoffreshcentrifugalurine/>40millionsWBC/1hrsoffreshurine/>100millionsWBC/12hrs;pyuria

bacteriuria

：bacteriaineveryHP/culturedbacteriacolonies>105/ml；GFRdeterminationGFR:theabilityofrenalclearanceofplasmasubstancesperunittime

EndogenousCcr(creatinineclearancerate)inclinicistheusualmeansofestimatingGFR→Recently,K/DOQIclinicalpracticeguiderecommend2formulastocalculateGFR:Cokcroff-Gault&MDRD.Imagingtests

ultrasonography

CT&MRIarteriography&venographyradionuclide,Commonsyndromesofrenaldiseases1.Nephroticsyndrome:proteininurine>3.5g/dproteininplasma<30g/dedemahyperlipemia腎臟疾病常見(jiàn)綜合征2.Nephritissyndrome:proteinuria,hematuria,hypertension;3.Asymptomaticurineabnormality:4.Acuterenalfailure&rapidlyprogressiverenalfailuresyndrome:5.Chronicrenalfailuresyndrome:progressiveirreversiblyrenalfunctionalfailure.EvaluationofrenaldiseasesEtiologydiagnose：primaryorsecondarypathologydiagnose：Nephritis,NS,AKI,proteinuria,

hematuria,percutaneousrenalbiopsy

functiondiagnose：AKI、CKDcomplicationdiagnose：ARF、CRFPrevention&cure:Principle＊Wipeoffind