腎臟病學(xué)總論

腎臟病學(xué)總論第1頁(yè)/共78頁(yè)NEPHROLOGYStructureofthekidney(結(jié)構(gòu))FunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes第2頁(yè)/共78頁(yè)第3頁(yè)/共78頁(yè)第4頁(yè)/共78頁(yè)第5頁(yè)/共78頁(yè)第6頁(yè)/共78頁(yè)第7頁(yè)/共78頁(yè)第8頁(yè)/共78頁(yè)TheNephron(腎單位)

Consistsoftheglomerulus(腎小球)

anditsattachedtubules(腎小管).Thefunctionalunitofthekidney(是腎臟的功能單位)第9頁(yè)/共78頁(yè)第10頁(yè)/共78頁(yè)第11頁(yè)/共78頁(yè)第12頁(yè)/共78頁(yè)Glomerulus(腎小球)Endothelialcells(內(nèi)皮細(xì)胞)Glomerularbasementmembrane(腎小球基底膜GBM)Podocytes(足突細(xì)胞)-VisceralEpithelialCellMesangialcellsandmatrix(系膜細(xì)胞和基質(zhì))

ParietalepitheliumBowman’sCapsule第13頁(yè)/共78頁(yè)第14頁(yè)/共78頁(yè)第15頁(yè)/共78頁(yè)第16頁(yè)/共78頁(yè)NormalGlomerulus(PAS)第17頁(yè)/共78頁(yè)第18頁(yè)/共78頁(yè)NormalGlomerulusEMGBMMesangium第19頁(yè)/共78頁(yè)GlomerularBasementMembraneCapillarySpaceEndotheliumUrinarySpaceGBMPodocyte第20頁(yè)/共78頁(yè)GlomerularBasementMembranePodocytes第21頁(yè)/共78頁(yè)第22頁(yè)/共78頁(yè)JuxtaglomerularApparatus

(近球旁器)VascularcomponentAfferentarterioleEfferentarterioleExtraglomerularmensangialregionTubulecomponentthickascendinglimb第23頁(yè)/共78頁(yè)第24頁(yè)/共78頁(yè)MechanismofreninreleaseThemaculadensatheorychangesintheNa+,Cl-concentrationThestretch-receptortheoryalterationsinthevolumestretchoftheafferentarteriol第25頁(yè)/共78頁(yè)TUBULAREPITHELIALCELLS第26頁(yè)/共78頁(yè)

NEPHROLOGYStructureofthekidneyFunctionofthekidney(功能)ClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes第27頁(yè)/共78頁(yè)NephronFunctionGlomerularfiltration(腎小球?yàn)V過(guò)功能）Tubulesecretionandreabsorption（腎小管重吸收和分泌功能）第28頁(yè)/共78頁(yè)腎小球?yàn)V過(guò)功能

（glomerularfiltrationfunction）

含氮廢物如尿素、肌酐等主要由腎小球?yàn)V過(guò)排出。馬尿酸、苯甲酸、各類(lèi)胺類(lèi)及尿酸也有部分經(jīng)濾過(guò)排出

腎小球?yàn)V過(guò)示意圖排泄功能

（excretoryfunction）第29頁(yè)/共78頁(yè)腎小管重吸收和分泌功能

（tubularreabsorptionandexcretionfunction）近端小管重吸收髓袢維持髓質(zhì)高張及尿液的濃縮和稀釋遠(yuǎn)端小管AVP作用下,尿素再循環(huán)馬尿酸、苯甲酸、各類(lèi)胺類(lèi)及尿酸主要由腎小管分泌第30頁(yè)/共78頁(yè)NephronFunctionWaterbalance(水平衡)Eletrolytemetabolism(電解質(zhì)代謝)Acid-basebalance(酸堿平衡)Ureasecretion(代謝產(chǎn)物排泄)Others:第31頁(yè)/共78頁(yè)內(nèi)分泌功能

（endocrinefunction）

球旁器分泌腎素血管緊張素原→血管緊張素Ⅰ→血管緊張素Ⅱ、血管緊張素ⅢRAS系統(tǒng)第32頁(yè)/共78頁(yè)Renin-angiotensinsystem

(腎素血管緊張素系統(tǒng)RAS)angiotensinogenangiotensinⅠangiotensinⅡAldosteroneAT1,AT2ReninACE第33頁(yè)/共78頁(yè)AngiotensinⅡIncreasepreglomerularandefferentarterioarresistancesEnhancethereabsorptionofsodiumEffectsonvasavectaDecreaseKf—adecreaseinhydraulicconductivityEnhanceproductionofPG,TGFβ

第34頁(yè)/共78頁(yè)

EndocrinefunctionProstaglandin:PGE2,I2,A2,F2,TXA2(前列腺素族)Bradykinin(緩激肽)Erythropietin,(促紅細(xì)胞生成素EPO)1,25-dihydroxycholecalciferol（活性ＶＤ３）

1,25-(OH)2D3(

1α羥化酶)Decomposeorgan:insulinTargetorgan:PTH,TH,CA,ADHEGF,PDGF,IGF-1,TGFα,β第35頁(yè)/共78頁(yè)

NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestation(臨床癥狀)LaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes第36頁(yè)/共78頁(yè)ClinicalmanifestationEdema(水腫)Hypertension高血壓Proteinuria蛋白尿Hematuria血尿Lossofrenalfunction腎功能喪失Painintheflankarea:renalcolicChangesinurinevolumeOthers第37頁(yè)/共78頁(yè)

NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes第38頁(yè)/共78頁(yè)尿液檢查

（uronoscopy）

第39頁(yè)/共78頁(yè)U/A

Chemistry(DipStick)ProteinGlucoseHemoglobinKetonespHBilirubinUrobilinogenNitriteLeukocyteesteraseMOREIMPORTANTLESS

IMPORTANT第40頁(yè)/共78頁(yè)U/A

ChemistryHoldhereDipuptohereThereactionsaretimedandthecolorschangeifanalysesarepresent.CompareSticktocolorsonDipStickBottleandgrade0,1+,2+,3+,4+;thedarkerthecolor,thegreaterthegrade!pHProteinGlucoseHgbETC.第41頁(yè)/共78頁(yè)P(yáng)roteinuria蛋白尿定義:

持續(xù)超過(guò)150mg/日尿蛋白/肌酐〉200mg/g微量白蛋白尿：30-300mg/d

尿白蛋白/肌酐17-250mg/g(male)25-355mg/g(female大量蛋白尿:超過(guò)3.5g/1.73m2/日或50mg/kg/日。第42頁(yè)/共78頁(yè)按發(fā)病機(jī)制分類(lèi)腎小球性腎小管性溢出性功能、體位性第43頁(yè)/共78頁(yè)按發(fā)病機(jī)制分類(lèi)1Glomerulardisease腎小球性蛋白尿：腎小球?yàn)V過(guò)膜損傷或通透性增高

機(jī)械屏障受損：濾過(guò)膜孔徑異常增大或斷裂

電荷屏障受損：濾過(guò)膜負(fù)電荷減少按分子量分類(lèi)：（1）選擇性蛋白尿：（2）非選擇性蛋白尿：第44頁(yè)/共78頁(yè)按發(fā)病機(jī)制分類(lèi)2Tubuledisease

腎小管性蛋白尿：腎小管重吸收↓，

由小分子蛋白構(gòu)成：β2-MG、溶菌酶。<2g/日

3Spillover溢出性蛋白尿：血中異常蛋白增多

（免疫球蛋白輕鏈、血紅蛋白）

第45頁(yè)/共78頁(yè)P(yáng)roteinuria４功能性蛋白尿:發(fā)熱、寒冷、運(yùn)動(dòng)、淤血、直立。

<1g/天

體位性蛋白尿：直立位或脊柱前凸第46頁(yè)/共78頁(yè)

3個(gè)/HP10萬(wàn)/h50萬(wàn)/12h血尿（紅細(xì)胞尿）hematuria泌尿系全身性鄰近器官

運(yùn)動(dòng)性第47頁(yè)/共78頁(yè)腎小球性非腎小球性第48頁(yè)/共78頁(yè)第49頁(yè)/共78頁(yè)

3.管型尿5000個(gè)/12h第50頁(yè)/共78頁(yè)WhatisanRBCcast?

第51頁(yè)/共78頁(yè)白細(xì)胞尿、膿尿、細(xì)菌尿5個(gè)/HP40萬(wàn)/h100萬(wàn)/12h每HP見(jiàn)細(xì)菌或培養(yǎng)105/ml第52頁(yè)/共78頁(yè)

腎小球?yàn)V過(guò)功能CcrScrBUN

腎小管功能近端腎小管功能B2-MG等尿濃縮-稀釋試驗(yàn)?zāi)驖B透壓測(cè)定腎血漿流量測(cè)定酸化功能

腎功能檢查（renalfunctionexamination）第53頁(yè)/共78頁(yè)GlomerularFiltrationRate

(AsmeasuredbyCreatinineClearance)

UrineFlow(ml/d)xUcr(m=umol/L)CrCl=--------------------------------------------Pcr(umol/L)x1440(min/d)WhereCrCl=CreatinineClearanceUcr=UrineCreatininePcr=PlasmaCreatinine第54頁(yè)/共78頁(yè)

KUB;IVP或逆行腎盂造影；膀胱鏡檢查；放射性核素；超聲檢查；CT；核磁共振等影像檢查第55頁(yè)/共78頁(yè)RenalbiopsyIndicationsPreparationComplications第56頁(yè)/共78頁(yè)RenalbiopsyTohelpestablishthediagnosis,suggestprognosis,directtherapy.第57頁(yè)/共78頁(yè)正常腎小球第58頁(yè)/共78頁(yè)a臟層上皮細(xì)胞bGBMc內(nèi)皮細(xì)胞d系膜e副系膜第59頁(yè)/共78頁(yè)NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDisease

MajorRenalSyndromes第60頁(yè)/共78頁(yè)MajorRenalSyndromesTheNephroticSyndrome

腎病綜合征AcuteNephriticSyndrome

急性腎炎綜合征RapidlyProgressiveGlomerulonephritis急進(jìn)性腎炎綜合征ChronicNephriticSyndrome慢性腎炎綜合征AsymptomaticHematuria

and/or

Proteinuria無(wú)癥狀性尿異常

第61頁(yè)/共78頁(yè)MajorRenalSyndromes(cont)AcuteRenalFailure急性腎衰竭綜合征Chronicrenalfailure慢性腎衰竭綜合征UrinaryTractInfection尿路感染綜合征Nephrolithiasis腎石癥

第62頁(yè)/共78頁(yè)腎病綜合征

TheNephroticSyndromeProteinuria(>3.5gm/day)Hypoalbuminemia（〈30g/L)EdemaHyperlipidemaLipiduria第63頁(yè)/共78頁(yè)急性腎炎綜合征

AcuteNephriticSyndromeSuddenonsetofhematuriawithRBCcastsandrenalfailure(days-weeks)RBCcastsnotlistedinthebook!!Butthisiscritical!!Proteinuria(mildtomoderatebutNOTNephroticRange)HypertensionHallmarkDisease:PostStreptococcalGlomerulonephritis第64頁(yè)/共78頁(yè)急進(jìn)性腎炎綜合征

RapidlyProgressiveGlomerulonephritisNephronalhematuriaRenalfailuredevelopingoverweekstomonthsDiffuseglomerularcrescentformation.第65頁(yè)/共78頁(yè)無(wú)癥狀性尿異常

AsymptomaticHematuria

orProteinuriaHematuriawithorwithoutRBCcastsand/orProteinuriausually<2.0gm/dayNORENALFAILURENONEPHROTICSYNDROME第66頁(yè)/共78頁(yè)急性腎衰竭綜合征

AcuteRenalFailureOliguria(<400ml/day)RarelyanuriaRecentOnsetofAzotemia(hours/days)第67頁(yè)/共78頁(yè)慢性腎衰竭綜合征

ChronicRenalFailureUremiaFinalCommonPathofAllChronicRenalDiseases第68頁(yè)/共78頁(yè)尿路感染綜合征

UrinaryTractInfectionBacteriuriaandPyuriaDysuria,Frequency,UrgencyPyelonephritisorCystitisWBCcasts=PyelonephritisTheBookMissesthisone!!FeverTheBookMissesthisone!!第69頁(yè)/共78頁(yè)腎石癥

NephrolithiasisRenalstonesRenalcolic-OOOUUUCCCHHH!!Severe,CrampyPainintheflankarea