腎臟病學(xué)總論

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

Consistsoftheglomerulus(腎小球)

anditsattachedtubules(腎小管).Thefunctionalunitofthekidney(是腎臟的功能單位)第9頁/共78頁第10頁/共78頁第11頁/共78頁第12頁/共78頁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/共78頁第14頁/共78頁第15頁/共78頁第16頁/共78頁NormalGlomerulus(PAS)第17頁/共78頁第18頁/共78頁NormalGlomerulusEMGBMMesangium第19頁/共78頁GlomerularBasementMembraneCapillarySpaceEndotheliumUrinarySpaceGBMPodocyte第20頁/共78頁GlomerularBasementMembranePodocytes第21頁/共78頁第22頁/共78頁JuxtaglomerularApparatus

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

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

（glomerularfiltrationfunction）

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

腎小球?yàn)V過示意圖排泄功能

（excretoryfunction）第29頁/共78頁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、各類胺類及尿酸主要由腎小管分泌第30頁/共78頁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/共78頁內(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/共78頁Renin-angiotensinsystem

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

第34頁/共78頁

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/共78頁

NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestation(臨床癥狀)LaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes第36頁/共78頁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/共78頁

NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes第38頁/共78頁尿液檢查

（uronoscopy）

第39頁/共78頁U/A

Chemistry(DipStick)ProteinGlucoseHemoglobinKetonespHBilirubinUrobilinogenNitriteLeukocyteesteraseMOREIMPORTANTLESS

IMPORTANT第40頁/共78頁U/A

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

持續(xù)超過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3.5g/1.73m2/日或50mg/kg/日。第42頁/共78頁按發(fā)病機(jī)制分類腎小球性腎小管性溢出性功能、體位性第43頁/共78頁按發(fā)病機(jī)制分類1Glomerulardisease腎小球性蛋白尿：腎小球?yàn)V過膜損傷或通透性增高

機(jī)械屏障受損：濾過膜孔徑異常增大或斷裂

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

3個(gè)/HP10萬/h50萬/12h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/共78頁腎小球性非腎小球性第48頁/共78頁第49頁/共78頁

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

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

腎小球?yàn)V過功能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/共78頁GlomerularFiltrationRate

(AsmeasuredbyCreatinineClearance)

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

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/共78頁RenalbiopsyIndicationsPreparationComplications第56頁/共78頁RenalbiopsyTohelpestablishthediagnosis,suggestprognosis,directtherapy.第57頁/共78頁正常腎小球第58頁/共78頁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/共78頁NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDisease

MajorRenalSyndromes第60頁/共78頁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無癥狀性尿異常

第61頁/共78頁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/共78頁腎病綜合征

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

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

RapidlyProgressiveGlomerulonephritisNephronalhematuriaRenalfailuredevelopingoverweekstomonthsDiffuseglomerularcrescentformation.第65頁/共78頁無癥狀性尿異常

AsymptomaticHematuria

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

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

ChronicRenalFailureUremiaFinalCommonPathofAllChronicRenalDiseases第68頁/共78頁尿路感染綜合征

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

NephrolithiasisRenalstonesRenalcolic-OOOUUUCCCHHH!!Severe,CrampyPainintheflankarea