診斷學-實驗室檢查-實驗室診斷-常用腎臟功能實驗室檢測

腎功能檢查

ASSESSMENTOFRENALFUNCTION

山東大學劉運芳提要UrineTests:Cheapandconvenient;ForscreeningandfollowingRenalFunctionsImmunologicalTestImagingExaminationRenalBiopsy2WhenorforWhatKidneydiseasesorinjuriesOtherdiseasesinducedkidneyfunctioninjuriesDiabetesmellitusHypertensionShockorextensiveburnAuto-immunologicaldiseasesDrugtoxicity3StructureofKidney4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腎小球功能檢查GLOMERULARFUNCTIONASSESSMENT5StructureandFunctionGFR:thevolumeoffluidfilteredfromtheglomerularcapillariesintotheBowman'scapsuleperunittime一二零-一六零ml/minContentsSerumCreatinine(sCr)&Serumurea(SU)CreatinineClearanceRate,CcrCystatinCMicroalbumin(MA),Transferrinuria(TRU),uricacid,urineIg……SerumCreatinine(sCr)EndogenousawasteproductproducedbymusclemetabolismCreatinineExogenousefromfoods,suchasmeat,fish,coffee,tea,etc.8SerumCreatinine(sCr)Asmallmolecule,filtratedbyglomerularpletely,andnotreabsorbedbytubulesCr:riseifthefilteringofthekidneyisdeficient,NormalValue:SerumCr:male:四四-一三二μmol/Lfemale:七零-一零六μmol/L9Stageofrenalfailure(male)10>四四五μmol/L>一七八μmol/L<一七七μmol/L四四-一三二μmol/LStage四(Failurestage)Stage三(De-pensatorystage)Stage二(pensatorystage)Stage一(Normalfunction)>七零七μmol/LStage五(Uremia)ScrClinicalSignificanceofsCrincrease11riseonlywithmarkeddamagetonephronsfiltrationSerumurea(SU)alsonamedasBUNInfluencefactorsProteinintakeProteindegradationLiverfunctionGlomerularfiltrationNormalvalue:Adults:一.八-七.一mmol/LChildrenorinfants:一.八-六.五mmol/L12UreaorornithinecycleinliverClinicalSignificanceofSURenaldamage:Chronicrenalfailurepensatorystage:SU<九mmol/LDepensatorystage:SU>九mmol/LFailurestage:SU>二零mmol/LUremia:SU>二八.六mmol/LAcuterenaldisease13ClinicalSignificancePhysical:↑:highproteindiet↓:pregnancyPre-renal:Highfever,Shock,Uppergastrointestinalhemorrhage,extensiveburn,severetrauma……Post-renal:Obstructioninurinarytract14SU/Crratio:BUN:七-二零mg/dLUrea:二.五-一零.七mmol/LsCr:零.七-一.二mg/dLsCr:七零-一零六μmol/LBUN:CrUrea:CrLocation>二零:一>一零零:一Pre-renal一零-二零:一四零-一零零:一NormalorPost-renal<一零:一<四零:一Intra-renalCreatinineClearanceRate,CcrDefinition:Ccristhevolumeofbloodplasmawithcreatininethatisclearedbykidneysperunittime.即:單位時間內(nèi),腎臟可全部清除多少毫升血漿地肌酐Normalvalue:八零-一二零ml/min·一.七三m二ClinicalSignificanceofCcrPhysiological:relatedwithsports,diets,age……PathologicaldecreaseSensitiveforkidneyinjuryGFR<五零%時Ccr≈五零ml/minStageofrenalfailure18一零-二零ml/min二零-五零ml/min>五零ml/min>八零ml/minStage四(Failurestage)Stage三(De-pensatorystage)Stage二(pensatorystage)Stage一(Normalfunction)<一零ml/minStage五(Uremia)CCrFortreatmentStageIIobservation,controlofbloodpressure.StageIIIa(三零-四零ml/min)limitedproteindiets,treatmentofplication,diureticStageIIIb(<三零ml/min)diureticisnotavailable19StageIVbinetreatment,planningforend-stagefailure

StageVreplacementtherapy,transplantationordialysis

StageofkidneyimpairementCcr（ml/min)sCr(umol/L)SU(mmol/L)pensatorystage八零-五零<一七七<九Depensatorystage五零-二零一七八-一四四九-二零Renalfailure二零-一零四四五-七零七二零-二八.六end-stagerenalfailure(uremia)<一零>七零七>二八.六Expressedinallnucleatedcells,encodedbyhousekeepinggeneLowmolecularweight,FiltratedfreelythroughglomerulusConcentrationinserumorplasmaisdeterminedbyGFRCystatinCCystatinCbetterthancreatinineinpredictingCystatinCbetterthancreatinineinpredicting優(yōu)點Highsensitivity:betterthanCcrHighspecificity:notinfluencedbyacutephasereaction,activities,genderandage,etal.Usedwidely:forrenaltransplantationstatusformonitoringGFRinnephrotoxicdrugtherapyforacuteandchronickidneydiseasesincludingadiabeticnephropathyOperatedeasily腎小管功能檢查TESTSOFTUBULARFUNCTION25Functionofrenaltubular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尿液稀釋,濃縮遠端腎單位近端腎小管功能檢查TESTSOFPROXIMALTUBULARFUNCTION27TestsofProximaltubularFunctionβ二-microglobulinα一-microglobulinRetinol-bindingprotein,RBPN-acetyl-β-D-glucosaminidase,N-NAGFractionofurinenatriumexcretion,FeNaβ二-microglobulin,β二-MGPresentonallnucleatedcells,especiallyonlymphocytes,andstableinbloodSmallprotein,freelyfiltratedbyglomeruliAlmostreabsorbedbytubulespletelyThresholdofreabsorption:五mg/LNormalvalue:Urine:<零.三mg/LClinicalSignificanceofβ二-MGSerumβ二-MG↑:GFR↓:whenCcr<八零ml/min,moresensitivethanScr惡腫瘤,炎疾?。ǜ窝?類風濕關(guān)節(jié)炎等）Reabsorptionfunctionofproximaltubules:urineβ二-MGincrease(bloodβ二-MG<五mg/L)AcuteandchronicpyelonephritisDrugortoxininducedtubularnecrosisClinicalSignificanceEvaluationfortransplantkidneyfunctionUrineβ二-MG↑↑,impliedgraftrejectionserumβ二-MG:helpforsub-clinicalrejectionofgrafts腎移植雖有少尿,但血β二-MG下降者提示預后良好。α一-microglobulin,α一-MGSmallglycoproteins,synthesizedinliverFreelyfiltratedthroughglomeruliAlmostreabsorbedbyproximaltubulespletelyNormalvalue:Urine:<一五mg/二四hClinicalSignificanceofα一-MGDecrease:severehepatitisandhepaticnecrosisSerumα一-MG↑:GFR↓:whenCcr<一零零ml/min,moresensitivethanScrandβ二-MGUrineα一-MG↑:ReabsorptionfunctionofproximaltubulesinjuryAcuteandchronicDiabeticnephropathyα一-MG↑:serumandurineDamageinbothglomeruliandtubulesRetinal-bindingprotein,RBP視黃醇結(jié)合蛋白Canbedetectedwidely,inallbodyfluidFreelyfiltratedbyglomeruli,almostreabsorbedbytubulespletely,anddegeneratedintoaminoacidsOnlyalittlewasexcretedwithurineNormal:零.一一±零.零七mg/LClinicalSignificanceBloodRBP:Increase:glomerularfunctionHigherspecificityandsensitivitythanScrDecrease:liverfunction,malnutritionUrineRBP:tubularfunctionmorespecific:similarsensitivewithβ二-MGandsensitivethanScrbetterstabilityN-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:Variousglomerulardiseases:diabeticnephropathy,hypertensivenephropathyUrinaryinfection:upper>lower,locationFractionofurinenatriumexcretionNatrium:freelyfiltratedthroughglomeruliand九九%wasreabsorbedbyproximaltubulesNormalvalues:FeNa:<一%ClinicalSignificancePre-renal:鈉攝入過多或血容量下降尿鈉↑同時伴有血鈉↑Reabsorptiondamage:急腎小管壞死尿鈉↑,但血鈉不高DifferentialdiagnosisofazotemiaPrerenal:FeNa<一%Renal:（腎小管）FeNa>一%Summaryβ二-microglobulinα一-microglobulinRetinol-bindingprotein,RBP——reabsorptionfunctionN-acetyl-β-D-glucosaminidase,N-NAG——kidneytoxicitydamageFractionofurinenatriumexcretion,FeNa——differentialdiagnosisofpre-renalandintra-renalazotemia遠端腎小管功能檢查TESTSOFDISTALTUBULARFUNCTION41RenalconcentrationfunctionMosenthal’stestAlsoas:Circadianurinespecificgravity(SG)testNormalintake(water<五零零-六零零ml),noextrawaterEmptybladderat八aminthemorningDetectth