蛋白尿的診斷與注意事項(xiàng)課件

1、蛋白尿的診斷治療與注意事項(xiàng)2021/7/131蛋白尿的診斷治療與注意事項(xiàng)2021/7/131basic structurebehind two sides of peritoneum11 cm 6 cm 3 cmWt. 100-140 g2021/7/132basic structure2021/7/1322021/7/1332021/7/1332021/7/1342021/7/1342021/7/1352021/7/1352021/7/1362021/7/136腎小球旁器（1）球旁細(xì)胞 afferent arteriole中膜內(nèi)的肌上皮樣細(xì)胞。分泌renin。 （2）系膜細(xì)胞afferent

2、 和 efferent arteriole 之間的間質(zhì)細(xì)胞群。吞噬功能。（3）致密斑:調(diào)節(jié)juxtaglomerular cell釋放renin。2021/7/137腎小球旁器（1）球旁細(xì)胞 afferent arteriol*（一）腎小球?yàn)V過率 GFR：單位時間內(nèi)（每分鐘） 兩腎生成的原尿量。 GFR與體表面積成正比。每日濾過量是全身total plasma volume 的60倍，即kidney 每日凈化處理全身plasma 60次。判斷腎功能的指標(biāo)-腎小球?yàn)V過率 GFR取決于：effective filtration pressure 和 filtration membrane 通透性2

3、021/7/138*（一）腎小球?yàn)V過率 判斷腎功能的指標(biāo)-腎小球?yàn)V過率 影響濾過率的因素filtration membraneeffective filtration pressure2021/7/139影響濾過率的因素filtration membrane2022021/7/13102021/7/1310濾過膜的結(jié)構(gòu) 1. 內(nèi)層毛細(xì)血管壁的內(nèi)皮細(xì) 胞：有50100 nm的窗孔，血細(xì)胞不能通過。 2. 中層基膜：有48 nm的纖維網(wǎng)孔，蛋白質(zhì)和脂質(zhì)不能通過。（主要） 3. 外層腎小囊的上皮細(xì)胞：裂隙膜上有414 nm的孔，大分子蛋白質(zhì)不能通過。2021/7/13112021/7/1311水分子

4、陽離子葡萄糖小分子陰離子蛋白質(zhì)濾過膜通透作用的選擇性 濾過膜的機(jī)械屏障作用：glomerular filtration membrane上大小不等的孔道，阻止大分子物質(zhì)通過。（起主要作用） 半徑3.6 nm 不能通過，如plasma globulin，fibrinogen。2021/7/1312水分子陽離子葡萄糖小分子陰離子蛋白質(zhì)濾過膜通透作用的選擇性 有效濾過壓 有效濾過壓: 是glomerular filtration的動力。腎小球有效濾過壓腎小球毛細(xì)血管血壓（血漿膠體滲透壓囊內(nèi)壓）2021/7/1313有效濾過壓 有效濾過壓: 是glomerular filtAfferent arter

5、iole端EFP45（2510）10 mmHg Efferent arteriole端EFP 45（3510）0 mmHg 由此可見， glomerular capillary不是全段都有濾過作用。2021/7/1314Afferent arteriole端EFP45（25 腎小球毛細(xì)血管壓 平均動脈壓（舒張壓+1/3脈壓差）： BP 80180 mmHg 腎小球毛細(xì)血管壓維持穩(wěn)定 GFR基本不變 。 BP 4080 mmHg 腎小球毛細(xì)血管壓 濾過壓 GFR 。 BP 40 mmHg GFR 0 無尿。 入球動脈 和 出球動脈 的口徑： 入球動脈收縮腎小球毛細(xì)血管壓 有效濾過壓 GFR 。

6、出球動脈收縮腎小球毛細(xì)血管壓 有效濾過壓 GFR 。 2021/7/1315 腎小球毛細(xì)血腎小管和集合管的轉(zhuǎn)運(yùn)功能 包括：reabsorption、secretion、excretion2021/7/1316腎小管和集合管的轉(zhuǎn)運(yùn)功能 包括：reabsorptionProteinuria 2021/7/1317Proteinuria 2021/7/1317What is proteinuria? Proteinuria means the appearance of protein in the urine. 24-hour urine Microalbuminuria 30 - 150 mg

7、Mild 150- 500 mg Moderate 500 - 1000 mg Heavy 1000 - 3000 mg Nephrotic range more than 3500 mg2021/7/1318What is proteinuria? ProteinurSIGNS AND SYMPTOMSfoamy urine edema Hypoalbuminemia and hypotension pre-renal acute renal failurehyperlipidemia Infection 2021/7/1319SIGNS AND SYMPTOMSfoamy urine Me

8、chanisms of ProteinuriaBenign Proteinuria Glomerular Proteinuria Primary or secondary glomerulopathy Tubular Proteinuria Tubular or interstitial disease Overflow Proteinuriaas in multiple myeloma secretory (post glomerular) 2021/7/1320Mechanisms of ProteinuriaBenig2021/7/13212021/7/1321Primary glome

9、rulonephropathy - Minimal change disease MsPGNIdiopathic membranous glomerulonephritis Focal segmental glomerulonephritis Membranoproliferative glomerulonephritis IgA nephropathy 2021/7/1322Primary glomerulonephropathy MCD2021/7/1323MCD2021/7/1323MsPGN2021/7/1324MsPGN2021/7/13242021/7/13252021/7/132

10、52021/7/13262021/7/1326IgAN2021/7/1327IgAN2021/7/1327IgAN2021/7/1328IgAN2021/7/1328IgAN2021/7/1329IgAN2021/7/1329MPGN2021/7/1330MPGN2021/7/13302021/7/13312021/7/1331Secondary glomerulonephropathy Diabetes mellitus Collagen vascular disorders (e.g., lupus nephritis) Amyloidosis Preeclampsia先兆子癇Infect

11、ion (e.g., HIV, hepatitis B and C, poststreptococcal illness, syphilis, malaria and endocarditis) Gastrointestinal and lung cancers Lymphoma, chronic renal transplant rejection 2021/7/1332Secondary glomerulonephropathySLE LN2021/7/1333SLE LN2021/7/1333淀粉樣變2021/7/1334淀粉樣變2021/7/1334DN2021/7/1335DN202

12、1/7/1335DN2021/7/1336DN2021/7/1336DN2021/7/1337DN2021/7/1337Tubular Hypertensive nephrosclerosis Tubulointerstitial disease due to: Uric acid nephropathy Acute hypersensitivity interstitial nephritis Fanconi syndrome Heavy metals Sickle cell disease NSAIDs, antibiotics 2021/7/1338Tubular Hypertensiv

13、e nephroscAcute pyelonephritis2021/7/1339Acute pyelonephritis2021/7/13AINS2021/7/1340AINS2021/7/1340AIN2021/7/1341AIN2021/7/1341CRF 2021/7/1342CRF 2021/7/1342Overflow- Hemoglobinuria Myoglobinuria Multiple myeloma Amyloidosis 2021/7/1343Overflow- Hemoglobinuria 2021Diagnostic Evaluation of Proteinuria Age health and family history physical examination Urinalysis Blood analysis kidney biopsy 2021/7/1344Diagnostic Evaluation of ProteHow is proteinuria treated? Dietary regulation Controlling hypertension is essential