腎臟病學(xué)總論

NEPHROLOGY

(腎臟病學(xué)總論）1整理pptNEPHROLOGYStructureofthekidney(結(jié)構(gòu))FunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes2整理ppt3整理ppt4整理ppt5整理ppt6整理ppt7整理ppt8整理pptTheNephron(腎單位)

Consistsoftheglomerulus(腎小球)

anditsattachedtubules(腎小管).Thefunctionalunitofthekidney(是腎臟的功能單位)9整理ppt10整理ppt11整理ppt12整理pptGlomerulus(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’sCapsule13整理ppt14整理ppt15整理ppt16整理pptNormalGlomerulus(PAS)17整理ppt18整理pptNormalGlomerulusEMGBMMesangium19整理pptGlomerularBasementMembraneCapillarySpaceEndotheliumUrinarySpaceGBMPodocyte20整理pptGlomerularBasementMembranePodocytes21整理ppt22整理pptJuxtaglomerularApparatus

(近球旁器)VascularcomponentAfferentarterioleEfferentarterioleExtraglomerularmensangialregionTubulecomponentthickascendinglimb23整理ppt24整理pptMechanismofreninreleaseThemaculadensatheorychangesintheNa+,Cl-concentrationThestretch-receptortheoryalterationsinthevolumestretchoftheafferentarteriol25整理pptTUBULAREPITHELIALCELLS26整理ppt

NEPHROLOGYStructureofthekidneyFunctionofthekidney(功能)ClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes27整理pptNephronFunctionGlomerularfiltration(腎小球?yàn)V過功能）Tubulesecretionandreabsorption（腎小管重吸收和分泌功能）28整理ppt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）29整理ppt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30整理pptNephronFunctionWaterbalance(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:31整理ppt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)32整理pptRenin-angiotensinsystem

(腎素血管緊張素系統(tǒng)RAS)angiotensinogenangiotensinⅠangiotensinⅡAldosteroneAT1,AT2ReninACE33整理pptAngiotensinⅡIncreasepreglomerularandefferentarterioarresistancesEnhancethereabsorptionofsodiumEffectsonvasavectaDecreaseKf—adecreaseinhydraulicconductivityEnhanceproductionofPG,TGFβ

34整理ppt

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,β35整理ppt

NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestation(臨床癥狀)LaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes36整理pptClinicalmanifestationEdema(水腫)Hypertension高血壓Proteinuria蛋白尿Hematuria血尿Lossofrenalfunction腎功能喪失Painintheflankarea:renalcolicChangesinurinevolumeOthers37整理ppt

NEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes38整理ppt尿液檢查

（uronoscopy）

39整理pptU/A

Chemistry(DipStick)ProteinGlucoseHemoglobinKetonespHBilirubinUrobilinogenNitriteLeukocyteesteraseMOREIMPORTANTLESS

IMPORTANT40整理pptU/A

ChemistryHoldhereDipuptohereThereactionsaretimedandthecolorschangeifanalysesarepresent.CompareSticktocolorsonDipStickBottleandgrade0,1+,2+,3+,4+;thedarkerthecolor,thegreaterthegrade!pHProteinGlucoseHgbETC.41整理pptProteinuria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。42整理ppt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43整理ppt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：44整理ppt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）

45整理pptProteinuria４功能性蛋白尿:發(fā)熱、寒冷、運(yùn)動、淤血、直立。

<1g/天

體位性蛋白尿：直立位或脊柱前凸46整理ppt

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)動性47整理ppt腎小球性非腎小球性48整理ppt49整理ppt

3.管型尿5000個(gè)/12h50整理pptWhatisanRBCcast?

51整理ppt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/ml52整理ppt

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透壓測定腎血漿流量測定酸化功能

腎功能檢查（renalfunctionexamination）53整理pptGlomerularFiltrationRate

(AsmeasuredbyCreatinineClearance)

UrineFlow(ml/d)xUcr(m=umol/L)CrCl=--------------------------------------------Pcr(umol/L)x1440(min/d)WhereCrCl=CreatinineClearanceUcr=UrineCreatininePcr=PlasmaCreatinine54整理ppt

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55整理pptRenalbiopsyIndicationsPreparationComplications56整理pptRenalbiopsyTohelpestablishthediagnosis,suggestprognosis,directtherapy.57整理ppt正常腎小球58整理ppta臟層上皮細(xì)胞bGBMc內(nèi)皮細(xì)胞d系膜e副系膜59整理pptNEPHROLOGYStructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDisease

MajorRenalSyndromes60整理pptMajorRenalSyndromesTheNephroticSyndrome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

61整理pptMajorRenalSyndromes(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

62整理ppt腎病綜合征

TheNephroticSyndromeProteinuria(>3.5gm/day)Hypoalbuminemia（〈30g/L)EdemaHyperlipidemaLipiduria63整理ppt急性腎炎綜合征

AcuteNephriticSyndromeSuddenonsetofhematuriawithRBCcastsandrenalfailure(days-weeks)RBCcastsnotlistedinthebook!!Butthisiscritical!!Proteinuria(mildtomoderatebutNOTNephroticRange)HypertensionHallmarkDisease:PostStreptococcalGlomerulonephritis64整理ppt急進(jìn)性腎炎綜合征

RapidlyProgressiveGlomerulonephritisNephronalhematuriaRenalfailuredevelopingoverweekstomonthsDiffuseglomerularcrescentformation.65整理ppt無癥狀性尿異常

AsymptomaticHematuria

orProteinuriaHematuriawithorwithoutRBCcastsand/orProteinuriausually<2.0gm/dayNORENALFAILURENONEPHROTICSYNDROME66整理ppt急性腎衰竭綜合征

AcuteRenalFailureOliguria(<400ml/day)RarelyanuriaRecentOnsetofAzotemia(hours/days)67整理ppt慢性腎衰竭綜合征

ChronicRenalFailureUremiaFinalCommonPathofAllChronicRenalDiseases68整理ppt尿路感染綜合征

UrinaryTractInfectionBacteriuriaandPyuriaDysuria,Frequency,UrgencyPyelonephritisorCystitisWBCcasts=PyelonephritisTheBookMissesthisone!!FeverTheBookMissesthisone!!69整理ppt腎石癥

NephrolithiasisRenalstonesRenalcolic-OOOUUUCCCHHH!!Severe,Crampy