上海交通大学医学院儿科学临床医学八年一贯制课件泌尿系统.ppt

urinary system 上海交通大学医学院附属新华医院 儿内科教研室 卫敏江 urinary system Urinary system includes the kidney、ureter、 bladder and urethra . The kidney is an important excretory organ , also , it is an essential adjuster and endocrine organ to maintain a precise balance of internal environment . anatomical character neonate larger，inmature，small glomerulus ，short tubule infant Ureter is much longer and incurvater, tube muscles and elastic fibers are dysontogenesis . Ureter close to the bladder is straighter and shorter, it is poor to prevent urine reverse flow. female infant has a shorter urethra ,but male infant often has capistration physiologic character glomerular filtration commences in the metanephric kidney at about 9 to 12 weeks of gestation， the full complement of nephrons is present at 36 weeks of gestation . low reserve capacity ，inmature regulatory mechanism，easy to dysfunction 。 the renal function(calculated by body weight or body surface area) reaches a value comparable to adult at 1 to 2 years of age. glomerular filtration rate neonate the first week of birth : glomerular filtration 2 year-old: adult level pathology extra moisture and solute can not excretion in time edema the reabsorption and the excretory function of renal tubule glomerulotubular balance neonate has already possess glomerulotubular balance ，but inmature。 amino acid /glucose term infant : normal reabsorption capacity premature infant: renal tubule function deficiency， glucose threshold glucosuria (reabsorpt glucose ） natrium neonate aldosterone natrium positive balance glomerular filtration rate natrium load natriume excretion edema infant of low-birth weight natriume duction if natriume intake （3mmol/kg/d） hyponatremia shock or convulsion potassium because Na-K-ATP enzyme system of renal tubules epithelium is inmature， neonate potassium excretionin 10 ayshyperkalemia tendency。 acid-base balance kidneyexcret H、reabsorb HCO3 acid-base balance at 2 weeks after birth the urine PH get the adult level at 2 years old the capability of ammonia excretion close to adult level renal threshold of HCO3 in neonate is low。 urine concentration and dilution urine dilution ability of newbron or infants close to adult glomerular filtration ratebody protein anabolism activelyurea excretioncan not form enough osmotic pressure gradient in kidney medulla urine concentration renal endosecretory function renin prostaglandin kallikrein erythropoietin 1,25-dihydroxycholecalciferol urinate character neonate urination in 24Hr (93%) urination in 48Hr(99%) pathology oliguria 5%, diagnostic。 CysC diagnosis and differential diagnosis diagnostic criteria ： medical history symptoms middle molecules protein : molecular weight 7 9.9Mr(albumin); macromolecule protein : molecular weight 10Mr(IgG15Mr) ， selective albuminuria/nonselective albuminuria serum albumin (30g/L)。 cholesterin （5.7mmol/L) serum complement determine laboratory examination of systemic disease laboratory examination of hypercoagulative state&thrombosis biopsy simple NS nephritis NS Age 16 7 pathological change MCD MsPGN 、MPGN 、FSGS symptom four chief symptoms four chief symptoms hypertensionhematuria Albuminuria selective nonselective Complemen normal some reduce Renal function normal some reduce Urine FDP negative positive Reaction to good ，easy to relapse poor glucocorticoid course of the disease relieve in 48weeks delayed easy to relapse , 12year complication 1. infection URI, skin , urinary tract , peritonitis, etc. 2. hypovolemic shock 3. electrolyte disturbance hyponatremia , low potassium phosphate , hypocalcemia, etc. 4. thrombogenesis 5. acute renal failure 6. renal tubules malfunction 7. delayed growth treatment general treatment rest , diet, sodium 12g/day，intake VitD，calcium， protein 1.52g/kg/day infection prevention vaccination 、the infection problem during the glucocorticoid Detumescence&diuresis pay attention to acid-base balance&electrolyte disturbance Glucocorticoid treatment mechanism: decrease immunoreaction，improve capillary permeability ，reduce urine protein eduction. Decrease ADH&ALD， inncrease GFR, diuresis short range almost desuetude intermediate range 1.52mg/Kg/d, tid-qid , continue dose till 2 weeks after urine protein is change to negative(need 4 weeks to basically completed ) The two-thirds dose of the total dose of 2 days , qod ，4weeks ，then reduce 510mg per 2-4weeks (need 6 months to basically completed ) long range same as the intermediate range， then reduce 2.55mg per 24weeks (need 9 months to basically completed ) Long term low dose glucocorticoid (0.4mg/Kg/qod), would not lead to side effect. Enough dose at first, decrease dose slowly, maintenance dose should be long. immunosuppressor indication a. Frequent relapse： relapse& reiteration 1year3 times、6 months twice。 b. Glucocorticoid dependence ：sensitive to glucocorticoid, can relieve，but relapse or reiteration in 2 weeks if dose reduction/drug withdrawal ，repeat 23 times 。 c. Glucocorticoid Resistant ： regular glucocorticoid treatment 8weeks ,urine protein + + immunosuppressor Cyclophosphamide per os : 2.53mg/Kg/d，accumulated dose 200mg/Kg，course 3 months in vein stosstherapy : 812mg/Kg/time，accumulated dose 150mg/Kg, per 2 weeks ，gradually extend ntermittence according to condition hydrate at the first and last 3 days of stosstherapy 。 sex gland Chlorambucil Per os ：0.2mg/Kg/d,couse 6 months， accumulated dose 10mg/Kg 。 Side effect ：sex gland CyclosporinA CsA Cy-A Azathioprine Mycophenolate （FK506）Tacrolimus Anticoagulant & fibrinolysis Heparin Sodium Heparin Calcium Urokinase Dipyridamole angiotensin-converting enzyme inhibitor mechanism: improve local glomerulus hemodynamics ，reduce albuminuria， delay glomerulus sclerosis Enalapril Maleate Tablets Benazepril Hydrochloride ACEI Sodium Fosinopril Losartan Potassium ARB chinese medcine improve general conditions ，mitigate drug side-effect 雷公滕多甙片 inh