肾功能检查全解.ppt

Renal Function Test 肾功能检查 p349,Kidney diseases,Urine tests: urinalysis and others Cheap and convenient; For screening and following Renal biopsy Renal functions Glomerulus: filtration Tubule: reabsorption and acidification Imaging Examination Immunological test,When and for What,Kidney diseases or injuries Overall checkup Kidney function assessment with other diseases Diabetes mellitus Hypertension Shock or extensive burn Auto-immunological diseases Drug toxicity,Structure of Kidney,肾单位,集合管,肾小体,肾小管,肾小球,肾小囊,近曲小管,远曲小管,髓袢,FUNCTIONS OF KIDNEY,Excrete metabolic products/wastes Keep the balance of water, acid-base and electrolyte Endocrine function: EPO (erythropoietin):RBC product 1,25(OH)2 D3: Calcium and phosphorus renin: bood pressure regulation,Related concepts,急性肾衰AFR 肾前性Pre-renal：休克早期、大面积烧伤、脱水等 功能性 肾性 renal：器质性 肾小管上皮细胞坏死 肾脏本身：肾小球肾炎、肾盂肾炎、狼疮肾炎 肾动脉血栓、栓塞 肾后性post renal：结石、肿瘤、前列腺肥大等尿路梗阻,Stages for renal failure： 代偿期compensatory stage 失代偿期decompensatory stage : 氮质血症Azotemia：血中尿素氮BUN或肌酐sCR超出正常范围 肾性 肾前性 肾后性 衰竭期Failure stage 尿毒症期Uremia Stage：综合症候群，“尿潴留在血中”而引起的中毒,Related concepts,Related concepts,Common symptoms of AFR 少尿期oliguria stage： Oliguria or anuria, Hematuria, Proteinuria and some kinds of casts Water intoxication Hyperpotassemia Metabolic acidosis Azotemia 多尿期polyuria stage 恢复期recovery stage,Related concepts,Common symptoms of CFR Early stage： polyuria, Nocturia, Hematuria, Proteinuria and some kinds of casts Azotemia Water intoxication Metabolic acidosis (moderate) Hypopotassemia Late stage: as above, Uremia, hyperpotassemia, hypertension, Osteodystrophy, anemia, bleeding tendency,Tests of glomerular function 肾小球功能检查,肾小球滤过功能,Tests of Glomerular Function,Glomerular Filtration Rate, GFR Endogenous Creatinine Clearance Rate, Ccr Serum Creatinine, Scr Blood Urea Nitrogen, BUN Serum 2-microglobulin Cystatin C,Renal blood flow ： 1200-1400ml/min， 占20%-25%心血流量 Crude urine ：即肾小球滤过液,120-160ml/min 影响因素： renal blood flow effective filtration pressure Filtration area membrane permeability,Glomerular Filtration,Renal Clearance Rate 肾清除率,肾小球滤过率（GFR)：单位时间内（分钟）经肾小球滤出的血浆量,即单位时间内产生的原尿量 正常值： 120-160ml/min 肾清除率：指在单位时间（min）内，肾脏能将多少毫升血浆中含有的某种物质全部加以清除，结果以ml/min表示 常用：菊粉清除率、内生肌酐清除率来反映肾小球滤过率,Endogenous Creatinine,肌酐,内源性肌酐,外源性肌酐,肌肉活动中肌酸代谢产物,来自于鱼类、肉类等食物和咖啡、茶等饮料,Endogenous Creatinine Clearance Rate, Ccr,Definition：Ccr is the volume of blood plasma with creatinine that is cleared by kidneys per unit time. 即：单位时间内,肾脏可全部清除多少毫升血浆中的内生肌酐 计算公式：,Normal value： 80-120 ml/min,Clinical Significance,Pathological decrease Sensitive for kidney injury GFR50ml/min decompensatory： 20-50ml/min failure： 10-19ml/min uremia： 10ml/min,For treatment 30-40: limited protein diets diuretic 30 diuretic: not available 10 replacement therapy,Physiologiccal ：related with sports, diets, age,Serum Creatinine, Scr 血肌酐测定,肌肉活动稳定、外源性肌酐来源不变的情况下，Scr浓度主要取决于肾小球的滤过能力。 Normal Value: Serum or Plasma Cr: male:53-106mol/L female:44-97mol/L,Clinical Significance of Scr increase,Glomerular Filtration Injury Chronic renal failure Compensatory stage: Scr178mol/L Failure stage: Scr445mol/L,Acute renal failure,Compensatory,Decompensatory,Failure,Clinical Significance of Scr increase,Differential diagnosis of prerenal and renal azotemia Prerenal oliguria: Scr200mol/L,Clinical Significance,Excessive intake of protein and proteolysis: High protein diet， High fever, Upper gastrointestinal hemorrhage, extensive burn，severe trauma, hyperthyroidism,Blood urea nitrogen, BUN,Influence factors Protein intake Protein degradation Liver function Glomerular filtration Normal value: Adults: 3.2-7.1mmol/L Children or infants: 1.8-6.5mmol/L,Urea or ornithine cycle in liver,Clinical Significance,Renal damage: Acute renal failure,Compensatory,Clinical Significance,Renal damage: Chronic renal failure Compensatory stage: BUN9mmol/L Failure stage: BUN20mmol/L Excessive intake of protein and proteolysis: high protein diet，high fever, Upper gastrointestinal hemorrhage, extensive burn，severe trauma, hyperthyroidism,Clinical Significance of BUN/Cr,Prerenal oliguria: BUN升高更明显，BUN/Cr 明显升高 prerenal azotemia Renal failure: BUN/Cr变化不大,Stage of kidney impairement,Ccr Scr BUN （ml/min) (umol/L) (mmol/L) Compensatory stage 80-51 707 28.6 (uremia),Expressed in all nucleated cells, encoded by house keeping gene Can be detected in all body fluid Almost filtrated through glomerulus completely, reabsorbed by tubulus and then degraded Concentration in serum or plasma is determined by GFR。 Normal Value：0.6-2.5mg/L,Cystatin C 胱氨酸蛋白酶抑制剂 C,优点,High specificity：不受炎症反应、恶性肿瘤、肌肉、性别以及年龄的影响。 High sensitivity：与GFR相关性优于Ccr，相当于菊粉清除率检测结果 Operated easily,Tests of tubular function 肾小管功能检查,Tests of proximal tubular function 近端肾小管功能检测,Urine 2-microglobulin, 2-MG,Freely filtrated by glomeruli Almost reabsorbed by tubules completely Threshold of reabsorption:5mg/L,Normal value: Urine：0.3mg/L,Clinical Significance,GFR： Serum 2-MG :more sensitive than Scr when Ccr80ml/min Reabsorption function of proximal tubules： blood2-MG5mg/L,urine2-MG increase Acute and chronic pyelonephritis,Clinical Significance,Evaluation for transplant kidney function urine2-MG，implied graft rejeciton 排异时血2-MG增高先于Ccr，测定2-MG有助于诊断尚处于亚临床期的肾排异反应。 肾移植虽有少尿，但血2-MG下降者提示预后良好。 恶性肿瘤、炎性疾病（肝炎、类风湿关节炎等）,Tests of distal nephron function 远端肾单位（远端小管和集合管）功能检测,Mosenthals test (renal concentration function),Also as : Circadian urine specific gravity (SG) test Normal intake (water500-600ml), no extra water Empty bladder at 8 am in the morning Detect the volume and SG of the urine every 2 hours from 10am to 8pm, and morning urine of next day,Normal Values,volume： 24h total volume: 10002000ml； 12h overnight urine: 341 SG specific gravity： 1.015-1.025 highest 1.018 the gap of the highest and the lowest 0.009,Clinical Significance,Impairment in distal tubules： Early stage： overnight urine750ml, Day/overnight , SG is normal Severe impairment: polyuria，overnight urine SG Failure：polyuria、SG:1.0101.012 Diabetes insipidus尿崩症:Total urine4L，SG1.006 Urine volume SG ： renal concentration function:normal blood volume or GF ,Urine osmol 尿渗量,Assess the ability of kidneys to dilute or concentrate urine and identify ADH abnormalities Normal value: Urine osmol: 600-1000 mOsm/kgH2O 800 mOsm/kg H2O Plasma osmol: 275-305 mOsm/kgH2O 300 mOsm/kgH2O Uosm/Posm=34.5:1 判断尿浓缩功能 1.Uosm= 300 mOsm/kgH2O : Isosthenuria等渗尿 2.Uosm300 mOsm/kgH2O 低渗尿 3.Uosm600 mOsm/kgH2O: 尿浓缩功能障碍,Urine osmol,Normal value: Plasma osmol: 275-305 mOsm/kgH2O 平均300 mOsm/kgH2O Urine osmol: 600-1000 mOsm/kgH2O 平均800 mOsm/kg H2O Uosm/Posm=34.5:1 Uosm600 mOsm/kgH2O, 肾小管浓缩功能障碍 Uosm= 300 mOsm/kgH2O ，等渗尿,Clinical significance,Increase: dehydration, Addisons disease, diarrhea, diabetes mellitus, hyperglycemia,hypernatremiacirrhosis Decrease: overhydration, aldosteronism, diabetes in