肾脏病学总论ppt学习课件.ppt

NEPHROLOGY(肾脏病学总论）,1,.,NEPHROLOGY,Structureofthekidney(结构)FunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes,2,3,4,5,6,7,8,TheNephron(肾单位),Consistsoftheglomerulus(肾小球)anditsattachedtubules(肾小管).Thefunctionalunitofthekidney(是肾脏的功能单位),9,10,11,12,Glomerulus(肾小球),Endothelialcells(内皮细胞)Glomerularbasementmembrane(肾小球基底膜GBM)Podocytes(足突细胞)-VisceralEpithelialCellMesangialcellsandmatrix(系膜细胞和基质)ParietalepitheliumBowmansCapsule,13,14,15,16,NormalGlomerulus(PAS),17,18,NormalGlomerulusEM,GBM,Mesangium,19,GlomerularBasementMembrane,CapillarySpace,Endothelium,UrinarySpace,GBM,Podocyte,20,GlomerularBasementMembrane,Podocytes,21,22,JuxtaglomerularApparatus(近球旁器),VascularcomponentAfferentarterioleEfferentarterioleExtraglomerularmensangialregionTubulecomponentthickascendinglimb,23,24,Mechanismofreninrelease,ThemaculadensatheorychangesintheNa+,Cl-concentrationThestretch-receptortheoryalterationsinthevolumestretchoftheafferentarteriol,25,TUBULAREPITHELIALCELLS,26,NEPHROLOGY,StructureofthekidneyFunctionofthekidney(功能)ClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes,27,NephronFunction,Glomerularfiltration(肾小球滤过功能）Tubulesecretionandreabsorption（肾小管重吸收和分泌功能）,28,肾小球滤过功能（glomerularfiltrationfunction）,含氮废物如尿素、肌酐等主要由肾小球滤过排出。马尿酸、苯甲酸、各类胺类及尿酸也有部分经滤过排出,肾小球滤过示意图,排泄功能（excretoryfunction）,29,肾小管重吸收和分泌功能（tubularreabsorptionandexcretionfunction）,近端小管重吸收髓袢维持髓质高张及尿液的浓缩和稀释远端小管AVP作用下,尿素再循环,马尿酸、苯甲酸、各类胺类及尿酸主要由肾小管分泌,30,NephronFunction,Waterbalance(水平衡)Eletrolytemetabolism(电解质代谢)Acid-basebalance(酸碱平衡)Ureasecretion(代谢产物排泄)Others:,31,内分泌功能（endocrinefunction）,球旁器分泌肾素血管紧张素原血管紧张素血管紧张素、血管紧张素RAS系统,32,Renin-angiotensinsystem(肾素血管紧张素系统RAS),angiotensinogenangiotensinangiotensinAldosteroneAT1,AT2,Renin,ACE,33,Angiotensin,IncreasepreglomerularandefferentarterioarresistancesEnhancethereabsorptionofsodiumEffectsonvasavectaDecreaseKfadecreaseinhydraulicconductivityEnhanceproductionofPG,TGF,34,Endocrinefunction,Prostaglandin:PGE2,I2,A2,F2,TXA2(前列腺素族)Bradykinin(缓激肽)Erythropietin,(促红细胞生成素EPO)1,25-dihydroxycholecalciferol（活性）1,25-(OH)2D3(1羟化酶)Decomposeorgan:insulinTargetorgan:PTH,TH,CA,ADHEGF,PDGF,IGF-1,TGF,35,NEPHROLOGY,StructureofthekidneyFunctionofthekidneyClinicalmanifestation(临床症状)LaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes,36,Clinicalmanifestation,Edema(水肿)Hypertension高血压Proteinuria蛋白尿Hematuria血尿Lossofrenalfunction肾功能丧失Painintheflankarea:renalcolicChangesinurinevolumeOthers,37,NEPHROLOGY,StructureofthekidneyFunctionofthekidneyClinicalmanifestationLaboratoryEvaluationofRenalDiseaseMajorRenalSyndromes,38,尿液检查（uronoscopy）,39,U/AChemistry(DipStick),ProteinGlucoseHemoglobinKetones,pHBilirubinUrobilinogenNitriteLeukocyteesterase,MOREIMPORTANT,LESSIMPORTANT,40,U/AChemistry,Holdhere,Dipuptohere,Thereactionsaretimedandthecolorschangeifanalysesarepresent.CompareSticktocolorsonDipStickBottleandgrade0,1+,2+,3+,4+;thedarkerthecolor,thegreaterthegrade!,pH,Protein,Glucose,Hgb,ETC.,41,Proteinuria蛋白尿,定义:持续超过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:超过3.5g/1.73m2/日或50mg/kg/日。,42,按发病机制分类,肾小球性,肾小管性,溢出性,功能、体位性,43,按发病机制分类,1Glomerulardisease肾小球性蛋白尿：肾小球滤过膜损伤或通透性增高机械屏障受损：滤过膜孔径异常增大或断裂电荷屏障受损：滤过膜负电荷减少按分子量分类：（1）选择性蛋白尿：（2）非选择性蛋白尿：,44,按发病机制分类,2Tubuledisease肾小管性蛋白尿：肾小管重吸收，由小分子蛋白构成：2-MG、溶菌酶。2g/日3Spillover溢出性蛋白尿：血中异常蛋白增多（免疫球蛋白轻链、血红蛋白）,45,Proteinuria,功能性蛋白尿:发热、寒冷、运动、淤血、直立。3.5gm/day)Hypoalbuminemia（30g/L)EdemaHyperlipidemaLipiduria,63,急性肾炎综合征AcuteNephriticSyndrome,SuddenonsetofhematuriawithRBCcastsandrenalfailure(days-weeks)RBCcastsnotlistedinthebook!Butthisiscritical!Proteinuria(mildtomoderatebutNOTNephroticRange)HypertensionHallmarkDisease:PostStreptococcalGlomerulonephritis,64,急进性肾炎综合征RapidlyProgressiveGlomerulonephritis,NephronalhematuriaRenalfailuredevelopingoverweekstomonthsDiffuseglomerularcrescentformation.,65,无症状性尿异常AsymptomaticHematuriaorProteinuria,HematuriawithorwithoutRBCcastsand/orProteinuriausually2.0gm/dayNORENALFAILURENONEPHROTICSYNDROME,66,急性肾衰竭综合征AcuteRenalFailure,Oliguria(400ml/day)RarelyanuriaRecentOnsetofAzotemia(hours/days),67,慢性肾衰竭综合征ChronicRenalFailure,UremiaFinalCommonPathofAllChronicRenalDiseases,68,尿路感染综合征UrinaryTractInfection,BacteriuriaandPyuriaDysuria,Frequency,UrgencyPyelonephritisorCystitisWBCcasts=PyelonephritisTheBookMissesthisone!FeverTheBookMissesthisone!,69,肾石症Nephrolithiasis,RenalstonesRenalcolic-OOOUUUCCCHHH!Severe,CrampyPainintheflankareaHematuria(NotRBCcasts!),70,肾脏疾病的诊断,根据患者的病史、症状及体征，并辅以实验室检查和特殊检查，作出正确诊断病因诊断部位诊断病理诊断功能诊断,71,去除病因抑制免疫反应及炎症反应对症治疗防治并发症延缓肾脏疾病进展肾脏替代治疗,治疗原则(therapeuticprinciples),72,Optimalpre-ESRDcare,EarlydetectionofCRF,Preventionofuremiccomplications,InterventionsthatDelayprogression,BPcotrol,PreparationforRRT,ModificationofCo-morbidity,ACEIandARB,Proteinrestriction,Bloodsugarcontrol,Osteodystrophy,Anemia,Malnutrition,Acidosis,Retinopathy(inDM),Education,Neuropa