急性链球菌感染后肾小球肾炎PPT课件.ppt

AcutePoststreptococcalGlomerulonephritis(APSGN),1,APSGNfollowsinfectionofthethroatorskinbycertain“nephritogenic”strainsofgroupA-hemolyticstreptococciThroat(serotype12),coldweathermonths.skin(serotype49),warmweathermonths.,Etiology,2,3,Diagramsdepictingtheultrastructuralfeaturesofanormalglomerularcapillaryloop(A),andtheultrastructuralfeaturesofAPSGN(B),Notethesubepithelialhumplikedensedepositsandendocapillaryhypercellularity.,Immunecomplexesantigens,ActivationofComplimentsRecruitmentofleukocytes,GBMdamage,Bloodingredientsleakage,HematuriaProteinuriaRBCCasts,ProliferationofMCandEC,BlockageofrenalcapillariesanddecreasedGFR,Edemahypertentionheartfailureencephalopathyrenalfailure,Oliguria,sodiumandwaterretention,hypervolemia,Inflammationmediates,Cytokines,proliferativeF.,Infectionofstreptocacci,PATHOGENESIS,4,Hematuria:Grosshematuria(30-50%),microscopichematuriaaremorecommon.Edema(90%):typicallypresentsinthefaceandupperextremities.Ascitesandanasarcamayoccurinchildren.Hypertension(75%):usuallymildtomoderate,andmostevidentattheonsetofnephritisandtypicallysubsidespromptlyafterdiuresis.Proteinuria:Manypatientshavesignificantproteinuria,but5%ofsymptomaticpatientsdevelopfranknephroticsyndrome.,Typicalmanifestations,5,LaboratoryFindings(1),UrinalysisHematuriaisnearlyalwayspresentinAPSGN.Otherfindingsonmicroscopyarethoseofleukocytes,redbloodcellcasts,andgranularcasts.Macroscopichematuriatypicallyhasarustyortea-color.Proteinuriaisnearlyalwayspresentbuttypicallyinthesub-nephroticrange.Nephrotic-rangeproteinuriaoccursin5%ofpatients.Theurinecontainslargeamountsoffibrindegradationproducts,andfibrinopeptides.,6,LaboratoryFindings(2),GFRandBloodchemistoryTheBUNconcentrationiselevatedin75%ofpatients,andserumcreatininelevelisincreasedinonehalfofthepatients,butprofounddecreaseinGFRisuncommoninchildren.Hyperkalemia,hypocalcaemia,hyponatremia,andmetabolicacidosisareseenonlyinseverepatients.Amildnormochromicanemiamaybepresentfromhemodilutionandlow-gradehemolysis.,7,LaboratoryFindings(3),evidencesofstreptococcalinfectionThroatorskincultures.AntistreptolysinO(ASO)titer.Pharyngitis(80%),skininfections(50%).Anti-deoxyribonuclease(DNase)Blevel.Pharyngitis(98%),skininfections(80%).ITsthebestsingleantibodytitertodocumentcutaneousstreptococcalinfection.ActivationofcomplementsSerumC3level,decrease(90%),returntonormalwithin4-8wk.SerumC4levelsaretypicallynormal.,8,TreatmentofAPSGNislargelythatofsupportivecare.Usually,patientsundergoaspontaneousdiuresiswithin7to10daysaftertheonsetoftheirillness.Managementisdirectedattreatingtheacuteeffectsofrenalinsufficiencyandhypertension,Treatments,9,BedrestBedrestisindicatedaslongasthereareclinicalmanifestationofactivedisease,suchasedema,hypertension,orgrosshematuria.Theacutephasegenerallyresolveswithin2-3wk.ChildrencouldgobackschoolafterESRreturnstonormal.But,exhaustingandcompetiveactivitesareprohibiteduntiltheAddiscountreturnstonormal.,10,DietProtein,sodiumandwaterintakeshouldberestrictedinpatientswithacuterenalfailure.Sodiumandwaterrestrictionisalsoneededintreatinghypertension.AntibioticsA10-daycourseofsystemicantibiotictherapywithpenic