肾脏病学总论

NEPHROLOGY (肾脏病学总论）,Zhou Fuhua（周富华）The second affiliated hospital of Nanjing Medical University,NEPHROLOGY,Structure of the kidney(结构)Function of the kidneyClinical manifestationLaboratory Evaluation of Renal Disease Major Renal Syndromes,The Nephron (肾单位),Consists of the glomerulus(肾小球) and its attached tubules(肾小管). The functional unit of the kidney (是肾脏的功能单位),Glomerulus(肾小球),Endothelial cells(内皮细胞)Glomerular basement membrane (肾小球基底膜GBM)Podocytes(足突细胞) - Visceral Epithelial CellMesangial cellsand matrix (系膜细胞和基质) Parietal epitheliumBowmans Capsule,Normal Glomerulus (PAS),Normal Glomerulus EM,GBM,Mesangium,Glomerular Basement Membrane,Capillary Space,Endothelium,Urinary Space,GBM,Podocyte,Glomerular Basement Membrane,Podocytes,Juxtaglomerular Apparatus(近球旁器),Vascular componentAfferent arterioleEfferent arterioleExtraglomerular mensangial regionTubule component thick ascending limb,Mechanism of renin release,The macula densa theory changes in the Na+,Cl- concentrationThe stretch-receptor theory alterations in the volume stretch of the afferent arteriol,TUBULAR EPITHELIAL CELLS,NEPHROLOGY,Structure of the kidneyFunction of the kidney(功能)Clinical manifestation Laboratory Evaluation of Renal DiseaseMajor Renal Syndromes,Nephron Function,Glomerular filtration (肾小球滤过功能）Tubule secretion and reabsorption （肾小管重吸收和分泌功能）,肾小球滤过功能（glomerular filtration function）,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（excretory function）,肾小管重吸收和分泌功能（tubular reabsorption and excretion function）,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,Nephron Function,Water balance(水平衡)Eletrolyte metabolism(电解质代谢)Acid-base balance(酸碱平衡)Urea secretion (代谢产物排泄)Others:,内分泌功能（endocrine function）,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,Renin-angiotensin system(肾素血管紧张素系统RAS),angiotensinogen angiotensinangiotensin AldosteroneAT1,AT2,Renin,ACE,Angiotensin ,Increase preglomerular and efferent arterioar resistancesEnhance the reabsorption of sodiumEffects on vasa vectaDecrease Kfa decrease in hydraulic conductivityEnhance production of PG, TGF,Endocrine function,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)Decompose organ: insulinTarget organ: PTH, TH, CA, ADHEGF, PDGF, IGF-1 ,TGF,NEPHROLOGY,Structure of the kidneyFunction of the kidneyClinical manifestation (临床症状)Laboratory Evaluation of Renal DiseaseMajor Renal Syndromes,Clinical manifestation,Edema(水肿)Hypertension 高血压Proteinuria 蛋白尿Hematuria 血尿Loss of renal function 肾功能丧失Pain in the flank area : renal colicChanges in urine volumeOthers,NEPHROLOGY,Structure of the kidneyFunction of the kidneyClinical manifestationLaboratory Evaluation of Renal DiseaseMajor Renal Syndromes,尿液检查（uronoscopy）,U/AChemistry (Dip Stick),ProteinGlucoseHemoglobinKetones,pHBilirubinUrobilinogenNitriteLeukocyte esterase,MORE IMPORTANT,LESS IMPORTANT,U/AChemistry,Hold here,Dip up to here,The reactions are timed and the colors change if analyses are present. Compare Stick to colors on Dip Stick Bottle and grade0, 1+, 2+, 3+, 4+; the darker the color, the greater the grade!,pH,Protein,Glucose,Hgb,ETC.,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。,按发病机制分类,肾小球性,肾小管性,溢出性,功能、体位性,按发病机制分类,1 Glomerular disease 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：,按发病机制分类,2 Tubule disease 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3 Spill over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）,Proteinuria,功能性蛋白尿: 发热、寒冷、运动、 淤 血、直立。 3.5gm/day)Hypoalbuminemia（30g/L)EdemaHyperlipidemaLipiduria,急性肾炎综合征Acute Nephritic Syndrome,Sudden onset of hematuria with RBC casts and renal failure (days - weeks)RBC casts not listed in the book! But this is critical!Proteinuria (mild to moderate but NOT Nephrotic Range)HypertensionHallmark Disease: Post Streptococcal Glomerulonephritis,急进性肾炎综合征Rapidly Progressive Glomerulonephritis,Nephronal hematuria Renal failure developing over weeks to monthsDiffuse glomerular crescent formation.,无症状性尿异常Asymptomatic Hematuria or Proteinuria,Hematuria with or without RBC casts and/orProteinuria usually 2.0gm/dayNO RENAL FAILURENO NEPHROTIC SYNDROME,急性肾衰竭综合征Acute Renal Failure,Oliguria (400ml/day)Rarely anuriaRecent Onset of Azotemia (hours/days),慢性肾衰竭综合征Chronic Renal Failure,UremiaFinal Common Path of All Chronic Renal Diseases,尿路感染综合征Urinary Tract Infection,Bacteriuria and PyuriaDysuria, Frequency, UrgencyPyelonephritis or CystitisWBC casts = PyelonephritisThe Book Misses this one!FeverThe Book Misses this one!,肾石症Nephrolithiasis,Renal stonesRenal colic - OOOUUUCCCHHH!Severe, Crampy Pain in the flank areaHematuria (Not RBC casts!),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,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(therapeutic principles),Optimal pre-ESRD care,Early detection of CRF,Prevention of uremiccomplications,Interventions thatDelay progression,BP cotrol,Preparation forRRT,Modification of Co-morbidity,ACEI and ARB,Protein restriction,Blood sugar control,Osteodystrophy,Anemia,Malnutrition,Acidosis,Retinopathy(in DM),Ed