内科学教学课件：Tubulointerstitial disease

1、OUTLINE,General introduction of urinary system Primary glomerular disease Nephrotic syndrome Secondary kidney diseases Tubulointerstitial disease Chronic renal failure Urinary tract infection,PCT: complete reabsorption of organic solutes such as glucose, AAs, organic acids, low mol. Wt proteins etc;

2、 reabsorbs a majority of NaHCO3. Fanconis syndrome, type II Renal tubular acidosis Loop of Henle: dissociates the absorption of sodium and water where countercurrent exchange mechanism occurs. DCT: absorbs Na by influence of aldosterone; secretes H+, NH3 and K+. type I Renal tubular acidosis Collect

3、ing duct: regulates osmolarity of urine, mediated by ADH.- Insipidus,Function of tubule,Tubulointerstitial disease P654,The tubulointerstitial compartment consists of everything that is not glomerular. 30-40 of ARF, and 20-40 of CRF are caused by these diseases. Tubulointerstitial diseases may be ac

4、ute or chronic, primary or secondary,Acute interstitial nephritis,Clinical manifestations of DURG-induced AIN: Usually caused by an adverse drug reaction General allergic reaction : rash, fever, eosinophils (in blood, kidney tissue or urine) Characterized by small amounts of protein in urine, often

5、with leucocyturia Acute renal failure (with normal volume of urine) Treatment: discontinue possible renal toxins. Prednisolone treatment ,Chronic interstitial nephritis（CIN,Usually with chronic medication and drug exposure Insidious onset, polyuria, nocturia Mild or moderate proteinuria, predominant

6、ly low-molecular-weight protein. Renal glycosuria, aminoaciduria Defects in urinary acidification (renal tubular acidosis) and concentrating ability Renal dysfunction (CRF,Analgesic nephropathy,The chronic consumption of large amounts of analgesics and NSAIDs leads to chronic tubulointerstitial neph

7、ritis. 去痛片1kg Presentation may be with anemia, polyuria, CRF. The consumption of the above analgesics should be discouraged,Aristolochic acid nephropathy,Chinese herb nephropathy” ? The causal agent has been identified as aristolochic acid. Slimming pills, “龙胆泻肝丸”,“冠心苏合丸”, and so on. Progressive chr

8、onic renal insufficiency Interstitial fibrosis and atrophy ( paucity of cells in kidney tissue) There is a high incidence of uroepithelial tumors,CHRONIC RENAL FAILURE (CRF) P700,CRF is a functional diagnosis and clinical syndrome. ESRD: end-stage renal disease - Uremia,CKD: chronic kidney disease A

9、vailable to all kidney diseases 20 million Americans, 1 in 9 adults have CKD. Early detection can help prevent the progression of CKD to ESRD. World Kidney Day,CKD,ESRD,Autosomal-dominant polycystic kidney disease adults,Solitary renal cyst,Alport syndrome,family history, young patients, nerve deafn

10、ess, ocular disorder in eyes renal damage,Pathophysiology of CRF-1,1)Mechanisms of renal progressive deterioration Glomerular hyper-filtration and intact nephron hypothesis Heavy proteinuria RAS Hypertension Lipid disorder Others,Pathophysiology of CRF-2,2)Mechanisms of uremic symptoms Uremic poison

11、s: metabolic end products Malnutrition Abnormal endocrine secretion (PTH) Trade-off hypothesis,Fluid and electrolyte homeostasis - Na+and K,Acid-base disorder- metabolic acidosis,Na,K,Ca2,Gastrointestinal and nutritional abnormalities,Hematologic abnormalities- anemia,Cardiovascular abnormalities- h

12、eart failure,Pulmonary system disorders,Neuromuscular abnormalities,Bone disease,B,Endocrine-metabolic disturbance,Immune system disorder- Infection,Others- Dermatologic abnormalities,Clinical manifestations (in uremia,1) Disturbances in homeostasis Water and Sodium Dehydration-hypernatremia, rare.

13、Retention of water -dilutional hyponatremia, common. Potassium Hyperkalemia is common. -EMERGENCY. Calcium and Phosphate - Hyperphosphatemia - Hypocalcemia parathyroid gland hyperplasia(PTH) renal bone disease and danger of calciphylaxis (Ca x Phosp product,2) Cardiovascular system and lung Hyperten

14、sion: could be malignant HTN Heart failure: hypertension + high blood volume + cardiomyopathy. - Emergency. Pericarditis - pericardial tamponade Atherosclerosis -ischemic heart and brain disease (cardiac arrest or stroke) Lung - shortness of breath Dyspnea Uremic lung Pleuritis,3) Hematological syst

15、em Anemia: erythropoietin, and else. Hemorrhagic disorder: platelet dysfunction Leukocyte: functional damage infection 4) Neuromuscular manifestations Psychologic symptoms: Peripheral neuropathy: restless legs, cramps in extremities Central nerve system: Encephalopathy,5) Gastrointestinal symptoms A

16、norexia, nausea, vomiting, hiccups Upper digestive tract hemorrhage Virus hepatitis: type B, type C 6) Cutaneous Uremic face: Uremic pruritus: intractable, intolerable,7) Renal osteodystrophy due to hyperparathyroidism High-bone turnover disease low-bone turnover disease Bony pain, spontaneous bone

17、fractures disabled 8) Disorders of endocrine and metabolism 1,25-(OH)2D3, EPO , abnormal function of thyroid, pancreas, adrenal gland and genital gland 9) Infection: Different sites and pathogens 10)Metabolic acidosis Mild or severe - Emergency,Diagnosis of CRF,Diagnosis of renal failure CRF（not Acu

18、te Renal Failure） Diagnosis of underlying diseases Searching for the possible aggravating factors for renal function Complications of CRF,Acute kidney injury (AKI,Acute renal failure (ARF) is defined as a sudden decrease in renal function, resulting in an inability to maitain fluid and electrolyte b

19、alance and to excrete nitrogenous wastes. Causes Reversible,Differentiation between ARF Goal: Hb 110g/L,Treatment of complications of CRF,Treatment of complications of CRF,Infection: - Selection of drugs: according to the pathogens (culture) - Dosage adjustment: according to the level of GFR Correct

20、ion of hypocalcemia and hyperphosphatemia, and osteodystrophy: - To decrease dietary phosphorus content - Administration of phosphate binders: excrete phosphate from GI, new agent (not aluminum-based) - Calcium salts: calcium carbonate, - Calcitriol(1, 25-(OH)2D3) is only used while necessary. (osteodystrophy and danger of calciphylaxis) 手术 for 甲旁亢,Indications for regular dialysis treatment: Marked uremic symptom