血尿蛋白尿鉴别定ppt课件

1、血尿、蛋白尿的诊断血尿、蛋白尿的诊断和鉴别诊断和鉴别诊断北京协和医院肾内科北京协和医院肾内科陈丽萌陈丽萌内 容w血尿的诊断与鉴别血尿的诊断与鉴别w蛋白尿的诊断与鉴别蛋白尿的诊断与鉴别w血尿、蛋白尿血尿、蛋白尿-肾小球疾病的诊断与鉴别肾小球疾病的诊断与鉴别血尿的诊断思绪血尿的诊断思绪w确定能否是真性血尿确定能否是真性血尿w判别出血部位判别出血部位w确定病变性质确定病变性质颜颜 色色正常时：无色廓清正常时：无色廓清-淡黄色淡黄色-琥珀色琥珀色病理情况：病理情况：近于无色：尿液稀释、尿崩症近于无色：尿液稀释、尿崩症深黄色：胆红素尿浓茶样尿药物、食物深黄色：胆红素尿浓茶样尿药物、食物 酱油色：血红蛋白

2、尿酱油色：血红蛋白尿(酸性酸性)ARF乳白色：乳白色： 乳糜尿、脓细胞尿乳糜尿、脓细胞尿红红 色：色： 血尿、血红蛋白尿、肌红蛋白尿血尿、血红蛋白尿、肌红蛋白尿 药物药物 (联苯胺实验联苯胺实验试纸法检测：潜试纸法检测：潜 血血w原理：试纸法原理：试纸法 Hb有类过氧化物酶作用有类过氧化物酶作用 催化分解过氧化物催化分解过氧化物-邻邻联甲苯胺氧化变色联甲苯胺氧化变色 假阳性假阳性假阴性假阴性 血红蛋白血红蛋白尿尿 肌红蛋白肌红蛋白尿尿 尿中尿中强氧化剂强氧化剂 脱水脱水还原剂还原剂尿尿 pH降低降低试纸预先暴露试纸预先暴露 在空气中在空气中试纸法的局限性：试纸法的局限性：血尿的定义血尿的定义w

3、尿沉渣尿沉渣 AddisAddis计数，计数，12h12h红细胞超越红细胞超越5050万万 每高倍视野每高倍视野HPHP超越超越3 3个红细胞个红细胞w尿检阳性是血尿吗？尿检阳性是血尿吗？确定能否是真性血尿确定能否是真性血尿w标本的可靠性标本的可靠性-污染污染 月经、子宫、阴道出血鉴别月经、子宫、阴道出血鉴别 容器、化验容器、化验w尿标本搜集的留意尿标本搜集的留意 晨尿晨尿 清洁中段尿清洁中段尿 防止生殖道的污染防止生殖道的污染 1小时内送检小时内送检-冰箱冰箱 血尿的诊断步骤血尿的诊断步骤w确定能否是真性血尿确定能否是真性血尿w判别出血部位判别出血部位w确定病变性质确定病变性质判别出血的部位

4、判别出血的部位1 1w按照血尿和排尿先后的按照血尿和排尿先后的关系进展分析通常根关系进展分析通常根据尿三杯实验来判别：据尿三杯实验来判别：w初血尿：尿道病变初血尿：尿道病变 w终末血尿：膀胱颈终末血尿：膀胱颈部和三角区或后尿道病部和三角区或后尿道病变变w全程血尿：上尿道全程血尿：上尿道或膀胱或膀胱判别出血的部位判别出血的部位2 2相差显微镜检查红细胞形状：相差显微镜检查红细胞形状：均一性均一性不均一不均一性性肾单位血尿肾单位血尿w穿过病变肾小球基底膜时受损穿过病变肾小球基底膜时受损w经过肾小管时遭到管腔内经过肾小管时遭到管腔内:w 浸透压、浸透压、PH值、代谢物质值、代谢物质(脂肪酸脂肪酸/溶

5、血卵磷溶血卵磷脂及胆酸脂及胆酸)w大小、外形改动大小、外形改动+同时合并红细胞管型同时合并红细胞管型=肾单位来源肾单位来源w例外例外:肾创伤、活检、堵塞、肾皮质坏死、肾创伤、活检、堵塞、肾皮质坏死、 猛烈运动也可有红细胞管型猛烈运动也可有红细胞管型判别出血的部位判别出血的部位3 3w微粒容积自动分析仪微粒容积自动分析仪10501001502001050100150200105010015020010501001502001050100150200血红细胞容积分布曲线非肾小球源性血尿肾小球源性血尿肾小球源性血尿混合性血尿血尿的诊断步骤血尿的诊断步骤w确定能否是真性血尿确定能否是真性血尿w判别出血

6、部位判别出血部位w确定病变性质确定病变性质确定病变性质确定病变性质1 1血尿的病因血尿的病因泌尿生殖系统疾病泌尿生殖系统疾病全身性疾病全身性疾病尿路临近器官疾病尿路临近器官疾病其他缘由其他缘由2%98%1.肾单位来源肾单位来源(内科性内科性): 原发、继发、家族性原发、继发、家族性2.非肾单位来源非肾单位来源(外科性外科性): 肿瘤、外伤、结石、畸形、血管等肿瘤、外伤、结石、畸形、血管等泌尿生殖系统疾病泌尿生殖系统疾病内科性血尿查什麽内科性血尿查什麽?内科性血尿内科性血尿w蛋白定量蛋白定量w管型管型w肾功能肾功能w肾活检肾活检w细菌学检查细菌学检查外科性血尿查什麽外科性血尿查什麽?外科性血尿外

7、科性血尿1. 1. 尿零落细胞尿零落细胞2. 2. 影像学影像学: : 腹部平片腹部平片 超声波检查超声波检查 CT/MRI CT/MRI 3. 3. 介入检查介入检查: : 膀胱镜检查膀胱镜检查 静脉肾盂造影静脉肾盂造影( (排泄性尿路造影排泄性尿路造影) ) 逆行尿路造影逆行尿路造影 肾动脉及肾静脉造影肾动脉及肾静脉造影4. 4.钙负荷实验钙负荷实验: : 尿钙尿钙4mg/kg.24h,4mg/kg.24h,尿钙尿钙/ /肌酐肌酐0.210.21胡桃夹子景象胡桃夹子景象w肠系膜上动脉压迫肠系膜上动脉压迫左肾静脉致左肾回左肾静脉致左肾回流妨碍，淤血；从流妨碍，淤血；从而引起血尿而引起血尿w多

8、发生于儿童，成多发生于儿童，成年后肠系膜上动脉年后肠系膜上动脉压迫解除病症消逝压迫解除病症消逝肠系膜上动脉肠系膜上动脉左肾静脉左肾静脉内 容w血尿的诊断与鉴别血尿的诊断与鉴别w蛋白尿的诊断与鉴别蛋白尿的诊断与鉴别w血尿、蛋白尿血尿、蛋白尿-肾小球疾病的诊断与鉴别肾小球疾病的诊断与鉴别正常尿蛋白正常尿蛋白w150mg/24hw组成: 60%滤过血浆蛋白 40%白蛋白, 15%免疫蛋白w 5%其他血浆蛋白w 40% Tamm-Horsfall蛋白失去大小选择性屏障失去大小选择性屏障实际上实际上GBM滤过孔孔径加大，长度缩短滤过孔孔径加大，长度缩短单位面积单位面积GBM上孔密度添加上孔密度添加以上两

9、项均有以上两项均有失去电荷选择性屏障失去电荷选择性屏障GBM失去带阴电荷的分子失去带阴电荷的分子(糖蛋白分解添加糖蛋白分解添加/合合成减少成减少) 带阳电荷的分子中阴电荷带阳电荷的分子中阴电荷以上两项均有以上两项均有蛋白尿的机理蛋白尿的机理肾小球滤过屏障肾小球滤过屏障肾小球滤过膜：内皮细胞基底膜上皮细胞系膜组织多种生理功能：参与免疫及肾小球炎症反响病理情况下致肾小球硬化蛋白尿的分类和特点蛋白尿的分类和特点w肾小球性蛋白尿肾小球性蛋白尿 肾小球滤过屏障损害肾小球滤过屏障损害 2.0 g/24 h2.0 g/24 h 大、中、小分子大、中、小分子w肾小管性蛋白尿肾小管性蛋白尿 肾小管对正常滤过蛋白

10、的重吸收妨碍肾小管对正常滤过蛋白的重吸收妨碍 2.0g/24 h 2.0g/24 h，小分子，小分子w溢出性蛋白尿溢出性蛋白尿 血浆中某种蛋白质浓度过高，经正常或异常肾小球血浆中某种蛋白质浓度过高，经正常或异常肾小球滤出滤出w分泌性蛋白尿分泌性蛋白尿 远端小管分泌：远端小管分泌：Tamm-HorsfallTamm-Horsfall蛋白蛋白尿诊断方法蛋白蛋白尿诊断方法及及诊断思绪诊断思绪w能否蛋白尿？尿常规能否蛋白尿？尿常规w继续性？一过性：继续性？一过性： 多见于少量蛋白尿多见于少量蛋白尿trace to 2+ proteinw定量：定量： 24小时尿蛋白定量小时尿蛋白定量 2gw定性：定性：

11、 SDS-PAGEw定位定位 ？内 容w血尿的诊断与鉴别血尿的诊断与鉴别w蛋白尿的诊断与鉴别蛋白尿的诊断与鉴别w血尿、蛋白尿的诊断与鉴别诊断血尿、蛋白尿的诊断与鉴别诊断诊断层次1.血尿、蛋白尿血尿、蛋白尿-临床诊断临床诊断2.肾功能肾功能3.病因病因:继发肾病继发肾病?原发肾病原发肾病4.病理病理5.并发症并发症诊断方法及程序诊断方法及程序w病史病史w体格检查体格检查w实验室检查实验室检查w特殊检查特殊检查w随访随访w排除假性血尿排除假性血尿w血凝块血凝块 血尿中混血凝块常提示非肾小球疾患出血血尿中混血凝块常提示非肾小球疾患出血w血尿与全身疾病及呼吸道感染的时间关系血尿与全身疾病及呼吸道感染的

12、时间关系wPSGN：感染后：感染后1014天出现血尿天出现血尿wIgAN： 几乎同时发生，普通不超越几乎同时发生，普通不超越3天。天。w家族史家族史:耳聋、血尿、肾衰耳聋、血尿、肾衰w血尿伴随病症血尿伴随病症w肾绞痛肾绞痛w尿路刺激症尿路刺激症w水肿、高血压及全身其他病症等水肿、高血压及全身其他病症等病史病史-血尿血尿Onset when began with conditions identified around the initial presentation, i.e., drug ingestion record of previous urinalyses precipitatio

13、n/palliation identification of triggering agents infectious, drugs, foods, chemicals, vaccinations helps to identify acquired forms of tubulointerstitial proteinuria 蛋白尿蛋白尿-问诊问诊quality associated with hematuria severity ： pathologic if associated with hematuria or Nephrotic Syndrome likely to be a p

14、rimary GN unlikely to be benign etiology or secondary GN timing acute vs acute-on-chronic intermittent vs persistent duration of proteinuria associated symptoms past medical history functional inquiry Specific Entities helps to differentiate acute GN from chronic GN identify overload proteinuria cau

15、ses 1. History of Presenting Illness1. History of Presenting Illnessat the end of the history, one should be able to discern: 1. benign vs pathologic proteinuria (if pathologic then) 2. glomerular vs tubulointerstitial proteinuria (if glomerular then) 3. hereditary vs non-hereditary (if non-heredita

16、ry then) 4. acute GN vs chronic GN (if chronic then) 5. primary GN vs secondary GN 6. nephrotic vs non-nephrotic proteinuria 7. proteinuria with or without hematuriauria 病史病史w功能性功能性w病理性病理性 肾小球性肾小球性 肾小管、间质性肾小管、间质性 溢出性溢出性 分泌性分泌性隐匿性肾炎综合征隐匿性肾炎综合征急性肾炎综合征急性肾炎综合征慢性肾炎综合征慢性肾炎综合征急进性肾炎综合征急进性肾炎综合征肾病综合征肾病综合征2. F

17、amily History2. Family Historyhelps to differentiate hereditary from non-hereditary : 1. Proteinuria family members must have had previous urinalysis to ascertain this 2. Renal Disease Polycystic Kidney Disease Nephrotic Syndrome, Fanconi Disease renal dialysis kidney transplantation 3. Others：heari

18、ng/ocular impairment (Alport Syndrome) PE? Lab? More information3 Physical Examination3 Physical Examination1. Vitals hypertension, fever 2. O/E edema, skin paleness or jaundice, rashes external genitalia外生殖器外生殖器 joints for signs of arthritis-red, warm, or swollen abdomen: masses or tenderness. C V

19、A t e n d e r n e s s enlarged kidneys. length and weight and plot on growth chart.Glomerular Proteinuriapresents in 1 of 3 ways: 1. Isolated Proteinuria 2. Proteinuria + Hematuria 3. Nephrotic Syndrome edema, hypoalbuminemia, hyperlipidemia 进一步检查w1.血尿、蛋白尿血尿、蛋白尿w2.肾功能肾功能w3.病因病因:继发肾病继发肾病?原发肾病原发肾病w4.病

20、理病理:肾活检肾活检w5.并发症并发症病因诊断继发继发: 感染相关感染相关 免疫相关免疫相关 肿瘤相关肿瘤相关/淀粉样变淀粉样变/MM 代谢性病代谢性病原发性肾病原发性肾病病理诊断w肾活检的顺应症和忌讳症肾活检的顺应症和忌讳症w穿刺方法穿刺方法w常见的病理类型常见的病理类型w常见的病理改动常见的病理改动随随 访访w无病症血尿患者无病症血尿患者w每半年一次尿液分析和细胞学检查每半年一次尿液分析和细胞学检查w每两年一次膀胱镜和静脉肾盂造影每两年一次膀胱镜和静脉肾盂造影w假设血尿反复发作，随访期至少假设血尿反复发作，随访期至少3 3年年CASE 1wA four year-old African A

21、merican male is brought to your office after his parents noticed that his urine appeared dark brown or coke 焦碳colored. Important questions to ask in your History 1wHas there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? wHas there been any recent URI symptoms or sore th

22、roat? wHas there been any type of skin rashes or sores? wAny abdominal pain or colicky pain? wAre the stools loose or bloody? Important questions to ask in your History 25. Has there been any recent trauma? 6. Has there been any joint pains or swellings? 7. Is there any history of sickle cell diseas

23、e or trait?8. Is there any family history of renal disease,transplants, or dialysis? 9.Is there a family history of hearing deficits? 10.What medications does the child take? wAccording to the parents, the child was treated with Bacitracin杆菌肽 2 weeks ago for impetigo脓疱病 on the legs and arms? Physica

24、l Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examinationSevere dehydrationPeripheral edema, Cardiovascular system Myocardial infarctionAtrial fibrillationHypertension AbdomenBruit Genitourinary system Enlarged prostate P

25、himosis （包茎）（包茎）Meatal stenosis（尿道狭窄）（尿道狭窄）Renal vein thrombosisNephrotic syndrome vasculitisRenal artery embolus or thrombus Renal artery embolus or thrombusGlomerulosclerosis with or without proteinuria Arteriovenous fistulaUrinary tract infectionUrinary tract infection Urinary tract infectionwThe

26、 patients examination was normal except for a blood pressure of 125/90 and some mild periorbital edema. 拟诊：最能够？拟诊：最能够？ 其次？其次？拟诊：能够拟诊：能够wpost streptococcal acute glomerular nephritis(PSAGN) 急性链球菌感染后肾炎secondary to a nephrogenic strain of streptococcus pyogenes wcausing impetigo 2 weeks ago w进一步检查证明？进一

27、步检查证明？进一步检查证明进一步检查证明wASOwanti-DNAse B titerswBUN and Creatininewcomplement levels.治疗治疗-有助于诊断有助于诊断wThe child should be monitored closely paying attention ：w blood pressure, wdaily weights,w urine output and po input. 预期结果预期结果wThe red blood urine ：w C3 complement ：w预后：预期结果预期结果wThe urine may continue t

28、o contain red blood cells for many months wthe C3 complement usually returns to normal levels in 6-8 weeks. wMost of the PSAGN patients recover completelyCommon causes of hematuria in childrenwUrinary tract infection. Diagnosed by symptoms of burning and frequency and a positive urine culture on a p

29、roperly collected specimen wFamilial benign hematuria- usually asymptomatic and may have minimal proteinuria. At times the hematuria may be gross. wHypercalcuria- usually asymptomatic and may be microscopic or gross hematuria. Do a spot urine and measure the Ca/Creatinine ratio. Age related. 19 mo.-6 years is 0.42(95%) wTransient- no etiology established. wHSP- hematuria may precede the rash Common Causes of Gross HematuriawLocal irritation or trauma to the perineal area wReanl trauma secondary to blunt abdomi