血尿蛋白尿鉴别定稿(精品)课件

1、血尿、蛋白尿的诊断和鉴别诊断北京协和医院肾内科陈丽萌内 容血尿的诊断与鉴别蛋白尿的诊断与鉴别血尿、蛋白尿肾小球疾病的诊断与鉴别血尿的诊断思路确定是否是真性血尿判断出血部位确定病变性质颜 色正常时：无色澄清淡黄色琥珀色病理情况：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 酱油色：血红蛋白尿(酸性)ARF乳白色： 乳糜尿、脓细胞尿红 色： 血尿、血红蛋白尿、肌红蛋白尿 药物 (联苯胺试验）试纸法检测：潜 血原理：试纸法 Hb有类过氧化物酶作用 催化分解过氧化物邻联甲苯胺氧化变色 假阳性假阴性 血红蛋白尿 肌红蛋白尿 尿中强氧化剂 脱水还原剂尿 pH降低试纸预先暴露 在空气中试

2、纸法的局限性：血尿的定义尿沉渣 Addis计数，12h红细胞超过50万 每高倍视野（HP）超过3个红细胞尿检阳性是血尿吗？确定是否是真性血尿标本的可靠性污染 月经、子宫、阴道出血鉴别 容器、化验尿标本收集的注意 晨尿 清洁中段尿 避免生殖道的污染 1小时内送检冰箱 血尿的诊断步骤确定是否是真性血尿判断出血部位确定病变性质判断出血的部位（1）按照血尿和排尿先后的关系进行分析（通常根据尿三杯试验来判断）：初血尿：尿道病变 终末血尿：膀胱颈部和三角区或后尿道病变全程血尿：上尿道或膀胱判断出血的部位（2）相差显微镜检查红细胞形态：均一性不均一性肾单位血尿穿过病变肾小球基底膜时受损通过肾小管时受到管腔内

3、: 渗透压、PH值、代谢物质(脂肪酸/溶血卵磷脂及胆酸）)大小、形状改变+同时合并红细胞管型=肾单位来源例外:肾创伤、活检、梗塞、肾皮质坏死、 剧烈运动也可有红细胞管型判断出血的部位（3）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确定是否是真性血尿判断出血部位确定病变性质确定病变性质（1）血尿的病因泌尿生殖系统疾病全身性疾病尿路邻近器官疾病其他原因2%98%1.肾单位来源(内科性): 原发、继发、家族性

4、2.非肾单位来源(外科性): 肿瘤、外伤、结石、畸形、血管等泌尿生殖系统疾病内科性血尿查什麽?内科性血尿蛋白定量管型肾功能肾活检细菌学检查外科性血尿查什麽?外科性血尿1. 尿脱落细胞2. 影像学: 腹部平片 超声波检查 CT/MRI 3. 介入检查: 膀胱镜检查 静脉肾盂造影(排泄性尿路造影) 逆行尿路造影 肾动脉及肾静脉造影4.钙负荷实验: 尿钙4mg/kg.24h,尿钙/肌酐0.21胡桃夹子现象肠系膜上动脉压迫左肾静脉致左肾回流障碍，淤血；从而引起血尿多发生于儿童，成年后肠系膜上动脉压迫解除症状消失肠系膜上动脉左肾静脉内 容血尿的诊断与鉴别蛋白尿的诊断与鉴别血尿、蛋白尿肾小球疾病的诊断与鉴

5、别正常尿蛋白150mg/24h组成: 60%滤过血浆蛋白 40%白蛋白, 15%免疫蛋白 5%其他血浆蛋白 40% Tamm-Horsfall蛋白失去大小选择性屏障理论上GBM滤过孔孔径加大，长度缩短单位面积GBM上孔密度增加以上两项均有失去电荷选择性屏障GBM失去带阴电荷的分子(糖蛋白分解增加/合成减少) 带阳电荷的分子中阴电荷以上两项均有蛋白尿的机理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应病理情况下致肾小球硬化蛋白尿的分类和特点肾小球性蛋白尿 肾小球滤过屏障损害 2.0 g/24 h 大、中、小分子肾小管性蛋白尿 肾小管对正常滤过蛋白

6、的重吸收障碍 2.0g/24 h，小分子溢出性蛋白尿 血浆中某种蛋白质浓度过高，经正常或异常肾小球滤出分泌性蛋白尿 远端小管分泌：Tamm-Horsfall蛋白蛋白尿诊断方法及诊断思路是否蛋白尿？尿常规持续性？一过性： 多见于少量蛋白尿（trace to 2+ protein）定量： 24小时尿蛋白定量 2g定性： SDS定位 ？内 容血尿的诊断与鉴别蛋白尿的诊断与鉴别血尿、蛋白尿的诊断与鉴别诊断诊断层次1.血尿、蛋白尿临床诊断2.肾功能3.病因:继发肾病?原发肾病4.病理5.并发症诊断方法及程序病史体格检查实验室检查特殊检查随访排除假性血尿血凝块 血尿中混血凝块常提示非肾小球疾患出血血尿与全

7、身疾病及呼吸道感染的时间关系PSGN：感染后1014天出现血尿IgAN： 几乎同时发生，一般不超过3天。家族史:耳聋、血尿、肾衰血尿伴随症状肾绞痛尿路刺激症水肿、高血压及全身其他症状等病史血尿Onset when began with conditions identified around the initial presentation, i.e., drug ingestion record of previous urinalyses precipitation/palliation identification of triggering agents infectious, dru

8、gs, foods, chemicals, vaccinations helps to identify acquired forms of tubulointerstitial proteinuria 蛋白尿问诊quality associated with hematuria severity ： pathologic if associated with hematuria or Nephrotic Syndrome likely to be a primary GN unlikely to be benign etiology or secondary GN timing acute

9、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 causes 1. History of Presenting Illnessat the end of the history, one sho

10、uld 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-hereditary then) 4. acute GN vs chronic GN (if chronic then) 5. primary GN vs secondary GN 6. nephrotic vs non

11、-nephrotic proteinuria 7. proteinuria with or without hematuriauria 病史功能性病理性 肾小球性 肾小管、间质性 溢出性 分泌性隐匿性肾炎综合征急性肾炎综合征慢性肾炎综合征急进性肾炎综合征肾病综合征2. Family Historyhelps to differentiate hereditary from non-hereditary : 1. Proteinuria family members must have had previous urinalysis to ascertain this 2. Renal Dise

12、ase Polycystic Kidney Disease Nephrotic Syndrome, Fanconi Disease renal dialysis kidney transplantation 3. Others：hearing/ocular impairment (Alport Syndrome) PE? Lab? More information3 Physical Examination1. Vitals hypertension, fever 2. O/E edema, skin paleness or jaundice, rashes external genitali

13、a（外生殖器） joints for signs of arthritis-red, warm, or swollen abdomen: masses or tenderness. CVA tenderness 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, hypoal

14、buminemia, hyperlipidemia 进一步检查1.血尿、蛋白尿2.肾功能3.病因:继发肾病?原发肾病4.病理:肾活检5.并发症病因诊断继发: 感染相关 免疫相关 肿瘤相关/淀粉样变/MM 代谢性病原发性肾病病理诊断肾活检的适应症和禁忌症穿刺方法常见的病理类型常见的病理改变随访无症状血尿患者每半年一次尿液分析和细胞学检查每两年一次膀胱镜和静脉肾盂造影若血尿反复发作，随访期至少3年CASE 1A four year-old African American male is brought to your office after his parents noticed that h

15、is urine appeared dark brown or coke （焦碳）colored. Important questions to ask in your History 1Has there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? Has there been any recent URI symptoms or sore throat? Has there been any type of skin rashes or sores? Any abdominal pa

16、in or colicky pain? Are 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 disease or trait?8. Is there any family history of renal disease,transplants, or

17、 dialysis? 9.Is there a family history of hearing deficits? 10.What medications does the child take? According 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? Physical Examination Findings and Associated Causes of Hematuria Physical exam

18、ination finding Cause of hematuria General (systemic) examinationSevere dehydrationPeripheral edema, Cardiovascular system Myocardial infarctionAtrial fibrillationHypertension AbdomenBruit Genitourinary systemEnlarged prostate Phimosis （包茎）Meatal stenosis（尿道狭窄）Renal vein thrombosisNephrotic syndrome

19、 vasculitisRenal artery embolus or thrombus Renal artery embolus or thrombusGlomerulosclerosis with or without proteinuria Arteriovenous fistulaUrinary tract infectionUrinary tract infection Urinary tract infectionThe patients examination was normal except for a blood pressure of 125/90 and some mil

20、d periorbital edema. 拟诊：最可能？ 其次？拟诊：可能post streptococcal acute glomerular nephritis(PSAGN) （急性链球菌感染后肾炎）secondary to a nephrogenic strain of streptococcus pyogenes （causing impetigo 2 weeks ago） 进一步检查证实？进一步检查证实ASOanti-DNAse B titersBUN and Creatininecomplement levels.治疗-有助于诊断The child should be monito

21、red closely paying attention ： blood pressure, daily weights, urine output and po input. 预期结果The red blood urine ： C3 complement ：预后：预期结果The urine may continue to contain red blood cells for many months the C3 complement usually returns to normal levels in 6-8 weeks. Most of the PSAGN patients recov

22、er completelyCommon causes of hematuria in childrenUrinary tract infection. Diagnosed by symptoms of burning and frequency and a positive urine culture on a properly collected specimen Familial benign hematuria- usually asymptomatic and may have minimal proteinuria. At times the hematuria may be gro

23、ss. Hypercalcuria- 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%) Transient- no etiology established. HSP- hematuria may precede the rash Common Causes of Gross HematuriaLocal irritation or trauma to the perineal area Reanl trauma secondary to blunt abdominal trauma or accident UTIs 如果1If the patient is asympotmatic and the physical exam is normal, and there is no family history of renal disease,recheck the urine in a few days.dips