肾功能检查1全解课件

RenalFunctionTest

肾功能检查p349RenalFunctionTest

肾功能检查pKidneydiseasesUrinetests:urinalysisandothersCheapandconvenient;ForscreeningandfollowingRenalbiopsyRenalfunctionsGlomerulus:filtrationTubule:reabsorptionandacidificationImagingExaminationImmunologicaltestKidneydiseasesUrinetests:urWhenandforWhatKidneydiseasesorinjuriesOverallcheckupKidneyfunctionassessmentwithotherdiseasesDiabetesmellitusHypertensionShockorextensiveburnAuto-immunologicaldiseasesDrugtoxicityWhenandforWhatKidneydiseasStructureofKidney肾单位集合管肾小体肾小管肾小球肾小囊近曲小管远曲小管髓袢StructureofKidney肾单位集合管肾小体肾小FUNCTIONSOFKIDNEYExcretemetabolicproducts/wastesKeepthebalanceofwater,acid-baseandelectrolyteEndocrinefunction:EPO(erythropoietin):RBCproduct1,25(OH)2D3:Calciumandphosphorusrenin:boodpressureregulationFUNCTIONSOFKIDNEYExcretemetRelatedconcepts急性肾衰AFR肾前性Pre-renal：休克早期、大面积烧伤、脱水等功能性肾性renal：器质性肾小管上皮细胞坏死肾脏本身：肾小球肾炎、肾盂肾炎、狼疮肾炎肾动脉血栓、栓塞肾后性postrenal：结石、肿瘤、前列腺肥大等尿路梗阻Relatedconcepts急性肾衰AFRStagesforrenalfailure：代偿期compensatorystage失代偿期decompensatorystage:

氮质血症Azotemia：血中尿素氮BUN或肌酐sCR超出正常范围肾性肾前性肾后性衰竭期Failurestage尿毒症期UremiaStage：综合症候群，“尿潴留在血中”而引起的中毒RelatedconceptsStagesforrenalfailure：RelatRelatedconceptsCommonsymptomsofAFR少尿期oliguriastage：Oliguriaoranuria,Hematuria,ProteinuriaandsomekindsofcastsWaterintoxicationHyperpotassemiaMetabolicacidosisAzotemia多尿期polyuriastage恢复期recoverystageRelatedconceptsCommonsymptomRelatedconceptsCommonsymptomsofCFREarlystage：polyuria,Nocturia,Hematuria,ProteinuriaandsomekindsofcastsAzotemiaWaterintoxicationMetabolicacidosis(moderate)HypopotassemiaLatestage:asabove,Uremia,hyperpotassemia,hypertension,Osteodystrophy,anemia,bleedingtendency……RelatedconceptsCommonsymptomTestsofglomerularfunction

肾小球功能检查——肾小球滤过功能Testsofglomerularfunction

肾TestsofGlomerularFunctionGlomerularFiltrationRate,GFREndogenousCreatinineClearanceRate,CcrSerumCreatinine,ScrBloodUreaNitrogen,BUNSerumβ2-microglobulinCystatinCTestsofGlomerularFunctionGlRenalbloodflow：1200-1400ml/min，占20%-25%心血流量Crudeurine：即肾小球滤过液,120-160ml/min影响因素：renalbloodfloweffectivefiltrationpressureFiltrationareamembranepermeabilityGlomerularFiltrationRenalbloodflow：1200-1400mRenalClearanceRate肾清除率肾小球滤过率（GFR)：单位时间内（分钟）经肾小球滤出的血浆量,即单位时间内产生的原尿量正常值：120-160ml/min肾清除率：指在单位时间（min）内，肾脏能将多少毫升血浆中含有的某种物质全部加以清除，结果以ml/min表示常用：菊粉清除率、内生肌酐清除率来反映肾小球滤过率RenalClearanceRate肾清除率肾小球滤EndogenousCreatinine肌酐内源性肌酐外源性肌酐肌肉活动中肌酸代谢产物来自于鱼类、肉类等食物和咖啡、茶等饮料EndogenousCreatinine肌酐内源性肌酐外源EndogenousCreatinineClearanceRate,CcrDefinition：Ccristhevolumeofbloodplasmawithcreatininethatisclearedbykidneysperunittime.即：单位时间内,肾脏可全部清除多少毫升血浆中的内生肌酐计算公式：Normalvalue：80-120ml/minEndogenousCreatinineClearancClinicalSignificancePathologicaldecreaseSensitiveforkidneyinjuryGFR<50%时Ccr≈50ml/minEstimatethestageofrenalfailurecompensatory：>50ml/mindecompensatory：20-50ml/minfailure：10-19ml/minuremia：<10ml/minFortreatment30-40:limitedproteindiets

diuretic<30diuretic:notavailable<10replacementtherapyPhysiologiccal：relatedwithsports,diets,age……ClinicalSignificancePathologiSerumCreatinine,Scr血肌酐测定肌肉活动稳定、外源性肌酐来源不变的情况下，Scr浓度主要取决于肾小球的滤过能力。NormalValue:SerumorPlasmaCr:male:53-106μmol/Lfemale:44-97μmol/LSerumCreatinine,Scr血肌酐测ClinicalSignificanceofScrincreaseGlomerularFiltrationInjuryChronicrenalfailureCompensatorystage:Scr<178μmol/LDecompensatorystage:Scr>178μmol/LFailurestage:Scr>445μmol/LClinicalSignificanceofScriAcuterenalfailureCompensatoryDecompensatoryFailureAcuterenalfailureCompensatorClinicalSignificanceofScrincreaseDifferentialdiagnosisofprerenalandrenalazotemiaPrerenaloliguria:Scr<200μmol/LRenaloliguria:Scr>200μmol/LClinicalSignificanceofScriClinicalSignificanceExcessiveintakeofproteinandproteolysis:Highproteindiet，Highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismClinicalSignificanceExcessiveBloodureanitrogen,BUNInfluencefactorsProteinintakeProteindegradationLiverfunctionGlomerularfiltrationNormalvalue:Adults:3.2-7.1mmol/LChildrenorinfants:1.8-6.5mmol/LUreaorornithinecycleinliverBloodureanitrogen,BUNInflueClinicalSignificanceRenaldamage:AcuterenalfailureCompensatoryClinicalSignificanceRenaldamClinicalSignificanceRenaldamage:ChronicrenalfailureCompensatorystage:BUN<9mmol/LDecompensatorystage:BUN>9mmol/LFailurestage:BUN>20mmol/LExcessiveintakeofproteinandproteolysis:

highproteindiet，highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismClinicalSignificanceRenaldamClinicalSignificanceofBUN/CrPrerenaloliguria:BUN升高更明显，BUN/Cr明显升高

prerenalazotemiaRenalfailure:BUN/Cr变化不大ClinicalSignificanceofBUN/CStageofkidneyimpairement

CcrScrBUN（ml/min)(umol/L)(mmol/L)Compensatorystage80-51<178<9Decompensatorystage50-20178～4459～20Renalfailure19-10445-70720-28.6end-stagerenalfailure

<10>707>28.6(uremia)StageofkidneyimpairementExpressedinallnucleatedcells,encodedbyhousekeepinggeneCanbedetectedinallbodyfluidAlmostfiltratedthroughglomeruluscompletely,reabsorbedbytubulusandthendegradedConcentrationinserumorplasmaisdeterminedbyGFR。NormalValue：0.6-2.5mg/LCystatinC胱氨酸蛋白酶抑制剂CExpressedinallnucleatedcel肾功能检查1全解课件肾功能检查1全解课件优点Highspecificity：不受炎症反应、恶性肿瘤、肌肉、性别以及年龄的影响。Highsensitivity：与GFR相关性优于Ccr，相当于菊粉清除率检测结果Operatedeasily优点Highspecificity：不受炎症反应、恶性肿瘤Testsoftubularfunction

肾小管功能检查Testsoftubularfunction

肾小管功Testsofproximaltubularfunction

近端肾小管功能检测TestsofproximaltubularfuncUrineβ2-microglobulin,β2-MGFreelyfiltratedbyglomeruliAlmostreabsorbedbytubulescompletelyThresholdofreabsorption:5mg/LNormalvalue:Urine：<0.3mg/LUrineβ2-microglobulin,β2-MGFClinicalSignificanceGFR：Serumβ2-MG↑:moresensitivethanScrwhenCcr<80ml/minReabsorptionfunctionofproximaltubules：

bloodβ2-MG<5mg/L,urineβ2-MGincreaseAcuteandchronicpyelonephritisClinicalSignificanceGFR：ClinicalSignificanceEvaluationfortransplantkidneyfunctionurineβ2-MG↑↑，impliedgraftrejeciton排异时血β2-MG增高先于Ccr，测定β2-MG有助于诊断尚处于亚临床期的肾排异反应。肾移植虽有少尿，但血β2-MG下降者提示预后良好。恶性肿瘤、炎性疾病（肝炎、类风湿关节炎等）ClinicalSignificanceEvaluatioTestsofdistalnephronfunction

远端肾单位（远端小管和集合管）功能检测TestsofdistalnephronfunctiMosenthal’stest(renalconcentrationfunction)Alsoas:Circadianurinespecificgravity(SG)testNormalintake(water<500-600ml),noextrawaterEmptybladderat8aminthemorningDetectthevolumeandSGoftheurineevery2hoursfrom10amto8pm,andmorningurineofnextdayMosenthal’stest(renalconcenNormalValuesvolume：24htotalvolume:1000～2000ml；12hovernighturine:<750ml；volumeratioofdaytimeandovernight

:>3～4∶1SGspecificgravity：1.015-1.025highest>1.018thegapofthehighestandthelowest>0.009NormalValuesvolume：ClinicalSignificanceImpairmentindistaltubules：Earlystage：overnighturine>750ml,Day/overnight↓,SGisnormalSevereimpairment:polyuria，overnighturine↑SG↓Failure：polyuria、SG:1.010~1.012Diabetesinsipidus尿崩症:Totalurine>4L，SG<1.006Urinevolume↓SG↑：renalconcentrationfunction:normalbloodvolume↓orGF↓ClinicalSignificanceImpairmenUrineosmol尿渗量AssesstheabilityofkidneystodiluteorconcentrateurineandidentifyADHabnormalitiesNormalvalue:Urineosmol:600-1000mOsm/kgH2O800mOsm/kgH2OPlasmaosmol:275-305mOsm/kgH2O300mOsm/kgH2O

Uosm/Posm=3~4.5:1判断尿浓缩功能1.Uosm=300mOsm/kgH2O:Isosthenuria等渗尿2.Uosm《300mOsm/kgH2O低渗尿3.Uosm<600mOsm/kgH2O:尿浓缩功能障碍Urineosmol尿渗量AssesstheabilUrineosmolNormalvalue:Plasmaosmol:275-305mOsm/kgH2O

平均300mOsm/kgH2O

Urineosmol:600-1000mOsm/kgH2O

平均800mOsm/kgH2OUosm/Posm=3~4.5:1Uosm<600mOsm/kgH2O,肾小管浓缩功能障碍Uosm=300mOsm/kgH2O，等渗尿UrineosmolNormalvalue:ClinicalsignificanceIncrease:dehydration,Addison'sdisease,diarrhea,diabetesmellitus,hyperglycemia,hypernatremiacirrhosisDecrease:overhydration,aldosteronism,diabetesinsipidus,hyponatremia,hypocalcemiaClinicalsignificanceIncrease:Differentialdiagnosisofoliguriacauses一次性尿渗透量检测用于鉴别肾性和肾前性少尿Renaloliguria:肾前性少尿

Uosm<350mOsm/kgH2OPrerenaloliguria:肾性少尿

Uosm>450mOsm/kgH2ODifferentialdiagnosisofolig肾功能检测项目的选择和应用怀疑泌尿系统疾病尿常规检查尿沉渣镜检β2-MG、Ccr早期监控肾脏损害Ccr血肌酐尿素氮β2-MG

尿钠FeNa昼夜尿比重尿渗量动态监测尿渗量肾小球滤过功能肾小球滤过功能肾小管吸收功能急性肾衰慢性肾衰累及肾小球累及远端肾小管累及近端肾小管肾功能检测项目的选择和应用怀疑泌尿系统疾病尿常规检查尿沉渣镜病例李XX，女性，31岁主诉：周身浮肿2周现病史：近两周无诱因出现眼睑及双下肢浮肿，尿量减少，每日700ml左右，伴乏力，食欲下降，恶心。于当地医院化验尿蛋白（＋＋），给青霉素治疗无效来诊。发病以来饮食、睡眠尚可，大便正常。既往史、家族史无特殊。病例李XX，女性，31岁病例体格检查：体温36C，脉搏72次／分，呼吸16次／分，血压150／100mmHg。皮肤无皮疹、出血点及瘀斑，浅表淋巴结未触及。颜面浮肿，无明显贫血貌，结膜无苍白，巩膜无黄染。无颈静脉怒张。心肺无异常，腹软，肝、脾未触及，移动性浊音阴性，肾区无叩痛，下肢轻度水肿。病例体格检查：体温36C，脉搏72次／分，呼吸16次／病例辅助检查：尿常规：蛋白（＋＋），尿蛋白定量2.3g/24h。红细胞5～8个/HP，畸形红细胞占80％以上。血常规：Hb120g/L，PLT168×109/L。血IgA1.06g／L，IgM0.97g／L，补体C30.46g／L，

BUN9.1mmol／L，Cr197μmol／L。B超：左肾10.6×5.6×3.4cm，右肾10.5×5.4×3.1cm，双肾弥漫性损害。病例辅助检查：RenalFunctionTest

肾功能检查p349RenalFunctionTest

肾功能检查pKidneydiseasesUrinetests:urinalysisandothersCheapandconvenient;ForscreeningandfollowingRenalbiopsyRenalfunctionsGlomerulus:filtrationTubule:reabsorptionandacidificationImagingExaminationImmunologicaltestKidneydiseasesUrinetests:urWhenandforWhatKidneydiseasesorinjuriesOverallcheckupKidneyfunctionassessmentwithotherdiseasesDiabetesmellitusHypertensionShockorextensiveburnAuto-immunologicaldiseasesDrugtoxicityWhenandforWhatKidneydiseasStructureofKidney肾单位集合管肾小体肾小管肾小球肾小囊近曲小管远曲小管髓袢StructureofKidney肾单位集合管肾小体肾小FUNCTIONSOFKIDNEYExcretemetabolicproducts/wastesKeepthebalanceofwater,acid-baseandelectrolyteEndocrinefunction:EPO(erythropoietin):RBCproduct1,25(OH)2D3:Calciumandphosphorusrenin:boodpressureregulationFUNCTIONSOFKIDNEYExcretemetRelatedconcepts急性肾衰AFR肾前性Pre-renal：休克早期、大面积烧伤、脱水等功能性肾性renal：器质性肾小管上皮细胞坏死肾脏本身：肾小球肾炎、肾盂肾炎、狼疮肾炎肾动脉血栓、栓塞肾后性postrenal：结石、肿瘤、前列腺肥大等尿路梗阻Relatedconcepts急性肾衰AFRStagesforrenalfailure：代偿期compensatorystage失代偿期decompensatorystage:

氮质血症Azotemia：血中尿素氮BUN或肌酐sCR超出正常范围肾性肾前性肾后性衰竭期Failurestage尿毒症期UremiaStage：综合症候群，“尿潴留在血中”而引起的中毒RelatedconceptsStagesforrenalfailure：RelatRelatedconceptsCommonsymptomsofAFR少尿期oliguriastage：Oliguriaoranuria,Hematuria,ProteinuriaandsomekindsofcastsWaterintoxicationHyperpotassemiaMetabolicacidosisAzotemia多尿期polyuriastage恢复期recoverystageRelatedconceptsCommonsymptomRelatedconceptsCommonsymptomsofCFREarlystage：polyuria,Nocturia,Hematuria,ProteinuriaandsomekindsofcastsAzotemiaWaterintoxicationMetabolicacidosis(moderate)HypopotassemiaLatestage:asabove,Uremia,hyperpotassemia,hypertension,Osteodystrophy,anemia,bleedingtendency……RelatedconceptsCommonsymptomTestsofglomerularfunction

肾小球功能检查——肾小球滤过功能Testsofglomerularfunction

肾TestsofGlomerularFunctionGlomerularFiltrationRate,GFREndogenousCreatinineClearanceRate,CcrSerumCreatinine,ScrBloodUreaNitrogen,BUNSerumβ2-microglobulinCystatinCTestsofGlomerularFunctionGlRenalbloodflow：1200-1400ml/min，占20%-25%心血流量Crudeurine：即肾小球滤过液,120-160ml/min影响因素：renalbloodfloweffectivefiltrationpressureFiltrationareamembranepermeabilityGlomerularFiltrationRenalbloodflow：1200-1400mRenalClearanceRate肾清除率肾小球滤过率（GFR)：单位时间内（分钟）经肾小球滤出的血浆量,即单位时间内产生的原尿量正常值：120-160ml/min肾清除率：指在单位时间（min）内，肾脏能将多少毫升血浆中含有的某种物质全部加以清除，结果以ml/min表示常用：菊粉清除率、内生肌酐清除率来反映肾小球滤过率RenalClearanceRate肾清除率肾小球滤EndogenousCreatinine肌酐内源性肌酐外源性肌酐肌肉活动中肌酸代谢产物来自于鱼类、肉类等食物和咖啡、茶等饮料EndogenousCreatinine肌酐内源性肌酐外源EndogenousCreatinineClearanceRate,CcrDefinition：Ccristhevolumeofbloodplasmawithcreatininethatisclearedbykidneysperunittime.即：单位时间内,肾脏可全部清除多少毫升血浆中的内生肌酐计算公式：Normalvalue：80-120ml/minEndogenousCreatinineClearancClinicalSignificancePathologicaldecreaseSensitiveforkidneyinjuryGFR<50%时Ccr≈50ml/minEstimatethestageofrenalfailurecompensatory：>50ml/mindecompensatory：20-50ml/minfailure：10-19ml/minuremia：<10ml/minFortreatment30-40:limitedproteindiets

diuretic<30diuretic:notavailable<10replacementtherapyPhysiologiccal：relatedwithsports,diets,age……ClinicalSignificancePathologiSerumCreatinine,Scr血肌酐测定肌肉活动稳定、外源性肌酐来源不变的情况下，Scr浓度主要取决于肾小球的滤过能力。NormalValue:SerumorPlasmaCr:male:53-106μmol/Lfemale:44-97μmol/LSerumCreatinine,Scr血肌酐测ClinicalSignificanceofScrincreaseGlomerularFiltrationInjuryChronicrenalfailureCompensatorystage:Scr<178μmol/LDecompensatorystage:Scr>178μmol/LFailurestage:Scr>445μmol/LClinicalSignificanceofScriAcuterenalfailureCompensatoryDecompensatoryFailureAcuterenalfailureCompensatorClinicalSignificanceofScrincreaseDifferentialdiagnosisofprerenalandrenalazotemiaPrerenaloliguria:Scr<200μmol/LRenaloliguria:Scr>200μmol/LClinicalSignificanceofScriClinicalSignificanceExcessiveintakeofproteinandproteolysis:Highproteindiet，Highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismClinicalSignificanceExcessiveBloodureanitrogen,BUNInfluencefactorsProteinintakeProteindegradationLiverfunctionGlomerularfiltrationNormalvalue:Adults:3.2-7.1mmol/LChildrenorinfants:1.8-6.5mmol/LUreaorornithinecycleinliverBloodureanitrogen,BUNInflueClinicalSignificanceRenaldamage:AcuterenalfailureCompensatoryClinicalSignificanceRenaldamClinicalSignificanceRenaldamage:ChronicrenalfailureCompensatorystage:BUN<9mmol/LDecompensatorystage:BUN>9mmol/LFailurestage:BUN>20mmol/LExcessiveintakeofproteinandproteolysis:

highproteindiet，highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismClinicalSignificanceRenaldamClinicalSignificanceofBUN/CrPrerenaloliguria:BUN升高更明显，BUN/Cr明显升高

prerenalazotemiaRenalfailure:BUN/Cr变化不大ClinicalSignificanceofBUN/CStageofkidneyimpairement

CcrScrBUN（ml/min)(umol/L)(mmol/L)Compensatorystage80-51<178<9Decompensatorystage50-20178～4459～20Renalfailure19-10445-70720-28.6end-stagerenalfailure

<10>707>28.6(uremia)StageofkidneyimpairementExpressedinallnucleatedcells,encodedbyhousekeepinggeneCanbedetectedinallbodyfluidAlmostfiltratedthroughglomeruluscompletely,reabsorbedbytubulusandthendegradedConcentrationinserumorplasmaisdeterminedbyGFR。NormalValue：0.6-2.5mg/LCystatinC胱氨酸蛋白酶抑制剂CExpressedinallnucleatedcel肾功能检查1全解课件肾功能检查1全解课件优点Highspecificity：不受炎症反应、恶性肿瘤、肌肉、性别以及年龄的影响。Highsensitivity：与GFR相关性优于Ccr，相当于菊粉清除率检测结果Operatedeasily优点Highspecificity：不受炎症反应、恶性肿瘤Testsoftubularfunction

肾小管功能检查Testsoftubularfunction

肾小管功Testsofproximaltubularfunction

近端肾小管功能检测TestsofproximaltubularfuncUrineβ2-microglobulin,β2-MGFreelyfiltratedbyglomeruliAlmostreabsorbedbytubulescompletelyThresholdofreabsorption:5mg/LNormalvalue:Urine：<0.3mg/LUrineβ2-microglobulin,β2-MGFClinicalSignificanceGFR：Serumβ2-MG↑:moresensitivethanScrwhenCcr<80ml/minReabsorptionfunctionofproximaltubules：

bloodβ2-MG<5mg/L,urineβ2-MGincreaseAcuteandchronicpyelonephritisClinicalSignificanceGFR：ClinicalSignificanceEvaluationfortransplantkidneyfunctionurineβ2-MG↑↑，impliedgraftrejeciton排异时血β2-MG增高先于Ccr，测定β2-MG有助于诊断尚处于亚临床期的肾排异反应。肾移植虽有少尿，但血β2-MG下降者提示预后良好。恶性肿瘤、炎性疾病（肝炎、类风湿关节炎等）ClinicalSignificanceEvaluatioTestsofdistalnephronfunction

远端肾单位（远端小管和集合管）功能检测TestsofdistalnephronfunctiMosenthal’stest(renalconcentrationfunction)Alsoas:Circadianurinespecificgravity(SG)testNormalintake(water<500-600ml),noextrawaterEmptybladderat8aminthemorningDetectthevolumeandSGoftheurineevery2hoursfrom10amto8pm,andmorningurineofnextdayMosenthal’stest(renalconcenNormalValuesvolume：24htotalvolume:1000～2000ml；12hovernighturine:<750ml；volumeratioofdaytimeandovernight

:>3～4∶1SGspecificgravity：1.015-1.025highest>1.018thegapofthehighestandthelowest>0.009NormalValuesvolume：ClinicalSignificanceImpairmentindistaltubules：Earlystage：overnighturine>750ml,Day/overnight↓,SGisnormalSevereimpairment:polyuria，overnighturine↑SG↓Failure：polyuria、SG:1.010~1.012Diabetesinsipidus尿崩症:Totalurine>4L，SG<1.006Urinevolume↓SG↑：renalconcentrationfunction:normalbloodvolume↓orGF↓ClinicalSignificance