肾功能检查1课件

RenalFunctionTest

肾功能检查p349KidneydiseasesUrinetests:urinalysisandothersCheapandconvenient;ForscreeningandfollowingRenalbiopsyRenalfunctionsGlomerulus:filtrationTubule:reabsorptionandacidificationImagingExaminationImmunologicaltestWhenandforWhatKidneydiseasesorinjuriesOverallcheckupKidneyfunctionassessmentwithotherdiseasesDiabetesmellitusHypertensionShockorextensiveburnAuto-immunologicaldiseasesDrugtoxicityFUNCTIONSOFKIDNEYExcretemetabolicproducts/wastesKeepthebalanceofwater,acid-baseandelectrolyteEndocrinefunction:EPO(erythropoietin):RBCproduct1,25(OH)2D3:Calciumandphosphorusrenin:boodpressureregulationRelatedconcepts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Stagesforrenalfailure：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RelatedconceptsRelatedconceptsCommonsymptomsofAFR少尿期oliguriastage：Oliguriaoranuria,Hematuria,ProteinuriaandsomekindsofcastsWaterintoxicationHyperpotassemiaMetabolicacidosisAzotemia多尿期polyuriastage恢复期recoverystageTestsofglomerularfunction

肾小球功能检查——肾小球滤过功能Renalbloodflow：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：renalbloodfloweffectivefiltrationpressureFiltrationareamembranepermeabilityGlomerularFiltrationEndogenousCreatinine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/minClinicalSignificancePathologicaldecreaseSensitiveforkidneyinjuryGFR<50%时Ccr≈50ml/minEstimatethestageofrenalfailurecompensatory：>50ml/mindecompensatory：20-50ml/minfailure：10-19ml/minuremia：<10ml/minFortreatment30-40:limitedproteindiets

diuretic<30diuretic:notavailable<10replacementtherapyPhysiologiccal：relatedwithsports,diets,age……SerumCreatinine,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/LClinicalSignificanceofScrincreaseGlomerularFiltrationInjuryChronicrenalfailureCompensatorystage:Scr<178μmol/LDecompensatorystage:Scr>178μmol/LFailurestage:Scr>445μmol/LClinicalSignificanceofScrincreaseDifferentialdiagnosisofprerenalandrenalazotemiaPrerenaloliguria:Scr<200μmol/LRenaloliguria:Scr>200μmol/LClinicalSignificanceExcessiveintakeofproteinandproteolysis:Highproteindiet，Highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismClinicalSignificanceRenaldamage:AcuterenalfailureCompensatoryClinicalSignificanceRenaldamage:ChronicrenalfailureCompensatorystage:BUN<9mmol/LDecompensatorystage:BUN>9mmol/LFailurestage:BUN>20mmol/LExcessiveintakeofproteinandproteolysis:

highproteindiet，highfever,Uppergastrointestinalhemorrhage,extensiveburn，severetrauma,hyperthyroidismStageofkidneyimpairement

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

<10>707>28.6(uremia)Expressedinallnucleatedcells,encodedbyhousekeepinggeneCanbedetectedinallbodyfluidAlmostfiltratedthroughglomeruluscompletely,reabsorbedbytubulusandthendegradedConcentrationinserumorplasmaisdeterminedbyGFR。NormalValue：0.6-2.5mg/LCystatinC胱氨酸蛋白酶抑制剂C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OperatedeasilyTestsoftubularfunction

肾小管功能检查Testsofproximaltubularfunction

近端肾小管功能检测Urineβ2-microglobulin,β2-MGFreelyfiltratedbyglomeruliAlmostreabsorbedbytubulescompletelyThresholdofreabsorption:5mg/LNormalvalue:Urine：<0.3mg/LClinicalSignificanceGFR：Serumβ2-MG↑:moresensitivethanScrwhenCcr<80ml/minReabsorptionfunctionofproximaltubules：

bloodβ2-MG<5mg/L,urineβ2-MGincreaseAcuteandchronicpyelonephritisClinicalSignificanceEvaluationfortransplantkidneyfunctionurineβ2-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）Testsofdistalnephronfunction

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

:>3～4∶1SGspecificgravity：1.015-1.025highest>1.018thegapofthehighestandthelowest>0.009ClinicalSignificanceImpairmentindistaltubules：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↓Urineosmol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UrineosmolNormalvalue: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ClinicalsignificanceIncrease:dehydration,Addison'sdisease,diarrhea,diabetesmellitus,hyperglycemia,hypernatremiacirrhosisDecrease:overhydration,aldosteronism,diabetesinsipidus,hyponatremia,hypocalcemiaDifferentialdiagnosisofoliguriacauses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>