儿科学教学课件：Acute Glomerulonephritis

AcuteGlomerulonephritisAcuteGlomerulonephritis

Etiology

病因ManifestationsLaboratorytest解剖生理特点classifi-cationOverviewPathogenesis，

pathology

Anatomical，Physiological发病机制病理临床表现实验室检查Diagnosis

诊断TreatmentPreventionAcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPreventionAnatomical

characteristicsKidneyUreterBladderUrethraPhysiologicalCharacteristicsKidneyisoneofthemainorganstomaintainhomeostasisoftheinternalenvironment.Thephysiologicalfunctionofkidneyinchildrenissimilartothatinadults,butitisnotmature.Itsfunctionreachesadultlevelattheagesof1-1.5years.GFR(Glomerularfiltrationrate）20ml/minper1.73m2goesto1/4oftheadultlevelattheageof1week,andthesametoadultat1-2years.Soovermuchfluidandsolutecannotbeexcretedefficientlyduringthisperiodoftime.reabsorptionandexcretioninrenaltubule,theendocrinefunctionofkidneys

TheclinicalclassificationofglomerulardiseasesPrimaryglomerulardiseasesSecondary

glomerulardiseasesHereditary

glomerulardiseasesTheclinicalclassificationofglomerulardiseases

PrimaryglomerulardiseasesGlomerulonephritisnephroticsyndromeisolatedhematuriaorproteinuria

TheclinicalclassificationofglomerulardiseasesSecondaryglomerulardiseases（SLE,hepatitisB,anaphylactoidpurpura）Hereditaryglomerulardiseases（Alportsyndrome,familialrecurrenthematuria）AcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPreventionAcuteglomerulonephritis

overviewAcuteglomerulonephritisisaclassicexampleoftheacutenephriticsyndromeinchildren.Itischaracterizedbythesuddenonsetofhematuria,varyingdegreesofproteinuria,edema,hypertension,orrenalinsufficiency.

3.AcuteglomerulonephritisthatfollowsaninfectionwithanephritogenicstrainofgroupAbeta-hemolyticstreptococci

（A组ß溶血性链球菌）isoneofthemostcommonformsofrenalparenchymaldiseaseinchildhood.4.Antigen-antibodycomplexesaredepositedintheglomeruli,andthecomplexesmayinciteglomerularinflammationandactivatethecomplementsystem.

AcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPreventionEtiologyAcutepoststreptococcalglomerulonephritis(APSGN)followsinfectionofthethroatorskinbycertain“nephritogenic”strainsofgroupAbeta-hemolyticstreptococci.pharyngitis(咽炎）--winterandspringskininfectionorpyoderma（脓疱疮）--summer.

Otherinfectionscancausesimilarglomerularinjury,suchasmycoplasmapneumonia（肺炎支原体）,cytomegalovirus（巨细胞病毒）,pneumococcus（肺炎球菌）andsoon.AcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPrevention肾小球滤过膜上皮细胞肾小球基底膜（GBM）内皮细胞发病机制形成CIC或IC肾小球局部免疫炎症反应毛细血管内增生GBM完整性受损GFR↓，球管失衡水、钠排出↓尿少血容量↑静脉压↑间质容量↑循环负荷↑水肿高血压血尿、蛋白尿A组溶血性链球菌致肾炎菌株（Ag）补体激活

光镜:

系膜细胞和内皮细胞增生normalAGN电镜：电子致密物沉积EM×10000在肾小球基底膜外侧见一圆锥状电子致密物（H）－驼峰病理IF×400IgG沿肾小球毛细血管壁呈不连续的颗粒样荧光肾小球系膜区也可见团块状沉积AcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPreventionClinicalManifestationsAPSGNiscommoninchildrenof5-14yearsoldbutuncommonbeforeageof2Theseverityofrenalsymptomsvariesfromasymptomaticmicroscopichematuria（无症状镜下血尿）withnormalrenalfunctiontoacuterenalfailure.Acutepoststreptocccalglomerulonephritis(APSGN)commonlyfollowsbystreptococcalpharyngitis(咽喉炎）duringwinterandspringandstreptococcalskininfectionsorpyoderma（脓疱疮）insummer.Precedinginfection

upperrespiratory（呼吸）tractinfection：causedbystreptococcus（链球菌），suchastonsillitis(扁桃腺炎）,otitismedia（中耳炎）,orlymphnoditis（淋巴结炎）.followedbyalatentperiodlastforabout10days.infectionofskin(notablypyoderma-脓疱疮),thelatentperiodcan3weeksinaverage.Acuteglomerulonephritis严重表现典型表现非典型表现临床表现ManifestationsEdema---palpebraedema（眼睑浮肿）

最早出现和最常见的症状（晨起眼睑、颜面部水肿）

下行性

非凹陷性urinaryabnormalities(hematuria,varyingdegreeofproteinuria),

肉眼血尿（grosshematuria）

镜下血尿（microscopichematuria）

血压（mmHg）学龄前>120/80学龄儿>130/90hypertension

oliguria

年龄正常尿量少尿无尿婴儿400-500<200幼儿500-600<200<30-50学龄前600-800<300学龄儿800-1400<400单位：ml/24hOthersymptomsLow-gradefeverabdominalpainAnorexia（厌食）nonspecificVomiting（呕吐）headacheAcutenephritiscomplications

Seriouscirculationcongestionhypertensiveencephalopathy（高血压脑病）acuterenalfailure

严重循环充血(Seriouscirculationcongestion)

GFR↓Water-sodiumretentionHyper-volemiahigherheartloading左心负荷增加：呼吸困难、两肺湿性罗音、心率增快、心脏扩大右心负荷增加：肝脏增大，颈静脉怒张高血压脑病

(hypertensiveencephalopathy)HemangiectasisvasospasmcerebralischemiaAnoxiaPapilledema

BP↑cerebralsymptom

高血压脑病

(hypertensiveencephalopathy)

HeadacheVomitingirritabilityorapathy(烦躁或表情淡漠）Convulsions（抽搐）transitoryparalyses（一过性麻痹）Coma（昏迷）temporarycompleteblindness

高血压脑病(hypertensiveencephalopathy)

脑血管痉挛→脑缺血缺氧→脑血管通透性↑→脑水肿→血压升高、头痛、呕吐并伴惊厥、昏迷、复视或一过性失明急性肾功能不全

(Acuterenalfailure)GFR↓→急性肾功能不全氮质血症少尿或无尿代谢性酸中毒电解质紊乱非典型表现无症状性急性肾炎肾外症状性急性肾炎肾病表现的急性肾炎镜下血尿、蛋白尿，但无临床症状水肿、高血压，但尿改变轻微或正常急性肾炎经过，蛋白尿达肾病水平AcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPrevention

LaboratoryTest

Routineurinalysis

•HematuriaGrosshematuria

Microscopichematuria

：RBC>3/HP12hAddis计数>50万

•LaboratoryTestProteinuria:milddegreeWBCrenaltubularepitheliumhyalinecastsgranularcasts.

urinaryabnormalitiesmaypersistformorethan1year.

LaboratoryTest

Bloodchemistry•BUNCrSerologicaltesting

C3：2w内↓↓6～8w恢复ASO：10～14d开始升高

3～5w高峰

3～6m恢复ADNaseB(+)ESR↑，代表疾病的活动性；2～3m恢复，增高程度与疾病严重度无关Bloodroutine

RBC↓,Hb↓(hepervolemiaandhemodilutionAcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPrevention急性肾炎的诊断要点起病1～3w有链球菌的前驱期感染临床出现水肿、少尿、血尿、高血压

尿检有蛋白、RBC、管型血清C3↓，伴或不伴ASO↑鉴别诊断

1）肾病综合征

2）IgA肾病

3）急进性肾炎

4）慢性肾炎急性发作

5）继发性肾炎：过敏性紫癜、系统性红斑狼疮、乙型肝炎等AcuteGlomerulonephritisAnatomical，PhysiologicalClassificationOverviewEtiologyPathogenesis，pathologyManifestationsLaboratorytestDiagnosisTreatmentPreventionTreatment治疗原则及程序自限性疾病，无特效治疗休息和对症治疗纠正其病理生理过程（如水钠潴留、血容量过大）防治急性期并发症、保护肾功能，以利其自然恢复Treatment

1、Bedrest

prolongedbedrestfor2-3weeksinacutephase,itisrequiredaslongastheclinicalsymptomsdisappearAfterESRreturnstonormal,childrencangobacktoschool,butexhaustingandcompetitiveactivitiesareprohibiteduntiltheaddiscountreturns