儿科学 第七版配套教材.ppt

1、Hematuria and glomerulonephritis Xiang xiao ,Song assistant Soochow university affiliated children hospital Nephrology department,Hematuria, gross hematuria, microscopic hematuria, 5 RBCs /HPF,Concept of Hematuria,Common reasons of Hematuria,Renal causes,Non-renal causes,Glomerular,Non-glomerular,ha

2、ematological,Non-haematological,Glomerular,Glomerulonephritis (AGN, CGN, RPGN) Recurrent hematuria ( Alport syndrome, IgA nephropathy) Haemolytic uraemic syndrome (HUS) Henoch-Schonlein purpura (HSP) Systemic lupus erythematosus (SLE),CGN, course of disease is over 1 year The renal function is abnor

3、mal,and may present with renal hypertension,AGN,RPGN,The sudden onset mainly present with hematuria ,associated with proteinuria of different extent, some patients may also present with edema,hypertension and renal dysfunction. course is less than 1 year,The sudden onset progressive renal dysfunctio

4、n. progress to end-stage renal failure within a few weeks, the outcome is poor,Alport syndrome, x-linked dominant nephritis associated with deafness the splitting of GBM No definitive treatment,IgA nephropathy, the prevalence is high in asia the renal biospy is characterized by mesangial proliferati

5、on under light microscope and mesangial IgA deposition by immunofluorescence 80-90% present with asymptomatic hematuria 1-3days after a URI or other infection ,renal function is normal most children recover or remain stable, however,30% of patients develop progressive renal disease and chronic renal

6、 failure after 10-20 years,Haemolytic uraemic syndrome (HUS), microangiopathic haemolytic anaemia acute renal failure thrombocytopenia,Non-glomerular,polycystic disease infection trauma tumours(wilms tumour) calculi,haematological,coagulopathy (hemophilia) thrombocytopenia( AA, ITP) renal vein throm

7、bosis,Non-haematological,exercise (often present with microscopic hematuria, and resolve after a few days of rest) drugs (cyclophosphamide ),Evaluation of Hematuria,history (preceding infections, latent peroid,relationship to exercise, past history of hematuria,past or recent history of edema,family

8、 history of kinney stone,deafness.etc physical examination (hypertension,edema,rash,abdominal mass, examination of genitalia,etc) laboratory tests, urinalysis(URT,PCM, urine culture) blood test(BRT,C3,BUN,creatinine) renal imaging: ultrasound ,X-ray,CT kidney biopsy,Phase contrast microscopy (PCM),d

9、ysmorphic RBCs 30 %,dysmorphic RBCs30 %,non-glomerular hematuria,glomerular hematuria,PCM,hematuria,renal causes,non-renal causes,glomerular,non-glomerular,history ,PE, simple tests,further-step examinations to confrim the suspected diagnosis,establish the suspected diagnosis,therapy,Step 1,Step 2,c

10、ase 1,One 9 years old gril, with the complaint that burning urination for 3 days associated with abnormal urine routine test,no fever, no cough, no diarrhea . PE: T: 37 。 R: 28 /min HR : 89/min BP: 110/70 mmHg The throat was a little red, no significant findings in the chest and abdominal examinatio

11、n , urethral orifice is red laboratory tests: URT :RBC 20-25/HPF, WBC 10- 15/HPF,PRO 1+ BRT is normal Phase contrast microscopy: dysmorphic RBCs 30 %,burning urination for 3 days,urethral orifice is red,BRT is normal,hematuria,renal causes,PCM: dysmorphic RBCs 30 %,non-glomerular,burning urination f

12、or 3 days,urethral orifice is red,URT: WBC 10-15/HPF,suspected diagnosis of UTI,urine culture to confrim the diagnosis of UTI,antibiotics,Step 1,Step 2,case 2,One 8 years old boy, with the complaint that gross hematuria for 3 days, no fever, no cough, no diarrhea .he got cold 2 weeks ago and has rec

13、overed now. PE: T: 36.9。 R: 34 /min HR : 94/min BP: 140/90 mmHg The throat was a little red, no significant findings in the chest and abdominal examination , mild edema around the eyes. laboratory tests: URT :RBC 50/HPF, WBC 3- 5/HPF, PRO 1+ BRT is normal Phase contrast microscopy: dysmorphic RBCs 9

14、0 %,gross haematuria for 3 days,mild edema around the eyes,BRT is normal,Haematuria,Renal causes,PCM: dysmorphic RBCs 90 %,glomerular,catched cold 2 weeks ago,mild edema around the eyes,URT: RBC50/HPF, PRO 1+,suspected diagnosis of PSAGN,Serum C3 etc, to confrim the diagnosis of PSAGN,rest, antibiot

15、ics, etc,Step 1,Step 2,Acute Glomerulonephritis，AGN,Acute glomerulonephritis is clinically chatacterized by the sudden onset of gross hematuria, edema, hypertension ,oliguria, and renal failure in a previously healthy child. There is usually a latent period of 1-3 weeks between the infection and the

16、 onset of disease.,AGN,Poststreptococcal AGN (PSAGN) 90%,Postinfectious AGN 10%,1、Poststreptococcal AGN (PSAGN) is one self-limited disease, the majority of the patients have good prognosis. 2、the incidence of it is declining now.,Poststreptococcal AGN (PSAGN),Pathogenesis,formation of IC(immune com

17、plex),Glomerular local immune reaction,endocapillary proliferation,GBM injury,hematuria proteinuria,grupa A streptococcal infection,GFR,output of fulid blood volume,oliguria edema hypertension,pathology,（left）normal， （right）endothelio（E） and mesangial（M）cellular proliferation，hump dense（D）deposition

18、,ideograph,Clinical manifestation,Preliminary infection,URI,Skin infection,Preceding infections 1-3 weeks before the onset of PSAGN,oliguria, edema(70% of patients have edema,usually just edema of the face especially around the eyes, but some patients present with severe general edema .）, hematuria

19、and proteinuria(50-70% present with gross hematuria,but change to microscopic hematuria within 1-2 weeks), hypertension（30-80 % present with hypertension),Typical manifestation,oliguria diagnosis standard,age oliguria (ml) 0-3 years 7 years 400,age BP（mmHg） 120/80 7years 130/90,Hypertension diagnosi

20、s standard,1、Severe circulation congestion: usually happen within the frist week,due to the output of fluid decrease,present with tachypnea, dyspnea,cough,etc， moist rales in the lung, severe edema,heart and liver may enlarge .,2、hypertensive encephalopathy: BP 140/90mmHg, present with convulsion ,c

21、oma, etc，the older may complain headache,vomit and temporary blind.,3、acute renal failure: oliguria,even anuria,renal dysfuction,usually last for 3-5 days, minority keep on over 10 days,grave manifestation,Usually take place in the frist 2 weeks,laboratory tests, urinalysis: hematuria and proteinuri

22、a blood test:C3 ASO(antistreptolysin O) kidney biopsy: not necessary,normal,C3,ASO,1 2 3 4 5 6 7 8,time (weeks),16,ASO: begin to raise in the 10-14th day,climb to the peak in 3-5th week,and recover normal in 3-6th month C3: decrese within 2weeks after the onset of disease and recover normal within 8

23、 weeks,diagnosis of AGN,diagnosis,1、Preceding infection(the latent period of 1-3 weeks),2、 Clinical manifestation（acute onset, oliguria, edema, hematuria ,proteinuria，hypertension ）,3、C3, ASO,differential diagnosis,1、 Postinfectious AGN 2、IgA nephropathy 3、acute episode of CGN 4、nephrotic syndrome 5、RPGN 6、HSPN, LPN,Treatment,1、essential supportive treatment,2、symptomatic treatment,3、clear residual streptococcus,4、treatment of severe case,essential supportive treatment,rest (especially wthin the frist 2 weeks) appropriate fluid and salt restriction,diuretics(furosemide, 1-2mg/k