內(nèi)科學(xué)教學(xué)課件：General Introduction

DISORDERSOFTHEURINARYSYSTEMOUTLINEGeneralintroductionofurinarysystemPrimaryglomerulardiseaseNephroticsyndromeSecondarykidneydisease(DN,LN)TubulointerstitialdiseaseChronicrenalfailureUrinarytractinfection

GeneralIntroduction(P614)

Urinarysystem:

kidney,ureter,bladder,urethra

NephrologyisdifferentfromUrology.“腎虛”Functionofkidney:UrineformationandendocrineactionClinicalfeaturesofrenaldiseaseproteinuria,hematuria,edema,hypertension,andrenalfailure.4.Evaluationofrenaldisease(eGFR,renalbiopsy)MajorFunctionsoftheKidneys1.Regulationof:bodyfluidosmolarityandvolumeelectrolytebalanceacid-basebalancebloodpressure2.Excretionofmetabolicproductsforeignsubstances(pesticides,chemicalsetc.)excesssubstance(water,etc)3.Secretionoferythropoitin1,25-dihydroxyvitaminD3(vitaminDactivation)reninEndocrineaction

ofkidney

Renin

convertingenzymeAngiotensinogen

angiotensinⅠ

angiotensinⅡ

aldosterone

RAAS

(Renin-Angiotensin-AldosteroneSystem)ACEI/ARB：controlsystemicandglomerularpressurel

Hydroxylase---1,25-(OH)2D3--1,25-dihydroxyvitaminDl

Erythropoietin(EPO)----l

Prostaglandins(PGs)l

Kallikrein-kininReducedperfusionpressurewithanACEIorARBPGCGFRAngIIAfferentArteriole

EfferentArteriole

PGEACEI/ARBΘFigure:LossofangiotensinIIactionreducesefferentresistance;thiscausestheglomerularcapillarypressuretodropbelownormalvaluesandtheGFRtodecrease.Reff/RaffratioRBFNEnglJMed357;8August23,2007MAINMANIFESTATIONSOFRENALDISEASE

1.Edemahypoalbuminemia→plasmaoncoticpressure↓GFR↓→intravascularvolume↑→hydrostaticpressure↑Otherdiseases:liver,heart,thyroid,malnutrition,drugs.2.

Hypertension:

Volume-dependent----sodiumandwaterretentionRenin-dependent----RAS↑parenchymalhypertension:glomerulonephritis

renovascularhypertension:ischemickidneydisease3.

Proteinuria

FoamyurineRulesforurinesample:earlymorning,clean,notinmenstruationNormal:(-)bydipstick(Spoturinetest)or<100mg/24hrs

urineProteinuria:>150mg/24hrs

(+)byurinedipstickalbumin/creatinine>300mg/g(randomurine)Mildproteinuria:<1000mg/24hrsHeavyproteinuria:>3.5g/24hrsMicroalbuminuria:urinealbumin/creatininevalueis30-300mg/gTypesofproteinuria

Glomerularproteinuria:heavyproteinuria,bigger

moleculeprotein,andcommonlyaccompanyingwithhematuria,hypertensionoredema.

Tubularproteinuria:smallmolecule(suchasβ2-MG,lysozyme)andsmallamountofproteininurine.

Overflow:highlevelofB-Jprotein(multiplemyeloma),hemoglobin(hemolysis)ormyoglobin(myolysis)inblood

Physiologic:posturalproteinuriaandfunctional

proteinuria(exercise,coldness)腎下垂、胡桃夾現(xiàn)象

4.

HematuriaDiagnosis:

RBC>3/HP

(urinesediments).

bld(+)bydipstickisnotreliable.Microscopic(invisible)hematuriaorgrosshematuria(visible,macroscopichematuria)Causesofhematuria:Disordersofkidneysorurinarytract:glomerulardiseases,infection,tumor,stone,tuberculosis.

Systemicdisorders:coagulationdisorders,SLE,drugs,Diseasesofneighbouringorgans

RBCsDysmorphicredbloodcellssuggestglomerularinjury.GlomerularversusextraglomerularbleedingUrinaryfindingGlomerularExtraglomerulrRedcellcastsMaybepresentAbsentRedcellmorphology(byphasecontrastmicroscope)DysmorphicUniformProteinuriaMaybepresentAbsentClotsAbsentMaybepresent5.

Pyuria

WBC>5/HP(urinesediments)UrinarytractinfectionTubularorinterstitialinflammation:AIN,SLE6.

CylindruriaFormationofcasts:Tamm-Horsfallprotein(uromodulin)andothersintheshapeoftubule.Redbloodcellcasts:acuteglomerularinjuryWhitebloodcellcasts:acutepyelonephritisGranularcasts+proteinuria:GNOthers:epithelial,hyaline,fracture,waxycastsRedbloodcellcastMarkerofglomerularinjuryGranularcast7.

Bacteriuria(cultureofurine)Significantbacteriuria:>105

organisms/ml(standardforbacillus).8.

Criteriaforurineoliguria:<400ml/danuria:<100ml/dpolyuria:>2500ml/dNocturia:>750mlduringnighttime,ormoreurineoutputatnight

Evaluationofrenaldisease

1.

RenalFiltrationGFR≈CCr

(Creatinineclearance)

90±10ml/min--Equationfromthe

Modificationof

Dietin

RenalDisease

study

--Cockcroft-Gault

equation

Serumcreatinine(SCr)

<1.5mg/dl(<132.6μmol/L)(88.4)CystatinCisbetter?BUN

(Bloodureanitrogen)islessreliable.2.

Imagingofkidneysandurogenitaltract

Ultrasonography:--screeningsomesurgicaldiseases--differentiationbetweenARFandCRF--renalbiopsyCT,CTuIntravenouspyelography(IVP)CystoscopyNewtests(andskillsinUrology)3.RenalbiopsyPurposesofrenalbiopsy:DefiningthemorphologicexpressionDiagnosis(orhelpingdiagnosis)forsomediseases(HBVrelatedGN,SLE,amyloidosis,etc)HelpingclinicaltreatmentsEstimatingprognosisRenalbiopsyIndications:p