診斷學(xué)-實驗室檢查-實驗室診斷-常用腎臟功能實驗室檢測

腎功能檢查

ASSESSMENTOFRENALFUNCTION

山東大學(xué)劉運芳提要UrineTests:Cheapandconvenient;ForscreeningandfollowingRenalFunctionsImmunologicalTestImagingExaminationRenalBiopsy2WhenorforWhatKidneydiseasesorinjuriesOtherdiseasesinducedkidneyfunctioninjuriesDiabetesmellitusHypertensionShockorextensiveburnAuto-immunologicaldiseasesDrugtoxicity3StructureofKidney4腎單位集合管腎小體腎小管腎小球腎小囊近曲小管遠(yuǎn)曲小管髓袢腎小球功能檢查GLOMERULARFUNCTIONASSESSMENT5StructureandFunctionGFR:thevolumeoffluidfilteredfromtheglomerularcapillariesintotheBowman'scapsuleperunittime一二零-一六零ml/minContentsSerumCreatinine(sCr)&Serumurea(SU)CreatinineClearanceRate,CcrCystatinCMicroalbumin(MA),Transferrinuria(TRU),uricacid,urineIg……SerumCreatinine(sCr)EndogenousawasteproductproducedbymusclemetabolismCreatinineExogenousefromfoods,suchasmeat,fish,coffee,tea,etc.8SerumCreatinine(sCr)Asmallmolecule,filtratedbyglomerularpletely,andnotreabsorbedbytubulesCr:riseifthefilteringofthekidneyisdeficient,NormalValue:SerumCr:male:四四-一三二μmol/Lfemale:七零-一零六μmol/L9Stageofrenalfailure(male)10>四四五μmol/L>一七八μmol/L<一七七μmol/L四四-一三二μmol/LStage四(Failurestage)Stage三(De-pensatorystage)Stage二(pensatorystage)Stage一(Normalfunction)>七零七μmol/LStage五(Uremia)ScrClinicalSignificanceofsCrincrease11riseonlywithmarkeddamagetonephronsfiltrationSerumurea(SU)alsonamedasBUNInfluencefactorsProteinintakeProteindegradationLiverfunctionGlomerularfiltrationNormalvalue:Adults:一.八-七.一mmol/LChildrenorinfants:一.八-六.五mmol/L12UreaorornithinecycleinliverClinicalSignificanceofSURenaldamage:Chronicrenalfailurepensatorystage:SU<九mmol/LDepensatorystage:SU>九mmol/LFailurestage:SU>二零mmol/LUremia:SU>二八.六mmol/LAcuterenaldisease13ClinicalSignificancePhysical:↑:highproteindiet↓:pregnancyPre-renal:Highfever,Shock,Uppergastrointestinalhemorrhage,extensiveburn,severetrauma……Post-renal:Obstructioninurinarytract14SU/Crratio:BUN:七-二零mg/dLUrea:二.五-一零.七mmol/LsCr:零.七-一.二mg/dLsCr:七零-一零六μmol/LBUN:CrUrea:CrLocation>二零:一>一零零:一Pre-renal一零-二零:一四零-一零零:一NormalorPost-renal<一零:一<四零:一Intra-renalCreatinineClearanceRate,CcrDefinition:Ccristhevolumeofbloodplasmawithcreatininethatisclearedbykidneysperunittime.即:單位時間內(nèi),腎臟可全部清除多少毫升血漿地肌酐Normalvalue:八零-一二零ml/min·一.七三m二ClinicalSignificanceofCcrPhysiological:relatedwithsports,diets,age……PathologicaldecreaseSensitiveforkidneyinjuryGFR<五零%時Ccr≈五零ml/minStageofrenalfailure18一零-二零ml/min二零-五零ml/min>五零ml/min>八零ml/minStage四(Failurestage)Stage三(De-pensatorystage)Stage二(pensatorystage)Stage一(Normalfunction)<一零ml/minStage五(Uremia)CCrFortreatmentStageIIobservation,controlofbloodpressure.StageIIIa(三零-四零ml/min)limitedproteindiets,treatmentofplication,diureticStageIIIb(<三零ml/min)diureticisnotavailable19StageIVbinetreatment,planningforend-stagefailure

StageVreplacementtherapy,transplantationordialysis

StageofkidneyimpairementCcr（ml/min)sCr(umol/L)SU(mmol/L)pensatorystage八零-五零<一七七<九Depensatorystage五零-二零一七八-一四四九-二零Renalfailure二零-一零四四五-七零七二零-二八.六end-stagerenalfailure(uremia)<一零>七零七>二八.六Expressedinallnucleatedcells,encodedbyhousekeepinggeneLowmolecularweight,FiltratedfreelythroughglomerulusConcentrationinserumorplasmaisdeterminedbyGFRCystatinCCystatinCbetterthancreatinineinpredictingCystatinCbetterthancreatinineinpredicting優(yōu)點Highsensitivity:betterthanCcrHighspecificity:notinfluencedbyacutephasereaction,activities,genderandage,etal.Usedwidely:forrenaltransplantationstatusformonitoringGFRinnephrotoxicdrugtherapyforacuteandchronickidneydiseasesincludingadiabeticnephropathyOperatedeasily腎小管功能檢查TESTSOFTUBULARFUNCTION25Functionofrenaltubular重吸收:水,電介質(zhì),小分子蛋白葡萄糖,氨基酸腎單位集合管腎小體腎小管腎小球腎小囊近端小管遠(yuǎn)端小管髓袢尿液稀釋,濃縮遠(yuǎn)端腎單位近端腎小管功能檢查TESTSOFPROXIMALTUBULARFUNCTION27TestsofProximaltubularFunctionβ二-microglobulinα一-microglobulinRetinol-bindingprotein,RBPN-acetyl-β-D-glucosaminidase,N-NAGFractionofurinenatriumexcretion,FeNaβ二-microglobulin,β二-MGPresentonallnucleatedcells,especiallyonlymphocytes,andstableinbloodSmallprotein,freelyfiltratedbyglomeruliAlmostreabsorbedbytubulespletelyThresholdofreabsorption:五mg/LNormalvalue:Urine:<零.三mg/LClinicalSignificanceofβ二-MGSerumβ二-MG↑:GFR↓:whenCcr<八零ml/min,moresensitivethanScr惡腫瘤,炎疾病（肝炎,類風(fēng)濕關(guān)節(jié)炎等）Reabsorptionfunctionofproximaltubules:urineβ二-MGincrease(bloodβ二-MG<五mg/L)AcuteandchronicpyelonephritisDrugortoxininducedtubularnecrosisClinicalSignificanceEvaluationfortransplantkidneyfunctionUrineβ二-MG↑↑,impliedgraftrejectionserumβ二-MG:helpforsub-clinicalrejectionofgrafts腎移植雖有少尿,但血β二-MG下降者提示預(yù)后良好。α一-microglobulin,α一-MGSmallglycoproteins,synthesizedinliverFreelyfiltratedthroughglomeruliAlmostreabsorbedbyproximaltubulespletelyNormalvalue:Urine:<一五mg/二四hClinicalSignificanceofα一-MGDecrease:severehepatitisandhepaticnecrosisSerumα一-MG↑:GFR↓:whenCcr<一零零ml/min,moresensitivethanScrandβ二-MGUrineα一-MG↑:ReabsorptionfunctionofproximaltubulesinjuryAcuteandchronicDiabeticnephropathyα一-MG↑:serumandurineDamageinbothglomeruliandtubulesRetinal-bindingprotein,RBP視黃醇結(jié)合蛋白Canbedetectedwidely,inallbodyfluidFreelyfiltratedbyglomeruli,almostreabsorbedbytubulespletely,anddegeneratedintoaminoacidsOnlyalittlewasexcretedwithurineNormal:零.一一±零.零七mg/LClinicalSignificanceBloodRBP:Increase:glomerularfunctionHigherspecificityandsensitivitythanScrDecrease:liverfunction,malnutritionUrineRBP:tubularfunctionmorespecific:similarsensitivewithβ二-MGandsensitivethanScrbetterstabilityN-acetyl-β-D-glucosaminidase(NAG)N-乙酰-β-D-氨基葡萄糖苷酶widelydistributedlysosomalhydrolasenotfilteredattheglomerulusLocatedpredominantlyintherenalproximaltubulesExcretedinlowamountsinurineClinicalSignificanceUrineNAGincrease:exocytosisprocessoftubularcellsToxicacutetubularinjuries:lead,aminoglycosideantibiotics,nephrotoxicdrugs,anti-cancerdrugs(cisplatin……)Acuterejection:Variousglomerulardiseases:diabeticnephropathy,hypertensivenephropathyUrinaryinfection:upper>lower,locationFractionofurinenatriumexcretionNatrium:freelyfiltratedthroughglomeruliand九九%wasreabsorbedbyproximaltubulesNormalvalues:FeNa:<一%ClinicalSignificancePre-renal:鈉攝入過多或血容量下降尿鈉↑同時伴有血鈉↑Reabsorptiondamage:急腎小管壞死尿鈉↑,但血鈉不高DifferentialdiagnosisofazotemiaPrerenal:FeNa<一%Renal:（腎小管）FeNa>一%Summaryβ二-microglobulinα一-microglobulinRetinol-bindingprotein,RBP——reabsorptionfunctionN-acetyl-β-D-glucosaminidase,N-NAG——kidneytoxicitydamageFractionofurinenatriumexcretion,FeNa——differentialdiagnosisofpre-renalandintra-renalazotemia遠(yuǎn)端腎小管功能檢查TESTSOFDISTALTUBULARFUNCTION41RenalconcentrationfunctionMosenthal’stestAlsoas:Circadianurinespecificgravity(SG)testNormalintake(water<五零零-六零零ml),noextrawaterEmptybladderat八aminthemorningDetectth