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1、NEPHROLOGY (肾脏病学总论）,Zhou Fuhua（周富华） The second affiliated hospital of Nanjing Medical University,NEPHROLOGY,Structure of the kidney(结构) Function of the kidney Clinical manifestation Laboratory Evaluation of Renal Disease Major Renal Syndromes,The Nephron (肾单位),Consists of the glomerulus(肾小球) and its
2、 attached tubules(肾小管). The functional unit of the kidney (是肾脏的功能单位),Glomerulus(肾小球),Endothelial cells(内皮细胞) Glomerular basement membrane (肾小球基底膜GBM) Podocytes(足突细胞) - Visceral Epithelial Cell Mesangial cellsand matrix (系膜细胞和基质) Parietal epithelium Bowmans Capsule,Normal Glomerulus (PAS),Normal Glom
3、erulus EM,GBM,Mesangium,Glomerular Basement Membrane,Capillary Space,Endothelium,Urinary Space,GBM,Podocyte,Glomerular Basement Membrane,Podocytes,Juxtaglomerular Apparatus (近球旁器),Vascular component Afferent arteriole Efferent arteriole Extraglomerular mensangial region Tubule component thick ascend
4、ing limb,Mechanism of renin release,The macula densa theory changes in the Na+,Cl- concentration The stretch-receptor theory alterations in the volume stretch of the afferent arteriol,TUBULAR EPITHELIAL CELLS,NEPHROLOGY,Structure of the kidney Function of the kidney(功能) Clinical manifestation Labora
5、tory Evaluation of Renal Disease Major Renal Syndromes,Nephron Function,Glomerular filtration (肾小球滤过功能） Tubule secretion and reabsorption （肾小管重吸收和分泌功能）,肾小球滤过功能 （glomerular filtration function）,含氮废物如尿素、肌酐等主要由肾小球滤过排出。马尿酸、苯甲酸、各类胺类及尿酸也有部分经滤过排出,肾小球滤过示意图,排泄功能 （excretory function）,肾小管重吸收和分泌功能 （tubular reab
6、sorption and excretion function）,近端小管 重吸收 髓袢 维持髓质高张及尿液的浓缩和稀释 远端小管 AVP作用下,尿素再循环,马尿酸、苯甲酸、各类胺类及尿酸主要由肾小管分泌,Nephron Function,Water balance(水平衡) Eletrolyte metabolism(电解质代谢) Acid-base balance(酸碱平衡) Urea secretion (代谢产物排泄) Others:,内分泌功能 （endocrine function）,球旁器分泌肾素 血管紧张素原血管紧张素血管紧张素、血管紧张素 RAS系统,Renin-angiot
7、ensin system (肾素血管紧张素系统RAS),angiotensinogen angiotensin angiotensin Aldosterone AT1,AT2,Renin,ACE,Angiotensin ,Increase preglomerular and efferent arterioar resistances Enhance the reabsorption of sodium Effects on vasa vecta Decrease Kfa decrease in hydraulic conductivity Enhance production of PG,
8、TGF,Endocrine function,Prostaglandin: PGE2, I2, A2, F2, TXA2 (前列腺素族) Bradykinin (缓激肽) Erythropietin, (促红细胞生成素EPO) 1,25-dihydroxycholecalciferol （活性） 1,25-(OH)2D3 ( 1羟化酶) Decompose organ: insulin Target organ: PTH, TH, CA, ADH EGF, PDGF, IGF-1 ,TGF,NEPHROLOGY,Structure of the kidney Function of the k
9、idney Clinical manifestation (临床症状) Laboratory Evaluation of Renal Disease Major Renal Syndromes,Clinical manifestation,Edema(水肿) Hypertension 高血压 Proteinuria 蛋白尿 Hematuria 血尿 Loss of renal function 肾功能丧失 Pain in the flank area : renal colic Changes in urine volume Others,NEPHROLOGY,Structure of the
10、 kidney Function of the kidney Clinical manifestation Laboratory Evaluation of Renal Disease Major Renal Syndromes,尿液检查 （uronoscopy）,U/A Chemistry (Dip Stick),Protein Glucose Hemoglobin Ketones,pH Bilirubin Urobilinogen Nitrite Leukocyte esterase,MORE IMPORTANT,LESS IMPORTANT,U/A Chemistry,Hold here
11、,Dip up to here,The reactions are timed and the colors change if analyses are present. Compare Stick to colors on Dip Stick Bottle and grade 0, 1+, 2+, 3+, 4+; the darker the color, the greater the grade!,pH,Pro tein,Glu cose,Hgb,ETC.,Proteinuria蛋白尿,定义: 持续超过150mg/日 尿蛋白/肌酐200mg/g 微量白蛋白尿：30-300mg/d 尿白
12、蛋白/肌酐17-250mg/g(male) 25-355mg/g(female 大量蛋白尿:超过3.5g/1.73m2/日 或50mg/kg/日。,按发病机制分类,肾小球性,肾小管性,溢出性,功能、体位性,按发病机制分类,1 Glomerular disease 肾小球性蛋白尿： 肾小球滤过膜损伤或通透性增高 机械屏障受损：滤过膜孔径异常增大或断裂 电荷屏障受损：滤过膜负电荷减少 按分子量分类： （1）选择性蛋白尿： （2）非选择性蛋白尿：,按发病机制分类,2 Tubule disease 肾小管性蛋白尿： 肾小管重吸收， 由小分子蛋白构成：2-MG、溶菌酶。 2g/日 3 Spill ove
13、r 溢出性蛋白尿： 血中异常蛋白增多 （免疫球蛋白轻链、血红蛋白）,Proteinuria, 功能性蛋白尿: 发热、寒冷、运动、 淤 血、直立。 1g/天 体位性蛋白尿：直立位或脊柱前凸,3个/HP 10万/h 50万/12h,血尿（红细胞尿）hematuria,泌尿系,全身性,邻近器官,运动性,肾小球性,非肾小球性,3.管型尿 5000个/12h,What is an RBC cast?,白细胞尿、脓尿、细菌尿 5个/HP 40万/h 100万/12h 每HP见细菌或培养105/ml,肾小球滤过功能Ccr Scr BUN 肾小管功能 近端肾小管功能 B2-MG等 尿浓缩-稀释试验 尿渗透压测
14、定 肾血浆流量测定 酸化功能,肾功能检查 （renal function examination）,Glomerular Filtration Rate (As measured by Creatinine Clearance),Urine Flow (ml/d) x Ucr (m=umol/L) CrCl = - Pcr (umol/L) x 1440 (min/d) Where CrCl = Creatinine Clearance Ucr = Urine Creatinine Pcr = Plasma Creatinine,KUB; IVP或逆行肾盂造影；膀胱镜检查；放射性核素；超声检查
15、；CT；核磁共振等,影像检查,Renal biopsy,Indications Preparation Complications,Renal biopsy,To help establish the diagnosis, suggest prognosis, direct therapy.,正常肾小球,a 脏层上皮细胞 b GBM c 内皮细胞 d 系膜 e 副系膜,NEPHROLOGY,Structure of the kidney Function of the kidney Clinical manifestation Laboratory Evaluation of Renal Di
16、sease Major Renal Syndromes,Major Renal Syndromes,The Nephrotic Syndrome 肾病综合征 Acute Nephritic Syndrome 急性肾炎综合征 Rapidly Progressive Glomerulonephritis 急进性肾炎综合征 Chronic Nephritic Syndrome 慢性肾炎综合征 Asymptomatic Hematuria and/or Proteinuria 无症状性尿异常,Major Renal Syndromes (cont),Acute Renal Failure急性肾衰竭综合征 Chronic renal failure慢性肾衰竭综合征 Urinary Tract I
