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1、NEPHROLOGY (肾脏病学总论）肾脏病学总论）1 1NEPHROLOGYStructure of the kidney(结构结构)Function of the kidneyClinical manifestationLaboratory Evaluation of Renal Disease Major Renal Syndromes2 23 34 45 56 67 78 8The Nephron (肾单位肾单位) Consists of the glomerulus(肾小球) and its attached tubules(肾小管). The functional unit of
2、the kidney (是肾脏的功能单位)9 9101011111212Glomerulus(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 CellMesangial cellsand matrix (系膜细胞和基质) Parietal epitheliumBowmans Capsule1313141415151616Normal Glomerulus (PAS)Normal Glomerulus (PAS)17171818Norm
3、al Glomerulus EMNormal Glomerulus EMGBMGBMMesangiumMesangium1919Glomerular Basement MembraneGlomerular Basement MembraneCapillary SpaceCapillary SpaceEndotheliumEndotheliumUrinary SpaceUrinary SpaceGBMGBMPodocytePodocyte2020Glomerular Basement MembraneGlomerular Basement MembranePodocytesPodocytes21
4、212222Juxtaglomerular Apparatus(近球旁器)Vascular componentAfferent arterioleEfferent arterioleExtraglomerular mensangial regionTubule component thick ascending limb23232424Mechanism of renin releaseThe macula densa theory changes in the Na+,Cl- concentrationThe stretch-receptor theory alterations in th
5、e volume stretch of the afferent arteriol2525TUBULAR EPITHELIAL CELLS2626 NEPHROLOGY Structure of the kidneyFunction of the kidney(功能功能)Clinical manifestation Laboratory Evaluation of Renal DiseaseMajor Renal Syndromes2727Nephron FunctionGlomerular filtration (肾小球滤过功能）肾小球滤过功能）Tubule secretion and re
6、absorption （肾小管重吸收和分泌功能）（肾小管重吸收和分泌功能）2828肾小球滤过功能肾小球滤过功能（glomerular filtration functionglomerular 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）2929肾小管重吸收和分泌功能（tubular reabsorption 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
7、 马尿酸、苯甲酸、各类胺类及尿酸主要由肾小管分泌3030Nephron FunctionWater 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:3131内分泌功能（endocrine functionendocrine 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 3232Renin-angiotensin system(肾素血管紧张素系统RAS)angiotensinogen angiotensinang
8、iotensin AldosteroneAT1,AT2ReninACE3333Angiotensin Increase preglomerular and efferent arterioar resistancesEnhance the reabsorption of sodiumEffects on vasa vectaDecrease Kfa decrease in hydraulic conductivityEnhance production of PG, TGF 3434 Endocrine functionProstaglandin: PGE2, I2, A2, F2, TXA2
9、 (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: insulinTarget organ: PTH, TH, CA, ADHEGF, PDGF, IGF-1 ,TGF,3535 NEPHROLOGY Structure of the kidneyFunction of the kidneyClinical manifestation (临床症状临床症状)Laboratory Evaluation of
10、 Renal DiseaseMajor Renal Syndromes3636Clinical manifestationEdema(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 colicChanges in urine volumeOthers3737 NEPHROLOGY Structure of the kidneyFunction of the kidneyClinical manifestationLaboratory
11、Evaluation of Renal DiseaseMajor Renal Syndromes3838尿液检查（uronoscopyuronoscopy） 3939U/AChemistry (Dip Stick)ProteinGlucoseHemoglobinKetonespHBilirubinUrobilinogenNitriteLeukocyte esteraseMORE IMPORTANTLESS IMPORTANT4040U/AChemistryHold hereDip up to hereThe reactions are timed and the colors change i
12、f analyses are present. Compare Stick to colors on Dip Stick Bottle and grade0, 1+, 2+, 3+, 4+; the darker the color, the greater the grade!pHProteinGlucoseHgbETC.4141Proteinuria蛋白尿定义定义: 持续持续超过150mg/日 尿蛋白/肌酐200mg/g微量白蛋白尿：30-300mg/d 尿白蛋白/肌酐17-250mg/g(male) 25-355mg/g(female大量蛋白尿:超过3.5g/1.73m2/日 或50mg
13、/kg/日。4242按发病机制分类按发病机制分类4343按发病机制分类按发病机制分类 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：按分子量分类： （1）选择性蛋白尿： （2）非选择性蛋白尿：4444按发病机制分类按发病机制分类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 over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） 4545Proteinuria功能性蛋白
14、尿: 发热、寒冷、运动、 淤 血、直立。 3.5gm/day)Hypoalbuminemia（30g/L)EdemaHyperlipidemaLipiduria6363急性肾炎综合征Acute Nephritic SyndromeSudden onset of hematuria with RBC casts and renal failure (days - weeks)RBC casts not listed in the book! But this is critical!Proteinuria (mild to moderate but NOT Nephrotic Range)Hyp
15、ertensionHallmark Disease: Post Streptococcal Glomerulonephritis6464急进性肾炎综合征Rapidly Progressive GlomerulonephritisNephronal hematuria Renal failure developing over weeks to monthsDiffuse glomerular crescent formation.6565无症状性尿异常Asymptomatic Hematuria or ProteinuriaHematuria with or without RBC casts
16、 and/orProteinuria usually 2.0gm/dayNO RENAL FAILURENO NEPHROTIC SYNDROME6666急性肾衰竭综合征Acute Renal FailureOliguria (400ml/day)Rarely anuriaRecent Onset of Azotemia (hours/days)6767慢性肾衰竭综合征Chronic Renal FailureUremiaFinal Common Path of All Chronic Renal Diseases6868尿路感染综合征Urinary Tract Infection Bacte
17、riuria and PyuriaDysuria, Frequency, UrgencyPyelonephritis or CystitisWBC casts = PyelonephritisThe Book Misses this one!FeverThe Book Misses this one!6969肾石症NephrolithiasisRenal stonesRenal colic - OOOUUUCCCHHH!Severe, Crampy Pain in the flank areaHematuria (Not RBC casts!)7070肾脏疾病的诊断 根据患者的病史、症状及体征
18、，并辅以实根据患者的病史、症状及体征，并辅以实验室检查和特殊检查，作出正确诊断验室检查和特殊检查，作出正确诊断 病因诊断病因诊断部位诊断部位诊断病理诊断病理诊断功能诊断功能诊断7171去除病因去除病因抑制免疫反应及炎症反应抑制免疫反应及炎症反应对症治疗对症治疗防治并发症防治并发症延缓肾脏疾病进展延缓肾脏疾病进展肾脏替代治疗肾脏替代治疗治疗原则(therapeutic principles)7272Optimal pre-ESRD careEarly detection of CRFPrevention of uremiccomplicationsInterventions thatDelay
19、progressionBP cotrolPreparation forRRTModification of Co-morbidityACEI and ARBProtein restrictionBlood sugar controlOsteodystrophyAnemiaMalnutritionAcidosisRetinopathy(in DM)EducationNeuropathy (in DM)Vascular diseaseCardiac diseaseBlood vessel accessInformed choice of RRTInitiation of dialysisSpecific therapy,based on causes7373血液透析7474肾脏替代治疗：透析、肾移植腹膜透析交换7575研究进展及展望(progress and prospect)(progress and prospect)对肾脏疾病的免疫发病机制认识溶质转运分子的基础研究慢性肾脏疾病进展机制研究替代治疗的进展76767777
