糖尿病肾病病理特点新

1、糖尿病肾病病理特点（新）2020-12-09糖尿病肾病病理特点2定义dkd是指由糖尿病引起的慢性肾病，主要包括肾小球滤过率(gfr)低于60 ml/min/1.73 m2或尿白蛋白肌酐比值(acr)30 mgg持续超过3个月糖尿病性肾小球肾病(diabetic glomerulopathy)专指经肾脏活检证实的由糖尿病引起的肾小球病变2020-12-09糖尿病肾病病理特点32020-12-09糖尿病肾病病理特点4糖尿病肾病的自然进程2020-12-09糖尿病肾病病理特点5糖尿病肾脏病变诊断标准在大部分糖尿病患者中，出现以下任何一条者考虑其肾脏损伤是由糖尿病引起的(1)大量白蛋白尿(2)糖尿病视

2、网膜病变伴微量白蛋白尿?(3)在1o年以上糖尿病病程的l型糖尿病中出现微量白蛋白尿2020-12-09糖尿病肾病病理特点6糖尿病合并肾脏损伤不一定是糖尿病肾病 (1)无糖尿病视网膜病变 (2)gfr较低或迅速下降 (3)蛋白尿急剧增多或有肾病综合征 (4)顽固性高血压 (5)尿沉渣活动表现（血尿、白细胞尿、管型尿） (6)其他系统性疾病的症状或体征 (7)acei或arb开始治疗后23个月内肾小球滤过率下降超过302020-12-09糖尿病肾病病理特点7糖尿病出现以下情况考虑活检 糖尿病病程较短 既往有肾脏病病史 肾损害早于糖尿病，糖尿病与肾损害同时出现，或糖尿病早期出现肾损害 血尿明显 有肾

3、损害而不伴有其他糖尿病微血管2020-12-09糖尿病肾病病理特点82020-12-09糖尿病肾病病理特点9糖尿病肾脏疾病的病理- 肾脏大体标本 2020-12-09糖尿病肾病病理特点101. 1. 弥漫性肾小球硬化：弥漫性肾小球硬化： 肾小球系膜基质增宽肾小球系膜基质增宽 肾小球基底膜弥漫增厚肾小球基底膜弥漫增厚 此型表现并非此型表现并非dndn特有特有2020-12-09糖尿病肾病病理特点11sl i de 3 n orm al gl om erul us: hem atoxyl i n andeosi n st ai n of a norm al gl om erul us sect i

4、 onedt hrough the vascul ar pol e. n ot e the w i de-opencapi l l ary l um i na and the l arge percent age of thecross-secti onal area of the gl om erul us devot ed t ot he capi l l ary ci rcul at i on. the m esangi al cel l ul ari t yand m at ri x are norm al .2020-12-09糖尿病肾病病理特点12sl i de 1 n orm a

5、l gl om erul us: schem at i zeddraw i ng of a norm al gl om erul us show i ng epi t hel i alcel l s i n green, endot hel i al cel l s i n yel l ow andm esangi al cel l s i n red. n ot e t hat t he gl om erul arbasem ent m em branes (i n bl ack) do notcom pl et el y surround capi l l ary l oops, and

6、t hatendot hel i al cel l s are i n di rect cont act w i t hm esangi al m at ri x (bl ue) at t he m esangi al pol esof capi l l ari es.2020-12-09糖尿病肾病病理特点13糖尿病肾病的特征性病理改变2020-12-09糖尿病肾病病理特点14sl i de 165 di abet i c nephropat hy: thi sschem at i zed draw i ng show s t he m arkedl yt hi ckened l am i n

7、a densa of t he gbm andi ncreased m esangi al m at ri x m at eri alw hi ch are t he si ne qua non of di abet i c renaldi sease. the subsequent sl i des (166-202)dem onst rat e t he spect rum of di abet i c renaldi sease (st art i ng w i t h a revi ew of norm algl om erul ar hi st ol ogy), and i l l

8、ust rat e di st i ngui shi ngpoi nt s bet w een ot her t ypes of gl om erul opat hi esw hi ch m ay m i m i c di abet i c nephropat hy.2020-12-09糖尿病肾病病理特点15sl i de 167 m oderat e di f f use di abet i cgl om erul oscl erosi s i n an i nsul i n-dependentdi abet i c (i ddm ) pat i ent w i t h 16 years d

9、urat i on.n ot e t he w i deni ng of t he gl om erul ar m esangi um ,t he rest ri ct i on of t he gl om erul ar capi l l aryci rcul at i on, t he t hi ckeni ng of t he gl om erul arbasem ent m em brane com pared t o sl i de 1, and t hehyal i nosi s of t he art eri ol ar w al l at t he vascul arpol e

10、 (pas).2020-12-09糖尿病肾病病理特点16sl i de 168 m arked di f f use di abet i cgl om erul oscl erosi s. there i s ext rem e expansi onof t he m esangi um w i t h bot h m at ri x and cel l ul arm at eri al . the capi l l ary l um enal ci rcul at i on i sm arkedl y const ri ct ed (pas). w hereas t hepat i ent

11、i n sl i de 2 had norm al renal f unct i on, t hi spat i ent had overt nephropat hy w i t h prot ei nuri a,hypert ensi on, and a 50% reduct i on i n gfr.2020-12-09糖尿病肾病病理特点17糖尿病肾病的病理变化（五）2. 2. 结节性肾小球硬化：结节性肾小球硬化：肾小球肾小球系膜基质增宽及分裂，系膜基质增宽及分裂，并且出现并且出现kimmelstiel-wilsonkimmelstiel-wilson结节结节 肾小球肾小球基底膜弥漫增厚，

12、球囊滴（透明变性），基底膜弥漫增厚，球囊滴（透明变性），纤维蛋白帽（透明变性和脂质沉着），毛细血纤维蛋白帽（透明变性和脂质沉着），毛细血管襻微血管瘤，出、入球小动脉透明变性及动管襻微血管瘤，出、入球小动脉透明变性及动脉硬化脉硬化 此型为此型为dndn特异特异2020-12-09糖尿病肾病病理特点18s lid e 1 7 1 n o d u la r d ia b e tic g lo m e ru lo scle ro sis(k im m e lstie l-w ilso n le sio n s) in a p a tie n t w itho ve rt d ia b e tic n

13、e p h ro p a th y a n d p ro te in u ria ,h yp e rte n sio n , a n d re d u ce d g fr . n o te th ep a lisa d in g o f m e sa n g ia l n u cle i a ro u n d th ep e rip h e ry o f th e n o d u le a n d th e fib rilla r n a tu reo f th e n o d u la r m a trix m a te ria l. n o te a lso th ere strictio

14、 n o f g lo m e ru la r ca p illa ry lu m e n a l sp a ce(p a s ).2020-12-09糖尿病肾病病理特点192020-12-09糖尿病肾病病理特点202020-12-09糖尿病肾病病理特点21sl i de 178 a capsul ar drop consi st i ng of hyal i nepas posi t i ve m at eri al deposi t ed on t he pari et alsurf ace of bowm ans m em brane (9 ocl ock).2020-12-09糖尿病肾

15、病病理特点22sl i de 179 form at i on of a capsul ar drop byadhesi on of gl om erul ar capi l l ary l oops cont ai ni ngsubendot hel i al hyal i ne (t he so-cal l ed “ exudat i vel esi on” ) t o bowm ans capsul e (9 ocl ock and11 ocl ock). i t i s l i kel y t hat t he gl om erul ar capi l l aryl oops ret

16、ract , deposi t i ng t he hyal i ne m at eri al al ongt he bowm ans capsul ar wal l .2020-12-09糖尿病肾病病理特点23sl i de 174 earl y gl om erul ar art eri ol ar hyal i nosi si n an af f erent art eri ol e. not e t he sm oot h, waxy,hom ogenous pas posi t i ve m at eri al i n t hesubendot hel i al space. thi

17、 s i ddm pat i ent hadnorm al renal f unct i on.2020-12-09糖尿病肾病病理特点24sl i de 176 art eri ol ar hyal i nosi s i n bot h af f erent(l ow er l ef t si de) and ef f erent (l ow er ri ght si de)gl om erul ar art eri ol es (pas). n ot e t he di f f use andnodul ar di abet i c gl om erul oscl erosi s i n t

18、 hi s i ddmpat i ent w i t h earl y overt nephropat hy.2020-12-09糖尿病肾病病理特点25sl i de 175 advanced arteri ol ar hyal i nosi s w i thvi rtual com pl ete repl acem ent of the vessel w al l byhyal i ne w axy m ateri al (pas).2020-12-09糖尿病肾病病理特点26sl i de 200 thi s and t he subsequent t w o sl i desi l l u

19、st rat e t he at ypi cal l esi ons com m onl y seen i nm i croal bum i nuri c n i ddm pat i ent s. som e of t hesepat i ent s, as i l l ust rat ed i n t hi s pas sl i de, haveest abl i shed art eri ol ar hyal i nosi s l esi ons w i t h l i t t l eor no gl om erul ar or t ubul oi nt erst i t i al i n

20、j ury.2020-12-09糖尿病肾病病理特点27s lid e 1 8 1 mild e x p a n s io n o f th e in te rs titia ls p a c e a n d tu b u la r b a s e me n t me mb ra n eth ic k e n in g w ith o u t tu b u la r a tro p h y (p a s ).t h is id d m p a tie n t h a d n o rma l re n a l fu n c tio n .t h is mild d e g re e o f in

21、te rs titia l e x p a n s io n isc o mmo n in d ia b e tic p a tie n ts , e v e n th o s e w h o s eg lo me ru la r a n d v a s c u la r d is e a s e d o n o t p ro g re s s .2020-12-09糖尿病肾病病理特点28sl i de 182 m ore advanced t ubul ar i nt erst i t i aldi sease w i t h t ubul ar at rophy and i nt erst

22、 i t i alf i brosi s i ndi cat ed by t he green col or on t het ri chrom e st ai ni ng. thi s i ddm pat i ent had m i l ddi f f use di abet i c gl om erul oscl erosi s andm i croal bum i nuri a.2020-12-09糖尿病肾病病理特点29s lid e 2 0 2 t h is n id d m p a tie n t w ithm ic ro a lb u m in u ria a n d h yp e

23、 rte n sio n sh o w s a re a so f a d va n c e d tu b u lo in te rstitia l in ju ry w ith o u tsig n ific a n t g lo m e ru lo p a th y o r va sc u lo p a th y. t h isa n d th e p re c e d in g tw o slid e s illu stra te th a tm ic ro a lb u m in u ric n id d m p a tie n ts m a y h a ve re n a lle s

24、io n s w h ic h a re n o t typ ic a l o f th o se se e n inid d m w h e re th e g lo m e ru la r, a rte rio la r,g lo m e ru lo sc le ro tic , a n d tu b u lo in te rstitia l le sio n ste n d to a d va n c e in p a ra lle l.p a tie n ts w ith th e p a tte rn s sh o w n in th e la st th re eslid e s

25、te n d n o t to h a ve p ro life ra tive re tin o p a th ya n d , g e n e ra lly, a re m o re o b e se th a n n id d mp a tie n ts w ith typ ic a l d ia b e tic n e p h ro p a th y.h o w e ve r, p a tie n ts w ith th e se a typ ic a l p a tte rn s a lsoh a ve h ig h e r le ve ls o f h e m o g lo b i

26、n a 1 c th a nn id d m p a tie n ts w ith o u t re n a l in ju ry, su g g e stin gth a t th e se “ a typ ic a l” fo rm s o f in ju ry m a y a lso b ein flu e n c e d b y th e d ia b e tic sta te .2020-12-09糖尿病肾病病理特点302020-12-09糖尿病肾病病理特点31sl i de 185 el ectron photom i crograph i l l ustrati nga norm

27、 al gl om erul ar basem ent m em brane w i dth(bottom panel ) and di ffuse thi ckeni ng of thegl om erul ar basem ent m em brane consequent todi abetes (upper panel ). the basem ent m em branew i dth of the di abeti c pati ent show n here i s m orethan tw i ce norm al thi ckness.2020-12-09糖尿病肾病病理特点3

28、2sl i de 186 el ect ron phot om i crograph of an i ddmpat i ent w i t h est abl i shed renal l esi ons. despi t e t hei ncreased gbm w i dt h and m esangi al expansi on,especi al l y w i t h i ncreased m esangi al m at ri xm at eri al , t hi s pat i ent had norm al renal f unct i on,i ncl udi ng nor

29、m al uri nary al bum i n excret i on rat es.2020-12-09糖尿病肾病病理特点33sl i de 187 el ect ron phot om i crographdem onst rat i ng advanced di abet i c nephropat hyw i t h m arked t hi ckeni ng of t he gbm , great l yi ncreased m esangi al m at ri x m at eri al , andconst ri ct i on of t he capi l l ary l um i na. thi s i ddmpat i ent had overt di abet i c nephropat hy.2020-12-09糖尿病肾病病理特点34s lid e 1 8 9 im m u n o flu o re sc e n t m