内科学教学课件：英文班泌尿系统疾病-总论

Chapter1

GeneralIntroduction

BasicstructureofkidneyLocationBasicstructureofkidneyLocation:towsidesofspinalcolumnbehindperitoneumLiftkidney:upperpoleT11lowpoleL2Rightkidney:neartheliverupperpoleT12lowpoleL3Length10.5-11.5cmWidth5-7.2cmThickness2-3cmBasicstructureofkidneyConstitute

kidneyunitjuxtaglomerularcomplexrenalinterstitiumbloodvesselnervusBasicstructureofkidneyKidneyunitBasicstructureofkidneyKidneyunitrenalcorpuscle:glomerulusrenalcapsulerenaltubule:proximaltubule thinsegmentdistaltubuleconnectingtubuleBasicstructureofkidneyStructureofglomerulusBasicstructureofkidneyStructureofglomerulus:

endotheliumcellglomerularbasementmembranepodocyte/footcellBasicstructureofkidneyfootcell

sticktoGBMbypodocyticprocessstenopaicholeisclosedbystenopaicmembraneBasicstructureofkidneyglomerularbasementmembrane(GBM):

1.middlelevel:compactlayersialoprotein2.strataexternumandendothecium:tectoriumheparansulfateanion3.Ⅳcollagenprotein:basicstructurefillinglaminin,fibronectionGBMfunction

maintainnormalstructuretiredjacentcellconstitutefiltrationbarrierconstitutefiltrationbarrier

size/molecular

barrier:limitpassingofbigmolecularchargebarrie:restrictfilterofnegativechargemateriala脏层上皮细胞bGBMc内皮细胞d系膜e副系膜PhysiologicalfunctionofkidneyExcretionofmetabolite

Regulationofwaterelectrolytes&acid-basebalance

MaintainingthestablenessofinternalenvironmentGlomerularfilterfunctionMainformofmetabolitesexcretionwhichincludeurea,creatine,hippuricacid,benzoicacid,amine&uricacid2.GFR

indicateifthefilterfunctionisnormalornot,whichisdeterminedbyhydrostaticpressure,colloidosmoticpressure,areaoffiltermembrane&filterfractionofcapillary。肾小球滤过功能Reabsorption&secretionfunctionofrenaltubuleCrudeurine(electrolytecomponentsaresimilarwithplasma)→180L/d;

Urinevolume→1500ml/d(99%isreabsorbed);

Reabsorption&secretionarecontrolledbyrenaltubule→makewater-electrolytebalance.肾小管重吸收和分泌功能近端小管是重吸收的主要部位，葡萄糖、氨基酸全部被重吸收，排泄有机酸、尿酸、造影剂、抗生素。髓袢细段的尿液浓缩起重要作用。远端小管调节终尿成分的主要场所，重吸收Na，排出K及分泌H、NH4。Endocrinefunctionofkidney①vasoactivehormones→actsonkidney→regulatephysiologicallyhemodynamics&water-saltmetabolism→includesrenin、angiotensin、prostategroup、kininsystem②non-vasoactivehormones→actsonwholebody→includes

1α—hydroxylase&erythropoietinExaminationofkidneydiseaseUrinalysis1、proteinuria

urineprotein>150mg/d,qualitativeanalysis(+),urineprotein/creatinine>200mg/g→proteinuriaurineprotein>30~300mg/d→minimalurineproteinClassificationofproteinuriaReasons:(1)Physiologic

proteinuria①functional～②positional～(2)Glomerularproteinuria

：

selective～nonselective～

Classificationofproteinuria(3)tubuleproteinuria

:proteinreabsorptiondefectofproximaltubule→β2－microglobulin、lysozymeinurine;≤2g/d.(4)overflowproteinuria:abnormalprotein(Hb/myoglobin/lightchainproteinofmultiplemyeloma)oflowmolecularweight↑Urinalysis2hematuriagrossµscopic～。新鲜尿离心沉渣每高倍视野红细胞超过３个，称为镜下血尿。尿外观呈洗肉水样、血样、酱油样或有血凝块时，称肉眼血尿。尿液检查尿液检查鉴别肾小球源性血尿：a新鲜尿沉渣镜检

变形红细胞为肾小球源性;原因:GBM断裂,红细胞通过受血管内压力挤出受损,其后通过肾小管各段时受渗透压变化和PH作用,呈现变形红细胞血尿，红细胞体积表小、破裂。均一形态正常红细胞尿为非肾小球源性尿液检查鉴别肾小球源性血尿b尿红细胞容积分布曲线肾小球源性血尿呈非对称曲线，其峰值红细胞容积小于静脉峰值红细胞容积非肾小球源性血尿呈对称曲线，其峰值红细胞容积大于静脉峰值50100150200a50100150200b5010015020050100150200c50100150200d尿液检查3.cylinderuria：castinurine→proteincoagulationintubule→cell/manygranularcasts&proteinuriaappearinthemeantimeismeaningfulinclinic原因：1、肾小球或肾小管性疾病

2、炎症、药物刺激使粘蛋白分泌少而形成尿液检查4leucocyturia、pyuria、bacteriurialeucocyturia

：pyuria→>5WBC/HPoffreshcentrifugalurine/>40millionsWBC/1hrsoffreshurine/>100millionsWBC/12hrs;pyuria

bacteriuria

：bacteriaineveryHP/culturedbacteriacolonies>105/ml；GFRdeterminationGFR:theabilityofrenalclearanceofplasmasubstancesperunittime

EndogenousCcr(creatinineclearancerate)inclinicistheusualmeansofestimatingGFR→Recently,K/DOQIclinicalpracticeguiderecommend2formulastocalculateGFR:Cokcroff-Gault&MDRD.Imagingtests

ultrasonography

CT&MRIarteriography&venographyradionuclide,Commonsyndromesofrenaldiseases1.Nephroticsyndrome:proteininurine>3.5g/dproteininplasma<30g/dedemahyperlipemia肾脏疾病常见综合征2.Nephritissyndrome:proteinuria,hematuria,hypertension;3.Asymptomaticurineabnormality:4.Acuterenalfailure&rapidlyprogressiverenalfailuresyndrome:5.Chronicrenalfailuresyndrome:progressiveirreversiblyrenalfunctionalfailure.EvaluationofrenaldiseasesEtiologydiagnose：primaryorsecondarypathologydiagnose：Nephritis,NS,AKI,proteinuria,

hematuria,percutaneousrenalbiopsy

functiondiagnose：AKI、CKDcomplicationdiagnose：ARF、CRFPrevention&cure:Principle＊Wipeoffind