医学精品课件：Acute Glomerulonephritis(new).ppt

1、Acute Glomerulonephritis,Li Min The Second Affiliated Hospital of Guangzhou Medical University,Acute Glomerulonephritis,Etiology 病因,Manifestations,Laboratory test,解剖生理特点,classifi-cation,Over view,Pathogenesis ， pathology,Anatomical ，Physiological,发病机制 病理,临床表现,实验室 检查,Diagnosis 诊断,Treatment,Prevention

2、,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,Anatomical characteristics,Kidney Ureter Bladder Urethra,Physiological Characteristics,Kidney is one of the main organs to mainta

3、in homeostasis of the internal environment.The physiological function of kidney in children is similar to that in adults,but it is not mature.Its function reaches adult level at the ages of 1-1.5 years.,GFR(Glomerular filtration rate）,20ml/min per 1.73m2goes to 1/4 of the adult level at the age of 1

4、 week,and the same to adult at 1-2 years.So overmuch fluid and solute can not be excreted efficiently during this period of time.,reabsorption and excretion in renal tubule,the endocrine function of kidneys,The clinical classification of glomerular diseases,Primary glomerular diseases Secondary glom

5、erular diseases Hereditary glomerular diseases,The clinical classification of glomerular diseases,Primary glomerular diseases Glomerulonephritis nephrotic syndrome isolated hematuria or proteinuria,The clinical classification of glomerular diseases,Secondary glomerular diseases （SLE, hepatitis B, an

6、aphylactoid purpura ） Hereditary glomerular diseases （ Alport syndrome,familial recurrent hematuria）,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,Acute glomerulonephritis over

7、view,Acute glomerulonephritis is a classic example of the acute nephritic syndrome in children. It is characterized by the sudden onset of hematuria,varying degrees of proteinuria,edema,hypertension,or renal insufficiency.,3. Acute glomerulonephritis that follows an infection with a nephritogenic st

8、rain of group A beta-hemolytic streptococci （A组溶血性链球菌）is one of the most common forms of renal parenchymal disease in childhood.,4. Antigen-antibody complexes are deposited in the glomeruli,and the complexes may incite glomerular inflammation and activate the complement system.,Acute Glomerulonephri

9、tis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,Etiology,Acute poststreptococcal glomerulonephritis(APSGN) follows infection of the throat or skin by certain “nephritogenic” strains of group A beta-

10、hemolytic streptococci. pharyngitis(咽炎）- winter and spring skin infection or pyoderma（脓疱疮）-summer.,Other infections can cause similar glomerular injury, such as mycoplasma pneumonia（肺炎支原体）,cytomegalovirus（巨细胞病毒）,pneumococcus （肺炎球菌）and so on.,Acute Glomerulonephritis,Anatomical ，Physiological Classif

11、ication Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,肾小球滤过膜,上皮细胞 肾小球基底膜（GBM） 内皮细胞,发病机制,形成CIC或IC,肾小球局部免疫炎症反应,毛细血管内增生,GBM完整性受损,GFR，球管失衡,水、钠排出,尿少,血容量 静脉压,间质容量,循环负荷,水肿,高血压,血尿、蛋白尿,A组溶血性链球菌致肾炎菌株（Ag）,补体激活,光镜: 系膜细胞和内皮细胞增生,normal,AGN,电镜：电子致密物沉积,EM100

12、00 在肾小球基底膜外侧见一圆锥状电子致密物（H）驼峰,病理,IF400 IgG沿肾小球毛细血管壁呈不连续的颗粒样荧光 肾小球系膜区也可见团块状沉积,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,Clinical Manifestations,APSGN is common in children of

13、5-14 years old but uncommon before age of 2 The severity of renal symptoms varies from asymptomatic microscopic hematuria（无症状镜下血尿） with normal renal function to acute renal failure.,Acute poststreptocccal glomerulonephritis (APSGN) commonly follows by streptococcal pharyngitis(咽喉炎） during winter and

14、 spring and streptococcal skin infections or pyoderma（脓疱疮） in summer.,Preceding infection,upper respiratory（呼吸） tract infection ：caused by streptococcus（链球菌），such as tonsillitis(扁桃腺炎）,otitis media（中耳炎）,or lymphnoditis（淋巴结炎）.followed by a latent period last for about 10 days. infection of skin(notabl

15、y pyoderma-脓疱疮), the latent period can 3 weeks in average.,Acute glomerulonephritis,严重 表现,典型表现,非典型表现,临床表现,Manifestations,Edema-palpebra edema （眼睑浮肿）, 最早出现和最常见的症状（晨起眼睑、颜面部水肿） 下行性 非凹陷性,urinary abnormalities(hematuria,varying degree of proteinuria), 肉眼血尿 （gross hematuria）, 镜下血尿 （microscopic hematuria）,

16、血压（mmHg） 学龄前 120/80 学龄儿 130/90,hypertension, oliguria,年龄 正常尿量 少尿 无尿 婴儿 400-500 200 幼儿 500-600 200 30-50 学龄前 600-800 300 学龄儿 800-1400 400 单位：ml/24h,Other symptoms,Low-grade fever,abdominal pain,Anorexia（厌食）,Vomiting（呕吐）,headache,Acute nephritis complications,Serious circulation congestion hypertensiv

17、e encephalopathy（高血压脑病） acute renal failure,严重循环充血(Serious circulation congestion),GFR,Water -sodium retention,Hyper-volemia,higher heart loading,左心负荷增加：呼吸困难、两肺湿性罗音、 心率增快、心脏扩大 右心负荷增加：肝脏增大，颈静脉怒张,高血压脑病 (hypertensive encephalopathy ),Hemangiectasis vasospasm cerebral ischemia Anoxia Papilledema,BP,cere

18、bral symptom,高血压脑病 (hypertensive encephalopathy ),Headache Vomiting irritability or apathy(烦躁或表情淡漠） Convulsions（抽搐） transitory paralyses（一过性麻痹） Coma（昏迷） temporary complete blindness,高血压脑病 (hypertensive encephalopathy ),脑血管痉挛脑缺血缺氧脑血管通透性 脑水肿 血压升高、头痛、呕吐并伴,急性肾功能不全 (Acute renal failure),GFR急性肾功能不全,氮质血症,少

19、尿或无尿,代谢性酸中毒,电解质紊乱,非典型表现,无症状性急性肾炎,肾外症状性急性肾炎,肾病表现的急性肾炎,镜下血尿、蛋白尿，但无临床症状,水肿、高血压，但尿改变轻微或正常,急性肾炎经过，蛋白尿达肾病水平,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,Laboratory Test,Routine urin

20、alysis Hematuria Gross hematuria Microscopic hematuria ：RBC3/HP 12hAddis计数 50万 ,Laboratory Test,Proteinuria:mild degree WBC renal tubular epithelium hyaline casts granular casts. urinary abnormalities may persist for more than 1 year.,Laboratory Test,Blood chemistry BUN Cr,Serological testing,C3： 2w

21、内 68w恢复 ASO：1014d开始升高 35w高峰 36m恢复 ADNaseB(+) ESR，代表疾病的活动性；23m恢复， 增高程度与疾病严重度无关,Blood routine,RBC,Hb (hepervolemia and hemodilution,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,

22、急性肾炎的诊断要点,起病13w有链球菌的前驱期感染,临床出现水肿、少尿、血尿、高血压,尿检有蛋白、RBC、管型,血清C3，伴或不伴ASO,鉴别诊断,1）肾病综合征 2）IgA肾病 3）急进性肾炎 4）慢性肾炎急性发作 5）继发性肾炎：过敏性紫癜、系统性红斑狼疮、乙型肝炎等,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prev

23、ention,Treatment,治疗原则及程序,自限性疾病，无特效治疗 休息和对症治疗 纠正其病理生理过程（如水钠潴留、血容量过大） 防治急性期并发症、保护肾功能，以利其自然恢复,Treatment,1、Bed rest prolonged bed rest for 2-3 weeks in acute phase,it is required as long as the clinical symptoms disappear After ESR returns to normal,children can go back to school,but exhausting and comp

24、etitive activities are prohibited until the addis count returns to normal.,Treatment,2、 Diet 水肿、高血压、少尿期低盐饮食，适当限水 氮质血症期优质低蛋白饮食（食入蛋白量0.5g/kg/日）,3、抗生素 因溶血性链球菌感染 选青霉素或红霉素治疗1014天 4、对症 利尿,降压 （1）利尿：双氢克尿噻、速尿 （2）降压：硝苯地平，卡托普利,Treatment,Treatment,5、严重病例治疗 严重循环充血 限制水盐 速尿 硝普钠：尤其有急性肺水肿 难治病例可采用腹膜透析或血液滤过,Treatment,

25、高血压脑病：止惊、降压、脱水 首选硝普钠 安定 速尿,Treatment,急性肾衰 争取时间以利肾功能恢复,1、去除病因 2、防止并发症的发生 3、少尿期严格控制液体入量：液体入量= 前一天尿量+显性失水+不显性失水-内生水量 4、纠正水电解质紊乱 5、透析疗法,Acute Glomerulonephritis,Anatomical ，Physiological Classification Overview Etiology Pathogenesis ，pathology Manifestations Laboratory test Diagnosis Treatment Prevention,预后与病因.病理改变有关 早期治疗可降低急性期死亡率。病毒感染及链球菌感染后肾炎预后好；多无复发 预防链球菌感染;发生链球菌感染应彻底治疗,并于感染后23周内随访尿常规,Prevention,教学目标,掌握： 1.急性肾小球肾炎的临床表现及实验室检查 2.急性肾小球肾炎的诊断及治疗 熟悉 急性肾小球肾炎的病因、发病机理及病理改变 了解 1.小儿泌尿系统的解剖生理特点 。 2.急性肾小球肾炎的鉴别诊断。,