1、NEPHROLOGY (肾脏病学总论）肾脏病学总论）Zhou Fuhua（周富华）（周富华）The second affiliated hospital of Nanjing Medical UniversityNEPHROLOGYStructure of the kidney(结构结构)Function of the kidney Clinical manifestation Laboratory Evaluation of Renal Disease Major Renal SyndromesThe Nephron(肾单位肾单位)Consists of the glomerulus(肾小球
2、)and its 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 CapsuleJuxtaglomerular Apparatus(近球旁器)Vascul
3、ar componentAfferent arterioleEfferent arterioleExtraglomerular mensangial region Tubule component thick ascending limbMechanism 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 arteriolTUBULAR
4、EPITHELIAL CELLS NEPHROLOGY Structure of the kidneyFunction of the kidney(功能功能)Clinical manifestation Laboratory Evaluation of Renal Disease Major Renal SyndromesNephron Function Glomerular filtration (肾小球滤过功能）肾小球滤过功能）Tubule secretion and reabsorption （肾小管重吸收和分泌功能）（肾小管重吸收和分泌功能）肾小球滤过功能（glomerular fil
5、tration 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 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 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(
6、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-angiotensin system(肾素血管紧张素系统RAS)angiotensinogen angiotensinangiotensin AldosteroneAT1,AT2ReninACEAngiotensin Increase preglomerular and efferent arterioar resistances Enhance the reabsorption of sod
7、ium Effects on vasa vecta Decrease Kfa decrease in hydraulic conductivity Enhance production of PG,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,
8、ADH EGF,PDGF,IGF-1,TGF,NEPHROLOGY Structure of the kidney Function of the kidneyClinical manifestation (临床症状临床症状)Laboratory Evaluation of Renal Disease Major Renal SyndromesClinical 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 ar
9、ea:renal colic Changes in urine volume Others NEPHROLOGY Structure of the kidney Function of the kidney Clinical manifestation Laboratory Evaluation of Renal Disease Major Renal Syndromes尿液检查（uronoscopy）U/AChemistry(Dip Stick)Protein Glucose Hemoglobin Ketones pH Bilirubin Urobilinogen Nitrite Leuko
10、cyte esteraseMORE IMPORTANTLESS IMPORTANTU/AChemistryHold hereDip up to hereThe reactions are timed and the colors change if 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.Proteinuria蛋白尿 定义定义:持
11、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/kg/日。按发病机制分类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：按发病机制分类按发病机制分类 2 Tub
12、ule 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）Proteinuria功能性蛋白尿:发热、寒冷、运动、淤 血、直立。3.5gm/day)Hypoalbuminemia（30g/L)Edema Hyperlipidema Lipiduria急性肾炎综合征Acute Nephritic Syndrome Sudden onset of hematuria with RBC casts and renal failure(days -weeks)RBC casts n
13、ot listed in the book!But this is critical!Proteinuria(mild to moderate but NOT Nephrotic Range)Hypertension Hallmark Disease:Post Streptococcal Glomerulonephritis急进性肾炎综合征Rapidly Progressive Glomerulonephritis Nephronal hematuria Renal failure developing over weeks to months Diffuse glomerular cresc
14、ent formation.无症状性尿异常Asymptomatic Hematuria or Proteinuria Hematuria with or without RBC casts and/or Proteinuria usually 2.0gm/day NO RENAL FAILURE NO NEPHROTIC SYNDROME急性肾衰竭综合征Acute Renal Failure Oliguria(400ml/day)Rarely anuria Recent Onset of Azotemia(hours/days)慢性肾衰竭综合征Chronic Renal Failure Ure
15、mia Final Common Path of All Chronic Renal Diseases尿路感染综合征Urinary Tract Infection Bacteriuria and Pyuria Dysuria,Frequency,Urgency Pyelonephritis or Cystitis WBC casts=Pyelonephritis The Book Misses this one!Fever The Book Misses this one!肾石症Nephrolithiasis Renal stones Renal colic-OOOUUUCCCHHH!Seve
16、re,Crampy Pain in the flank area Hematuria(Not RBC casts!)肾脏疾病的诊断 根据患者的病史、症状及体征，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)Optimal pre-ESRD careEarly de
17、tection of CRFPrevention of uremiccomplicationsInterventions thatDelay progressionBP cotrolPreparation forRRTModification of Co-morbidityACEI and ARBProtein restrictionBlood sugar controlOsteodystrophyAnemiaMalnutritionAcidosisRetinopathy(in DM)EducationNeuropathy(in DM)Vascular diseaseCardiac disea
18、seBlood vessel accessInformed choice of RRTInitiation of dialysisSpecific therapy,based on causes血液透析肾脏替代治疗：透析、肾移植腹膜透析交换研究进展及展望(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 替代治疗的进展提问与解答环节Questions And Answers谢谢聆听 学习就是为了达到一定目的而努力去干,是为一个目标去战胜各种困难的过程,这个过程会充满压力、痛苦和挫折Learning Is To Achieve A Certain Goal And Work Hard,Is A Process To Overcome Various Difficulties For A Goal
