泌尿系统整合PBL.pptx

余先生怎么了 泌尿系统PBL 第二组 肾小球正常结构 杨佳妮、肾单位（Nephron）血管球毛细血管（有孔毛细管）：有孔（70nm左右，最大100nm）无隔膜 内皮细胞游离面细胞衣 负电荷 肾脏基膜（Renal Basement Membrane）连续结构 由毛细血管内皮细胞 与足细胞共同产生 足细胞（podocyte)：突起（process）裂孔（slit pore)裂孔膜(slit membrane)Glomerulus Function 张家旭 Glomerular filtration Glomerular filtration barrier Neutral solutes:Solutes smaller than 2 nanometers in radius are freely filtered Solutes greater than 4.2 nanometers do not filter Solutes between 2 and 4.2 nm are filtered to various degrees Glomerular filtration rate(GFR)is the volume of fluid filtered from the renal(kidney)glomerular capillaries into the Bowmans capsule per unit time.Kf is the filtration coefficient a proportionality constant Pgc is the glomerular capillary hydrostatic pressure Pbc is the Bowmans capsule hydrostatic pressure gc is the glomerular capillary oncotic pressure bc is the Bowmans capsule oncotic pressure=0 EFR 125ml/min 1.Changes in renal blood flow 2.Changes in glomerular capillary hydrostatic P -changes in systemic BP -afferent or efferent arteriolar constriction 3.Changes in hydrostatic P in Bowmans capsule -ureteral obstruction,renal edema 4.Changes in glomerular capillary oncotic pressure 5.Changes in Kf -Reduction in effective filtration surface area -Changes in glomerular capillary permeability Two mechanisms control the GFR Renal autoregulation Nervous and humoral regulation Regulation of Glomerular Filtration Under normal conditions(MAP=80-180mmHg)renal autoregulation maintains a nearly constant glomerular filtration rate Two mechanisms are in operation for autoregulation:Myogenic mechanism Tubuloglomerular feedback 尿常觃 刘逸馨 项目 理学检验（physical exam）：尿量、尿气味、尿外观、比重（SG）化学检验（chemical exam）pH、蛋白质、葡萄糖、酮体、胆红素、尿胆原、血红蛋白/隐血、亚硝酸盐、白细胞酯酶、维生素C、微量白蛋白 显微镜检验（microscopic exam）细胞（RBC、WBC）、管型、结晶、微生物 尿量（Vol）正常：成人6002000ml/24h 少尿（oliguria）：尿量400ml/d，常伴脱水，如呕吐、腹泻、流汗、烧伤。无尿（anuria）：尿量2500ml/d，如糖尿病、尿崩症、使用利尿剂、呿啡因呾乙醇 尿气味（Odor）正常：芳香味，不摄入食物中挥发酸有关 异常：提示病理情况、标本处理或贮存丌当 外观 尿色(Col)正常：淡黄色至黄褐色（尿胆素）异常：血尿、胆红素尿、血红蛋白尿 透明度(Clr)正常：清澈透明无沉淀。放置一段时间后，可出现絮状沉淀，尤其女性尿液；异常：尿液排挤时即浑浊，多由白细胞、上皮细胞、粘液、微生物等引起，需作显微镜检查予以辨别 比重（SG）反映肾小管重吸收肾小球滤过成分、肾功能状态、患者脱水状态。正常：1.0151.025，晨尿最高 增高：高热性脱水、急性肾小球肾炎、心功能丌全，蛋白尿及糖尿病 降低：尿崩症、慢性肾炎等肾脏浓缩功能减退 等张尿：牢固在1.010左右，为肾实质严重受损，肾脏浓缩及稀释功能下降所致 化学检验（chemical exam）蛋白质（PRO）肾功能异常的早期症状。正常：定性（-），定量080mg/24h 肾小球性：重度（34g/d），以白蛋白为主，如链球菌感染后AGN，糖尿病肾病。肾小管性：轻度（1g/d），以1M、球蛋白（2M、轻链、溶菌酶）为主，如急性肾盂肾炎，肾移植排斥。RBC（血尿）正常：小亍3个RBC/HPF。异形RBC Birech畸形RBC分类 畸形红细胞占80%以上为肾小球性血尿 畸形红细胞80%以上为非肾小球性血尿 畸形红细胞20%、80%,为混合型血尿 WBC 正常：150mg/24h)in the urine For children:140 mg/24h Benign proteinuria Pathological proteinuria Glomerular proteinuria Tubular proteinuria Overflow proteinuria Dehydration Fever Inflammatory process Intensive activity Most acute illnesses Orthostatic/Postural proteinuria Mechanisms:Mechanisms:Filtration barrier injury (Size/Charge barrier)Characteristic:Characteristic:HMW proteins 70%-80%(IgG,transferrin,albumin)More than 2g/24h Cause:Cause:Primary:GN,nephrotic syndrome Secondary:Diabetes mellitus,Lupus nephritis Drugs:Heroin,NSAIDs Mechanisms:Mechanisms:Low reabsorption at proximal tubule Characteristic:Characteristic:LMW proteins 50%(/-microglobulin)Albumin25%Less than 1g/24h Cause:Cause:Interstitial nephritis Drugs:Heavy metals,NSAIDs,antibiotics Transplantation Mechanisms:Mechanisms:Increased quantity of proteins in serum CharacteristicCharacteristic:LMW plasma proteins(Bence-Jones protein,Myoglobin,Hemoglobin)Cause:Cause:Monoclonal gammopathy Leukemia Rhabdomyolysis Hemolysis Definitions of microalbuminuria Individual Lower limit Upper limit Unit 24h urine collection 30 300 mg/24h(milligram albumin per 24 hours)Short-time urine collection 20 200 g/min(microgram albumin per minute)Spot urine albumin sample 30 300 mg/L(milligram albumin per liter of urine)Spot urine albumin/creatinine ratio Women 3.5 25 or 35 mg/mmol(milligram albumin per millimole creatinine)30 400 g/mg(microgram albumin per milligram creatinine)Men 2.5 or 3.5 25 or 35 mg/mmol 30 300 g/mg Detected by special albumin-specific urine dipsticks Diabetes mellitus,hypertensive nephropathy,Lupus nephritis SPI=Urinary IgG/Plasma IgG Urinary TRF/Plasma TRF IgG 150kD TRF 70kD 0.1SPI0.2 Non-selective proteinuria Size SPI Charge SPI:AMY-S/AMY-P1 Edema 乔义 Introduction Increased fluid in the interstitial space of the ECF compartment 2 causes:A.Increase in capacity of ECF B.Loss of exchange balance between intra&extra vessel fluid(Starling forces)Hydrostatic pressure&oncotic pressure Type 1 Transudate A.Protein-poor(3.5 g/24h)Type 1 Transudate Both OP&HP involved A.Ascites in cirrhosis,HP,OP B.Retention of sodium&water,HP,OP(dilution effect)a.Periorbital edema common due to loose interstitial tissue b.i.e.ARF,CRF,glomerulonephritis,drugs(CCB)Type 2 Exudate A.Protein-rich(3 g/dL)and cell-rich fluid B.Swelling of tissue,no pitting edema due to viscosity C.Increased vascular permeability in venules,associated with inflammation D.i.e.Tissue swelling after a bee sting,cellulitis Type 3 Lymphedema A.Protein-rich fluid B.No pitting edema due to viscosity C