血尿蛋白尿鑒別定稿

1、內(nèi) 容,血尿的診斷與鑒別蛋白尿的診斷與鑒別血尿、蛋白尿---腎小球疾病的診斷與鑒別,血尿的診斷思路,確定是否是真性血尿,判斷出血部位,確定病變性質(zhì),顏 色,正常時(shí)：無(wú)色澄清---淡黃色---琥珀色病理情況：近于無(wú)色：尿液稀釋、尿崩癥深黃色：膽紅素尿（濃茶樣尿）藥物、食物 醬油色：血紅蛋白尿(酸性)→ARF乳白色： 乳糜尿、膿細(xì)胞尿紅 色： 血尿、血紅蛋白尿、肌紅蛋白尿

2、 藥物 (聯(lián)苯胺試驗(yàn)）,試紙法檢測(cè)：潛 血,原理：試紙法 Hb有類(lèi)過(guò)氧化物酶作用 催化分解過(guò)氧化物---鄰聯(lián)甲苯胺氧化變色,,,試紙法的局限性：,,,血尿的定義,尿沉渣 Addis計(jì)數(shù)，12h紅細(xì)胞超過(guò)50萬(wàn) 每高倍視野（HP）超過(guò)3個(gè)紅細(xì)胞,尿檢陽(yáng)性是血尿嗎？,確定是否是真性血尿,標(biāo)本的

3、可靠性---污染 月經(jīng)、子宮、陰道出血鑒別 容器、化驗(yàn)?zāi)驑?biāo)本收集的注意 晨尿 清潔中段尿 避免生殖道的污染 1小時(shí)內(nèi)送檢---冰箱,血尿的診斷步驟,確定是否是真性血尿,判斷出血部位,確定病變性質(zhì),判斷出血的部位（1）,按照血尿和排尿先后的關(guān)系進(jìn)行分析（通常根據(jù)尿三杯試驗(yàn)來(lái)判斷）：初血尿：尿道病變 終末血尿：膀胱頸部和三角區(qū)或后尿道

4、病變?nèi)萄颍荷夏虻阑虬螂?判斷出血的部位（2）,相差顯微鏡檢查紅細(xì)胞形態(tài)：,均一性,不均一性,腎單位血尿,穿過(guò)病變腎小球基底膜時(shí)受損通過(guò)腎小管時(shí)受到管腔內(nèi): 滲透壓、PH值、代謝物質(zhì)(脂肪酸/溶血卵磷脂及膽酸）)大小、形狀改變+同時(shí)合并紅細(xì)胞管型=腎單位來(lái)源例外:腎創(chuàng)傷、活檢、梗塞、腎皮質(zhì)壞死、 劇烈運(yùn)動(dòng)也可有紅細(xì)胞管型,判斷出血的部位（3）,微粒容積自動(dòng)分析儀,血紅細(xì)胞容積分布曲線(xiàn),

5、非腎小球源性血尿,,腎小球源性血尿,腎小球源性血尿,混合性血尿,血尿的診斷步驟,確定是否是真性血尿,判斷出血部位,確定病變性質(zhì),確定病變性質(zhì)（1）,血尿的病因,泌尿生殖系統(tǒng)疾病,全身性疾病,尿路鄰近器官疾病,其他原因,2%,98%,1.腎單位來(lái)源(內(nèi)科性): 原發(fā)、繼發(fā)、家族性2.非腎單位來(lái)源(外科性): 腫瘤、外傷、結(jié)石、畸形、血管等,泌尿生殖系統(tǒng)疾病,內(nèi)科性血尿查什麼?,內(nèi)科性血尿,蛋白定量管型腎功能腎活檢

6、細(xì)菌學(xué)檢查,外科性血尿查什麼?,外科性血尿,1. 尿脫落細(xì)胞2. 影像學(xué): 腹部平片 超聲波檢查 CT/MRI 3. 介入檢查: 膀胱鏡檢查 靜脈腎盂造影(排泄性尿路造影) 逆行尿路造影 腎動(dòng)脈及腎靜脈造影4.鈣負(fù)荷實(shí)驗(yàn): 尿鈣>4mg/kg.24h,尿鈣/肌酐&

7、gt;0.21,胡桃?jiàn)A子現(xiàn)象,腸系膜上動(dòng)脈壓迫左腎靜脈致左腎回流障礙，淤血；從而引起血尿多發(fā)生于兒童，成年后腸系膜上動(dòng)脈壓迫解除癥狀消失,腸系膜上動(dòng)脈,,左腎靜脈,,內(nèi) 容,血尿的診斷與鑒別蛋白尿的診斷與鑒別血尿、蛋白尿---腎小球疾病的診斷與鑒別,正常尿蛋白,<150mg/24h組成: 60%濾過(guò)血漿蛋白 40%白蛋白, 15%免疫蛋白

8、 5%其他血漿蛋白 40% Tamm-Horsfall蛋白,失去大小選擇性屏障理論上GBM濾過(guò)孔孔徑加大，長(zhǎng)度縮短單位面積GBM上孔密度增加以上兩項(xiàng)均有失去電荷選擇性屏障GBM失去帶陰電荷的分子(糖蛋白分解增加/合成減少) 帶陽(yáng)電荷的分子中陰電荷以上兩項(xiàng)均有,蛋白尿的機(jī)理,腎小球?yàn)V過(guò)屏障,腎小球?yàn)V過(guò)膜：內(nèi)皮細(xì)胞基底膜上皮細(xì)胞系

9、膜組織多種生理功能：參與免疫及腎小球炎癥反應(yīng)病理情況下致腎小球硬化,蛋白尿的分類(lèi)和特點(diǎn),腎小球性蛋白尿 腎小球?yàn)V過(guò)屏障損害 〉2.0 g/24 h 大、中、小分子腎小管性蛋白尿 腎小管對(duì)正常濾過(guò)蛋白的重吸收障礙 < 2.0g/24 h，小分子溢出性蛋白尿 血漿中某種蛋白質(zhì)濃度過(guò)高，經(jīng)正?；虍惓ＤI小球?yàn)V出分泌性蛋白尿 遠(yuǎn)端小管分泌：Tamm-Horsfall蛋白蛋白尿診斷方法及,診斷思路,是否蛋

10、白尿？尿常規(guī)持續(xù)性？一過(guò)性： 多見(jiàn)于少量蛋白尿（trace to 2+ protein）定量： 24小時(shí)尿蛋白定量 2g定性： SDS-PAGE定位 ？,內(nèi) 容,血尿的診斷與鑒別蛋白尿的診斷與鑒別血尿、蛋白尿的診斷與鑒別診斷,診斷層次,1.血尿、蛋白尿----臨床診斷2.腎功能3.病因:繼發(fā)腎病?原發(fā)腎病4.病理5.并發(fā)癥,診斷方法及程序,病史體格檢查實(shí)驗(yàn)室檢查特殊檢查隨訪(fǎng),排

11、除假性血尿血凝塊 血尿中混血凝塊常提示非腎小球疾患出血血尿與全身疾病及呼吸道感染的時(shí)間關(guān)系PSGN：感染后10－14天出現(xiàn)血尿IgAN： 幾乎同時(shí)發(fā)生，一般不超過(guò)3天。家族史:耳聾、血尿、腎衰血尿伴隨癥狀腎絞痛尿路刺激癥水腫、高血壓及全身其他癥狀等,病史-----血尿,Onset when began with conditions identified around the initial prese

12、ntation, i.e., drug ingestion record of previous urinalyses precipitation/palliation identification of triggering agents infectious, drugs, foods, chemicals, vaccinations helps to identify acquired forms of tubuloi

13、nterstitial proteinuria,蛋白尿---問(wèn)診,quality associated with hematuria severity ： pathologic if associated with hematuria or Nephrotic Syndrome likely to be a primary GN unlikely to be be

14、nign etiology or secondary GN timing acute vs acute-on-chronic intermittent vs persistent duration of proteinuria,associated symptoms past medical history functional inquiry S

15、pecific Entities helps to differentiate acute GN from chronic GN identify overload proteinuria causes,1. History of Presenting Illness,at the end of the history, one should be

16、able to discern: 1. benign vs pathologic proteinuria (if pathologic then) 2. glomerular vs tubulointerstitial proteinuria (if glomerular then) 3. hereditary vs non-hereditary (if non-hereditary then) 4. acute GN vs c

17、hronic GN (if chronic then) 5. primary GN vs secondary GN 6. nephrotic vs non-nephrotic proteinuria 7. proteinuria with or without hematuriauria,病史,功能性病理性 腎小球性 腎小管、間質(zhì)性 溢出性 分泌性,隱匿性

18、腎炎綜合征急性腎炎綜合征慢性腎炎綜合征急進(jìn)性腎炎綜合征腎病綜合征,,2. Family History,helps to differentiate hereditary from non-hereditary : 1. Proteinuria family members must have had previous urinalysis to ascertain this 2. Renal Disease

19、 Polycystic Kidney Disease Nephrotic Syndrome, Fanconi Disease renal dialysis kidney transplantation 3. Others：hearing/ocular impairment (Alport Syndrome),PE? Lab? More information……,3 Physical Exami

20、nation,1. Vitals hypertension, fever 2. O/E edema, skin paleness or jaundice, rashes external genitalia（外生殖器） joints for signs of arthritis-red, warm, or swollen abdomen: mas

21、ses or tenderness. CVA tenderness enlarged kidneys. length and weight and plot on growth chart.,Glomerular Proteinuria,presents in 1 of 3 ways: 1. Isolated Prote

22、inuria 2. Proteinuria + Hematuria 3. Nephrotic Syndrome edema, hypoalbuminemia, hyperlipidemia,進(jìn)一步檢查,1.血尿、蛋白尿2.腎功能3.病因:繼發(fā)腎病?原發(fā)腎病4.病理:腎活檢5.并發(fā)癥,病因診斷,繼發(fā): 感染相關(guān) 免疫相關(guān) 腫瘤相關(guān)/淀粉樣變/MM

23、 代謝性病原發(fā)性腎病,病理診斷,腎活檢的適應(yīng)癥和禁忌癥穿刺方法常見(jiàn)的病理類(lèi)型常見(jiàn)的病理改變,隨訪(fǎng),無(wú)癥狀血尿患者每半年一次尿液分析和細(xì)胞學(xué)檢查每?jī)赡暌淮伟螂诅R和靜脈腎盂造影若血尿反復(fù)發(fā)作，隨訪(fǎng)期至少3年,CASE 1,A four year-old African American male is brought to your office after his parents noticed that

24、his urine appeared dark brown or coke （焦碳）colored.,Important questions to ask in your History 1,Has there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? Has there been any recent URI symptom

25、s or sore throat? Has there been any type of skin rashes or sores? Any abdominal pain or colicky pain? Are the stools loose or bloody?,Important questions to ask in your History 2,5. Has there been any recent trauma?

26、 6. Has there been any joint pains or swellings? 7. Is there any history of sickle cell disease or trait?8. Is there any family history of renal disease,transplants, or dialysis? 9.Is there a family history of heari

27、ng deficits? 10.What medications does the child take?,According to the parents, the child was treated with Bacitracin（桿菌肽） 2 weeks ago for impetigo（膿皰病 ）on the legs and arms?,,,,,The patients examination was normal exce

28、pt for a blood pressure of 125/90 and some mild periorbital edema.,擬診：最可能？ 其次？,擬診：可能,post streptococcal acute glomerular nephritis(PSAGN) （急性鏈球菌感染后腎炎）secondary to a nephrogenic strain of streptococcus pyogenes （

29、causing impetigo 2 weeks ago）,進(jìn)一步檢查證實(shí)？,進(jìn)一步檢查證實(shí),ASOanti-DNAse B titersBUN and Creatininecomplement levels.,治療-有助于診斷,The child should be monitored closely paying attention ： blood pressure, daily weights, urine outpu

30、t and po input.,預(yù)期結(jié)果,The red blood urine ： C3 complement ：預(yù)后：,預(yù)期結(jié)果,The urine may continue to contain red blood cells for many months the C3 complement usually returns to normal levels in 6-8 weeks. Most of the PSAGN

31、patients recover completely,Common causes of hematuria in children,Urinary tract infection. Diagnosed by symptoms of burning and frequency and a positive urine culture on a properly collected specimen Familial benign he

32、maturia- usually asymptomatic and may have minimal proteinuria. At times the hematuria may be gross. Hypercalcuria- usually asymptomatic and may be microscopic or gross hematuria. Do a spot urine and measure the Ca/Crea

33、tinine ratio. Age related. 19 mo.-6 years is 0.42(95%) Transient- no etiology established. HSP- hematuria may precede the rash,Common Causes of Gross Hematuria,Local irritation or trauma to the perineal area  Rea

34、nl trauma secondary to blunt abdominal trauma or accident UTIs,如果1,If the patient is asympotmatic and the physical exam is normal, and there is no family history of renal disease,,,recheck the urine in a few days.dipst

35、ick is still positive,,check a spun urine for blood, casts, protein, wbc's，bacteriaObtain a urine for culture Check immediate family members for hematuria Ca++/Cr. on spot urine CBC , platelet count, and rbc morp

36、hology,如果2,if glomerular disease is not suspectedSome authorities suggest a renal ultrasoundto rule out structural disease and masses,,,If increased blood pressure, edema, decreased urine output, casts pro

37、teinuria a total hemolytic complement and C3,,如果3：,Glomerulonephritis associated with decreased C3 include,SLE- do ANA Shunt nephritis Post streptococcus glomerulonephritis Membrao-proliferative glomerulonephritis