血尿蛋白尿鉴别定稿.ppt

内 容w血尿的血尿的诊断与断与鉴别w蛋白尿的蛋白尿的诊断与断与鉴别w血尿、蛋白尿血尿、蛋白尿-肾小球疾病的小球疾病的诊断与断与鉴别1.血尿的血尿的诊断思路断思路w确定是否是确定是否是真性真性血尿血尿w判断出血判断出血部位部位w确定病确定病变变性性质质2.颜 色色正常正常时：无色澄清-淡黄色-琥珀色病理情况病理情况：w近于无色近于无色：尿液稀释、尿崩症w深黄色深黄色：胆红素尿（浓茶样尿）药物、食物 w酱油色油色：血红蛋白尿(酸性)ARFw乳白色乳白色：乳糜尿、脓细胞尿w红 色：色：血尿、血血尿、血红蛋白尿、肌蛋白尿、肌红蛋白尿蛋白尿 药物物 (联苯胺苯胺试验）3.试纸法法检测：潜：潜 血血w原理：原理：试纸法法 HbHb有有类过氧化物氧化物酶作用作用 催化分解催化分解过氧化物氧化物-邻联甲苯甲苯胺氧化胺氧化变色色4.假阳性假阳性假阴性假阴性血血红蛋白蛋白尿尿肌肌红红蛋白蛋白尿尿尿中尿中强强氧化氧化剂剂脱水脱水还还原原剂剂尿尿pH降低降低试纸预先暴露先暴露在空气中在空气中试纸试纸法的局限性：法的局限性：5.血尿的定血尿的定义w尿沉渣尿沉渣 AddisAddis计数，数，12h12h红细胞超胞超过5050万万 每高倍每高倍视野（野（HPHP）超）超过3 3个个红细胞胞6.w尿尿检阳性是血尿阳性是血尿吗？7.确定是否是真性血尿确定是否是真性血尿w标本的可靠性本的可靠性-污染染 月月经、子、子宫、阴道出血、阴道出血鉴别 容器、化容器、化验w尿尿标本收集的注意本收集的注意 晨尿晨尿 清清洁中段尿中段尿 避免生殖道的避免生殖道的污染染 1 1小小时内送内送检-冰箱冰箱 8.血尿的血尿的诊断步断步骤w确定是否是真性血尿确定是否是真性血尿w判断出血部位判断出血部位w确定病确定病变变性性质质9.判断出血的部位（判断出血的部位（1 1）w按照血尿和排尿先后的按照血尿和排尿先后的关系关系进行分析行分析（通常根据通常根据尿三杯尿三杯试验来判断来判断）：）：初血尿：初血尿：尿道病尿道病变 终末血尿末血尿：膀胱膀胱颈部和三角部和三角区或后尿道病区或后尿道病变全程血尿：全程血尿：上尿道或膀胱上尿道或膀胱10.判断出血的部位（判断出血的部位（2 2）相差相差显显微微镜检查红细镜检查红细胞形胞形态态：均一性均一性不均一性不均一性11.12.肾单位血尿位血尿w穿穿过病病变肾小球基底膜小球基底膜时受受损w通通过肾小管小管时受到管腔内受到管腔内:渗透渗透压、PHPH值、代、代谢物物质(脂肪酸脂肪酸/溶血卵磷脂及溶血卵磷脂及胆酸）胆酸）)w大小、形状改大小、形状改变+同同时合并合并红细胞管型胞管型=肾单位来源位来源例外例外:肾创伤、活、活检、梗塞、梗塞、肾皮皮质坏死、坏死、剧烈运烈运动也可有也可有红细胞管型胞管型13.判断出血的部位（判断出血的部位（3 3）w微粒容微粒容积自自动分析分析仪10501001502001050100150200105010015020010501001502001050100150200血红细胞容积分布曲线非肾小球源性血尿肾小球源性血尿肾小球源性血尿混合性血尿14.血尿的血尿的诊断步断步骤w确定是否是真性血尿确定是否是真性血尿w判断出血部位判断出血部位w确定病确定病变变性性质质15.确定病确定病变性性质（1 1）血尿的病因血尿的病因泌尿生殖系泌尿生殖系统统疾病疾病全身性疾病全身性疾病尿路尿路邻邻近器官疾病近器官疾病其他原因其他原因2%2%98%98%16.1.1.肾单位来源位来源(内科性内科性):):原原发、继发、家族性、家族性2.2.非非肾单位来源位来源(外科性外科性):):肿瘤、外瘤、外伤、结石、畸形、血管石、畸形、血管等等泌尿生殖系泌尿生殖系统疾病疾病17.内科性血尿内科性血尿查什麽什麽?18.内科性血尿内科性血尿w蛋白定量蛋白定量w管型管型w肾功能功能w肾活活检w细菌学菌学检查19.外科性血尿外科性血尿查什麽什麽?20.外科性血尿外科性血尿1.1.尿脱落尿脱落细胞胞2.2.影像学影像学:腹部平片腹部平片 超声波超声波检查 CT/MRI CT/MRI 3.3.介入介入检查:膀胱膀胱镜检查 静脉静脉肾盂造影盂造影(排泄性尿路造影排泄性尿路造影)逆行尿路造影逆行尿路造影 肾动脉及脉及肾静脉造影静脉造影4.4.钙负荷荷实验:尿尿钙4mg/kg.24h,4mg/kg.24h,尿尿钙/肌肌酐0.210.2121.胡桃胡桃夹子子现象象w肠系膜上系膜上动脉脉压迫迫左左肾静脉致左静脉致左肾回回流障碍，淤血；从流障碍，淤血；从而引起血尿而引起血尿w多多发生于儿童，成生于儿童，成年后年后肠系膜上系膜上动脉脉压迫解除症状消失迫解除症状消失肠肠系膜上系膜上动动脉脉左左肾肾静脉静脉22.内 容w血尿的血尿的诊断与断与鉴别w蛋白尿的蛋白尿的诊断与断与鉴别w血尿、蛋白尿血尿、蛋白尿-肾小球疾病的小球疾病的诊断与断与鉴别23.正常尿蛋白正常尿蛋白w150mg/24hw组成:60%60%滤过血血浆蛋白蛋白 40%白蛋白,15%免疫蛋白 5%其他血浆蛋白 40%Tamm-Horsfall蛋白24.失去大小失去大小选择性屏障性屏障w理理论上上GBMGBM滤过孔孔径加大，孔孔径加大，长度度缩短短w单位面位面积GBMGBM上孔密度增加上孔密度增加w以上两以上两项均有均有失去失去电荷荷选择性屏障性屏障wGBMGBM失去失去带阴阴电荷的分子荷的分子(糖蛋白分解增加糖蛋白分解增加/合成减少合成减少)w带阳阳电荷的分子中阴荷的分子中阴电荷荷w以上两以上两项均有均有蛋白尿的机理蛋白尿的机理25.肾肾小球小球滤过滤过屏障屏障肾小球滤过膜：内皮细胞基底膜上皮细胞系膜组织多种生理功能：参与免疫及肾小球炎症反应病理情况下致肾小球硬化26.蛋白尿的分蛋白尿的分类和特点和特点w肾小球性蛋白尿小球性蛋白尿 肾小球小球滤过屏障屏障损害害 2.0 g/24 h2.0 g/24 h 大、中、小分子大、中、小分子w肾小管性蛋白尿小管性蛋白尿 肾小管小管对正常正常滤过蛋白的重吸收障碍蛋白的重吸收障碍 2.0g/24 h 2.0g/24 h，小分子，小分子w溢出性蛋白尿溢出性蛋白尿 血血浆中某种蛋白中某种蛋白质浓度度过高，高，经正常或异常正常或异常肾小球小球滤出出w分泌性蛋白尿分泌性蛋白尿 远端小管分泌：端小管分泌：Tamm-HorsfallTamm-Horsfall蛋白蛋白尿蛋白蛋白尿诊断方法及断方法及27.诊断思路断思路w是否蛋白尿是否蛋白尿？尿常？尿常规w持持续性？一性？一过性性：多多见于少量蛋白尿（于少量蛋白尿（trace to 2+trace to 2+proteinprotein）w定量定量：2424小小时尿蛋白定量尿蛋白定量 2g2gw定性定性：SDS-PAGESDS-PAGEw定位定位？28.内 容w血尿的血尿的诊断与断与鉴别w蛋白尿的蛋白尿的诊断与断与鉴别w血尿、蛋白尿的血尿、蛋白尿的诊断与断与鉴别诊断断29.诊断层次1.1.血尿、蛋白尿血尿、蛋白尿-临床床诊断断2.2.肾功能功能3.3.病因病因:继发肾病病?原原发肾病病4.4.病理病理5.5.并并发症症30.诊断方法及程序断方法及程序w病史病史w体格体格检查w实验室室检查w特殊特殊检查w随随访31.w排除假性血尿排除假性血尿w血凝血凝块 血尿中混血凝血尿中混血凝块常提示非常提示非肾小球疾患出血小球疾患出血w血尿与全身疾病及呼吸道感染的血尿与全身疾病及呼吸道感染的时间关系关系wPSGNPSGN：感染后：感染后10101414天出天出现血尿血尿wIgANIgAN：几乎同几乎同时发生，一般不超生，一般不超过3 3天。天。w家族史家族史:耳耳聋、血尿、血尿、肾衰衰w血尿伴随症状血尿伴随症状w肾绞痛痛w尿路刺激症尿路刺激症w水水肿、高血、高血压及全身其他症状等及全身其他症状等病史病史-血尿血尿32.Onseto when began with conditions identified around the initial presentation,i.e.,drug ingestion orecord of previous urinalyses precipitation/palliation oidentification of triggering agents oinfectious,drugs,foods,chemicals,vaccinations whelps to identify acquired forms of tubulointerstitial proteinuria 蛋白尿蛋白尿-问诊33.quality associated with hematuria severity：pathologic if associated with hematuria or Nephrotic Syndrome likely to be a primary GN likely to be a primary GN unlikely to be benign etiology or unlikely to be benign etiology or secondary GNsecondary GN timing acute vs acute-on-chronic intermittent vs persistent duration of proteinuria 34.associated symptoms past medical history functional inquiry Specific Entities helps to differentiate acute GN from chronic GN identify overload proteinuria causes 35.1.History of Presenting Illness1.History of Presenting Illnessat the end of the history,one should be at the end of the history,one should be able to able to discerndiscern:1.benign vs pathologicbenign vs pathologic proteinuria(if pathologic then)2.glomerular vs tubulointerstitialglomerular vs tubulointerstitial proteinuria(if glomerular then)3.hereditary vs non-hereditaryhereditary vs non-hereditary(if non-hereditary then)4.acute GN vs chronic GNacute GN vs chronic GN(if chronic then)5.primary GN vs secondary GNprimary GN vs secondary GN 6.nephrotic vs non-nephrotic proteinurianephrotic vs non-nephrotic proteinuria 7.proteinuria with or withoutproteinuria with or without hematuriauria hematuriauria 36.病史病史w功能性功能性w病理性病理性 肾小球性小球性 肾小管、小管、间质性性 溢出性溢出性 分泌性分泌性隐隐匿性匿性肾肾炎炎综综合征合征急性急性肾肾炎炎综综合征合征慢性慢性肾肾炎炎综综合征合征急急进进性性肾肾炎炎综综合征合征肾肾病病综综合征合征37.2.Family History2.Family Historyhelps to differentiate hereditary from non-hereditary:1 1.Proteinuria.Proteinuria family members must have had previous urinalysis to ascertain this 2.2.Renal DiseaseRenal Disease Polycystic Kidney Disease Nephrotic Syndrome,Fanconi Disease renal dialysis kidney transplantation 3.3.OthersOthers：hearing/ocular impairment(Alport Syndrome)38.PE?Lab?More information39.THANK YOUSUCCESS2024/5/27 周一40.3 Physical Examination3 Physical Examination1.Vitals 1.Vitals hypertension,fever hypertension,fever 2.O/E 2.O/E edema,skin edema,skin paleness or jaundice,rashespaleness or jaundice,rashes external genitaliaexternal genitalia（外生殖器）（外生殖器）joints joints for signs of arthritis-red,warm,or for signs of arthritis-red,warm,or swollen swollen abdomen:abdomen:masses or tenderness.masses or tenderness.CVA tendernessCVA tenderness enlarged kidneys enlarged kidneys.length and weight and plot on growth chart.length and weight and plot on growth chart.41.Glomerular Proteinuriapresents in 1 of 3 ways:1.Isolated Proteinuria 2.Proteinuria+Hematuria 3.Nephrotic Syndrome edema,hypoalbuminemia,hyperlipidemia 42.进一步检查w1.1.血尿、蛋白尿血尿、蛋白尿w2.2.肾功能功能w3.3.病因病因:继发肾病病?原原发肾病病w4.4.病理病理:肾活活检w5.5.并并发症症43.病因诊断继发:感染相关感染相关 免疫相关免疫相关 肿瘤相关瘤相关/淀粉淀粉样变/MM/MM 代代谢性病性病原原发性性肾病病44.病理诊断w肾活活检的适的适应症和禁忌症症和禁忌症w穿刺方法穿刺方法w常常见的病理的病理类型型w常常见的病理改的病理改变45.46.47.48.49.50.51.52.53.54.55.56.57.随随 访w无症状血尿患者无症状血尿患者每半年一次尿液分析和每半年一次尿液分析和细胞学胞学检查每两年一次膀胱每两年一次膀胱镜和静脉和静脉肾盂造影盂造影若血尿反复若血尿反复发作，随作，随访期至少期至少3 3年年58.CASE 1wA four year-old African American male is brought to your office after his parents noticed that his urine appeared dark brown or coke（焦碳）colored.59.Important questions to ask in your History 1Important questions to ask in your History 1wHas there been any signs of a UTI such as dysuria and frequency?Any suprapubic pain?wHas there been any recent URI symptoms or sore throat?wHas there been any type of skin rashes or sores?wAny abdominal pain or colicky pain?wAre the stools loose or bloody?60.Important questions to ask in your History 2Important questions to ask in your History 25.Has there been any recent trauma?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 hearing deficits?10.What medications does the child take?61.wAccording to the parents,the child was treated with Bacitracin（杆菌肽）2 weeks ago for impetigo（脓疱病）on the legs and arms?62.PhysicalExaminationFindingsandAssociatedCausesofHematuria PhysicalexaminationfindingCauseofhematuria General(systemic)examinationSeveredehydrationPeripheraledema,CardiovascularsystemMyocardialinfarctionAtrialfibrillationHypertensionAbdomenBruitGenitourinarysystemEnlargedprostatePhimosis（包茎）（包茎）Meatalstenosis（尿道狭窄）（尿道狭窄）RenalveinthrombosisNephroticsyndromevasculitisRenalarteryembolusorthrombusRenalarteryembolusorthrombusGlomerulosclerosiswithorwithoutproteinuriaArteriovenousfistulaUrinarytractinfectionUrinarytractinfectionUrinarytractinfection63.wThe patients examination was normal except for a blood pressure of 125/90 and some mild periorbital edema.64.拟诊：最可能？：最可能？其次？其次？65.拟诊：可能：可能wpost streptococcal acute glomerular nephritis(PSAGN)（急性急性链球菌感染后球菌感染后肾炎炎）secondary to a nephrogenic strain of streptococcus pyogenes w（causing impetigo 2 weeks ago）66.w进一步一步检查证实？67.进一步一步检查证实wASOwanti-DNAse B titerswBUN and Creatininewcomplement levels.68.治治疗-有助于有助于诊断断wThe child should be monitored closely paying attention：w blood pressure,wdaily weights,w urine output and po input.69.预期期结果果wThe red blood urine：w C3 complement：w预后：70.预期期结果果wThe urine may continue to contain red blood cells for many months wthe C3 complement usually returns to normal levels in 6-8 weeks.wMost of the PSAGN patients recover completely71.Common causes of hematuria in children1.1.Urinary tract infectionUrinary tract infection.Diagnosed by symptoms of burning and.Diagnosed by symptoms of burning and frequency and a positive urine culture on a properly collected frequency and a positive urine culture on a properly collected specimenspecimen 2.2.Familial benign hematuriaFamilial benign hematuria-usually asymptomatic and may have-usually asymptomatic and may have minimal proteinuria.At times the hematuria may be gross.minimal proteinuria.At times the hematuria may be gross.3.3.HypercalcuriaHypercalcuria-usually asymptomatic and may be microscopic or-usually asymptomatic and may be microscopic or gross hematuria.Do a spot urine and measure the Ca/Creatinine gross hematuria.Do a spot urine and measure the Ca/Creatinine ratio.Age related.ratio.Age related.19 mo.-6 years19 mo.-6 years is 0.42(95%)is 0.42(95%)4.4.TransientTransient-no etiology established.-no etiology established.5.5.HSPHSP-hematuria may precede the rash-hematuria may precede the rash 72.Common Causes of Gross Hematuria1.Local irritation or trauma to the perineal area 2.Reanl trauma secondary to blunt abdominal trauma or accident 3.UTIs 73.如果如果1 1wIf the patient is If the patient is asympotmaticasympotmatic and the and the physical exam is normalphysical exam is normal,and there is and there is no family historyno family history of renal disease,of renal disease,recheck the urine in a few days.dipstick is still positivecheck a spun urine for blood,casts,protein,wbcscheck a spun urine for blood,casts,protein,wbcs，bacteriabacteriaObtain a urine for Obtain a urine for cultureculture Check immediate Check immediate family membersfamily members for hematuria for hematuria Ca+/Cr.on spot urine Ca+/Cr.on spot urine CBC,platelet count,and rbc morphologyCBC,platelet count,and rbc morphology74.如果2if glomerular disease is not suspectedSome authorities suggest a renal ultrasoundto rule out structural disease and masses75.If increased blood pressure,edema,decreased urine output,casts proteinuria a total hemolytic complement and C3如果如果3 3：76.Glomerulonephritis associated with decreased C3 includea.SLE-do ANA b.Shunt nephritis c.Post streptococcus glomerulonephritis d.Membrao-proliferative glomerulonephritis e.Glomerulonephritis associated with SBE77.如果4IF with persistent blood in the urine decreased real function proteinuria hypertension.with laboratory evidence of SLE.Renal biopsyRenal biopsy78.THANK YOUSUCCESS2024/5/27 周一79.