急性肾小球肾炎讲课ppt课件.ppt

,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,1,suffered from tonsillitis,after 10 days,an eight-year-old boy,case,hematuria,edema,Childs,mothers,2,？,3,张建江 博士,郑州大学第一附属医院儿内科,急性肾小球肾炎,Acute glomerulonephritis,，,AGN,4,To be familiar with the etiology of AGN,To be familiar with the pathogenesis of AGN,To master the clinical manifestation of AGN,To master the diagnosis and treatment of AGN,To be familiar with the course and prognosis of AGN,purpose and requirement,急性肾小球肾炎,5,指一组,病因不一,，临床表现为急性起病，多有前期感染，以,血尿,为主，伴不同程度的,蛋白尿,，可有,水肿,.,高血压,或,肾功能不全,等特点的肾小球疾病。,introduction,急性肾小球肾炎,水肿,e,dema,少尿,oliguria,血尿,h,ematuria,高血压,hypertension,6,introduction,急性肾小球肾炎,绝大多数为,A,组,溶血性链球菌感染后所致，称之为,acute poststreptococcal glomerulonephritis,（,APSGN,）。,5,14,岁儿童好发。,其中以上呼吸道感染和扁桃体炎最常见，占,51%,，脓皮病或皮肤感染次之，占,25.8%,。,7,etiology,急性肾小球肾炎,其他,如葡萄球菌、肺炎球菌、麻疹病毒、流感病毒及腮腺炎病毒也可引起急性肾炎，但较,少见,。,绝大多数为,A,组,溶血性链球菌的某些致肾炎菌株,（,nephritogenic streptococci,）感染后所致,。,M,蛋白,肾炎菌株协同蛋白,内链球菌素,致肾炎菌株的抗原成分,8,pathogenesis,急性肾小球肾炎,循环免疫复合物,circulating immune complexes,原位免疫复合物,insitu immune complexes,自身免疫,autoimmunization,链球菌神经氨酸酶,（,neuraminidase,NM,）,细胞免疫,cellular immunity,非免疫因素（如激肽释放酶和前列腺素）,Y,Y,Y,+,自身抗原,9,pathogenesis,急性肾小球肾炎,Inflammation,infection,10,急性肾小球肾炎,pathology,AGN,病理模式图,proliferation of both endothelial,and mesangial cell,Infiltration of leukocytes,antigen antibody complex deposits,(humps)in the subepithelial space,Characteristic of pathology,11,急性肾小球肾炎,pathology,PASM-HE,染色 400 正常,12,pathology,急性肾小球肾炎,13,pathology,急性肾小球肾炎,14,急性肾小球肾炎,pathogenesis,antigen antibody complex,激活补体,过敏毒素,Immunologic,injury,肾小球基底膜断裂,血浆及红、白细胞渗入肾小球囊,肾小球毛细血管狭窄,闭锁,肾小球滤过率下降,水钠潴留血容量,全身毛细血管通透性,hypertension,高血压,hematuria,（血尿）,proteinuria,（蛋白尿）,cylindruria,（管型尿）,edema,水肿,oliguria,少尿,complement,cytokine,15,clinical manifestation,急性肾小球肾炎,前驱感染（,prodrome,）,-,呼吸道感染和皮肤感染,tonsillitis/cutaneous infection,*,不同感染所致,APSGN,的差异,always,3 weeks,about 10 days,latent period,Summer,autumn,Winter,spring,season,49,，,55,，,57,12,，,1,，,4,serotype of streptococci,respiratory tract infection,cutaneous infection,16,最早出现和最常见的症状,下行性,非凹陷性,急性肾小球肾炎,typical manifestation,-,水肿,edema,clinical manifestation,Edema is the most frequent and sometimes the only clinical finding.,It,may be either local or generalized.,17,急性肾小球肾炎,typical manifestation,-,尿量减少,oliguria or anuria,clinical manifestation,age,normal,urine volume,oliguria,anuria,school age,800-1400,400,30-50,preschool age,600-800,300,toddler,500-600,120/80,学龄儿,130/90,20,高血压脑病,h,ypertensive encephalopathy,急性肾小球肾炎,severe manifestation,BP,脑血管痉挛,headache,头痛,cereral edema,脑水肿,脑血管充血,vomiting,呕吐,visual disturbance,视力障碍,convulsion,惊厥,coma,昏迷,140/90mmHg,21,急性肾小球肾炎,severe manifestation,严重循环充血,severe circulatory congestion,呼吸困难,颈静脉怒张,双肺湿罗音,奔马律,肾小球滤过率,血容量,心脏负荷,呼吸心率加快,肝脏增大,水钠潴留,轻 症,加 重,22,严重循环充血,心肌泵衰竭,病因,水钠潴留，血容量,心肌泵功能,临床表现,气急、咳嗽、肺底湿罗音、肝大压痛,伴有肾炎的临床表现,左心衰：呼吸困难、双肺湿罗音,右心衰：水肿、少尿、肝增大压痛,伴有心脏原发病的临床表现,洋地黄制剂,非首选,首选,利尿剂,效好,有效,*,肾小球肾炎时循环充血与心肌泵衰竭的区别,急性肾小球肾炎,severe manifestation,23,急性肾功能不全,acute renal failure,急性肾小球肾炎,severe manifestation,GFR,anuria,oliguria,少尿或无尿,ARF,azotemia,氮质血症,metabolic,acidosis,代谢性酸中毒,electrolyte,disturbance,电解质紊乱,BUN,Cr,低钠、低钙、低氯,高钾、高镁、高磷,Fortunately,anuria or severe and persistent oliguria is usually transient,24,急性肾小球肾炎,clinical manifestation,非典型表现,atypical manifestation,急性肾炎非典型表现,肾内症状,肾外症状,实验室检查,血尿,少尿,蛋白尿,水肿,高血压,C,3,ASO,无症状性,AGN,肾外症状性,AGN,肾病综合症表现的,AGN,25,急性肾小球肾炎,clinical manifestation,严重循环充血,高血压脑病,急性肾功能不全,水肿,高血压,少尿或无尿,血尿,前驱期,症状加重,非典型表现,前,驱,感,染,无症状性,AGN,肾外症状性,AGN,肾病综合症表现的,AGN,呼吸道感染,皮肤感染,典,型,表,现,严,重,表,现,出现在疾病早期（,2,周之内）,26,laboratory examination,Urinalysis,尿常规：,RBC+,WBC +,尿蛋白,+,尿沉渣：透明、颗粒和细胞管型,;,2/3,病例,R,BC,管型,急性肾小球肾炎,27,laboratory examination,Hemogram,Anemia,WBC,增高或正常,ESR,（代表疾病活动，,23m,恢复，增高程度与疾病严重度无关）,Renal function,B,UN,、,Scr,急性肾小球肾炎,28,laboratory examination,抗链球菌抗体,ASO,（,70%,）,1014d,开始,35w,达高峰,36m,恢复,抗双磷酸吡啶核苷酸酶（,ADPNase,）,抗透明质酸酶（,ASH,）,抗链球菌,DNA,酶,B(ADNaseB),（,90%,）,急性肾小球肾炎,29,laboratory examination,Serum complement,C,3,在,2,周内，,6-8,周内恢复,Renal biopsy,病理：毛细血管内增生性肾小球肾炎,急性肾小球肾炎,30,diagnosis,典型表现诊断：,起病前,1-3,周有链球菌前驱感染,少尿、水肿、血尿、高血压,尿检查有蛋白、,RBC,和管型,血,C,3,，伴或不伴,ASO,升高,非典型表现诊断：,起病前,1-3,周有链球菌前驱感染,ASO,血,C,3,在,2,周内，,8,周内恢复,急性肾小球肾炎,31,病毒性肾炎,IgA,肾病,慢性肾炎急性发作,急进性肾炎,特发性肾病综合征,diagnosis,急性肾小球肾炎,32,diagnosis,急性肾小球肾炎,33,treatment,principle,本病为自限性疾病，无特效治疗，主要在于休息和对症治疗，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。,急性肾小球肾炎,34,treatment,休息,起病,2,周内,卧床休息,水肿消退、血压正常、血尿消失后可,下床活动,ESR,正常后（,2-3,月,）可,上学,，避免剧烈活动,Addis,计数正常后（,4-8,月,）可,正常活动,急性肾小球肾炎,35,treatment,饮食,尿少、水肿期 限盐,(60m g/kg.d),氮质血症期 限蛋白,(0.5g/kg.d),抗感染,青霉素,5,万,u/kg.d im Bid,，连用,10-14,天,红霉素,急性肾小球肾炎,36,treatment,对症处理,1,、水肿,尿少、水肿显著可口服双氢克尿噻,尿少显著伴,B,U,N,可应用速尿,2,、高血压,首选硝苯地平,，,0.2-0.3mg/Kg.,次，口服或,舌下含化，,3,次,/,日,卡托普利，初始,0.3-0.5mg/Kg.d,最大剂量,5-6mg/Kg.d,分,3,次,急性肾小球肾炎,37,treatment,四、严重病例的治疗,1,、,h,ypertensive encephalopathy,降压、止惊、脱水,降压用硝普钠：,5-20mg,硝普钠加入,5%G.S 100mL,，以,0.02mL/Kg.min,（,1,g/,k,g,）,ivgtt,；,无效可增加滴速，最快,0.16mL/,k,g.min,急性肾小球肾炎,38,treatment,2,、,severe circulatory congestion,限水、利尿、降压、强心、腹膜或 血液透析,3,、,acute renal failure,量入为出,，处理水过多、高钾血症、酸中毒,透析治疗,急性肾小球肾炎,39,Prognosis,95%,急性链球菌肾炎患儿预后良好，可完全康复。仅极少数在急性期肾损害严重、肾衰竭持续较长时间可发展为慢性肾炎和慢性肾衰竭。,急性肾小球肾炎,40,prognosis,改善居住环境，提高卫生水平，及时,治疗化脓性感染。,急性肾小球肾炎,41,选择题,患儿,9,岁,男,以浮肿、尿少一周入院。近一天头痛,呕吐,眼花,呼吸急促,发绀,端坐呼吸,测血压,160/110mmHg,心率,140,次,/,分,两肺可闻及水泡音,其紧急处理应首选,A.,利血平与地高辛,B.,利血平与抗菌素,C.,甘露醇与地高辛,D.,甘露醇与肾上腺皮质激素,E.,硝普纳与速尿,急性肾小球肾炎,42,选择题,2,急性肾小球肾炎早期,患儿血中补体多下降,其原因最主要是,A.,原发性补体合成障碍,B.,补体从尿中排出增多,C.,补体参与反应时消耗,D.,补体活性降低,难以检出,E.,以上都不是,急性肾小球肾炎,43,为什么说急性肾小球肾炎是一种非感染性疾病？,急性肾小球肾炎的典型临床表现和严重表现分别是什么？,为什么红色尿不一定是“血尿”，而“血尿”不一定是红色？,为什么急性链球菌感染后的肾小球肾炎,ASO,也不一定增高？,思考题,急性肾小球肾炎,相关英文教材,1,、,Nelson textbook of pediatrics.17th edition,2,、,end,Thank you!,