蛋白尿的診斷與注意事項(xiàng)

1、蛋白尿的診斷治療與注意事項(xiàng),,basic structurebehind two sides of peritoneum11 cm ?6 cm ? 3 cmWt. 100-140 g,腎小球旁器,（1）球旁細(xì)胞 afferent arteriole中膜內(nèi)的肌上皮樣細(xì)胞。分泌renin。 （2）系膜細(xì)胞afferent 和 efferent arteriole 之間的間質(zhì)細(xì)胞群。吞噬功能。,（3）致密斑:調(diào)節(jié)juxtaglome

2、rular cell釋放renin。,*（一）腎小球?yàn)V過(guò)率 GFR：?jiǎn)挝粫r(shí)間內(nèi)（每分鐘） 兩腎生成的原尿量。 GFR與體表面積成正比。每日濾過(guò)量是全身total plasma volume 的60倍，即kidney 每日凈化處理全身plasma 60次。,判斷腎功能的指標(biāo)---腎小球?yàn)V過(guò)率,GFR取決于：effective filtration pressure 和 filtration membrane 通透性,影響濾過(guò)率的因素

3、,filtration membraneeffective filtration pressure,濾過(guò)膜的結(jié)構(gòu) 1. 內(nèi)層－毛細(xì)血管壁的內(nèi)皮細(xì) 胞：有50～100 nm的窗孔，血細(xì)胞不能通過(guò)。 2. 中層－基膜：有4～8 nm的纖維網(wǎng)孔，蛋白質(zhì)和脂質(zhì)不能通過(guò)。（主要） 3. 外層－腎小囊的上皮細(xì)胞：裂隙膜上有4～14 nm的孔，大分子蛋白質(zhì)不能通過(guò)。,水分子,陽(yáng)離子,葡萄糖,小分子陰離子,蛋白質(zhì),,,,,,濾過(guò)膜通透作用的選擇

4、性 濾過(guò)膜的機(jī)械屏障作用：glomerular filtration membrane上大小不等的孔道，阻止大分子物質(zhì)通過(guò)。（起主要作用） 半徑3.6 nm 不能通過(guò)，如plasma globulin，fibrinogen。,有效濾過(guò)壓,有效濾過(guò)壓: 是glomerular filtration的動(dòng)力。腎小球有效濾過(guò)壓＝腎小球毛細(xì)血管血壓－（血漿膠體滲透壓＋囊內(nèi)壓）,Afferent arteriole端EFP＝45－（25＋10

5、）＝10 mmHg Efferent arteriole端EFP＝ 45－（35＋10）＝0 mmHg 由此可見(jiàn)， glomerular capillary不是全段都有濾過(guò)作用。,腎小球毛細(xì)血管壓 平均動(dòng)脈壓（舒張壓+1/3脈壓差）： BP 80～180 mmHg →腎小球毛細(xì)血管壓維持穩(wěn)定 → GFR基本不變 。 BP 40～80 mmHg →腎小球毛細(xì)血管壓↓ → 濾過(guò)壓 ↓ → GFR ↓。

6、 BP <40 mmHg → GFR 0 →無(wú)尿。 入球動(dòng)脈 和 出球動(dòng)脈 的口徑： 入球動(dòng)脈收縮→腎小球毛細(xì)血管壓↓ → 有效濾過(guò)壓 ↓ → GFR ↓。 出球動(dòng)脈收縮→腎小球毛細(xì)血管壓↑ →有效濾過(guò)壓↑ → GFR ↑ 。,腎小管和集合管的轉(zhuǎn)運(yùn)功能,包括：reabsorption、secretion、excretion,Proteinuria,What is proteinuria?,Proteinur

7、ia means the appearance of protein in the urine. 24-hour urine Microalbuminuria 30 - 150 mg Mild 150- 500 mg Moderate 500 - 1000 mg Heavy 1000 - 300

8、0 mg Nephrotic range more than 3500 mg,SIGNS AND SYMPTOMS,foamy urine edema Hypoalbuminemia and hypotension pre-renal acute renal failurehyperlipidemia Infection,Mechanisms of Proteinuria,Benign Proteinuria

9、Glomerular Proteinuria Primary or secondary glomerulopathy Tubular Proteinuria Tubular or interstitial disease Overflow Proteinuriaas in multiple myeloma secretory (post glomerular),,,Primary glomerulonephropathy,

10、- Minimal change disease MsPGNIdiopathic membranous glomerulonephritis Focal segmental glomerulonephritis Membranoproliferative glomerulonephritis IgA nephropathy,MCD,MsPGN,IgAN,IgAN,IgAN,MPGN,Secondary glomerulone

11、phropathy,Diabetes mellitus Collagen vascular disorders (e.g., lupus nephritis) Amyloidosis Preeclampsia先兆子癇Infection (e.g., HIV, hepatitis B and C, poststreptococcal illness, syphilis, malaria and endocarditis) Gas

12、trointestinal and lung cancers Lymphoma, chronic renal transplant rejection,SLE LN,淀粉樣變,DN,DN,DN,Tubular,Hypertensive nephrosclerosis Tubulointerstitial disease due to: Uric acid nephropathy Acute hypersensitivity in

13、terstitial nephritis Fanconi syndrome Heavy metals Sickle cell disease NSAIDs, antibiotics,Acute pyelonephritis,AINS,AIN,CRF,Overflow,-- Hemoglobinuria Myoglobinuria Multiple myeloma Amyloidosis,Diagnostic Evalua

14、tion of Proteinuria,Age health and family history physical examination Urinalysis Blood analysis kidney biopsy,How is proteinuria treated?,Dietary regulation Controlling hypertension is essential in reducing protei