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肾脏生理机能
主要的功能有三:
1.再吸收氨基酸,葡萄糖,
2.排出尿素,尿酸,肌酸肝,
3.维持水份,电解质,酸碱,钙,镁,磷的平衡.
4.其他的功能还包括,维他命D的代谢,renin肾素的合成和分泌,红血球的生成(合成erythropoietin红血球生成素).
人的肾脏纵切面图
肾元的结构
Functions of Kidney
1) They regulate the concentration of many
solutes_ in the extracellular fluids..
_2) They eliminate waste products.
_3) They control the concentration of the urine.
4) They play an important role in pH control.
5) They secrete hormones which regulate
erythrocyte production, Vitamin D3
production__and blood pressure.
肾脏病的分类
一.肾丝球肾炎
二.肾小管间质性肾炎
三.急性肾功能不全
四.慢性肾功能不全
依肾脏衰退情况可分为四种程度 :
一,肾功能仅有正常的50%时
二,肾功能不全 : 肾功能约正常的
25%至 50% .
三,肾功能约正常的10%至25%时称为肾衰竭.
四,尿毒症,肾功能仅及正常的10%以下.
肾脏病常见的症状或病徵
1.尿量异常 :乏尿,多尿 , 频尿
2.血尿
3.蛋白尿
4.浮肿
5.高血压
6.尿毒症
Renal Function Tests
肾脏功能的评估
尿液分析: proteinuria,hematuria.pyeuria…
肾丝球过滤率: Creatinine clearance rate;
Inulin or PAH clearance rate
肾小管功能: Phenolsulfonphthalein dye test,
Beta2-microglobulin, Osmolality
Urinalysis
Purpose
Estiment of renal funtion, urinary tract disorders.
Metabolites in urine may reveal the systemic disease especially in liver disease, and toxicology, uremia.
Eg. proteinuria-glomerulonephritis, nephrotic syndrome.
glucosuria-diabetes mellitus.
pyuria-urinary tract or kidney infection.
hematuria-stone, T.B.kidney, tumor, acute glomerulonephritis.
Urinalysis
Why the Urinalsysis is important
Some disease have gone unnoticed.
It is cost effective.
It is easy to do and quickly.
Urinalysis
1.Summary of urine collection
First morning urine
Random urine
Postprandial urine
2 hr interval urine
p.s. Decomposition of urine begins within 30 min at room temperature, and 4 hrs at refrigeration. For long term storage, boric acid, Thymol can be used as preservative.
Urinalysis
2.Physical finding
Color
light brown-Urochrome
Gross red-hematuria, hemoglobinuria
Deep brown-Bilirulin
Dark brown-Delayed hemoglobinuria
Black-Alkaptonuria (Homogentisic acid oxidase def.)
Turbidity:Normally clear and transparent
Chyluria—Filariasis or lyphnode obst.
Lipiduria—nephrotic sydrome
Pyeuria—Infection
Volume:Normally 1000~1500 mL
Polyuria-more than 2000 mL
Oligouria-less than 500 mL
Anuria-less than 100 mL
Urine color
Urinalysis
3. Chemical testing
Protein: proteinuria, microalbuminuria, posture proteinuria, Bence Jones P.
Sugar: Glucosuria vs. mellituria
Ketone bodies: Diabetes and non diabetes ketonuria.
Bilirubin and urobilinogen: Differentiation of Jaundice
Porphobilnogen and Porphyrins: Porphyuria and lead poisoning.
Occult blood: Hematuria and Hemoglobinuria (Hb-uria), myglobin uria
Nitrite: Bacteria can reduce urinary nitrate to nitrite.
Leukocyte esterase: An indicator of increased WBC in urine.
Vit. C(Ascorbic acid): It inhibits reading of glucose, bilrubin, nitrite…etc.
pH: Normal 6.0, range 5.0~8.0
Multitest urine strip
Automatic urine chemistry analyzer
Normal protein in Urine
Source:Plasma filtrate and nephron secretion (Tamm-Horsfall protein)
Amount:150 mg/24hrs or 10 mg/dL
Bromophenol blue used as indicator for albumin but not good for globulin and Bence-Jones protein.
Heat denaturation or sulfosalicylic acid ppt. can be used.
Proteinuria
Prerenal
Hb-uria
Myo-uria
Bence Jones P.
Proteinuria
Renal
Postrenal
Glomerular P.
Tubular P.
Stones
Cystitis
Tumors
Glucosuria
Normally less than 0.1%glucose or <130 mg/24hrs in urine.
Glucose oxidase reaction used for detection of glucose in urine.
Mellituria indicates some reducing sugar ( galatose, fructose) in urine of newborn and infants.
Clinitest can detect most reducing sugar include glucose.
Ketoacidosis
Ketone bodies contains acetone, acetoacetic acid and beta-hydroxybutyric acid.
Diabetes ketosis and starvation can produce ketone bodies.
Ketone bodies are very acidic in plasma and in urine.
Ketoacidosis makes blood pH4hrs), the bacteria can reduce urinary nitrate to nitrite which can be detected by Na-nitroprusside reaction.
Nitrite(-) and WBC esterase (-) can rule out urinary infection.
4 Sediments in normal urine
+
Microorgaisms:
Bacteria
Fungi(yeasts)
+ present in both men and women
Spermatozoa
Variable
Crystal in acid, neutral, or basic urine
0-1/hpf
0-2/hpf
Variable/hpf
Epithelial cells
Renal
Transitional
Squamous
Variable
Mucus
0-2/lpf
0-1/lpf
Casts:
Hyaline
Granular
0-2/hpf
3-5/hpf
Blood cells:
Red blood cells
White blood cells
Quality
Sediment
Hematuria
无痛血尿 painless hematuria
肾癌
多囊肾 Polycystic kidney
外力伤害 Post-traumatic damage
运动血尿 Postexercise hematuria
肾结核 Kidney tuberculosis
膀胱癌 Bladder tumor
痛血尿 painful hematuria
肾结石
RBC's in urine
Refractile disks
Hypertonicity
Dismorphic RBC's
WBC's in urine
Lobe nuclei
Refactile cytoplasmic granules
Leukocyte in Urine(with cytospin tech.)
WBC in Urine (without cytospin tech.)
Casts Formation
Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation.
Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells.
The Tamm-Horsfall protein secretion (green dots) is illustrated in the diagram below, forming a hyaline cast in the collecting duct.
Hyaline casts
Very pale and slightly refractile, are common findings in urine
Granular casts
There are granular casts with a roughly rectangular shape
Granular cast
Casts which persist may break down, so that the cell forming it are degenerated into granular debris, as has occurred in this granular cast
Renal tubular cell cast
This renal tubular cell cast suggests injury to the tubular epithelium
Waxy cast
This is a broad
The edges are sharp and there are "Cracks" in this cast
Fat in urine
Oval fat bodies consist of degenerated tubular cells containing abundant lipid
Fat in urine (under polarized light)
Oval fat bodies demostrate the "Maltese cross" appearance
Squamous epithelial cells
Large polygonal Squamous epithelial cells with small nuclei are seen here
Oxalate crystals
Look like little envelopes (or tetrahedrons)
Triple phosphate crystals
Look like rectangles or coffin lids, if you are feeling depressed
Cystine crystals
Shaped like "stop" signs
Quite rare
Diseases State Related to Urinary Findings
Edema,hypertention,anemia,
oligouria
Red blood cells, white blood cells, proteinuria(.2.5g/dL), granular casts and cellular casts.
Chronic Glomerulonephritis
Nephrotic syndrome
Smoky urine
Edema,hypertention
Red blood cell casts, white blood cells, proteinuria (<1.0g/dL), granular casts
Acute Glomerulonephritis
Flank pain
Ossasionally gross hematuria
Renal calculi
Urgency, frequency dysuria
Cloudy urine and
foul smelling
Bacteriuria No casts
White blood cells especially in clumps
Proteinuria (mild <0.5g/dL)
Nitrite and leucocyte esterase (+)
Cystitis /pyelonephritis
History of trauma to region of kidney
Hematuria varing from microscopic to gross
Trauma
Vigorous exercise
Microscopic hematuria, mild proteinuria cylindruria.
Exercise
Clinical Features
Urinary findings
Disease State
22岁男性病人有急性肾丝球肾炎(Acute glomerulonephritis)病史,血压130/84mmHg ,没有水肿,有轻微的蛋白尿.五年后,出现下肢水肿,实验室检查结果如下:
RBC in urine (0~1) :8~10/HPF
Albumin in urine (neg) : 4+
Total serum protein (6~8) : 7.6 gm/dL
Serum albumin (3.5~5.0) : 2.0 gm/dL
24-hrs urine protein(0~150) : 829 mg/24hrs
Cholesterol in serum(125~200) :483 mg/dL
Urine protein electrophoresis:
Urine protein electrophoresis
8888888
88888888888
99999999999
999999999999
Urine protein electrophoresis
Serum protein electrophoresis
Question:
1.Lab data 显示什麼诊断
The high urine protein, low serum albumin,and hyperlipidemia are consistent with Nephrotic syndrome.
2.Urine sediment预料会出现什麼东西
Granular and wexy casts and oval fat bodies can be found in urine sediment.
3.如何进一步评估肾脏排泄功能
Serum blood urea nitrogen (BUN):40 mg/dL(8~20)
Creatinine : 3.0 mg/dL (0.5~1.5)
Creatinine clerance rate (Ccr):80 cc/min.(97~137)
Creatinine clearance rate(Ccr)
Ccr = (Ucreatinine x V) / Pcreatinine
Creatinine is an endogenous substance
filtered exclusively by the glomeruli.
CCR test is th ebest laboratory test to detect mild glomerular damage.
24Hrs. Urine collection is a big problem.
Normal reference range : 70~130ml/min
when < 50 ml/min,it means low renal function.
肾小管功能评估
Phenolsulfonphthalein(PSP) dye test: PSP is an exogenous substance to assess tulular secretory function. It is injected into the patient and the amount secreted into yhe urine is tested at 15 min. interval.
The PSP tast reflect the renal plasma flow and the tubular secretory function.
Renal excretory function
Osmolality and Specific gravity:
Osmolality: 290+/- 10 mOsm/kg H2O
Specific gravity: 1.007~1.020
They reflect the concentration ability of kidney.
Impairment of this ability leads to nocturia and polyuria
59754
·上一篇：急性肾盂肾炎CP(职员用)
·下一篇：拯救八千万糖尿病患者
主要的功能有三:
1.再吸收氨基酸,葡萄糖,
2.排出尿素,尿酸,肌酸肝,
3.维持水份,电解质,酸碱,钙,镁,磷的平衡.
4.其他的功能还包括,维他命D的代谢,renin肾素的合成和分泌,红血球的生成(合成erythropoietin红血球生成素).
人的肾脏纵切面图
肾元的结构
Functions of Kidney
1) They regulate the concentration of many
solutes_ in the extracellular fluids..
_2) They eliminate waste products.
_3) They control the concentration of the urine.
4) They play an important role in pH control.
5) They secrete hormones which regulate
erythrocyte production, Vitamin D3
production__and blood pressure.
肾脏病的分类
一.肾丝球肾炎
二.肾小管间质性肾炎
三.急性肾功能不全
四.慢性肾功能不全
依肾脏衰退情况可分为四种程度 :
一,肾功能仅有正常的50%时
二,肾功能不全 : 肾功能约正常的
25%至 50% .
三,肾功能约正常的10%至25%时称为肾衰竭.
四,尿毒症,肾功能仅及正常的10%以下.
肾脏病常见的症状或病徵
1.尿量异常 :乏尿,多尿 , 频尿
2.血尿
3.蛋白尿
4.浮肿
5.高血压
6.尿毒症
Renal Function Tests
肾脏功能的评估
尿液分析: proteinuria,hematuria.pyeuria…
肾丝球过滤率: Creatinine clearance rate;
Inulin or PAH clearance rate
肾小管功能: Phenolsulfonphthalein dye test,
Beta2-microglobulin, Osmolality
Urinalysis
Purpose
Estiment of renal funtion, urinary tract disorders.
Metabolites in urine may reveal the systemic disease especially in liver disease, and toxicology, uremia.
Eg. proteinuria-glomerulonephritis, nephrotic syndrome.
glucosuria-diabetes mellitus.
pyuria-urinary tract or kidney infection.
hematuria-stone, T.B.kidney, tumor, acute glomerulonephritis.
Urinalysis
Why the Urinalsysis is important
Some disease have gone unnoticed.
It is cost effective.
It is easy to do and quickly.
Urinalysis
1.Summary of urine collection
First morning urine
Random urine
Postprandial urine
2 hr interval urine
p.s. Decomposition of urine begins within 30 min at room temperature, and 4 hrs at refrigeration. For long term storage, boric acid, Thymol can be used as preservative.
Urinalysis
2.Physical finding
Color
light brown-Urochrome
Gross red-hematuria, hemoglobinuria
Deep brown-Bilirulin
Dark brown-Delayed hemoglobinuria
Black-Alkaptonuria (Homogentisic acid oxidase def.)
Turbidity:Normally clear and transparent
Chyluria—Filariasis or lyphnode obst.
Lipiduria—nephrotic sydrome
Pyeuria—Infection
Volume:Normally 1000~1500 mL
Polyuria-more than 2000 mL
Oligouria-less than 500 mL
Anuria-less than 100 mL
Urine color
Urinalysis
3. Chemical testing
Protein: proteinuria, microalbuminuria, posture proteinuria, Bence Jones P.
Sugar: Glucosuria vs. mellituria
Ketone bodies: Diabetes and non diabetes ketonuria.
Bilirubin and urobilinogen: Differentiation of Jaundice
Porphobilnogen and Porphyrins: Porphyuria and lead poisoning.
Occult blood: Hematuria and Hemoglobinuria (Hb-uria), myglobin uria
Nitrite: Bacteria can reduce urinary nitrate to nitrite.
Leukocyte esterase: An indicator of increased WBC in urine.
Vit. C(Ascorbic acid): It inhibits reading of glucose, bilrubin, nitrite…etc.
pH: Normal 6.0, range 5.0~8.0
Multitest urine strip
Automatic urine chemistry analyzer
Normal protein in Urine
Source:Plasma filtrate and nephron secretion (Tamm-Horsfall protein)
Amount:150 mg/24hrs or 10 mg/dL
Bromophenol blue used as indicator for albumin but not good for globulin and Bence-Jones protein.
Heat denaturation or sulfosalicylic acid ppt. can be used.
Proteinuria
Prerenal
Hb-uria
Myo-uria
Bence Jones P.
Proteinuria
Renal
Postrenal
Glomerular P.
Tubular P.
Stones
Cystitis
Tumors
Glucosuria
Normally less than 0.1%glucose or <130 mg/24hrs in urine.
Glucose oxidase reaction used for detection of glucose in urine.
Mellituria indicates some reducing sugar ( galatose, fructose) in urine of newborn and infants.
Clinitest can detect most reducing sugar include glucose.
Ketoacidosis
Ketone bodies contains acetone, acetoacetic acid and beta-hydroxybutyric acid.
Diabetes ketosis and starvation can produce ketone bodies.
Ketone bodies are very acidic in plasma and in urine.
Ketoacidosis makes blood pH4hrs), the bacteria can reduce urinary nitrate to nitrite which can be detected by Na-nitroprusside reaction.
Nitrite(-) and WBC esterase (-) can rule out urinary infection.
4 Sediments in normal urine
+
Microorgaisms:
Bacteria
Fungi(yeasts)
+ present in both men and women
Spermatozoa
Variable
Crystal in acid, neutral, or basic urine
0-1/hpf
0-2/hpf
Variable/hpf
Epithelial cells
Renal
Transitional
Squamous
Variable
Mucus
0-2/lpf
0-1/lpf
Casts:
Hyaline
Granular
0-2/hpf
3-5/hpf
Blood cells:
Red blood cells
White blood cells
Quality
Sediment
Hematuria
无痛血尿 painless hematuria
肾癌
多囊肾 Polycystic kidney
外力伤害 Post-traumatic damage
运动血尿 Postexercise hematuria
肾结核 Kidney tuberculosis
膀胱癌 Bladder tumor
痛血尿 painful hematuria
肾结石
RBC's in urine
Refractile disks
Hypertonicity
Dismorphic RBC's
WBC's in urine
Lobe nuclei
Refactile cytoplasmic granules
Leukocyte in Urine(with cytospin tech.)
WBC in Urine (without cytospin tech.)
Casts Formation
Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation.
Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells.
The Tamm-Horsfall protein secretion (green dots) is illustrated in the diagram below, forming a hyaline cast in the collecting duct.
Hyaline casts
Very pale and slightly refractile, are common findings in urine
Granular casts
There are granular casts with a roughly rectangular shape
Granular cast
Casts which persist may break down, so that the cell forming it are degenerated into granular debris, as has occurred in this granular cast
Renal tubular cell cast
This renal tubular cell cast suggests injury to the tubular epithelium
Waxy cast
This is a broad
The edges are sharp and there are "Cracks" in this cast
Fat in urine
Oval fat bodies consist of degenerated tubular cells containing abundant lipid
Fat in urine (under polarized light)
Oval fat bodies demostrate the "Maltese cross" appearance
Squamous epithelial cells
Large polygonal Squamous epithelial cells with small nuclei are seen here
Oxalate crystals
Look like little envelopes (or tetrahedrons)
Triple phosphate crystals
Look like rectangles or coffin lids, if you are feeling depressed
Cystine crystals
Shaped like "stop" signs
Quite rare
Diseases State Related to Urinary Findings
Edema,hypertention,anemia,
oligouria
Red blood cells, white blood cells, proteinuria(.2.5g/dL), granular casts and cellular casts.
Chronic Glomerulonephritis
Nephrotic syndrome
Smoky urine
Edema,hypertention
Red blood cell casts, white blood cells, proteinuria (<1.0g/dL), granular casts
Acute Glomerulonephritis
Flank pain
Ossasionally gross hematuria
Renal calculi
Urgency, frequency dysuria
Cloudy urine and
foul smelling
Bacteriuria No casts
White blood cells especially in clumps
Proteinuria (mild <0.5g/dL)
Nitrite and leucocyte esterase (+)
Cystitis /pyelonephritis
History of trauma to region of kidney
Hematuria varing from microscopic to gross
Trauma
Vigorous exercise
Microscopic hematuria, mild proteinuria cylindruria.
Exercise
Clinical Features
Urinary findings
Disease State
22岁男性病人有急性肾丝球肾炎(Acute glomerulonephritis)病史,血压130/84mmHg ,没有水肿,有轻微的蛋白尿.五年后,出现下肢水肿,实验室检查结果如下:
RBC in urine (0~1) :8~10/HPF
Albumin in urine (neg) : 4+
Total serum protein (6~8) : 7.6 gm/dL
Serum albumin (3.5~5.0) : 2.0 gm/dL
24-hrs urine protein(0~150) : 829 mg/24hrs
Cholesterol in serum(125~200) :483 mg/dL
Urine protein electrophoresis:
Urine protein electrophoresis
8888888
88888888888
99999999999
999999999999
Urine protein electrophoresis
Serum protein electrophoresis
Question:
1.Lab data 显示什麼诊断
The high urine protein, low serum albumin,and hyperlipidemia are consistent with Nephrotic syndrome.
2.Urine sediment预料会出现什麼东西
Granular and wexy casts and oval fat bodies can be found in urine sediment.
3.如何进一步评估肾脏排泄功能
Serum blood urea nitrogen (BUN):40 mg/dL(8~20)
Creatinine : 3.0 mg/dL (0.5~1.5)
Creatinine clerance rate (Ccr):80 cc/min.(97~137)
Creatinine clearance rate(Ccr)
Ccr = (Ucreatinine x V) / Pcreatinine
Creatinine is an endogenous substance
filtered exclusively by the glomeruli.
CCR test is th ebest laboratory test to detect mild glomerular damage.
24Hrs. Urine collection is a big problem.
Normal reference range : 70~130ml/min
when < 50 ml/min,it means low renal function.
肾小管功能评估
Phenolsulfonphthalein(PSP) dye test: PSP is an exogenous substance to assess tulular secretory function. It is injected into the patient and the amount secreted into yhe urine is tested at 15 min. interval.
The PSP tast reflect the renal plasma flow and the tubular secretory function.
Renal excretory function
Osmolality and Specific gravity:
Osmolality: 290+/- 10 mOsm/kg H2O
Specific gravity: 1.007~1.020
They reflect the concentration ability of kidney.
Impairment of this ability leads to nocturia and polyuria
59754
·上一篇：急性肾盂肾炎CP(职员用)
·下一篇：拯救八千万糖尿病患者
