23 renal disease

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  • 世纪之交,糖尿病的治疗观念发生了巨大变化,以往糖尿病的诊断标准、随访指标和疗效评估主要依据空腹血糖,但随着 UKPDS 等大规模临床研究结果公布于世,人们逐渐认识到餐后高血糖的重要性。从只重视空腹血糖到更注重餐后血糖是内分泌学术界认识上的飞跃,是治疗观念的更新。 下面我们复习近年来有关餐后血糖的文献,从多个层面讨论餐后血糖的重要性。
  • The glomerulus is formed by the Invagination of the tuft of capilleries into dilated blind end of a nephron
  • The glomerulus is formed by the Invagination of the tuft of capilleries into dilated blind end of a nephron
  • The glomerulus is formed by the Invagination of the tuft of capilleries into dilated blind end of a nephron. They are supplied by the afferent arterioles and drained by the efferent artioles.
  • dilated blind end of a nephron
  • Be made up of three layers
  • Amylosis, multiple myeloma
  • More than 3 red blood cells per high-power field
  • mass
  • 23 renal disease

    1. 1. General Concept of Renal Diseases Department of Nephrology,the First Affiliated Hospital , Sun Yat-sun University Qiongqiong Yang [email_address]
    2. 2. outline <ul><li>Anatomy and function </li></ul><ul><li>Physiology functions of Kidney </li></ul><ul><li>Clinical Manifestations of Renal Diseases </li></ul><ul><li>Ur ination disorders </li></ul><ul><li>Estimation of renal function </li></ul><ul><li>Clinic syndromes of urinary diseases </li></ul>
    3. 3. Anatomy <ul><li>Retroperitoneally posterior part of the abdomen </li></ul><ul><li>Either side of the vertebral column </li></ul><ul><li>Right kidney is one vertebral body lower than the left. </li></ul>Right
    4. 4. Anatomy Renal Function Remove wastes Maintain homeostasis Secrete EPO Diagram of a bisected kidney
    5. 5. Afferent arteriole Efferent arteriole Capillary loops
    6. 6. Anatomy-nephron <ul><li>Functional unit of kidney </li></ul><ul><li>1,000,000 nephrons each kidney </li></ul>Renal corpuscle ( 肾小体 ) Renal tubule <ul><li>Glomerulus </li></ul><ul><li>Bowman’s Capsule </li></ul><ul><li>Proximal tubule </li></ul><ul><li>Loop of Henle </li></ul><ul><li>Distal tubule </li></ul><ul><li>Collecting duct </li></ul><ul><li>visceral epithelium </li></ul><ul><li>Bowman space </li></ul><ul><li>parietal epithelium </li></ul>
    7. 7. Formed by the Invagination of the tuft of capilleries into dilated blind end of a nephron Afferent arteriole Efferent arteriole Bowman’s Capsule Basement membrane Visceral Epithelium(Podocyte) Parietal Epithelium Capillary loops Bowman’s Space Endothelial cells Stucture of renal glomerulus Mesangial matrix and cell Basement membrane
    8. 8. View of glomerulus by scanning electron microscope Afferent arteriole Efferent arteriole The Invagination of the tuft of capilleries into dilated blind end of a nephron
    9. 9. Ultramicroscopic Stucture of glomerullar Capillaries Filtration Mem
    10. 10. Glomerular Filtration Barrier
    11. 11. Glomerular Anatomy Capillary Lumen Endothelial cell Glomerular basement membrane Epithelial Cell of Bowman’s capsule Epithelial Foot process Electron micrograph Capillary Lumen 毛细血管腔 Endothelial cell of the glomerular capillary Podocytes
    12. 12. 1. Each kidney contains 1.0 × 10 6 nephrons 2.About 25% of the cardiac output perfuses the kidneys (only 0.5% of body mass) 3. possess abundant microvascular networks 4. countercurrent multiplication of renal tubule Anatomic features of Kidney
    13. 13. <ul><li>Filtration: excreting metabolic waste and water </li></ul><ul><li>Reabsorption: control of water and electronic balance </li></ul><ul><li>Endocrinology: producing hormones such as EPO, renin, angiotension </li></ul>Physiology functions of Kidney
    14. 14. Clinical Manifestations of Renal Diseases <ul><li>Edema </li></ul><ul><li>Renal Hypertension </li></ul><ul><li>Flank pain & renal colic </li></ul><ul><li>urethral stimulate symptom </li></ul>
    15. 15. Edema <ul><li>Decreased urinary sodium and water excretion </li></ul><ul><li>Humoral factor (RAS) </li></ul><ul><li>Hypoalbuminemia </li></ul><ul><li>Cardiac function insufficiency </li></ul><ul><li>Capillary permeability ↑ </li></ul>
    16. 16. Renal Hypertension <ul><li>Renal vascular & renal parenchymal hypertension </li></ul><ul><li>Volume-dependent Renin-dependent </li></ul><ul><li>Impairment of renal vasodilatation (NO) </li></ul><ul><li>Other endocrine hormones </li></ul>
    17. 17. Flank pain & renal colic <ul><li>Acute and chronic renal inflammation </li></ul><ul><li>Urinary stones (Nephrolithiasis) </li></ul><ul><li>Renal vascular embolism </li></ul><ul><li>Loin pain-Hematuria syndrome </li></ul>
    18. 18. urethral stimulate symptom <ul><li>dysuria (burning or discomfort on urination), frequency </li></ul><ul><ul><li>Infectious or noninfectious stimulate </li></ul></ul><ul><ul><li>Decreased volume of bladder </li></ul></ul><ul><ul><li>Disorder of cystic nerve function </li></ul></ul>
    19. 19. Urination disorders <ul><li>Abnormalities of urine volume </li></ul><ul><li>Proteinuria </li></ul><ul><li>Hematuria </li></ul><ul><li>Cast urine </li></ul><ul><li>Pyuria, bacteriuria </li></ul>
    20. 20. Abnormalities of urine volume <ul><li>Oliguria (<400ml/d or 17ml/h) & anuria (<100ml/d) </li></ul><ul><li>Polyuria (>2500ml/d) </li></ul><ul><ul><ul><li>water diuresis </li></ul></ul></ul><ul><ul><ul><li>solute diuresis </li></ul></ul></ul><ul><ul><ul><li>water-solute (Mix) diuresis </li></ul></ul></ul><ul><li>Nocturia(UV 8pm-8am  UV day ;frequency  3) </li></ul><ul><ul><li>renal failure </li></ul></ul><ul><ul><li>urination nocturia: edema </li></ul></ul><ul><ul><li>psychogenic nocturia </li></ul></ul>
    21. 21. Proteinuria <ul><li>More than 150mg/24h </li></ul><ul><li>Differentiate physiologic or pathologic original </li></ul><ul><li>The features of physiologic proteinuria </li></ul><ul><ul><li>transient ,from stress(acute illness,exercise) </li></ul></ul><ul><ul><li>small amount </li></ul></ul><ul><ul><li>disappear after the causes relief </li></ul></ul><ul><li>pathologic proteinuria :persistent, large </li></ul><ul><ul><li>glomerular proteinuria </li></ul></ul><ul><ul><li>tubular Proteinuria </li></ul></ul><ul><ul><li>Abnormal proteinuria: overflow or tissue secretion </li></ul></ul>
    22. 22. Proteinuria Parameter Glomerular Tubulointerstitial Amount MW of Protein Massive>++ >1.5~2.0g/d Large/Medium/Small: Selective: mostly albumin;MCD Nonselective: FSGS,diabetes Small amount<2+ <1.0g/d Small: Tam-Horsfall,B2-microglobulin Abnormal proteinuria: Light chains (  ,  );Bence-Jones proteins Plasma cell dyscrasias
    23. 23. Proteinuria <ul><li>Urinary dipstick : primary detects albumin and intact globulins; overlooking positively charged light chains of immunoglobulins. </li></ul><ul><li>Sulfosalicylic acid </li></ul><ul><li>Quantification :24-hour urine protein </li></ul><ul><ul><li>>150mg/24h abnormal;>3.5g/24h nephrotic-range </li></ul></ul><ul><ul><li>Ratio of urinary protein to creatine concentration(Upro/cr) <0.2 normal </li></ul></ul><ul><ul><ul><li>less accurate, but simple, collect a random urine sample </li></ul></ul></ul>
    24. 24. Hematuria <ul><li>Diagnosis criterion </li></ul><ul><ul><li>≥ 3RBC/HFP </li></ul></ul><ul><ul><li>≥ 8000/ml </li></ul></ul><ul><ul><li>≥ 100 × 10 3 /1hr </li></ul></ul><ul><ul><li>≥ 50 × 10 3 /12hr </li></ul></ul><ul><li>the false hematuria should be excluded </li></ul>
    25. 25. Hematuria Isomorphic nonglomerular erythrocytes Dysmorphic glomerular erythrocytes Examination of the urine sediment by a phase constrast microscope Dysmorphic glomerular erythrocytes>8000/ml, Acanthocytes 棘红细胞 >5% crenated erythrocytes 皱缩红细胞 , Acanthocytes with their typical ring-formed cell bodies with one or more blebs 水泡 of different sizes and shapes
    26. 26. Dysmorphic glomerular erythrocytes Isomorphic nonglomerular erythrocytes
    27. 27. Hematuria <ul><li>Causes of false hematuria </li></ul><ul><li>menstruous blood </li></ul><ul><li>violent exercise, fever </li></ul><ul><li>catheterization or diseases around urethral </li></ul><ul><li>hemoglobinuria or myoglobinuria </li></ul><ul><li>the influence of drug or (and) food </li></ul>
    28. 28. Hematuria <ul><li>Main causes of hematuria </li></ul><ul><li>renal parenchyma diseases </li></ul><ul><li>urinary tract abnormalities </li></ul><ul><li>hemorrhagic disorders </li></ul><ul><li>diseases around urinary tract </li></ul><ul><li>Dysmorphic hematuria is a strong evidence for glomerular hematuria </li></ul>
    29. 29. Cast urine <ul><li>hyaline cast </li></ul><ul><li>red cell cast </li></ul><ul><li>white blood cell cast </li></ul><ul><li>granular cast </li></ul>
    30. 30. red cell cast
    31. 31. Pyuria, bacteriuria <ul><li>Pyuria </li></ul><ul><li>≥ 5 wbc/HFP; ≥0.4 × 10 6 /hr;≥ 1.0 × 10 6 /12hr </li></ul><ul><li>Bacteriuria </li></ul><ul><li>bacteria can be seen /HFP </li></ul><ul><li>colony counts≥10 5 CFU /ml [colony forming unit] </li></ul><ul><li>G+ colony counts ≥ 10 3 CFU /ml </li></ul><ul><li>the false bacteriuria should be.excluded </li></ul>
    32. 34. Estimation of renal function <ul><li>Serum creatinine (Scr)test </li></ul><ul><li>Blood urea nitrogen (Bun)test </li></ul><ul><li>Clearance of creatinine (Ccr) test </li></ul><ul><ul><ul><ul><ul><li>Estimated GFR:MDRD equation; </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cockcroft-Gault Equation </li></ul></ul></ul></ul></ul>
    33. 35. 1 . MDRD ( the Modification of Diet in Renal Disease study ) equation eGFR (mL/min per 1.73 m 2 ) = 1.86 x (P Cr ) –1.154 x (age) –0.203    0.742 for female;   1.21 for African American 2 . Cockcroft-Gault equation (mL/min) =    0.85 for female Estimated GFR (eGFR) equation
    34. 36. Stage of chronic kidney disease From K-DOQI guidelines Recommendation Stage Description GFR ( ml/min ) Action 1 Kidney damage with normal or GFR   90 Diagnosis and treatment of CKD. Treatment of comormid condition. Slowing of progression. CVD risk reduction. 2 Kidney damage with mildly GRF ↓ 60-90 Estimating progression 3 Moderately GRF↓ 30-59 Evaluating and treating complications 4 Severely GRF↓ 15-29 Preparation for kidney replacement therapy 5 Kidney failure <15 Replacement (if uremia is present)
    35. 37. clinic syndromes of urinary diseases <ul><li>Acute renal failure syndrome </li></ul><ul><li>nephrotic syndrome </li></ul><ul><li>nephritic syndrome: acute rapidly progrssive GN syndrome; acute GN syndrome; chronic GN syndrome </li></ul><ul><li>isolated hematuria or(and) proteinuria </li></ul><ul><li>Chronic renal failure syndrome : uremia syndrome </li></ul><ul><li>urethral syndrome </li></ul>
    36. 38. Clinical syndromes and presentation of glomerular disease Latent GN (asymptomatic urinary abnormalities) Nephrotic syndrome Acute GN RPGN Chronic GN microscopic or Macroscopic hematuria Proteinuria Dysmorphic Glomerular erythrocytes Proteinuria>3.5g/d Hypoalbuminemia Hyperlipidemia Edema Hematuria Proteinuria (1-3g/d) ARF Edema Hypertension Red cell casts <ul><li>Rapidly deterioration of renal function </li></ul><ul><li>Hematuria, Proteinuria </li></ul><ul><li>oliguria or anuria </li></ul><ul><li>Red cell casts </li></ul><ul><li>With or without systemic symptom </li></ul><ul><li>Hematuria, Proteinuria </li></ul><ul><li>Hypertension </li></ul><ul><li>Reduced GFR </li></ul>nephritic syndrome
    37. 39. Diagnosis Clue for urinary diseases clinic syndromes of urinary diseases
    38. 40. Diagnosis Clue for urinary diseases
    39. 41. General Principles of Diagnosis
    40. 42. Renal Biopsy Processing <ul><li>The trigger mechanism is released with the pt stopping the breath </li></ul><ul><li>firing the needle into the kidney </li></ul><ul><li>Needle is immediately withdrawn </li></ul>renal biopsy material
    41. 43. Histology of GN PAS MASSON H&E PASM
    42. 44. Pathological classification of GN
    43. 45. CASE <ul><li>65 year-old, male, Smoke for 40 years </li></ul><ul><li>History: Fatigue x 3 months </li></ul><ul><li>Cough and chest pain x 2 months </li></ul><ul><li>Facial edema x 1 week </li></ul><ul><li>Physical: edema, </li></ul><ul><li>Urinalysis: protein ++++ </li></ul><ul><li>Lab Data: proteinuria 8g/d , </li></ul><ul><li>alb 24g/l, normal renal function, </li></ul><ul><ul><li>Hepatitis (-), </li></ul></ul><ul><li>Auto-immunity Ab (-) </li></ul>
    44. 46. Nephrotic syndromes
    45. 48. CASE Lung Carcinoma
    46. 49. Silver PAS
    47. 50. CASE LM-PASM:”spikes” along the GBM
    48. 51. CASE IF: IgG deposition along GBM
    49. 52. CASE EM: subepithelial electron dense material
    50. 53. Diagnosed: carcinoma related Membranous nephropathy
    51. 54. General Principle of Treatment <ul><li>Etiologic treatment </li></ul><ul><ul><li>Immunosuppressive treatment: Glucocorticoids and cyclophosphamide </li></ul></ul><ul><ul><li>MMF and cyclosporin A </li></ul></ul><ul><li>Symptomatic treatment </li></ul><ul><ul><li>Management of hypertension:130/80;125/75mmHg(Upro>1g/d) </li></ul></ul><ul><li>Control infection </li></ul><ul><li>Renal replacement therapy: PD,HD, TX </li></ul>
    52. 55. 新鲜 腹透液 透出液 管路
    53. 56. Integrated ESRD Care Residual renal function HD CCr (ml/min) 20 15 10 5 0 Time on dialysis Start time peritoneal dialysis TX PD
    54. 57. Tranæus, December 2002 Early referral of patient with CRF to renal center Pre-ESRD medical management Patient Education Program CAPD/APD as first option if medically suitable, allowing for patient choice CAPD/APD HD Transplant Adapted from Coles,G, et al. Kidney Int, 54:2234-2240, 1998 Late referral increases mortalityDe Veechi et al, PDI 1999 1 1
    55. 58. THANKS !

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