1、內 容血尿的診斷與鑒別蛋白尿的診斷與鑒別血尿、蛋白尿腎小球疾病的診斷與鑒別2021/7/20 星期二1血尿的診斷思路確定是否是真性血尿判斷出血部位確定病變性質2021/7/20 星期二2顏 色正常時：無色澄清淡黃色琥珀色病理情況：近于無色：尿液稀釋、尿崩癥深黃色：膽紅素尿（濃茶樣尿）藥物、食物 醬油色：血紅蛋白尿(酸性)ARF乳白色： 乳糜尿、膿細胞尿紅 色： 血尿、血紅蛋白尿、肌紅蛋白尿 藥物 (聯苯胺試驗）2021/7/20 星期二3試紙法檢測：潛 血原理：試紙法 Hb有類過氧化物酶作用 催化分解過氧化物鄰聯甲苯胺氧化變色2021/7/20 星期二4 假陽性假陰性 血紅蛋白尿 肌紅蛋白尿

2、尿中強氧化劑 脫水還原劑尿 pH降低試紙預先暴露 在空氣中試紙法的局限性：2021/7/20 星期二5血尿的定義尿沉渣 Addis計數，12h紅細胞超過50萬 每高倍視野（HP）超過3個紅細胞2021/7/20 星期二6尿檢陽性是血尿嗎？2021/7/20 星期二7確定是否是真性血尿標本的可靠性污染 月經、子宮、陰道出血鑒別 容器、化驗尿標本收集的注意 晨尿 清潔中段尿 避免生殖道的污染 1小時內送檢冰箱 2021/7/20 星期二8血尿的診斷步驟確定是否是真性血尿判斷出血部位確定病變性質2021/7/20 星期二9判斷出血的部位（1）按照血尿和排尿先后的關系進行分析（通常根據尿三杯試驗來判斷

3、）：初血尿：尿道病變 終末血尿：膀胱頸部和三角區或后尿道病變全程血尿：上尿道或膀胱2021/7/20 星期二10判斷出血的部位（2）相差顯微鏡檢查紅細胞形態：均一性不均一性2021/7/20 星期二112021/7/20 星期二12腎單位血尿穿過病變腎小球基底膜時受損通過腎小管時受到管腔內: 滲透壓、PH值、代謝物質(脂肪酸/溶血卵磷脂及膽酸）)大小、形狀改變+同時合并紅細胞管型=腎單位來源例外:腎創傷、活檢、梗塞、腎皮質壞死、 劇烈運動也可有紅細胞管型2021/7/20 星期二13判斷出血的部位（3）微粒容積自動分析儀1050100150200105010015020010501001502

4、0010501001502001050100150200血紅細胞容積分布曲線非腎小球源性血尿腎小球源性血尿腎小球源性血尿混合性血尿2021/7/20 星期二14血尿的診斷步驟確定是否是真性血尿判斷出血部位確定病變性質2021/7/20 星期二15確定病變性質（1）血尿的病因泌尿生殖系統疾病全身性疾病尿路鄰近器官疾病其他原因2%98%2021/7/20 星期二161.腎單位來源(內科性): 原發、繼發、家族性2.非腎單位來源(外科性): 腫瘤、外傷、結石、畸形、血管等泌尿生殖系統疾病2021/7/20 星期二17內科性血尿查什麼?2021/7/20 星期二18內科性血尿蛋白定量管型腎功能腎活檢細

5、菌學檢查2021/7/20 星期二19外科性血尿查什麼?2021/7/20 星期二20外科性血尿1. 尿脫落細胞2. 影像學: 腹部平片 超聲波檢查 CT/MRI 3. 介入檢查: 膀胱鏡檢查 靜脈腎盂造影(排泄性尿路造影) 逆行尿路造影 腎動脈及腎靜脈造影4.鈣負荷實驗: 尿鈣4mg/kg.24h,尿鈣/肌酐0.212021/7/20 星期二21胡桃夾子現象腸系膜上動脈壓迫左腎靜脈致左腎回流障礙，淤血；從而引起血尿多發生于兒童，成年后腸系膜上動脈壓迫解除癥狀消失腸系膜上動脈左腎靜脈2021/7/20 星期二22內 容血尿的診斷與鑒別蛋白尿的診斷與鑒別血尿、蛋白尿腎小球疾病的診斷與鑒別2021

6、/7/20 星期二23正常尿蛋白150mg/24h組成: 60%濾過血漿蛋白 40%白蛋白, 15%免疫蛋白 5%其他血漿蛋白 40% Tamm-Horsfall蛋白2021/7/20 星期二24失去大小選擇性屏障理論上GBM濾過孔孔徑加大，長度縮短單位面積GBM上孔密度增加以上兩項均有失去電荷選擇性屏障GBM失去帶陰電荷的分子(糖蛋白分解增加/合成減少) 帶陽電荷的分子中陰電荷以上兩項均有蛋白尿的機理2021/7/20 星期二25腎小球濾過屏障腎小球濾過膜：內皮細胞基底膜上皮細胞系膜組織多種生理功能：參與免疫及腎小球炎癥反應病理情況下致腎小球硬化2021/7/20 星期二26蛋白尿的分類和特

7、點腎小球性蛋白尿 腎小球濾過屏障損害 2.0 g/24 h 大、中、小分子腎小管性蛋白尿 腎小管對正常濾過蛋白的重吸收障礙 2.0g/24 h，小分子溢出性蛋白尿 血漿中某種蛋白質濃度過高，經正常或異常腎小球濾出分泌性蛋白尿 遠端小管分泌：Tamm-Horsfall蛋白蛋白尿診斷方法及2021/7/20 星期二27診斷思路是否蛋白尿？尿常規持續性？一過性： 多見于少量蛋白尿（trace to 2+ protein）定量： 24小時尿蛋白定量 2g定性： SDS定位 ？2021/7/20 星期二28內 容血尿的診斷與鑒別蛋白尿的診斷與鑒別血尿、蛋白尿的診斷與鑒別診斷2021/7/20 星期二29

8、診斷層次1.血尿、蛋白尿臨床診斷2.腎功能3.病因:繼發腎病?原發腎病4.病理5.并發癥2021/7/20 星期二30診斷方法及程序病史體格檢查實驗室檢查特殊檢查隨訪2021/7/20 星期二31排除假性血尿血凝塊 血尿中混血凝塊常提示非腎小球疾患出血血尿與全身疾病及呼吸道感染的時間關系PSGN：感染后1014天出現血尿IgAN： 幾乎同時發生，一般不超過3天。家族史:耳聾、血尿、腎衰血尿伴隨癥狀腎絞痛尿路刺激癥水腫、高血壓及全身其他癥狀等病史血尿2021/7/20 星期二32Onset when began with conditions identified around the init

9、ial presentation, i.e., drug ingestion record of previous urinalyses precipitation/palliation identification of triggering agents infectious, drugs, foods, chemicals, vaccinations helps to identify acquired forms of tubulointerstitial proteinuria 蛋白尿問診2021/7/20 星期二33quality associated with hematuria

10、 severity ： pathologic if associated with hematuria or Nephrotic Syndrome likely to be a primary GN unlikely to be benign etiology or secondary GN timing acute vs acute-on-chronic intermittent vs persistent duration of proteinuria 2021/7/20 星期二34associated symptoms past medical history functional in

11、quiry Specific Entities helps to differentiate acute GN from chronic GN identify overload proteinuria causes 2021/7/20 星期二351. History of Presenting Illnessat the end of the history, one should be able to discern: 1. benign vs pathologic proteinuria (if pathologic then) 2. glomerular vs tubulointers

12、titial proteinuria (if glomerular then) 3. hereditary vs non-hereditary (if non-hereditary then) 4. acute GN vs chronic GN (if chronic then) 5. primary GN vs secondary GN 6. nephrotic vs non-nephrotic proteinuria 7. proteinuria with or without hematuriauria 2021/7/20 星期二36病史功能性病理性 腎小球性 腎小管、間質性 溢出性 分

13、泌性隱匿性腎炎綜合征急性腎炎綜合征慢性腎炎綜合征急進性腎炎綜合征腎病綜合征2021/7/20 星期二372. Family Historyhelps to differentiate hereditary from non-hereditary : 1. Proteinuria family members must have had previous urinalysis to ascertain this 2. Renal Disease Polycystic Kidney Disease Nephrotic Syndrome, Fanconi Disease renal dialysis

14、 kidney transplantation 3. Others：hearing/ocular impairment (Alport Syndrome) 2021/7/20 星期二38PE? Lab? More information2021/7/20 星期二393 Physical Examination1. Vitals hypertension, fever 2. O/E edema, skin paleness or jaundice, rashes external genitalia（外生殖器） joints for signs of arthritis-red, warm, o

15、r swollen abdomen: masses or tenderness. CVA tenderness enlarged kidneys. length and weight and plot on growth chart.2021/7/20 星期二40Glomerular Proteinuriapresents in 1 of 3 ways: 1. Isolated Proteinuria 2. Proteinuria + Hematuria 3. Nephrotic Syndrome edema, hypoalbuminemia, hyperlipidemia 2021/7/20

16、 星期二41進一步檢查1.血尿、蛋白尿2.腎功能3.病因:繼發腎病?原發腎病4.病理:腎活檢5.并發癥2021/7/20 星期二42病因診斷繼發: 感染相關 免疫相關 腫瘤相關/淀粉樣變/MM 代謝性病原發性腎病2021/7/20 星期二43病理診斷腎活檢的適應癥和禁忌癥穿刺方法常見的病理類型常見的病理改變2021/7/20 星期二442021/7/20 星期二452021/7/20 星期二462021/7/20 星期二472021/7/20 星期二482021/7/20 星期二492021/7/20 星期二502021/7/20 星期二512021/7/20 星期二522021/7/20 星

17、期二532021/7/20 星期二542021/7/20 星期二552021/7/20 星期二56隨訪無癥狀血尿患者每半年一次尿液分析和細胞學檢查每兩年一次膀胱鏡和靜脈腎盂造影若血尿反復發作，隨訪期至少3年2021/7/20 星期二57CASE 1A 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. 2021/7/20 星期二58Important quest

18、ions to ask in your History 1Has there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? Has there been any recent URI symptoms or sore throat? Has there been any type of skin rashes or sores? Any abdominal pain or colicky pain? Are the stools loose or bloody? 2021/7/20 星期二

19、59Important 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

20、deficits? 10.What medications does the child take? 2021/7/20 星期二60According to the parents, the child was treated with Bacitracin（桿菌肽） 2 weeks ago for impetigo（膿皰病 ）on the legs and arms? 2021/7/20 星期二61Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Caus

21、e of hematuria General (systemic) examinationSevere dehydrationPeripheral edema, Cardiovascular system Myocardial infarctionAtrial fibrillationHypertension AbdomenBruit Genitourinary systemEnlarged prostate Phimosis （包莖）Meatal stenosis（尿道狹窄）Renal vein thrombosisNephrotic syndrome vasculitisRenal art

22、ery embolus or thrombus Renal artery embolus or thrombusGlomerulosclerosis with or without proteinuria Arteriovenous fistulaUrinary tract infectionUrinary tract infection Urinary tract infection2021/7/20 星期二62The patients examination was normal except for a blood pressure of 125/90 and some mild per

23、iorbital edema. 2021/7/20 星期二63擬診：最可能？ 其次？2021/7/20 星期二64擬診：可能post streptococcal acute glomerular nephritis(PSAGN) （急性鏈球菌感染后腎炎）secondary to a nephrogenic strain of streptococcus pyogenes （causing impetigo 2 weeks ago） 2021/7/20 星期二65進一步檢查證實？2021/7/20 星期二66進一步檢查證實ASOanti-DNAse B titersBUN and Creatin

24、inecomplement levels.2021/7/20 星期二67治療-有助于診斷The child should be monitored closely paying attention ： blood pressure, daily weights, urine output and po input. 2021/7/20 星期二68預期結果The red blood urine ： C3 complement ：預后：2021/7/20 星期二69預期結果The urine may continue to contain red blood cells for many mont

25、hs the C3 complement usually returns to normal levels in 6-8 weeks. Most of the PSAGN patients recover completely2021/7/20 星期二70Common causes of hematuria in childrenUrinary tract infection. Diagnosed by symptoms of burning and frequency and a positive urine culture on a properly collected specimen

26、Familial benign hematuria- usually asymptomatic and may have minimal proteinuria. At times the hematuria may be gross. Hypercalcuria- usually asymptomatic and may be microscopic or gross hematuria. Do a spot urine and measure the Ca/Creatinine ratio. Age related. 19 mo.-6 years is 0.42(95%) Transien

27、t- no etiology established. HSP- hematuria may precede the rash 2021/7/20 星期二71Common Causes of Gross HematuriaLocal irritation or trauma to the perineal area Reanl trauma secondary to blunt abdominal trauma or accident UTIs 2021/7/20 星期二72如果1If the patient is asympotmatic and the physical exam is normal, and there is no family history of renal disease