UrinarySystem

UrinarySystem泌尿系統全英文第1頁ContentCompositionAnatomyPhysiologyCommondiseaseExaminationUrinarySystem泌尿系統全英文第2頁CompositionKidneyUreterUrinarybladderUrethraUrinarySystem泌尿系統全英文第3頁Part1kidneyBean-shape:aconcaveareaontheedgetowardthecentrecalledhilum,whererenalarteryentersthekidneyandrenalveinleavesit.Theuretersalsoleavethekidneysatthehilum,leadingtothebladder.Thehumankidneysrepresentabout0.5%ofthetotalweightofthebody,butreceive20–25%ofthetotalarterialbloodpumpedbytheheart.

UrinarySystem泌尿系統全英文第4頁NephronsThefunctionalunitofthekidneyResponsiblefortheactual

purificationandfiltrationofthe

blood

Aboutonemillionnephronsareinthecortexofeachkidney

Consistsofarenalcorpuscleandarenaltubule

TherenaltubuleconsistsoftheconvolutedtubuleandtheloopofHenle

近端小管遠端小管Urineformationproceedsthrough3majorprocessesinthekidney:Glomerularfiltration-bytheglomeruli.2.Tubularreabsorptionandsecretionintherenaltubules.3.TubularsecretionUrinarySystem泌尿系統全英文第5頁nephronrenalcorpusclerenaltubuleglomerularcapsule(Bowman’scapsule)glomerulusafferentarterioleefferentarteriole腎單位腎小體腎小球Urineformationproceedsthrough3majorprocessesinthekidney: 1.Glomerularfiltration-bytheglomeruli. 2.Tubularreabsorptionandsecretionintherenaltubules. 3.TubularsecretionUrinarySystem泌尿系統全英文第6頁Workingmechanismofthekidneys:

Bloodisbroughttothekidneyviatherenalartery.Thekidneysfilterthebloodandthenreabsorbusefulmaterialssuchasglucose.Afterithasbeenpurifiedthebloodreturnstothecirculationthroughtherenalvein.UrinarySystem泌尿系統全英文第7頁NewwordsaboutkidneyGeneralEnglishRootEg.kidneyRen/oRenographySuprarenalLienorenalNephr/oNephritisHydronephrosisRenalpelvisPyel/oPyelographyPyelonephritisPelvi/opelvilithotomypelvioplastyGlomerularGlomerul/oGlomerulonephritisUrinarySystem泌尿系統全英文第8頁Part2UretersTwomusculartubeswhichconveytheurinefromtherenalpelvistotheurinarybladder.Eachmeasures20-30cminlength,0.5-0.7cmindiameter.Accordingtothecourse,eachuretercanbedividedinto3parts:

Abdominalpart

Pelvicpart

IntramuralpartThreeconstrictions:1st:atpelviuretericjunction2nd:whereuretercrossesthepelvicinletandiliacvessels3rd:atintramuralpartUrinarySystem泌尿系統全英文第9頁NewwordsabouturetersGeneralEnglishRootEg.UretersUreter/oUreteroceleUreterographyUreterostenosisUreterorrhaphyUrinarySystem泌尿系統全英文第10頁Part3UrinarybladderTheurinarybladderisahollowmuscularorgansituatedinthepelviccavityposteriortothepubicsymphysis.Intheflooroftheurinarybladderisasmall,smoothtriangulararea,thetrigone.Theuretersentertheurinarybladderneartwoposteriorpointsinthetriangle;theurethradrainstheurinarybladderfromtheanteriorpointofthetriangle.UrinarySystem泌尿系統全英文第11頁NewwordsaboouturinarybladderGeneralEnglishRootEg.UrinarybladderVesic/oIntravesicalvesicoureteralCyst/oCystitisCystographyCystoptosiscystostomyUrinarySystem泌尿系統全英文第12頁Part4Urethra

Femaleurethraisrelativelyshorter(about3-5cmlong),widerandstraighter.InternalorificeofurethraExternalorificeofurethra：(opensintovaginalvestibule)UrinarySystem泌尿系統全英文第13頁NewwordsabouturethraandurineGeneralEnglishRootEg.UrethraUrethr/oUrethritisUrethrograpyMeat/oMeatorrhaphyMeatotomyUrineUrin/oUrinogenitialUrinationUr/oHematuriaUrobilinPolyuriaAnuriaUrinarySystem泌尿系統全英文第14頁THEURINARYSYSTEMIncludingthekidneys,ureters,urethraandurinarybladder.Thekidneysaretheprimaryexcretoryinthehumanbody.Theyfunctionbyremovingtoxinsfromthebodywhilereturningnecessarycompoundsbacktothebody.Thekidneysfilterapproximately200litersoffluidfromthebodyeveryday.ThePrimaryFunctionsoftheUrinarySysteminclude:1.Filteringwasteproductsofmetabolismfromthebloodandremovingthewastesfromthebodyviatheurine；2.Responsibleforhomeostasis:Regulatethelevelofelectrolytessuchassodium,potassium,chloride,bicarbonate.MaintainthecorrectpHrangewithinthebody3.Endocrinefunction：ProducingtheenzymeReninwhichregulatesbloodpressureandproperkidneyfunctioning；ProducingthehormoneErythropoietin

（EPO）whichregulatesandstimulateserythrocytesproduction;MetabolizingvitaminDtoitsactiveform.UrinarySystem泌尿系統全英文第15頁MechanismUrinarySystemfilterandremovewasteproductsfromthebloodproductionandexcretionofurinemainfunctionresultin

UrinarySystem泌尿系統全英文第16頁UrinarysystemdiseasesUrinarySystem泌尿系統全英文第17頁

Themost

commondisease

list

Acuterenalfailure(ARF)Chronicrenalfailure(CRF)UrinarytractinfectionUrinarycalculus

PrimaryglomerulardiseaseAcuteglomerulonephritis(AGN)Chronicglomerulonephritis(CGN)Nephroticsyndrome(NS)

Akidneyinfection

AcutepyelonephritisChronicpyelonephritis

CystitisPerinephricabscess

RenaldamageinmetabolicdiseaseDiabeticnephropathyHyperuricemianephrosisUrinarySystem泌尿系統全英文第18頁

auxiliaryexaminationHowtousetheauxiliaryexamination(輔助檢驗)indiagnosisofurinarysystemdiseases?UrinarySystem泌尿系統全英文第19頁IconographyUrinalysisRenalbiopsyKidneyfunctiontestUrinarySystem泌尿系統全英文第20頁IconographyX-rayexamination：（1）Plainabdominalradiograph

（radio-放射，-graph描繪、統計，radiographX光照片）（2）Urography：

Excretoryurography

Retrogradeurography（retro-向后、倒退，

Retrograde逆行性）

SelectiverenalarteriographyCTdetection

PlainscanCTEnhancedCTMagneticResonanceImagingUltrasonography

（ultrasono-超聲）UrinarySystem泌尿系統全英文第21頁ComparationandPreference1.Urographyexaminationusefor

hydronephrosis,

ureterectasisandcongenitalanomalydetectionanddiagnosis,aswellaspreoperativeassessmentofthevalueofthecontralateralkidneyfunction.2.CTexaminationcanbeusedinthefoundingofvastmajorityoftumors,stones,cystsandotherdiseasesandcongenitalanomalies.3.MRIisoftenusedassecondaryscreeningmethodofatypicallesionsforfurtherdiagnosisanddifferentialdiagnosis.UrinarySystem泌尿系統全英文第22頁

Urinalysis1.Aurinalysis(UA),isanarrayoftestsperformedonurine,andoneofthemostcommonmethodsofmedicaldiagnosis.2.Thetargetparametersthatcanbemeasuredorquantifiedinurinalysisincludemanysubstancesandcells,aswellasotherproperties,suchasspecificgravity.3.Itisthemainbasisfordiagnosisofkidneyinjury.UrinarySystem泌尿系統全英文第23頁UrinalysisMethods1.UrineteststripLeukocytes–withpresenceinurineknownasleukocyturiaNitrite–withpresenceinurineknownasnitrituriaProtein–withpresenceinurineknownasproteinuria,albuminuria,ormicroalbuminuriaBlood–withpresenceinurineknownashematuriaspecificgravity比重UrinarySystem泌尿系統全英文第24頁Thenumbersandtypesofcellsand/ormaterialsuchasurinarycastscanyieldagreatdetailofinformationandmaysuggestaspecificdiagnosis.■Hematuria–associatedwithkidneystones,infections,tumorsandotherconditions■Pyuria–associatedwithurinaryinfections■Eosinophiluria–associatedwithallergicinterstitialnephritis,atheroembolicdisease■Redbloodcellcasts–associatedwithglomerulonephritis,vasculitis,ormalignanthypertension■Whitebloodcellcasts–associatedwithacuteinterstitialnephritis,exudativeglomerulonephritis,orseverepyelonephritis■(Heme)granularcasts–associatedwithacutetubularnecrosis■Crystalluria–associatedwithacuteuratenephropathy(oracuteuricacidnephropathy,AUAN)■Calciumoxalatin–associatedwithethyleneglycol2.MicroscopicexaminationUrinarySystem泌尿系統全英文第25頁3.OthermethodsofurinalysisUrineculture

–amicrobiologicalcultureofurinesamples,detectingbacteriuria,isindicatedwhenaurinarytractinfectionissuspected.Ictotest

–thistestisusedtodetectthedestructionofoldredbloodcellsintheurine.Hemoglobintest

–thistestsforhemolysisinthebloodvessels,aruptureinthecapillariesoftheglomerulus,orhemorrhageintheurinarysystem,whichcausehemoglobintoappearintheurine.UrinarySystem泌尿系統全英文第26頁

Renalbiopsy

Renalbiopsy,oftenusedinthediagnosisofkidneydiseases,isregardedasthegoldstandardoftheglomerulardisease.Itcannotonlyguideourtreatmentoptions,butalsotimelyreflecttheprognosisanddeterminethetherapeuticeffect.Sometimesweneedtorepeatit.UrinarySystem泌尿系統全英文第27頁

kidneyfunctiontestClearancerate:GlomerularfiltrationrateGFR

Endogenouscreatinineclearancerate，Ccr

RenalbloodflowRBFConcentration-dilutiontest（濃縮稀釋試驗）

UrinarySystem泌尿系統全英文第28頁AcuteRenalFailure（ARF）DifinitionClassificationPathogenesisDiagnosisDifferentialTreatmentPrognosisUrinarySystem泌尿系統全英文第29頁DefinitionAcuterenalfailure

（ARF）isasyndromecharacterizedbyarelativelyrapiddeclineinrenalfunctionthatleadstotheaccumulationofwater,crystalloidsolutes,andnitrogenousmetabolitesinthebody.

UrinarySystem泌尿系統全英文第30頁Classification

PrerenalAcuteRenalFailurePostrenalAcuteRenalFailureIntrarenalAcuteRenalFailure

ARFUrinarySystem泌尿系統全英文第31頁EtiologyDiabeticnephropathy

Hypertensivenephrosclerosis

Primaryorsecondaryglomerulonephritis

Tubulointerstitialdisease

（tubulo-管，tubulointerstitial小管間質性）

Renalvasculardisease（vas-血管、輸精管）Hereditarykidneydiseases

UrinarySystem泌尿系統全英文第32頁

MainMechanism

renalhemodynamicchangesrenalischemia（reperfusioncelldamage)acutetubulardamageUrinarySystem泌尿系統全英文第33頁PathogenesisDecreasedRenalbloodflowRenalischemiaIschemia-reperfusioninjuryGFRAcuterenaltubulardamageHypovolemiaTheresistanceofafferentarterioleincreasedRenalpoisoningARFUrinarySystem泌尿系統全英文第34頁PathologyofacuterenalfailureUrinarySystem泌尿系統全英文第35頁Ingeneral：nephromegaly,

kidneyispale,RenalcortexispaleandRenalmedullaisdarkred.（-megaly異常擴大，eg.Splenomegalycardiomegaly）Microscope:renaltubularepithelialcellsaredegenerative,necroticanddeciduous.Toxicantcause:Pathologicalchangesisuniformintheproximaltubule,glomerularbasementmembrane(GBM)isrelativelycomplete.Ischemiacause:Pathologicalchangesisnotuniforminmedullarythickascendinglimb

anddistalconvolutedtubule,glomerularbasementmembrane(GBM)isfractured.UrinarySystem泌尿系統全英文第36頁NephromegalynormalkidneyUrinarySystem泌尿系統全英文第37頁Theepithelialcells

of

renalproximalconvolutedtubulearehydropic（eg：Themoststrikingchangeinthetubulesishydropicdegenerationoftheepithelium.PathologicalsectionsUrinarySystem泌尿系統全英文第38頁ManifestationsofacuterenalfailureOliguricacuterenalfailure

oliguricstagediureticstagerecoverystageNonoliguricacuterenalfailure

UrinarySystem泌尿系統全英文第39頁ManifestationsofOliguricacuterenalfailure

1.TheinitialphaseTheprimarydiseaseperformance:Hypotension，Manifestationscausedby

bleeding、infection、poisonandsoon.UrinarySystem泌尿系統全英文第40頁(1)GeneralsymptomsofeachsystemThedigestivesystemdyspnea，thoracalgia

Therespiratorysystemhypertension，myocardiosisThecirculatorysystemnausea，vomitingThenervoussystemhemorrhage，anemia

Thebloodsystemuremicencephalopathycoma2.Maintenancephase

(oliguricstage)UrinarySystem泌尿系統全英文第41頁(2)Water,electrolyteandacid-basebalancedisorders①Metabolicacidosis：weak、cephalalgia、coma、arrhythmia②hyperpotassaemia(K+>5.5mmol/L)：

earlystage：nocharacteristicmanifestations.laterstage：weak、tendonreflexdisappearing、drowsiness、arrhythmia.

Hyperpotassaemiaisoneofthemostcommoncausesofdeath！UrinarySystem泌尿系統全英文第42頁③hyponatremia

[ha?p?n?‘trem??]

(Na+<135mmol/L)

hypochloraemia

[ha?p?k‘l?:ri:mj?]

(Cl-<95mmol/L)④hypocalcemia[?ha?p??k?l‘si:m??]

(Ca2+<2.25mmol/L)

hyperphosphatemia[:ha?p?f?sf?‘ti:mj?]

(P>1.61mmol/L)(2)Water,electrolyteandacid-basebalancedisordersUrinarySystem泌尿系統全英文第43頁3.recoveryphase

(diureticstage)

Hydrouria:morethan3000ml---5000ml/d.Earlystage:themarkelyelevatedCreatinine(Cr)andbloodurinenitrogen(BUN)levelsLaterstage:hyponatremia,dehydrationAllkindsofcomplicationscanstillexistAfewpatientshavesevereandpermanentrenalfunctiondamages.UrinarySystem泌尿系統全英文第44頁

ManifestationsofNonoliguricacuterenalfailureCharacteristics:unobviousoligurialowspecificgravityofurinelowurinarysodiumlevelsazotemiamostpatienthavenothyperpotassaemiaUrinarySystem泌尿系統全英文第45頁DiagnosticcriteriaTheserumcreatinineofabsolutevalueofaveragedailyincreaseof44.2μmol/L,or88.4μmol/L;orinthe24~72hoursbloodcreatininevaluesincreasedfrom25%to100%.UrinarySystem泌尿系統全英文第46頁Differentialdiagnosis1.Firstly,weshouldexcludetheARFbasedontheCKD(chronickindnydiseases),whichcanbeevidencedfromthefollowingsigns:doublekidneyshrinks,anemia,uremiafaceandrenalneuropathy.2.Secondlyweshouldexcludeprerenalandpostrenalcauses.3.AfterthedeterminationofrenalARF,thereshouldbedifferentiatedwhetheritiscausaedbyglomerular,renalvascularortubulointerstitiallesions.UrinarySystem泌尿系統全英文第47頁(1)ATNvs.Pre-renaloliguriaFluidinfusiontest

Priortotheonset,therearemedicalhistorysuchascapacitylackandbodyfluidlossetc.Ifthephysicalexaminationfoundskinandmucousmembranesdry,andhypotension,weshouldconsiderfirstlytheprerenaloliguria.Atthistimeyoucantrytoinfuseandinjectloopdiureticsforobservingtheloadofcirculatorysystemafterinfusion.UrinarySystem泌尿系統全英文第48頁

Ifthebloodpressurereturnedtonormalandurinevolumeincreasedafterthesupplementofbloodvolume,itsupportsthediagnosisofprerenaloliguric.Thehypotensionlastsforatlongtime,especiallyfortheelderwithheartdysfunctionandwithoutincreasedurineoutputafterfluidinfusion,itshouldbesuspectedthatprerenalazotemiahavetransformedintoATN.UrinarySystem泌尿系統全英文第49頁(2)ATNvs.urinarytractobstruction

Post-renalobstructionoftheurinarytract:1.Cause：stone/tumor/prostatauxe2.Symptom：anuriaorintermittentanuresissuddenly;Renalcolic,ribabdomenorabdominalpain;Renalpercussivepain;3.Auxiliaryexamination：UltrasonographyandX-rayexaminationcanhelpdiagnosisUrinarySystem泌尿系統全英文第50頁TreatmentandprognosisofacuterenalfailureUrinarySystem泌尿系統全英文第51頁TheprincipleoftreatmentTreatmentofprimarydiseaseTreatmentbasedonsymptoms1.Strictlycontrolthe

liquidintake2.Treatmentof

hyperkalemia

高鉀血癥

3.Correctionof

metabolicacidosis代謝性酸中毒

4.Therapy

ofazotemia

氮質血癥

5.Dialysistherapy透析療法

UrinarySystem泌尿系統全英文第52頁Treatment

ⅠCorrectthereversibleetiology,preventadditionaldamage:Activetreatmentoftheprimarydisease,eliminatethefactorsthatleadtoorexacerbate(加重)ARF；

Quicklyandaccuratelysupplementthebloodvolume,maintaineffectivecirculatingbloodvolumeenough；

Preventandcorrectlowperfusion,avoidtheuseofnephrotoxicdrugs。UrinarySystem泌尿系統全英文第53頁TreatmentⅡMaintainfluidbalanceFluidvolumeisequaltodominantfluidlossaddnondominantfluidlosssubtracttheendogenouscontent補液量＝顯性失液量＋非顯性失液量－內生水量

Estimating:theliquidfeedingamountisequaltoamountofurineadd500ml估算：進液量＝尿量＋５００ml

UrinarySystem泌尿系統全英文第54頁TreatmentⅢDietandnutritionWeshouldprovidesufficientheat,tein.carbohydrateandfatProteinrestrictionis0.8g/(kg?d)Asmuchaspossibletoreducetheintakeofsodium(鈉),potassium(鉀)andchloride(氯).UrinarySystem泌尿系統全英文第55頁Treatment

ⅣHyperkalemia

（Hyperkalemia>6.5mmol/L,