1、蛋白尿的诊断治疗与注意事项,basic structurebehind two sides of peritoneum11 cm 6 cm 3 cmWt. 100-140 g,肾小球旁器,（1）球旁细胞 afferent arteriole中膜内的肌上皮样细胞。分泌renin。 （2）系膜细胞afferent 和 efferent arteriole 之间的间质细胞群。吞噬功能。,（3）致密斑:调节juxtaglomerular cell释放renin。,*（一）肾小球滤过率 GFR：单位时间内（每分钟） 两肾生成的原尿量。 GFR与体表面积成正比。每日滤过量是全身total plasma v
2、olume 的60倍，即kidney 每日净化处理全身plasma 60次。,判断肾功能的指标-肾小球滤过率,GFR取决于：effective filtration pressure 和 filtration membrane 通透性,影响滤过率的因素,filtration membraneeffective filtration pressure,滤过膜的结构 1. 内层毛细血管壁的内皮细 胞：有50100 nm的窗孔，血细胞不能通过。 2. 中层基膜：有48 nm的纤维网孔，蛋白质和脂质不能通过。（主要） 3. 外层肾小囊的上皮细胞：裂隙膜上有414 nm的孔，大分子蛋白质不能通过。,水分
3、子,阳离子,葡萄糖,小分子阴离子,蛋白质,滤过膜通透作用的选择性 滤过膜的机械屏障作用：glomerular filtration membrane上大小不等的孔道，阻止大分子物质通过。（起主要作用） 半径3.6 nm 不能通过，如plasma globulin，fibrinogen。,有效滤过压,有效滤过压: 是glomerular filtration的动力。肾小球有效滤过压肾小球毛细血管血压（血浆胶体渗透压囊内压）,Afferent arteriole端EFP45（2510）10 mmHg Efferent arteriole端EFP 45（3510）0 mmHg 由此可见， glome
4、rular capillary不是全段都有滤过作用。,肾小球毛细血管压 平均动脉压（舒张压+1/3脉压差）： BP 80180 mmHg 肾小球毛细血管压维持稳定 GFR基本不变 。 BP 4080 mmHg 肾小球毛细血管压 滤过压 GFR 。 BP 40 mmHg GFR 0 无尿。 入球动脉 和 出球动脉 的口径： 入球动脉收缩肾小球毛细血管压 有效滤过压 GFR 。 出球动脉收缩肾小球毛细血管压 有效滤过压 GFR 。,肾小管和集合管的转运功能,包括：reabsorption、secretion、excretion,Proteinuria,What is proteinuria?,Pr
5、oteinuria 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 - 3000 mg Nephrotic range more than 3500 mg,SIGNS AND SYMPTOMS,foamy urine edema Hypoalbuminemia and hypotension pre-renal acute renal failurehyperlip
6、idemia Infection,Mechanisms of Proteinuria,Benign Proteinuria Glomerular Proteinuria Primary or secondary glomerulopathy Tubular Proteinuria Tubular or interstitial disease Overflow Proteinuriaas in multiple myeloma secretory (post glomerular),Primary glomerulonephropathy,- Minimal change disease Ms
7、PGNIdiopathic membranous glomerulonephritis Focal segmental glomerulonephritis Membranoproliferative glomerulonephritis IgA nephropathy,MCD,MsPGN,IgAN,IgAN,IgAN,MPGN,Secondary glomerulonephropathy,Diabetes mellitus Collagen vascular disorders (e.g., lupus nephritis) Amyloidosis Preeclampsia先兆子痫Infec
8、tion (e.g., HIV, hepatitis B and C, poststreptococcal illness, syphilis, malaria and endocarditis) Gastrointestinal and lung cancers Lymphoma, chronic renal transplant rejection,SLE LN,淀粉样变,DN,DN,DN,Tubular,Hypertensive nephrosclerosis Tubulointerstitial disease due to: Uric acid nephropathy Acute h
9、ypersensitivity interstitial nephritis Fanconi syndrome Heavy metals Sickle cell disease NSAIDs, antibiotics,Acute pyelonephritis,AINS,AIN,CRF,Overflow,- Hemoglobinuria Myoglobinuria Multiple myeloma Amyloidosis,Diagnostic Evaluation 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 proteinuria. ACEI or ARBs immunosuppression Treating hypercholesterolemia others,
