23 renal disease

General ConceptGeneral Concept of of Renal DiseasesRenal Diseases

Department of Nephrology,the First Affiliated

Hospital , Sun Yat-sun University

Qiongqiong Yang

qqyzzm@yahoo.com.cn

outlineoutline

• Anatomy and function• Physiology functions of Kidney•Clinical Manifestations of Renal Diseases• Urination disorders• Estimation of renal function• Clinic syndromes of urinary diseases

Anatomy

•Retroperitoneally posterior part of the abdomen•Either side of the vertebral column

•Right kidney is one vertebral body lower than the left.

Right

Anatomy

Renal FunctionRenal FunctionRenal FunctionRenal Function

Remove wastesMaintain homeostasisSecrete EPO

Diagram of a bisected kidney

Afferent arteriole

Efferent arterioleCapillary

loops

Anatomy-nephron

•Functional unit of kidney• 1,000,000 nephrons each kidney

Renal corpuscle( 肾小体 )

Renal tubule

•Glomerulus• Bowman’s Capsule

•Proximal tubule• Loop of Henle• Distal tubule•Collecting duct•visceral

epithelium•Bowman space •parietal epithelium

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

Stucture of renal glomerulus

Mesangial matrix and cell

Basement membrane

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

Ultramicroscopic Stucture of glomerullar Capillaries

Filtration Mem

Glomerular Filtration BarrierGlomerular Filtration Barrier

Glomerular AnatomyGlomerular Anatomy

Capillary Lumen

Endothelial cell

Glomerularbasementmembrane

EpithelialCell of Bowman’s capsule

Epithelial Foot process

Electron micrograph

Capillary Lumen毛细血管腔

Endothelial cellof the glomerular capillary

Podocytes

1. Each kidney contains 1.0 × 106

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

Filtration: excreting metabolic waste and water

Reabsorption: control of water and electronic balance

Endocrinology: producing hormones such as EPO, renin, angiotension

Physiology functions of Kidney

Clinical Manifestations of Renal Diseases

Edema

Renal Hypertension

Flank pain & renal colic

urethral stimulate

symptom

EdemaEdema

Decreased urinary sodium and water excretion

Humoral factor (RAS) Hypoalbuminemia Cardiac function insufficiency Capillary permeability ↑

Renal HypertensionRenal Hypertension

Renal vascular & renal parenchymal hypertension

Volume-dependent Renin-dependent

Impairment of renal vasodilatation (NO)

Other endocrine hormones

Flank pain & renal colicFlank pain & renal colic

Acute and chronic renal inflammation

Urinary stones (Nephrolithiasis)

Renal vascular embolism

Loin pain-Hematuria syndrome

urethral stimulate symptomurethral stimulate symptom

dysuria (burning or discomfort on

urination), frequency

Infectious or noninfectious

stimulate

Decreased volume of bladder

Disorder of cystic nerve function

Urination disordersUrination disorders

Abnormalities of urine volume

Proteinuria

Hematuria

Cast urine

Pyuria, bacteriuria

Abnormalities of urine volumeAbnormalities of urine volume

Oliguria (<400ml/d or 17ml/h) & anuria (<100ml/d)

Polyuria (>2500ml/d)water diuresis solute diuresiswater-solute (Mix) diuresis

Nocturia(UV8pm-8amUVday;frequency 3) renal failure urination nocturia: edema psychogenic nocturia

ProteinuriaProteinuria

More than 150mg/24hDifferentiate physiologic or pathologic

original The features of physiologic proteinuria

transient ,from stress(acute illness,exercise)small amount disappear after the causes relief

pathologic proteinuria :persistent, largeglomerular proteinuria tubular ProteinuriaAbnormal proteinuria: overflow or tissue secretion

ProteinuriaProteinuria

Parameter Glomerular Tubulointerstitial

Amount

MW of Protein

Massive>++>1.5~2.0g/dLarge/Medium/Small:Selective: mostly albumin;MCDNonselective: FSGS,diabetes

Small amount<2+<1.0g/dSmall: Tam-Horsfall,B2-microglobulin

Abnormal proteinuria: Light chains (,);Bence-Jones proteins Plasma cell dyscrasias

ProteinuriaProteinuria

Urinary dipstick : primary detects albumin and intact globulins; overlooking positively charged light chains of immunoglobulins.

Sulfosalicylic acid Quantification :24-hour urine protein

>150mg/24h abnormal;>3.5g/24h nephrotic-range Ratio of urinary protein to creatine concentration(Upro/cr)

<0.2 normal less accurate, but simple, collect a random urine sample

HematuriaHematuria

Diagnosis criterion≥3RBC/HFP≥8000/ml≥100 × 103 /1hr≥50 × 103 /12hr

the false hematuria should be excluded

HematuriaHematuria

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

Dysmorphic glomerular erythrocytes

Isomorphic nonglomerular erythrocytes

HematuriaHematuria

Causes of false hematuria

menstruous blood

violent exercise, fever

catheterization or diseases around

urethral

hemoglobinuria or myoglobinuria

the influence of drug or (and) food

HematuriaHematuria

Main causes of hematuria renal parenchyma diseases urinary tract abnormalities hemorrhagic disordersdiseases around urinary tract Dysmorphic hematuria is a strong

evidence for glomerular hematuria

Cast urine

hyaline cast

red cell cast

white blood cell cast

granular cast

red cell cast

Pyuria, bacteriuria

Pyuria ≥5 wbc/HFP; ≥0.4 × 106 /hr;≥ 1.0 ×

106 /12hr Bacteriuria bacteria can be seen /HFP colony counts≥105 CFU /ml [colony forming unit]

G+ colony counts≥103 CFU /mlthe false bacteriuria should be.excluded

Estimation of renal function

Serum creatinine (Scr)test

Blood urea nitrogen (Bun)test

Clearance of creatinine (Ccr)

test• Estimated GFR:MDRD equation;

Cockcroft-Gault Equation

1 ． MDRD （ the Modification of Diet in

Renal Disease study ） equation

eGFR (mL/min per 1.73 m2) =

1.86 x (PCr)–1.154x (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

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)

Stage of chronic kidney disease

From K-DOQI guidelines Recommendation

clinic syndromes of urinary diseases

1. Acute renal failure syndrome

2. nephrotic syndrome

3. nephritic syndrome: acute rapidly progrssive GN

syndrome; acute GN syndrome; chronic GN syndrome

4. isolated hematuria or(and) proteinuria

5. Chronic renal failure syndrome: uremia

syndrome

6. urethral syndrome

Clinical syndromes and presentation Clinical syndromes and presentation of glomerular diseaseof glomerular disease

Latent GN(asymptomatic

urinary abnormalities)

Nephrotic syndrome

Acute GN RPGN Chronic GN

microscopic or Macroscopic

hematuriaProteinuria

Dysmorphic Glomerular erythrocytes

Proteinuria>3.5g/dHypoalbuminemiaHyperlipidemiaEdema

Proteinuria>3.5g/dHypoalbuminemiaHyperlipidemiaEdema

HematuriaProteinuria(1-3g/d)ARFEdemaHypertensionRed cell casts

•Rapidly deterioration of renal function•Hematuria, Proteinuria• oliguria or anuriaRed cell casts•With or without systemic symptom

•Hematuria, Proteinuria•Hypertension•Reduced GFR

nephritic syndrome

Diagnosis Clue for urinary diseases

clinic syndromes of urinary diseases

Diagnosis Clue for urinary diseases

General Principles of Diagnosis

Renal Biopsy ProcessingRenal Biopsy Processing

• The trigger mechanism is released with the pt stopping the breath•firing the needle into the kidney• Needle is immediately withdrawn

renal biopsy material

Histology of GNHistology of GN

PAS MASSON H&E PASM

Pathological classification of GN

CASE CASE

65 year-old, male, Smoke for 40 years History: Fatigue x 3 months

Cough and chest pain x 2 months Facial edema x 1 week Physical: edema, Urinalysis: protein ++++ Lab Data: proteinuria 8g/d , alb 24g/l, normal renal function,

Hepatitis (-), Auto-immunity Ab (-)

Nephrotic syndromes

CASECASE

Lung Carcinoma

SilverSilver

PASPAS

CASECASE

LM-PASM:”spikes” along the GBM

CASECASE

IF: IgG deposition along GBM

CASECASE

EM: subepithelial electron dense material

Diagnosed: carcinoma related Membranous nephropathy

General Principle of Treatment

Etiologic treatment Immunosuppressive treatment:

Glucocorticoids and cyclophosphamide MMF and cyclosporin A

Symptomatic treatment Management of

hypertension:130/80;125/75mmHg(Upro>1g/d)

Control infection Renal replacement therapy: PD,HD, TX

新鲜腹透液

透出液

管路

Integrated ESRD CareIntegrated ESRD Care

Residual renal

function

HD

C

Cr (

ml/m

in)

20

15

10

5

0

Time on dialysis

Start time

peritoneal dialysisTX

PD

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

THANKS THANKS ！！