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General ConceptGeneral Concept of of Renal DiseasesRenal Diseases
Department of Nephrology,the First Affiliated
Hospital , Sun Yat-sun University
Qiongqiong Yang
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outlineoutline
• Anatomy and function• Physiology functions of Kidney•Clinical Manifestations of Renal Diseases• Urination disorders• Estimation of renal function• Clinic syndromes of urinary diseases
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Anatomy
•Retroperitoneally posterior part of the abdomen•Either side of the vertebral column
•Right kidney is one vertebral body lower than the left.
Right
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Anatomy
Renal FunctionRenal FunctionRenal FunctionRenal Function
Remove wastesMaintain homeostasisSecrete EPO
Diagram of a bisected kidney
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Afferent arteriole
Efferent arterioleCapillary
loops
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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
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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
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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
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Ultramicroscopic Stucture of glomerullar Capillaries
Filtration Mem
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Glomerular Filtration BarrierGlomerular Filtration Barrier
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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
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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
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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
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Clinical Manifestations of Renal Diseases
Edema
Renal Hypertension
Flank pain & renal colic
urethral stimulate
symptom
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EdemaEdema
Decreased urinary sodium and water excretion
Humoral factor (RAS) Hypoalbuminemia Cardiac function insufficiency Capillary permeability ↑
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Renal HypertensionRenal Hypertension
Renal vascular & renal parenchymal hypertension
Volume-dependent Renin-dependent
Impairment of renal vasodilatation (NO)
Other endocrine hormones
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Flank pain & renal colicFlank pain & renal colic
Acute and chronic renal inflammation
Urinary stones (Nephrolithiasis)
Renal vascular embolism
Loin pain-Hematuria syndrome
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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
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Urination disordersUrination disorders
Abnormalities of urine volume
Proteinuria
Hematuria
Cast urine
Pyuria, bacteriuria
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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
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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
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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
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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
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HematuriaHematuria
Diagnosis criterion≥3RBC/HFP≥8000/ml≥100 × 103 /1hr≥50 × 103 /12hr
the false hematuria should be excluded
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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
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Dysmorphic glomerular erythrocytes
Isomorphic nonglomerular erythrocytes
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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
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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
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Cast urine
hyaline cast
red cell cast
white blood cell cast
granular cast
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red cell cast
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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
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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
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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
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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
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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
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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
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Diagnosis Clue for urinary diseases
clinic syndromes of urinary diseases
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Diagnosis Clue for urinary diseases
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General Principles of Diagnosis
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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
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Histology of GNHistology of GN
PAS MASSON H&E PASM
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Pathological classification of GN
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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 (-)
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Nephrotic syndromes
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CASECASE
Lung Carcinoma
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SilverSilver
PASPAS
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CASECASE
LM-PASM:”spikes” along the GBM
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CASECASE
IF: IgG deposition along GBM
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CASECASE
EM: subepithelial electron dense material
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Diagnosed: carcinoma related Membranous nephropathy
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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
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新鲜腹透液
透出液
管路
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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
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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
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THANKS THANKS !!