泌尿系疾病49張課件

Theurinarysystem

Paediatricsof1sthospitalaffiliatedDalianmedicaluniversity

馬路一1TheurinarysystemPaediatrics22PhysiologicalfeaturesGlomerularfiltrationrate(GFR):

lowinneonateandinfantperiodUrineconcentrationanddilutionability

shortageRenaltubulefunction

insufficiency3PhysiologicalfeaturesGlomerulPhysiologicalFeaturesNormalurinaryoutput:

neonate:48h1～3ml/kg.h3～10d100～300ml/d2m250～400ml/d

～1y:400～500ml/d

～3y:500～600ml/d

～5y:600～700ml/d

～8y:600～1000ml/d

～14y:800～1400ml/d

＞14y:1000～1600ml/d4PhysiologicalFeaturesNormaluPhysiologicalfeaturesurinaryoutput

neonateml/kg.hInfanttoddlerml/dPreschoolageml/dSchoolageml/doliguria＜1.0＜200＜300＜400urineless＜0.5＜505PhysiologicalfeaturesurinaryUrinalysisColor:colorlessorlightyellowpH:5～7Specificgravity:1.003～1.030(often1.011～1.025)Osmoticpressure:

infant:50～600mmol/L

children:

500～800mmol/LPhysiologicalfeatures6UrinalysisColor:colorlessorUrinalysisprotein：

negative：≤100mg/m2.24hprotein／creatinine≤０.２

positive：＞150mg/d

or＞4mg/m2.h

or＞100mg/LUrinarycellandcast：

Urinarysediment:RBC＜3/HP

WBC＜5/HP

colorlesscastoccasionally

12hurineAddiscount：RBC＜500000WBC＜1000000cast＜5000

PhysiologicalFeatures7Urinalysisprotein：PhysiologicaSerumanalysisThestandardindicatorsofrenalfunction

ureanitrogenandcreatinine

Theratio

:10:1.

Theratioincrease:

renalperfusion

or

urineflowisdecreased8SerumanalysisThestandardindSection2Classificationof

GlomerularDisease9Section2Classificationof

GClinicalClassification一、PrimaryGlomerularDisease

Glomerulonephritis

acutglomerulonephritis(AGN)

(Acutepoststreptococcalglomerulonephritis,APSGN)rapidlyprograssive(RPGN)

persistentchronic10ClinicalClassification一、PrimaClinicalClassificationniphroticsyndrome,NS

simpleTypeNSnephriticTypeNS

steroid-responsiveNSsteroid-resistantNSsteroid-dependentNSrelapsandfrequentlyrelaps11ClinicalClassificationniphrotClinicalClassificationIsolatedhemarutiaorproteinuria

Isolatedhematuria

persistentrecurrent

IsolatedProteinuria

orthostaticnon-orthostatic

12ClinicalClassificationIsolateClassificationClassification二、SecondaryglomerulardiseasespurpuranephritislupusnephritisHBV-associatedglomerulonephritisothers:poison,drug,viruset.al三、Hereditaryglomerulardiseasescongenitalnephroticsyndromehereditaryprogressivenephritisfamilialrecurrenthematuria13ClassificationClassificationSection3AcuteglomerulonephritisAG急性腎小球腎炎AcutepoststreptococcalglomerulonephritisAPSGN急性腎小球腎炎14Section3AcuteglomeruloneEtiologygroupAβ-heamolyticstreptococcalinfection.

upperrespiratorytractinfection51%skininfection25.8%acutepharyngtis，scarletfever1～5%othersbacteriaVirushelminth15EtiologygroupAβ-heamolyticsNephritisstrainassociatedprotein(Ag)

antigen-antibodycomplexesactivatethecomplementsystem

inciteglomemlarinflammationCap.endotheliumGMBGFR↓oliguriaNa,water↑edemahypertensionProteinuriahematuriacastMechanism16NephritisstrainassociatedprClinicalmanifestation

respiratorytractinfection

6~12dayspreviously

skininfection

14~28

dayspreviouslyrecenthistoryofgroupAβ-heamolyticstreptococcalinfection.17ClinicalmanifestationrespiraClinicalmanifestation

1.edema

70%，eyelidandface，

non-pitting；oliguria2.hematuria

50～70%,grosshematuriacoffee-colored

ortea-coloredurine

Typicform18Clinicalmanifestation1.edemClinicalmanifestation3.hypertension

30～80%,headachemaybepresent

4.Proteinuriadegreeisdifferent

pathology:

membranoproliferationTypicform19Clinicalmanifestation3.hyperClinicalmanifestationSeverehyperaemiaonthe

circulatorysystemHypertensiveencephalopathyAcuterenalfailure

severe

form20ClinicalmanifestationSeverehClinicalmanifestationAtypicformAsymptomsAGNOutofrenalsymptomsAGNAGNwhichissimilartonephroticsyndrom21ClinicalmanifestationAtypicf

hematuria：

+~+++

ESR：

↑↑

ASO：

10-14d

3-5w

peak

3-6m

normal

C3：

↓↓

6-8wnormal

protein:

+~+++Laboratoryevaluation

22hematuria：+~+++ESR：↑Diagnoses

previouslystreptococcaldisease

acuteonset

edema,

hematuria,

Proteinuria,

cast,

hypertension

ASO，C323DiagnosespreviouslystrepTreatmentRest:

keepthebed2～3W

Non-symptom:

Beoffthebed

ESRnormal:

gotoschool

Urinarysedimentcount:

normal,resumemovementGenerallytreatmentrest

24TreatmentRest:Generallytreatmdiet

Edemaandhypertension:Waterandsodiumsalt:belimited

sodiumsalt:

60mg/(kg.d)

water:

potentiallylosswatervolume

＋urineoutput

serumlevelsofureanitrogenandcreatinine:proteinislimited

TreatmentGenerallytreatment25dietEdemaandTreatmentGen

Treatment

penicillineForinfectionifstillpresentPenicillin10～14dAntibiotictherapy

26

Treatment

penicillineForinfeTreatmentdiureticsantihypertensiveDihydrochlorothiazideFurosemideNifedipineCaptoprilReserpineSymptomatictreatment27TreatmentdiureticsantihypertenTreatmentSeverehyperaemia

HypertensiveencephalopathyAcuterenalfailurediuretics、antihypertensive、hemodialysisorperitonealdialysis

SodiumNitroprusside:thefirstchoices,SymptomatictreatmentSymptomatictreatmentaccordingtovariousmanifestation28TreatmentSeverehyperaemiaHypPrognosis

and

prevent

Theacuteabnormalitiesgenerallyresolvein2-3weeks;keypointofprevention:preventandcureinfection29Prognosis

and

Section4NephroticsyndromeNS

腎病綜合征30Section4NephroticsyndromeNIntrodution

Itisglomerulardisease,whichhascharacteristicclinicalandlaboratoryfindings,causebyvariousfactors.

Age:schoolage

male:female：3.7:1

31IntrodutionItisglomCharacteristic

proteinuriahypoproteinemia

（hypoalbuminemia）

hyperlipemiaandhyperlipoproteinemiaedema32Characteristicproteinuria32Classification1.primarynephroticsyndrome,PNS2.secondarynephroticsyndrome,SNS3.congenital

nephroticsyndrome,HNS33Classification1.primarynephroPathophysiology

Primaryrenalinjury

proteinuria

hypoproteinemiaedemahyperlipidemia

secondaryPathophysiologicalchange34PathophysiologyGlomemlarcapillaryvasselmoleculeandstaticbarrier－分子屏障靜電屏障分子屏障plasmproteinmoleculewithvariousdiameter

－－－－－－－－－－－－－－－－－－35GlomemlarcapillaryvasselmolClinicalFinding

anddiagnosisAccordingtoClinicalFinding

1.simpletypeNS2.nephritictypeNS36ClinicalFinding

Clinicalmanifestation

anddiagnosis1.simpletypeNS

1)proteinuria:

urineprotein3＋～4＋

24hurineproteinquantitate≥50mg/kg

2)hypoproteinemia：

plasmalbumin＜25g/L

3)hyperlipidemia：

plasmcholesterol

＞5.7mmol/L

4)edema：

theseriouscase:anasarca，ascites,pleuraleffusions37Clinicalmanifestation

ClinicalFinding

anddiagnosis2.nephritictypeNS

Thereisoneormoreofitemsunderline:

①hematuria：

Urinarysediment:

3timeswithin2WRBC≥10/HP

②hypertension：

schoolage≥130/90mmHg,preschoolage≥120/80mmHg。

③renalfailure

④persistenthypocomplementemia

38ClinicalFinding

Complication1.infection

respiratorytractskinurethraperitonitis39Complication1.infection39Complication2.electrolytedisorderandintravascularvolumedepletion3.thrombosisandhypercoagulability

renalveinthrombusiscommon40Complication2.electrolytedisComplication

4.acuterenalfailure5.growthanddevelopisretarded41Complication4.acuterenalfTreatmentGenerally

1.rest2.diet:Waterandsodiumsaltarelimitedprotein：1.5~2g/kg·dCalciumandVitD；

3.diuretics:DihydrochlorothiazideFurosemide4.preventionandcureinfection42TreatmentGenerally42TreatmentCorticosteroidtreatment

：

Assoonasthediagnosisismade,corticosteroidtreatmentshouldbestarted.

Predinisone:2mg/kg.d(maximum,80mg/d),6W1.5mg/kg，singledose,qod,po,6Wthen,Gradually

reducethe