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1、血尿、蛋白尿的诊断和鉴别诊断,北京协和医院肾内科陈丽萌,内 容,血尿的诊断与鉴别蛋白尿的诊断与鉴别血尿、蛋白尿-肾小球疾病的诊断与鉴别,血尿的诊断思路,确定是否是真性血尿,判断出血部位,确定病变性质,颜 色,正常时：无色澄清-淡黄色-琥珀色病理情况：近于无色：尿液稀释、尿崩症深黄色：胆红素尿（浓茶样尿）药物、食物 酱油色：血红蛋白尿(酸性)ARF乳白色： 乳糜尿、脓细胞尿红 色： 血尿、血红蛋白尿、肌红蛋白尿 药物 (联苯胺试验）,试纸法检测：潜 血,原理：试纸法 Hb有类过氧化物酶作用 催化分解过氧化物-邻联甲苯胺氧化变色,试纸法的局限性：,血尿的定义,尿沉渣 Addis计数，12h红细胞超
2、过50万 每高倍视野（HP）超过3个红细胞,尿检阳性是血尿吗？,确定是否是真性血尿,标本的可靠性-污染 月经、子宫、阴道出血鉴别 容器、化验尿标本收集的注意 晨尿 清洁中段尿 避免生殖道的污染 1小时内送检-冰箱,血尿的诊断步骤,确定是否是真性血尿,判断出血部位,确定病变性质,判断出血的部位（1）,按照血尿和排尿先后的关系进行分析（通常根据尿三杯试验来判断）：初血尿：尿道病变 终末血尿：膀胱颈部和三角区或后尿道病变全程血尿：上尿道或膀胱,判断出血的部位（2）,相差显微镜检查红细胞形态：,均一性,不均一性,肾单位血尿,穿过病变肾小球基底膜时受损通过肾小管时受到管腔内: 渗透压、PH值、代谢物质(
3、脂肪酸/溶血卵磷脂及胆酸）)大小、形状改变+同时合并红细胞管型=肾单位来源例外:肾创伤、活检、梗塞、肾皮质坏死、 剧烈运动也可有红细胞管型,判断出血的部位（3）,微粒容积自动分析仪,血红细胞容积分布曲线,非肾小球源性血尿,肾小球源性血尿,肾小球源性血尿,混合性血尿,血尿的诊断步骤,确定是否是真性血尿,判断出血部位,确定病变性质,确定病变性质（1）,血尿的病因,泌尿生殖系统疾病,全身性疾病,尿路邻近器官疾病,其他原因,2%,98%,1.肾单位来源(内科性): 原发、继发、家族性2.非肾单位来源(外科性): 肿瘤、外伤、结石、畸形、血管等,泌尿生殖系统疾病,内科性血尿查什麽?,内科性血尿,蛋白定量
4、管型肾功能肾活检细菌学检查,外科性血尿查什麽?,外科性血尿,1. 尿脱落细胞2. 影像学: 腹部平片 超声波检查 CT/MRI 3. 介入检查: 膀胱镜检查 静脉肾盂造影(排泄性尿路造影) 逆行尿路造影 肾动脉及肾静脉造影4.钙负荷实验: 尿钙4mg/kg.24h,尿钙/肌酐0.21,胡桃夹子现象,肠系膜上动脉压迫左肾静脉致左肾回流障碍，淤血；从而引起血尿多发生于儿童，成年后肠系膜上动脉压迫解除症状消失,肠系膜上动脉,左肾静脉,内 容,血尿的诊断与鉴别蛋白尿的诊断与鉴别血尿、蛋白尿-肾小球疾病的诊断与鉴别,正常尿蛋白,150mg/24h组成: 60%滤过血浆蛋白 40%白蛋白, 15%免疫蛋白
5、 5%其他血浆蛋白 40% Tamm-Horsfall蛋白,失去大小选择性屏障理论上GBM滤过孔孔径加大，长度缩短单位面积GBM上孔密度增加以上两项均有失去电荷选择性屏障GBM失去带阴电荷的分子(糖蛋白分解增加/合成减少) 带阳电荷的分子中阴电荷以上两项均有,蛋白尿的机理,肾小球滤过屏障,肾小球滤过膜：内皮细胞基底膜上皮细胞系膜组织多种生理功能：参与免疫及肾小球炎症反应病理情况下致肾小球硬化,蛋白尿的分类和特点,肾小球性蛋白尿 肾小球滤过屏障损害 2.0 g/24 h 大、中、小分子肾小管性蛋白尿 肾小管对正常滤过蛋白的重吸收障碍 2.0g/24 h，小分子溢出性蛋白尿 血浆中某种蛋白质浓度过
6、高，经正常或异常肾小球滤出分泌性蛋白尿 远端小管分泌：Tamm-Horsfall蛋白蛋白尿诊断方法及,诊断思路,是否蛋白尿？尿常规持续性？一过性： 多见于少量蛋白尿（trace to 2+ protein）定量： 24小时尿蛋白定量 2g定性： SDS-PAGE定位 ？,内 容,血尿的诊断与鉴别蛋白尿的诊断与鉴别血尿、蛋白尿的诊断与鉴别诊断,诊断层次,1.血尿、蛋白尿-临床诊断2.肾功能3.病因:继发肾病?原发肾病4.病理5.并发症,诊断方法及程序,病史体格检查实验室检查特殊检查随访,排除假性血尿血凝块 血尿中混血凝块常提示非肾小球疾患出血血尿与全身疾病及呼吸道感染的时间关系PSGN：感染后1
7、014天出现血尿IgAN： 几乎同时发生，一般不超过3天。家族史:耳聋、血尿、肾衰血尿伴随症状肾绞痛尿路刺激症水肿、高血压及全身其他症状等,病史-血尿,Onset when began with conditions identified around the initial presentation, i.e., drug ingestion record of previous urinalyses precipitation/palliation identification of triggering agents infectious, drugs, foods, chemicals
8、, vaccinations helps to identify acquired forms of tubulointerstitial proteinuria,蛋白尿-问诊,quality associated with hematuria severity ： pathologic if associated with hematuria or Nephrotic Syndrome likely to be a primary GN unlikely to be benign etiology or secondary GN timing acute vs acute-on-chroni
9、c intermittent vs persistent duration of proteinuria,associated symptoms past medical history functional inquiry Specific Entities helps to differentiate acute GN from chronic GN identify overload proteinuria causes,1. History of Presenting Illness,at the end of the history, one should be able to di
10、scern: 1. benign vs pathologic proteinuria (if pathologic then) 2. glomerular vs tubulointerstitial proteinuria (if glomerular then) 3. hereditary vs non-hereditary (if non-hereditary then) 4. acute GN vs chronic GN (if chronic then) 5. primary GN vs secondary GN 6. nephrotic vs non-nephrotic protei
11、nuria 7. proteinuria with or without hematuriauria,病史,功能性病理性 肾小球性 肾小管、间质性 溢出性 分泌性,隐匿性肾炎综合征急性肾炎综合征慢性肾炎综合征急进性肾炎综合征肾病综合征,2. Family History,helps to differentiate hereditary from non-hereditary : 1. Proteinuria family members must have had previous urinalysis to ascertain this 2. Renal Disease Polycysti
12、c Kidney Disease Nephrotic Syndrome, Fanconi Disease renal dialysis kidney transplantation 3. Others：hearing/ocular impairment (Alport Syndrome),PE? Lab? More information,3 Physical Examination,1. Vitals hypertension, fever 2. O/E edema, skin paleness or jaundice, rashes external genitalia（外生殖器） joi
13、nts for signs of arthritis-red, warm, or swollen abdomen: masses or tenderness. CVA tenderness enlarged kidneys. length and weight and plot on growth chart.,Glomerular Proteinuria,presents in 1 of 3 ways: 1. Isolated Proteinuria 2. Proteinuria + Hematuria 3. Nephrotic Syndrome edema, hypoalbuminemia
14、, hyperlipidemia,进一步检查,1.血尿、蛋白尿2.肾功能3.病因:继发肾病?原发肾病4.病理:肾活检5.并发症,病因诊断,继发: 感染相关 免疫相关 肿瘤相关/淀粉样变/MM 代谢性病原发性肾病,病理诊断,肾活检的适应症和禁忌症穿刺方法常见的病理类型常见的病理改变,随访,无症状血尿患者每半年一次尿液分析和细胞学检查每两年一次膀胱镜和静脉肾盂造影若血尿反复发作，随访期至少3年,CASE 1,A four year-old African American male is brought to your office after his parents noticed that h
15、is urine appeared dark brown or coke （焦碳）colored.,Important questions to ask in your History 1,Has there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? Has there been any recent URI symptoms or sore throat? Has there been any type of skin rashes or sores? Any abdominal p
16、ain or colicky pain? Are the stools loose or bloody?,Important questions to ask in your History 2,5. Has there been any recent trauma? 6. Has there been any joint pains or swellings? 7. Is there any history of sickle cell disease or trait?8. Is there any family history of renal disease,transplants,
17、or dialysis? 9.Is there a family history of hearing deficits? 10.What medications does the child take?,According to the parents, the child was treated with Bacitracin（杆菌肽） 2 weeks ago for impetigo（脓疱病 ）on the legs and arms?,The patients examination was normal except for a blood pressure of 125/90 an
18、d some mild periorbital edema.,拟诊：最可能？ 其次？,拟诊：可能,ost streptococcal acute glomerular nephritis(PSAGN) （急性链球菌感染后肾炎）secondary to a nephrogenic strain of streptococcus pyogenes （causing impetigo 2 weeks ago）,进一步检查证实？,进一步检查证实,ASOanti-DNAse B titersBUN and Creatininecomplement levels.,治疗-有助于诊断,The child s
19、hould be monitored closely paying attention ： blood pressure, daily weights, urine output and po input.,预期结果,The red blood urine ： C3 complement ：预后：,预期结果,The urine may continue to contain red blood cells for many months the C3 complement usually returns to normal levels in 6-8 weeks. Most of the PS
20、AGN patients recover completely,Common causes of hematuria in children,Urinary tract infection. Diagnosed by symptoms of burning and frequency and a positive urine culture on a properly collected specimen Familial benign hematuria- usually asymptomatic and may have minimal proteinuria. At times the
21、hematuria may be gross. Hypercalcuria- usually asymptomatic and may be microscopic or gross hematuria. Do a spot urine and measure the Ca/Creatinine ratio. Age related. 19 mo.-6 years is 0.42(95%) Transient- no etiology established. HSP- hematuria may precede the rash,Common Causes of Gross Hematuri
22、a,Local irritation or trauma to the perineal area Reanl trauma secondary to blunt abdominal trauma or accident UTIs,如果1,If the patient is asympotmatic and the physical exam is normal, and there is no family history of renal disease,recheck the urine in a few days.dipstick is still positive,check a s
23、pun urine for blood, casts, protein, wbcs，bacteriaObtain a urine for culture Check immediate family members for hematuria Ca+/Cr. on spot urine CBC , platelet count, and rbc morphology,如果2,if glomerular disease is not suspectedSome authorities suggest a renal ultrasoundto rule out structural disease
24、 and masses,If increased blood pressure, edema, decreased urine output, casts proteinuria a total hemolytic complement and C3,如果3：,Glomerulonephritis associated with decreased C3 include,SLE- do ANA Shunt nephritis Post streptococcus glomerulonephritis Membrao-proliferative glomerulonephritis Glomerulonephritis associated with SBE,如果4,IF with persistent blood in the urine decreased real function proteinuria hypertension. with laboratory evidence of SLE.,Renal biopsy,
