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1、尿液、肾功能、粪便实验室检测,思考题,1.尿检的主要临床应用2.何为多尿、少尿、无尿、蛋白尿3.选择性蛋白尿、非选择性蛋白尿4.管型形成条件及临床意义5.内生肌酐清除率（Ccr）及临床意义6.粪便的检测的临床应用7 BUN、Cr的临床意义,尿液是血液经肾小球滤过、肾小管和集合管排泌和重吸收后形成的终末产物,排泄代谢废物、异物维持体内水、盐代谢和酸碱平衡，维持内环境稳定同时还有内分泌功能，调节血压，钙磷代谢，红细胞生成,尿检的主要临床应用(The main clinical application of urinalyisis),泌尿系统疾病的诊断和疗效判断：(Urinary tract dis
2、ease diagnosis and efficacy judgment)全身其它系统疾病的诊断：(other system disease diagnosis)应用肾损伤药物的监控：(The application of kidney damage drugs surveillance),尿液检测的基本内容(The basic content of urinalysis),物理性状检查：量，颜色，气味，比重等(Physical properties:urine volume,color,smell,specific gravity,etc.)化学成分分析：蛋白，糖，胆红素，酮体(Chemic
3、al composition analysis:Protein,glucose,bilirubin,ketone body)观察有形成分：细胞，管型，结晶等(Observation urinary sediment:cells,casts,urates)病原微生物检查及其它特殊检查(Pathogenic microorganism inspection and other special inspection),尿液分析的自动化(Urine analysis of automation),酸碱度（PH）蛋白（Protein）葡萄糖（Glucose）酮体（Ketons）胆红素（Bilirubin
4、）尿胆原（Urobilinogen）比重（Specific gravity）隐血（Blood）白细胞（Leukocytes）亚硝酸盐（Nitrite）,自动化尿液分析仪组合项目报告模式,尿标本的种类及注意事项(Urine specimen types and matters needing attention),首次晨尿:经过浓缩、酸化，适合蛋白和有形成分(The first morning urine:after concentrated and acidified,suitable for protein,and urinary sediment test)随机尿:门诊和急诊患者临时检测(
5、Random urine:outpatient and emergency patients temporary detection)24小时尿 检测溶质总量，如蛋白，糖，激素等(24-hour urine:Total solute detection,such as protein,glucose,hormone,etc)清洁中段尿:用于病原微生物的检测(clean midstream urine:Used for testing the pathogenic microorganisms),物理性状检查(Physical properties),一.尿量(urine volume)参考值：
6、1000-2000ml/24h(Normal Range of urine volume:1000-2000ml/24h)少尿:2500 ml/24h(Polyuria:more than 2500ml/24h),临床意义(Clinical significance)多尿(Polyuria)：1.内分泌疾病：糖尿病、尿崩症、甲旁亢等。（Endocrine diseases:Diabetes、insipidus、hyperparathyroidism,etc）2.肾脏疾病 慢性肾炎，肾间质炎症（Kidney disease：Chronic nephritis，Renal interstitial
7、 inflammation）少尿和无尿：(Oliguria and Anuria)1.肾前性：心衰、脱水等有效循环血量减少。(Prerenal：heart failure、dehydration，etc)2.肾性：各类肾小球疾病的急性肾炎综合症。(Renal:Acute nephritis syndrome)3.肾后性：因尿路狭窄、结石、肿瘤引起的梗阻或排尿功能障碍。(After kidney:Obstruction、Micturition dysfunction),二.尿液外观(COLOR),常见的异常变化有(Abnomal-Colored Urine)：1.血尿 肉眼血尿（血液1ml/L尿
8、液），镜下血尿(Hematuria:Gross hematuria,Microscopic hematuria)(3RBC/Hp)。见于泌尿系统炎症、结石、结核、肿瘤、外伤，或血友病，紫癜肾等。(In urological system inflammation,stones,tuberculosis,cancer,trauma,or hemophilia,purpura kidney,etc)2.血红蛋白尿或肌红蛋白尿:（Hemoglobinuria or myoglobinuria）可使尿液呈红葡萄酒色、浓茶色或酱油色，尿中无红细胞但尿隐血试验阳性。见于严重的血管内溶血如血型不合输血反应、
9、某些溶血性贫血等。(Like red wine color,Strong brown,there is no red cells in urine.Concealed blood test positive.In severe hemolytic such as blood vessels are within the transfusion reactions,some hemolytic anemia,etc),3.胆红素尿(Bilirubinuria)尿中含有大量结合胆红素时，呈深黄色，常见于阻塞性黄疸和肝细胞性黄疸。(Contains a large number of Conjuga
10、ted bilirubin in the urine,Common symptoms of obstructive jaundice and liver cell jaundice)4.结晶尿(Urinary crystals)出现浑浊，或砖红色沉淀，尿酸盐结晶和磷酸盐结晶最多见(Appear turbid,or brick red precipitate,urate crystals and phosphate crystallization,)5.脓尿和菌尿(Pyuria and bacteriuria)尿液出现白色或云雾状浑浊，多伴有尿路刺激征，见于泌尿系统感染(White or tur
11、bidity,with urinary irritation,for urinary tract infection)。6.乳糜尿和脂肪尿(chyluria and lipiduria)尿液呈乳白色，多见于丝虫病和肾周围淋巴管梗阻，脂肪尿见于脂肪挤压伤、肾病综合症。(Urine has milk-white,see more at filariasis and kidneys obstruction of the surrounding lymph,lipiduria may occur with nephrotic syndrome.),三.气味(smell),典型病理性气味 1.氨味：慢性
12、膀胱炎、慢性尿潴留（Ammonia smell:Chronic cystitis Chronic urinary retention）2.发酵苹果味：糖尿病酮症酸中毒(Rotten apples taste：diabetic ketoacidosis)3.蒜臭味：有机磷中毒(Garlic smell:organophosphorouspoisoning),四.酸碱反应(ACIDITY),肾小管上皮细胞分泌的H+与滤液中的NH3和HPO42结合，形成NH4+或可滴定酸H2PO4随尿排出。参考值：4.58.0(Normal Range of pH):4.58.0临床意义：1.尿PH降低：酸中毒、高
13、热、痛风、糖尿病等。(Decreased Urine pH:Acidosis,high fever,gout and diabetes)2.尿PH增高：碱中毒、尿潴留、膀胱炎、肾小管 酸中毒。(Increased Urine pH:Alkali poisoning,urinary retention,cystitis,renal tubular acidosis),五.尿比重测定(SPECIFIC GRAVITY),是指4条件下尿液与同体积纯水的重量之比。受尿中可溶性物质的量及尿量影响。可大致反映肾小管的浓缩功能。(the specific gravity measures the kidne
14、ys to ability concentrate urine)参考值：成人1.0151.025(Normal Urine Specific Gravity Range:1.0151.025)临床意义：1.增高：禁食、脱水，糖尿病，急性肾小球肾炎等（Fasting and dehydration,glycosuria,Acute glomerulonephritis）。2.降低：大量饮水，急、慢间质性肾炎，尿崩症。(Compulsive water drinking,acute/chronic Interstitial nephritis,diabetes insipidus),化学成分分析,
15、一.尿蛋白测定(Urinary protein determination)正常情况下肾小球毛细血管滤过膜具有孔径屏障和电荷屏障，血浆中高分子量蛋白质（7万）如白蛋白、球蛋白不能通过滤膜，低分子量的蛋白质（2万）如2-M、1-M滤过后95在近曲小管重吸收，因此正常情况下尿液中蛋白含量很低，定性试验阴性，定量检测150mg/24h。(Normally,only the smallest protein molecules can pass the filtration barrier of the glomerulus,and most of these are reabsorbed by th
16、e tubules,Therefore normally urine protein content is low,the qualitative test negative,Quantitative detection 150mg 24h.),蛋白尿,尿蛋白定性检查为阳性，蛋白质含量超过150mg/24h，称为蛋白尿。（proteinuria:urinary protein for positive,protein content more than 150mg/24h,called proteinuria.）,化学成分分析,一.尿蛋白产生机理1.肾小球屏障破坏(Glomerular bar
17、rier damage.)选择性蛋白尿：以白蛋白及以下分子量的蛋白质为主，无大分子量蛋白质如免疫球蛋白、补体等，最常见于肾病综合症。(Selective proteinuria:increased albumin in the urine,no large protein molecules appear,most for Nephrotic syndrome 非选择性蛋白尿：除了含有白蛋白，还有免疫球蛋白、补体等大分子量蛋白质存在，最多见于急性肾小球肾炎。(Non-selective proteinuria:besides albumin,such as Immunoglobulin,The
18、 complement also appear in urine,In the most acute glomerulonephritis),2.肾小管受损重吸收能力下降,组分以2-M、1-M为主。(Tubular injury limits reabsorption of filtered proteins.)3.血浆中、小分子量蛋白质含量增加超过重吸收阈值，导致尿蛋白定性检查为阳性,尿蛋白以异常蛋白为主如血红蛋白、肌红蛋白、免疫球蛋白轻链等。(the smallest protein molecules in plasma increased above the capacity for
19、tubular reabsorption and protein appear in the urine，like hemoglobin,myoglogin.Immunoglobulin light chain，ect)4蛋白分泌增加：Tamm-Horsfall糖蛋白。,尿蛋白检测方法：1.定性检测 常用试纸条法，简便、敏感，受到尿量干扰，100mg/L以上即可检出。(Qualitative detection:Test strips，Simple,sensitive，By urine volume interference)2.定量检测 收集24小时尿量，检测蛋白排出总量，评价肾小球滤过膜受
20、损程度及疗效监测较客观的指标。(Quantitative detection:Collect 24-hour urine volume and detect total proteins,Evaluation of glomerular filtration membrane damage degree and it is the objective monitoring index for therapeutic effect.),临床意义：生理性蛋白尿：指泌尿系统无器质性病变，在剧烈运动、寒冷、发热等交感神经兴奋情况下，肾小球毛细血管通透性增加出现的一过性蛋白尿，含量低。(Physiolo
21、gical proteinuira:filtration of the glomerulus increase when body in strenuous exercise,cold fever.)病理性蛋白尿：(Pathologic proteinuria)1.肾小球性蛋白尿 见于肾脏疾病中肾小球肾炎，肾病综合症，其他系统疾病引起的继发性肾小球损害如糖尿病、高血压、系统性红斑狼疮等。Glomerular proteinuria:Kidney disease glomerulonephritis,Nephrotic syndrome;Other system diseases caused
22、by the secondary glomerular damage,Diabetes,hypertension,systemic lupus erythematosus(sle)etc 2.肾小管性蛋白尿 见于肾盂肾炎，间质性肾炎，药物性肾损伤。(Renal tubular proteinuria:Pyelonephritis,interstitial nephritis,renal damage by drug),3.混合性蛋白尿：肾小球和肾小管同时受损所致的蛋白尿，如肾小球肾炎或肾盂肾炎后期，以及了同时累积肾小球和肾小管的全身性疾病，如糖尿病、系统性红斑狼疮等。(Mixed protei
23、nuria:glomerular and renal tubular injury simultaneously,produces measurable proteinuria,Glomerulonephritis or Pyelonephritis,Other system diseases caused by the secondary glomerular damage,Diabetes,hypertension,systemic lupus erythematosus(sle)etc)4.溢出性蛋白尿 见于急性溶血，浆细胞病中的重链病、轻链病、骨髓瘤等。(Overflow protei
24、nuria:Acute hemolysis,Heavy chain disease,light chain disease,multiple myeloma)5.组织性蛋白尿：肾组织破坏或肾小管分泌蛋白增多所致的蛋白尿，为低分子蛋白尿，以T-H糖蛋白为主。(Histic proteinuria:T-H glycoprotein)6.假性蛋白尿：血、脓、粘液等。(False proteinuria:blood,pus,Mucus,etc),二.尿糖测定(Glucosuria),原理和检测方法：血浆中的葡萄糖可以自由通过肾小球滤过膜，几乎完全被近曲小管重吸收，正常尿液中只含有微量的葡萄糖，定性试验
25、阴性。(Glucose is normally filtered in the glomerulus and completely reabsorbed,mostly in the proximal tubule.Glucose in randomly collectable fresh urine specimens is normally undetectable)当血糖浓度超过肾小管对葡萄糖的重吸收能力（肾糖阈）时，或者肾糖阈值下降时，尿中葡萄糖含量增加，定性试验阳性。一般用氧化酶法。(When the serum glucose rises above 8.88mmol/L,the f
26、iltered load will exceed the capacity for tubule reabsorption and glucose will appear in the urine.Dipsticks,impregnated with glucose oxidase and an indicator color),临床意义：血糖增高性糖尿(blood glucose Increased glucosuria)糖尿病因胰岛素分泌量的绝对或相对减少导致血糖升高，(Hyperglycemia in diabetes mellitus)其他升高血糖激素异常疾病如库欣综合症、甲亢、嗜铬细
27、胞瘤、肢端肥大症，血糖升高，还见于胰腺炎Other blood glucose increased hormone disorder:cushing syndrome,hyperthyroidism,Pheochromocytoma,Acromegaly,Pancreatitis,应激性尿糖见于颅脑外伤、脑出血、急性心梗等，由于延髓血糖中枢受刺激或应激时肾上腺素分泌增多导致的高血糖。(Glucosuria by stress:Craniocerebral trauma,Hemorrhage,Acute myocardial infarction)血糖正常性糖尿 见于肾小管病变如间质性肾炎。家族
28、性糖尿-一部分会发展为糖尿病。blood glucose normal glucosuria:proximal tubular dysfunction,and hereditary renal glycosuria,三.尿酮体测定(Urine ketone body),原理和检测方法：酮体是机体脂肪酸代谢的中间产物，分为-羟丁酸、乙酰乙酸和丙酮。当糖代谢受抑制或不足时，脂肪代偿性分解代谢增强，当超过机体氧化利用能力而堆积，血酮体升高，从尿中排出形成酮尿。一般用试纸条法测定丙酮和乙酰乙酸。Ketones are the products of fatty acid metabolism.Incr
29、eased ketones in the urine indicate that cellular metabolism is dependent upon fattyacid rather than glucose for energy.Progressively diminished glucose utilization in uncontrolled diabetes mellitus leads to lipolysis with increasing plasma and urinary concentration of acetoacetic acid,beta-hydroxyb
30、utyric acid,and ketones.参考值：正常人为阴性,临床意义：糖尿病性酮尿 糖尿病未得到有效控制，胰岛素量的绝对或相对不足，糖代谢受抑制，酮体大量生成，导致糖尿病酮症酸中毒（DKA）,多伴有较高血糖。(Diabetic Ketonuris:uncontrolled diabetes mellitus leads to lipolysis with increasing plasma and urinary concentration of acetoacetic acid,beta-hydroxybutyric acid,and ketones.diabetic ketoac
31、idosis)非糖尿病性酮尿 见于高热，严重呕吐，腹泻、禁食、肝硬化等糖代谢不足，酮体升高也易造成酸中毒。(Non-diabetic Ketonuris:high fever,Severe vomiting,Diarrhea.Fast,Cirrhosis),四.尿胆红素和尿胆原测定（Bilirubinuria）and Urobilinogen）,原理和检测方法：,尿胆红素、尿胆原，称为尿二胆，是目前常用的检测项目，多用试纸条法。(Bilirubin Urobilinogen,Test strips）参考值：正常人尿胆红素阴性，尿胆原弱阳性。临床意义：尿胆红素阳性见于肝细胞性黄疸，肝内外胆管阻塞
32、性黄疸，先天性高胆红素血症中D-J综合症（结合胆红素排泌障碍）和Rotor综合症（摄取和排泌均有一定障碍）(Common symptoms of obstructive jaundice and liver cell jaundice)尿胆原升高见于肝细胞性黄疸和溶血性黄疸，减低见于阻塞性黄疸(Urobilinogen increased in liver cell jaundice,hemolytic jaundice,dereased in obstructive jaundice),尿液的有形成分(URINARY SEDIMENT),方 法取混匀新鲜晨尿10ml，1500rpm离心5mi
33、n，留沉淀物0.2ml混匀取50 l涂片以弱光低倍镜观察，用高倍镜辨认记录各类细胞在10个视野内或各类管型在20个视野内所见到的最低和最高数目(Centrifuge 10ml of urine in a conical tube for 5 minutes,decant the supernatant,flick the tube to disperse formed elements in the remaining drop,and place it on a slide under a cover slipe to be examined with the high-power obje
34、ctive of a microscope(hpf).Abnormal numbers of cells and casts or any bacteria reveal the presence of disease.),尿液中主要的有形成分,一.红细胞(Erythrocytes)参考值：正常平均每高倍视野0-3个，3个称镜下血尿。(Hematuria:Normal:0-3 red blood cells(RBCs)/hpf)临床意义：1.肾小球源性血尿 红细胞通过滤过膜受到机械性损伤，肾小管中受到不同PH和渗透压变化的影响，呈多形性改变，常见于急慢性肾小球肾炎、紫癜肾、狼疮肾炎等。(Glo
35、merular haematuria:Erythrocytes polymorphism,like glomerulonephritis,Purpura nephritis,sle nephritis)2.非肾小球性血尿 损伤在肾间质或输尿管以下部位，常见于肾结石、泌尿系肿瘤、肾盂肾炎、急性膀胱炎、尿道炎等。Non-Glomerular haematuria:In the renal stroma damage or below the ureteral,stones,urinary tract tumors,pyelonephritis,acute cystitis,urethritis,e
36、tc,二.白细胞和脓细胞(Leukocytes and purulent cells)白细胞外形完整，分散存在，以中性粒细胞多见。脓细胞是指在炎症过程中破坏或死亡的中性粒细胞，外形不规则，常成堆聚集存在。Leucocyte appearance,complete,scattered by neutrophils.Pus cell refers to the process of inflammation of the destruction or death,irregular shape neutrophils,often gathered there heaps 参考值：正常平均0-5个/
37、高倍视野 Normal:0-5 white blood cells(WBSs)/hpf.临床意义：若 有较多白细胞或脓细胞，多为泌尿系感染如肾盂肾炎、膀胱炎、尿道炎。(more white cells,or septic for urinary tract infection such as pyelonephritis,cystitis,urethritis),三.上皮细胞(Epithelial cells)1.肾小管上皮细胞：来自近曲小管和远曲小管，较多出现提示肾小管病变。慢性炎症时肾小管上皮细胞发生脂肪变性，称脂肪颗粒细胞。Renal tubular epithelial cells:F
38、rom the proximal convoluted tubules and far convoluted tubules,prompting renal tubular lesions.2.移行上皮细胞：有尾形、小圆、大圆，来自肾盂、输尿管、膀胱，有炎症时在尿中出现增多.transitional epithelium cells:With tail shape,small circle,big circle,from the pelvis,ureter,bladder,when these parts inflammation,transitional epithelium cells a
39、ppeared in the urine3.复层扁平上皮细胞：来源于尿道前段，女性排除阴道分泌物污染后，且伴有尿白细胞增多，见于尿道炎。Stratified squamous epithelial cells:urethritis,肾小管上皮细胞,尾形、小圆、大圆上皮细胞,扁平上皮细胞,四.管型Casts 是滤出液中的蛋白质、细胞或其它物质在肾小管、集合管中凝固而成的类圆柱形蛋白聚体。其形成条件：(The proteins,cell,or other substances in renal tubular collection,frozen tube of cylindrical protei
40、n together.)1.尿中有少量的清蛋白和由肾小管上皮细胞产生的T-H糖蛋白是构成管型的基质(A small amount of albumin and T-H glycoproteins)2.肾小管有使尿液浓缩和酸化能力（浓缩可提高蛋白质含量、盐类浓度，尿液酸化后使蛋白质沉淀）(The tubular has ability to fully concentrated and acidify the urine)3.有交替使用的肾单位，处于休息状态的肾单位，尿液在肾小管内有一定的滞留时间，使蛋白质浓缩和凝结，当该肾单位活动时，已形成的管型随尿排出(Have the alternate
41、use of renal units),尿液中的管型和临床意义：1.透明管型：由T-H糖蛋白和白蛋白构成，某些人在剧烈运动、发热、麻醉后等无肾脏器质性病变时有轻度增多，在慢性肾炎，肾病综合症，高血压肾损伤的增多。(hyaline casts:component by T-H glycoprotein and albumin,occur Chronic nephritis,Nephrotic syndrome,Hypertensive renal damage)2.红细胞管型：基质中含有红细胞，最多见于急性肾小球肾炎。(Red cell casts:Acute glomerulonephriti
42、s)3.白细胞管型：含有白细胞，见于肾盂肾炎。Leukocyte cast:Pyelonephritis4.颗粒管型：(granular casts)基质中含有较多粗大颗粒，多见于急慢性肾小球肾炎初期，肾盂肾炎累及肾小球。细颗粒多为粗颗粒转化而来，见于急慢性肾小球肾炎后期。,5.蜡样管型：由颗粒管型、红细胞管型在肾小管中长期滞留变性形成，提示较严重的肾小管损伤，预后不良。(Waxy cast:By granular casts,and red cell casts for long-term retention in tubular,indicate more serious injury o
43、f the renal tubular d and bad prognosis.)6.宽幅管型：由基质和坏死的集合管上皮构成，外形宽大，又称肾衰管型。在急性肾衰多尿早期可大量出现，随着肾功能改善而渐少消失，在慢性肾衰时出现，提示预后不良。(Broad casts:occur in chronic renal failure.Indicate the poor prognosis),透明管型,蜡样管型,宽幅管型,五.结晶体(crystals),尿液经沉淀后，有些会出现形态各异的结晶体。1.碱性尿中易出现磷酸盐结晶，phosphate may occur in Alkaline urine 2.酸
44、性尿中易出现尿酸盐结晶。Urate may occur in acidic urine 与饮食和个人体质代谢有关，一般无致病意义，较多出现并伴有红细胞者提示泌尿系统结石可能。,尿酸盐结晶,草酸钙结晶,尿液的其它检验,尿蛋白电泳(Urinary protein electrophoresis)一般用聚丙烯酰胺凝胶电泳来区分不同分子量和电荷的蛋白质。(General use polyacrylamide gel electrophoresis to distinguish different molecular weight and charge of protein.)可分辨不同分子量的蛋白质。
45、区分肾小球和肾小管性蛋白尿。(Can distinguish different molecular weight of protein.Distinguish glomerular and tubular proteinuria)临床意义 推断损害部位。(Clinical significance:a site of injury in the urinary tract or kidney should be sought.),尿淀粉酶测定(Urine amylase determination)参考值：1000U/L(Reference:1000U/L)临床意义：1.急性胰腺炎尿淀粉酶升
46、高，一般12-24小时开始升高，持续3-10天，活性高低与病情无关。(Acute pancreatitis,generally increased amylase urine,12-24 hours beginning to rise,the last 3-10 days.)2.任何原因所致的胰液排出障碍，如胆囊炎、胆管阻塞、胰腺外伤、胰腺癌等均可使血和尿淀粉酶增高。(Due to any reason of pancreatic juice from obstacles such as cholecystitis,bile duct obstruction,pancreas trauma,p
47、ancreatic cancer and blood and urine to increased amylase.),尿本周蛋白测定(BENCE-JONES PROTEIN,BJP)本-周蛋白是免疫球蛋白的轻链，能自由通过肾小球滤过膜。此种蛋白质在酸性条件下加热40-60 时可发生凝固而沉淀，温度升至90-100时又可溶解，而温度下降至56 时又凝固，因此称凝溶蛋白。也可通过尿蛋白电泳测出。(BJP is the light chain of immunoglobulin,can freely through the glomerular filtration membrane.The pr
48、otein in acidic condition heating 40-60 c can happen frozen precipitation,the temperature rise to 90-100 c and soluble and temperature dropped to 56 c and solidification,so called fibrinolytic coagulation.Also can examine by urine protein electrophoresis.)临床意义：BJP阳性主要见于浆细胞病如骨髓瘤(BJ P positive may occ
49、ur in multiple myeloma),尿钠测定(Urinary sodium determination)钠主要通过肾由尿液排出。经肾小球滤出的钠离子99被肾小管重吸收，正常人尿钠130260mmol/24h。Sodium mainly excreted by urine through kidney.99%sodium Through glomerular filtration were reabsorption by renal tubular,normal urinary sodium 130-260mmol/24h.临床意义：主要用来鉴别肾前性少尿和肾性少尿Mainly us
50、ed to identify the cause of Oliguria(before kidney or kidney)1.肾性少尿 重吸收下降，一次性尿钠40mmol/LKidneys oliguria:reabsorption decreased,urinary sodium 40mmol/L 2.肾前性少尿 重吸收正常或增强，一次性尿钠20mmol/L(before Kidneys oliguria:reabsorption increased,urinary sodium 20mmol/L),肾脏功能的常用实验室检测RENAL FUNCTION,肾小球功能检测(Glomerular
