实验诊疗学之尿液肾功能检验专家讲座

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,尿液、肾功效、粪便试验室检测,杭州师范大学从属医院检验科 刘霞,实验诊疗学之尿液肾功能检验,第1页,思索题,1,.尿检主要临床应用,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.内生肌酐去除率（,Ccr,）,及临床意义,6.粪便检测临床应用,7 BUN,、,Cr,临床意义,实验诊疗学之尿液肾功能检验,第2页,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,同时还有内分泌功效，调整血压，钙磷代谢，红细胞生成,实验诊疗学之尿液肾功能检验,第3页,尿检主要临床应用,(,The main clinical application of urinalyisis,),泌尿系统疾病诊疗和疗效判断：,(Urinary tract disease diagnosis and efficacy judgment),全身其它系统疾病诊疗：,( other system disease diagnosis),应用肾损伤药品监控：,(The application of kidney damage drugs surveillance),实验诊疗学之尿液肾功能检验,第4页,尿液检测基本内容,(,The basic content of urinalysis),物理性状检验,：量，颜色，气味,，,比重等,(Physical properties :urine volume,color,smell,specific gravity,etc.),化学成份分析,：蛋白，糖，胆红素，酮体,(Chemical composition analysis:Protein, glucose, bilirubin, ketone body),观察有形成份,：细胞，管型，结晶等,(Observation urinary sediment:cells,casts,urates),病原微生物检验,及其它,特殊检验,(Pathogenic microorganism inspection and other special inspection),实验诊疗学之尿液肾功能检验,第5页,实验诊疗学之尿液肾功能检验,第6页,尿液分析自动化,(Urine analysis of automation),酸碱度（,PH,）,蛋白（,Protein）,葡萄糖（,Glucose）,酮体（,Ketons）,胆红素（,Bilirubin,）,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汇报模式,实验诊疗学之尿液肾功能检验,第7页,尿标本种类及注意事项,(Urine specimen types and matters needing attention),首次晨尿,:,经过浓缩、酸化，适合蛋白和有形成份,(The first morning urine: after concentrated and acidified, suitable for protein, and,urinary sediment,test),随机尿,:,门诊和急诊患者暂时检测,(Random urine :outpatient and emergency patients temporary detection),二十四小时尿,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,:,用于病原微生物检测,(clean midstream urine:Used for testing the pathogenic microorganisms),实验诊疗学之尿液肾功能检验,第8页,物理性状检验,(Physical properties),一,.,尿量,(,urine volume ),参考值：1000-,ml/24h,(Normal Range of,urine volume:,1000-,ml/24h),少尿,:,400,ml/24h,或少于17,ml/h,(Oliguria:,less than,400,ml/24h or less than,17,ml/h),无尿,:,2500,ml/24h,(Polyuria:more than 2500ml/24h),实验诊疗学之尿液肾功能检验,第9页,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 inflammation,）,少尿和无尿：,(Oliguria and Anuria),1.,肾前性：心衰、脱水等有效循环血量降低。,(Prerenal,：,heart failure,、,dehydration,，,etc),2.,肾性：各类肾小球疾病急性肾炎综合症。,(Renal:Acute nephritis syndrome),3.,肾后性：因尿路狭窄、结石、肿瘤引发梗阻或排尿功效障碍。,(,After kidney: Obstruction,、,Micturition dysfunction),实验诊疗学之尿液肾功能检验,第10页,二.尿液外观,(COLOR),常见异常改变有,(,Abnomal-Colored Urine,),：,1.,血尿,肉眼血尿（血液,1ml/L,尿液）,，,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。见于严重血管内溶血如血型不合输血反应、一些溶血性贫血等。,(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),实验诊疗学之尿液肾功能检验,第11页,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 Conjugated 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 turbidity, 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.),实验诊疗学之尿液肾功能检验,第12页,三.气味,(smell),经典病理性气味,1.氨味：慢性膀胱炎、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),实验诊疗学之尿液肾功能检验,第13页,四.酸碱反应,(,ACIDITY),肾小管上皮细胞分泌,H,+,与滤液中,NH,3,和,HPO,4,2,结合，形成,NH,4,+,或可滴定酸,H,2,PO,4,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),实验诊疗学之尿液肾功能检验,第14页,五.尿比重测定,(,SPECIFIC GRAVITY),是指4条件下尿液与同体积纯水重量之比。受尿中可溶性物质量及尿量影响。可大致反应,肾小管浓缩功效,。,(the specific gravity measures the kidneys 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),实验诊疗学之尿液肾功能检验,第15页,化学成份分析,一.尿蛋白测定,(,Urinary protein determination),正常情况下肾小球毛细血管滤过膜含有,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、球蛋白不能经过滤膜，低分子量蛋白质（2万）如,2,-M、,1,-M,滤过后95在近曲小管重吸收，所以正常情况下尿液中蛋白含量很低，定性试验阴性，定量检测150,mg/24h,。(,Normally,only the smallest protein molecules can pass the filtration barrier of the glomerulus,and most of these are reabsorbed by the tubules, Therefore normally urine protein content is low, the qualitative test negative, Quantitative detection 150mg 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,红细胞经过滤过膜受到机械性损伤，肾小管中受到不一样,PH,和渗透压改变影响，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,。,(Glomerular 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, etc,实验诊疗学之尿液肾功能检验,第30页,实验诊疗学之尿液肾功能检验,第31页,实验诊疗学之尿液肾功能检验,第32页,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/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),实验诊疗学之尿液肾功能检验,第33页,实验诊疗学之尿液肾功能检验,第34页,实验诊疗学之尿液肾功能检验,第35页,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，较多出现提醒肾小管病变。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: From 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,appeared in the urine,3.复层扁平上皮细胞：起源于尿道前段，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,实验诊疗学之尿液肾功能检验,第36页,肾小管上皮细胞,尾形、小圆、大圆上皮细胞,扁平上皮细胞,实验诊疗学之尿液肾功能检验,第37页,四.管型,Casts,是滤出液中蛋白质、细胞或其它物质在肾小管、集合管中凝固而成类圆柱形蛋白聚体。其形成条件：,(,The proteins ,cell, or other substances in renal tubular collection, frozen tube of cylindrical protein together. ),1.尿中有少许清蛋白和由肾小管上皮细胞产生,T-H,糖蛋白是组成管型基质,(,A small amount of albumin and T - H glycoproteins),2.肾小管有使尿液浓缩和酸化能力（浓缩可提升蛋白质含量、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.有交替使用肾单位，处于休息状态肾单位，尿液在肾小管内有一定滞留时间，使蛋白质浓缩和凝结，当该肾单位活动时，已形成管型随尿排出,(Have the alternate use of renal units),实验诊疗学之尿液肾功能检验,第38页,实验诊疗学之尿液肾功能检验,第39页,尿液中管型和临床意义：,1.,透明管型,：由,T-H,糖蛋白和白蛋白组成，一些人在猛烈运动、发烧、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 glomerulonephritis),3.,白细胞管型,：含有白细胞，见于肾盂肾炎。,Leukocyte cast: Pyelonephritis,4.,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早期，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。,实验诊疗学之尿液肾功能检验,第40页,5,.,蜡样管型,：由颗粒管型、红细胞管型在肾小管中长久滞留变性形成，提醒较严重肾小管损伤，预后不良。,(,Waxy cast: By,granular casts, and red,cell casts,for long-term retention in tubular,indicate,more serious injury of the renal tubular d and bad prognosis.),6,.,宽幅管型,：由基质和坏死集合管上皮组成，外形宽大，又称肾衰管型。在急性肾衰多尿早期可大量出现，伴随肾功效改进而渐少消失，在慢性肾衰时出现，提醒预后不良。,(,Broad casts :occur in chronic renal failure.,Indicate t,he poor prognosis),实验诊疗学之尿液肾功能检验,第41页,透明管型,蜡样管型,宽幅管型,实验诊疗学之尿液肾功能检验,第42页,五.结晶体,(crystals),尿液经沉淀后，有些会出现形态各异结晶体。,1.碱性尿中易出现磷酸盐结晶，,phosphate may occur in Alkaline urine,2.酸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相关，普通无致病意义，较多出现并伴有红细胞者提醒泌尿系统结石可能。,实验诊疗学之尿液肾功能检验,第43页,尿酸盐结晶,草酸钙结晶,实验诊疗学之尿液肾功能检验,第44页,尿液其它检验,尿蛋白电泳,(,Urinary protein electrophoresis),普通用聚丙烯酰胺凝胶电泳来区分不一样分子量和电荷蛋白质。,(General use polyacrylamide gel electrophoresis to distinguish different molecular weight and charge of protein.),可分辨不一样分子量蛋白质。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.),实验诊疗学之尿液肾功能检验,第45页,尿淀粉酶测定,(,Urine amylase determination),参考值：1000,U/L,(Reference: 40,mmol/L,Kidneys,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),实验诊疗学之尿液肾功能检验,第48页,肾脏功效惯用试验室检测,RENAL FUNCTION,肾小球功效检测,(,Glomerular function testing),1.血尿素氮测定,（,blood urea nitrogen BUN,）,2.,血清肌酐测定,（,serum,creatinine,SCr）,3.,内生肌酐去除率测定,（,CREATININE CLEARANCE,Ccr,),实验诊疗学之尿液肾功能检验,第49页,血尿素氮测定,原理：,BUN,是蛋白质代谢终产物。主要经过肾小球滤过随尿排出体外。,Urea nitrogen,an end product of protein metabolism,is excreted by the kidney,1.,蛋白质摄入量增多、组织蛋白分解代谢增强会使尿素合成量增加；肝功效受损会使合成量降低。,.,BUN is directly related to protein intake and nitrogen metabolism,2.,当肾实质受损时，肾小球滤过功效降低，造成血浆尿素浓度增加,。,When renal parenchymal is damaged, Glomerular filtration function is reduced, cause plasma concentrations of urea.,实验诊疗学之尿液肾功能检验,第50页,参考值：成人3.2,7.1,mmol/L,儿童,1.86.5 mmol/L,临床意义：主要经过观察血浆尿素氮升高水平来大致判断肾小球滤过功效。,当滤过功效下降至50以下时,BUN,才见升高，不能作为肾功效损害早期指标。,Mainly through the observation of plasma urea nitrogen increased level for glomerular filtration function judgment. BUN increased when the filter function drops below 50% , so BUN is not a early sign for renal impairment,1.,各种肾小球肾炎，肾盂肾炎，间质性肾炎，肾肿瘤，囊性肾病变等器质性肾功效损害。,Various glomerulonephritis, pyelonephritis, interstitial nephritis, renal tumors, cystic renal damage,2.,慢性肾衰分期标准： 9,mmol/L,失代偿期， 20,mmol/L,肾衰期。,Chronic renal failure stages: 9 mmol/L decompensated 20mmol/L renal failure.,实验诊疗学之尿液肾功能检验,第51页,3,.,肾前性少尿：当严重脱水，大量腹水，心功效衰竭等血容量不足，肾血流灌注不足造成滤过率下降而少尿，,BUN,升高，但升高幅度较小，经扩容后尿量增加可自行下降。,At before Renal oliguria: when severe dehydration, a lot of ascites, heart failure ,kidney blood perfusion shortages filtration rate decreases oliguria, BUN rise, but smaller, after the expansion may decline.,4.,组织蛋白分解增强：当高热，大面积烧伤，严重创伤，大手术后，甲亢，上消化道出血等。,Renal tissue protein decomposing enhancement: when high fever, burned, serious injuries, hyperthyroidism, upper gastrointestinal bleeding, etc.,实验诊疗学之尿液肾功能检验,第52页,血清肌酐测定,原理：,外源性：肉类食物中摄取,External: meat food intake,内源性：肌酸和磷酸肌酸经非酶促反应生成,当肾小球滤过功效下降到一定程度（低于50以下）时，血肌酐浓度会上升，经过观察该指标来判断肾小球滤过功效损伤情况。敏感性较,BUN,好，也非早期诊疗指标。,When the glomerular filtration function decline to a certain degree (below 50%), serum creatinine levels rise, through the observation of the index to judge glomerular filtration function.,，,nor early diagnosis.,(serum,creatinine,Scr,),实验诊疗学之尿液肾功能检验,第53页,参考值：血清：男：,53,106,mol/L,女：,4497 mol/L,临床意义：升高见于,1.尿量显著降低伴血肌酐进行性升高，每日升高44.2,mol/L,，应考虑急性肾衰。血肌酐442,mol/L，,急慢性肾衰透析指征之一。,Urine volume reduce rapidly and serum creatinine increased with progressive , creatinine daily increased more than 44.2 mol/L should consider the acute renal failure. Creatinine 442 mol/L may occur acute renal failure,it is indications of dialysis,实验诊疗学之尿液肾功能检验,第54页,2.,慢性肾衰分期标准： 178,mol/L,失代偿期， 445,mol/L,肾衰期。,Chronic renal failure stages: 178 mol/L decompensated, mol/L renal failure,.,3.判别肾前性和肾性少尿指标之一：肾前性血尿素氮升高幅度更大,BUN/Cr10；,肾性血肌酐升高幅度更大,BUN/Cr10;when kideys damage, creatinine rising more ,BUN/Cr 10,.,实验诊疗学之尿液肾功能检验,第