诊断学英文课件：Renal Function Tests

Renal Function TestsGross structure of the kidneyThe kidneys - what are they for?eiminationeimination of waste substances of waste substancesbut theres more - much more!Salvage of essential compoundsSalvage of essential compoundsRegulation of ions: HRegulation of ions: H+ + (pH), Na (pH), Na+ +, K, K+ +, Ca, Ca2+2+Regulation of plasma volume / blood pressureRegulation of plasma volume / blood pressureRegulation of plasma Regulation of plasma osmolalityosmolalityProduction of hormones Production of hormones ，etcFUNCTIONS OF THE KIDNEYS The kidneys are the major organs responsible for maintaining a constant level of composition and the volume of the body fluid homeostasis.They have several functions, which can be summarized as the following two basic functions:Urinary function（泌尿功能）（泌尿功能）Endocrine function（内分泌功能）（内分泌功能）(1) Urinary functionElimination of waste products of metabolism, e.g.urea (from protein metabolism)uric acid ( from nucleic acids) creatinine (from muscle creatine).Removal off oreign chemicals from the blood and their excretion in urine, e.g.drugs, pesticides, food additives(2) Endocrine functionKidneys secrete some hormones such as: Erythropoietin, EPO controls erythrocyte production,Renin(catalyzes the formation of angiotensin I from angiotensinogen in a series of biochemical reactions that result in the stimulation of aldosterone synthesis),1,25 dihydroxy-cholecalciferol regulates calcium reabsorption by the gut.endothelinRenal disease testsurinalysisRenal biopsyRenal functionGlomerular filtrationRenal tubular RoutinetestChemistryType,Nature,Site,Extent,State Purpose of renal function testuTo judge the extent of kidney damageuTo make a prognosisuTo evaluate the therapy effectsuTo instruct medicine administrationGlomerular filtration function Renal tubular function Renal function tests Glomerular Filtration Rate, GFRConceptthe quantity of prime urine produced by both kidneys in unit time(per min) is called Glomerular Filtration Rate.Reference value:*120160ml/min Renal clearance testsDefinitionthe volume of plasma from which a measured amount of substance can be completely eliminated (cleared) into the urine per unit of time.Standard for Ideal substances nGeneral:nOnly be filtered at glomerularnNeither be absorbed nor be secreted in tubularnNot bound to plasma proteinnExogenous: nnontoxic;n not be transformed or metabolized in bodynEndogenous: nend metabolite; produced steadily; nno difference between genders ; nnot be influenced by dietaryDifferent manners of substances filtered by kidneysubstancesGlomerular filtrationTubular absorptionTubular secretionEvaluation Inulin菊粉菊粉completeneverneverIdeal reagent for GFR testcreatininecompleteneverlittleBasically GFRglucosecompletecompleteneverTubular absorption testpara-amino-hippurate （对氨马尿酸）（对氨马尿酸）20%little80%（by capillary around tubular）Kidney blood flow hydrometryGlomerular filtration function testsCreatinine clearance（Ccr)Serum creatinine, ureaSerum cystatin CSerum 2-MGSerum CreatininenEndogenous: released from skeletal muscle at a steady rate (1mg Cr/20g muscle)nExogenous: meat in the diet(small amount) variable n Character: filtered at the glomerulus; a small amount secreted tubular absorption:never Endogenous Creatinine Clearance rate (Ccr) The ability of how much (volume) endogenous creatinine in the plasma can be cleared completely by both kidneys per unit time (ml/min or L/24h）.Concept:Completely filtered, no absorption, few secretion 17specimen collection PreparationMethodExamine serum and urine creatinine Ucr(umol/L)V(ml/min) Scr(umol/L) Ccr =lCalculation：Urine: 45ml toluene (antisepsis ), collect 24h urine， count volume exactlySerum: 23ml venous bloodlfree of Cr diet for 3 dayslfree of vigorously exerciselfree of diureticnReference value：adult：80120ml/min neonate：25 70ml/minEndogenous Creatinine Clearance rate (Ccr)nClinical significance：n 1.1 impaired kidney function: Acute glomerulonephritis Acute tubular necrosis Chronic renal disease 1.2 conditions causing decreased blood present: shock congestive heart failure cirrhosis with ascites(腹水）腹水） dehydration1. Decreased Ccr:19Endogenous Creatinine Clearance rate(Ccr)nClinical significance： 1.3 To evaluate the extent of glomerular filtration function damage 1.4 To guide therapy e.g.Ccr 3040ml/min-low protein diet severemild70 50 30CcrmoderateEndogenous Creatinine Clearance rate(Ccr)Clinical significance： 1.5 assessment of renal transplantation effect success： gradually increase acute rejection： decrease again failure： no-increase2. Increased Ccr exercise pregnancy Glomerular filtration function testsCreatinine clearance（Ccr)Serum creatinine, ureaSerum cystatine CSerum 2-MGCan not be used as an early diagnosis indicator: exogenous intake muscle mass variable kidney has great functional reserve Serum Creatinine (Cr)Start to increase only when the GFR has been decreased to 1/3 normal Serum Creatinine (Cr) Serum (plasma) Cr：59-104 umol/L（M） 45-84 umol/L （F）Reference valueSerum Creatinine(Cr)Clinical significance ：Cr increase 1. prerenal: 1.1 increased synthesis of creatinine muscle hypertrophy muscle necrosis High-meat diet severe exercise 1.2 decreased renal perfusion hypotention, shock congestive heart failure cirrhosis, ascitesSerum Creatinine(Cr)Clinical significance ：Cr increase2. renal: 2.1 glomerular damage various glomerulonephritis 2.2 decreased tubular secretion tubulointerstitial nephritis(肾小管间质性肾炎)Serum Creatinine(Cr)Clinical significance ：Cr increase3. postrenal: postrenal obstruction urinary tract obstruction Benign prostatic hyperplasia carcinoma of prostate, bladder, or ureters calculi retroperitoneal tumor 1. elder, decrease in muscle mass 2. emaciated(消瘦） 3. pregnancySerum Creatinine(Cr)Clinical significance ：Cr decrease*one of the protein metabolism end products liverPro BUN filtered by the glomerulusurineabout 30-40% reabsorbedSerum UreaSerum UreaTwo resources:dietary intakeprotein catabolismReference value： adults：3.0-9.2 mmol/L（M） 2.57.2 mmol/L（F） Serum UreaClinical significance1. Urea increase1.1 impaired kidney functionrenal diseases：glomerulonephritis, pyelonephritis, tumor of kidney, polycystic kidneyprerenal： ascites，dehydration, heart failurepostrenal： prostate trouble, ureteral obstruction, tumorchronic renal failure31Clinical significanceSerum Urea1.Urea increase high protein diet Sever stress: myocardial infarction, high fever gastrointestinal bleeding, burn, hyperthyroidism 1.2 Increased protein catabolism ： severe liver disease: decreased synthesis lack of protein: malnutrition, anemia, etc.32Clinical significanceSerum Urea2. Urea decreaseSerum UreaClinical significance3. Identification of renal and non-renal azotemia （氮质血症）（氮质血症） renal：Urea, Cr non-renal：Urea, Cr (-)/nTo judge kidney damage: Ccr is more sensitive、earlier than Scr and UreanUrea/Scr 10:1 - intrinsic renal failure (器质性肾衰）nUrea/Scr 10:1 - prerenal oliguria postrenal obstruction protein decompose intake increaseCcr, SCr, UreaRenal insufficient stages Urea Ccr SCr (mmol/L) （ml/min) (umol/L)compensatory stage 9 80-51 9 50-20 178-445(azotemia)Renal failure 20-28.6 19-10 445-707Uremia 28.6 707Glomerular filtration function testsCreatinine clearance（Ccr)Serum creatinine, ureaSerum cystatin CSerum 2-MGnCystatin C is a low- molecular weight protein steadily produced by all human nucleated cellsnThe specific indicator of glomerular filtration function： freely filtered at the glomerulus, uptaken and degraded in the proximal tubular cells. serum concentration of cystatin C appears not to be affected by muscle mass, diet, gender , age, tumor Serum Cystatin CSerum Cystatin CReference value：0.59 1.03 mg/L No difference between genders A steady correlation between GFR and Cys C in whole lifeSerum Cystatin CCystatin C & GFR Renal function tests Glomerular filtration function Renal tubular function Proximal tubular functionn reabsorption of micromolecule protein 1. urine alpha1 microglobulin 2. urine beta2 microglobulin 1-MG 2-MG Urine : tubular damage fever : tubular damageAttention Easily destroyed in aciduria threshold 5mg/L:sesum+urine(same time)Resource Liver cells, tumor cells, lymphocyte almost all cells except RBCM.W 26KD 11.8KDClearance freely filtered freely filtered 99.9% reabsorption 99.9% reabsorption degradation degradation Serum : GFR : GFR , Tumor, : hepatonecrosis/ hepatitis,Reference serum: 1030mg/L 12mg/L value urine: 15mg/24h 0.3mg/L Distal tubular function Mosenthal test(莫氏试验） n Urine osmotic pressure test Mosenthal Test method： 1. normal diet: water intake 500600ml/meal2. count urine volume and specific gravity: 6 counts during day time (8:00 AM8: 00PM) once/2h 1 count during night(8:00 PM8: 00AM ) Mosenthal Test*Reference value：l1.volume in 24h：10002000mll2.ratio of volume between day time and night 34:1l3.urine volume during night (12h)1.018; dmax- dmin0.009Mosenthal Test1. polyuria , low specific gravity, decreased increased urine volume concentration ability during night， chronic nephritis, pyelonephritis, gout, renal disease in hypertensionClinical significanceMosenthal Test2. oliguria high specific gravity，fixed at 1.018 acute glomerulonephritis （impaired filtration function）Clinical significanceosmolality,osm尿渗量尿渗量n Assess the ability of kidneys to dilute or concentrate urinenNormal value:l osmol: 600-1000 mOsm/kgH2Ol Plasma osmol: 275-305 mOsm/kgH2Ol Uosm/Posm=34.5:1osmolality判断尿浓缩功能1.Uosm= 300 mOsm/kgH2O : Isosthenuria等渗尿2.Uosm 300 mOsm/kgH2O 低渗尿3.Uosm600 mOsm/kgH2O: 尿浓缩功能障碍Clinical significanceIncrease: n dehydration, diarrhea, diabetes mellitus, hyperglycemia, hypernatremiaDecrease: n overhydration, insipidus(尿崩症）, hyponatremia, hypocalcemia differential diagnosis of oliguria causesn Renal oliguria:肾性少尿 Uosm 450 mOsm/kgH2OpurineSerum uricuric acid liverGlomerular filtration function &Renal tubular functiongoutGlomerular filtrationTubular absorptionTubular secretionfree 90% return to bloodokClinical significance中文名称中文名称缩写缩写临床应用临床应用1.尿微量白蛋白MA肾小球滤过膜电荷屏障受损的传统标志蛋白2.尿转铁蛋白TRU肾小球滤过膜电荷屏障受损的敏感标志蛋白3.尿免疫球蛋白GIGU肾小球滤过膜分子筛屏障受损的标志蛋白4.尿1微球蛋白 1M肾小管重吸收功能受损的标志蛋白肾功能检查法肾功能检查法功能定位功能定位标准检查法标准检查法临床常用检查法临床常用检查法肾小球滤过功能肾小球滤过功能菊粉清除率菊粉清除率内生肌酐清除率（内生肌酐清除率（Ccr)血尿素氮、血肌酐血尿素氮、血肌酐血血 2微球蛋白微球蛋白( 2-MG)浓度浓度放射性核素放射性核素GFR测定测定 近端肾小管功能近端肾小管功能肾小管最大葡萄糖重吸收肾小管最大葡萄糖重吸收量（量（TmG） 肾小管对氨马尿酸最大排肾小管对氨马尿酸最大排泌量（泌量（TmPAH） 2 2-MG-MG、 1-M1-M、尿尿NAGNAG、 溶菌酶、溶菌酶、钠、氨基酸、糖、滤过钠排泄钠、氨基酸、糖、滤过钠排泄分数（分数（FeNaFeNa）远端肾单位功能远端肾单位功能禁饮尿渗量、浓缩稀释试验、一次禁饮尿渗量、浓缩稀释试验、一次性尿渗量（少尿）、晨尿比重性尿渗量（少尿）、晨尿比重肾血流量肾血流量对氨马尿酸盐清除率对氨马尿酸盐清除率碘锐特清除率碘锐特清除率131131I-I-邻碘马尿酸钠检查有效肾邻碘马尿酸钠检查有效肾血浆流量（血浆流量（ERPFERPF）肾小管性酸中毒诊肾小管性酸中毒诊断试验断试验氯化铵负荷试验氯化铵负荷试验 碱负荷试验碱负荷试验 Case analysisHistory and physical examination : A 48-year- old female patient was admitted with the complains of severe headache with a fever, edema in her face and eyelids for 3 days. From yesterday, she found her amount of urine was decrease once a day . The color of her urine is reddish and cloudy. Physical examination her blood pressure is 180/100 mm Hg , there is severe pitting edema in her face and legs.Question After physical examination, what laboratory test do you plan to do? How do you think or judge this case? What urinary abnormalities and renal function test results do you probably find?Laboratory tests： 1.blood routine：RBC：3.61012/L， Hb：72g/L 2.urine routine：waxy cast：12/Hp， RBC：1020/Hp， WBC：03/Hp， pro：+ 3.renal function tests：Cr：494umo/L， UREA：21.1mmol/L 4. serum Ca2+：2.01mmol/L 5.serum 2-MG：13mg/L 6.urine 2-MG：0.5mg/Lconclusion：chronic nephritis renal insufficient, Renal failure Treatment：dialysis case2： Li# male 57y ID：38481complain：尿频、排尿不畅两年，尿量少3个 月，浮肿两个月history：尿频、尿急，排尿不畅，尿线变细，排尿不尽，诊断为“前列腺增生”， 3个月前尿量减少：24h700ml，经“膀胱造瘘”术后，尿量：1500ml/24h，近3日浮肿加重入院。Physical examination： Bp：170/100mmHg， anemia looking， 腹部叩移动浊音（+）， 双下肢凹陷水肿。问题：1.该患者考虑做哪些检查？2.实验室检查应做哪些指标？3.该患者有无肾功不全，为何期，什么原因所致？Laboratory tests：1.Blood routine：RBC：3.21012/L； Hb：64g/L2.Urine routine：RBC：1015/Hp；WBC：2530/Hp，pro：3+，BLO：2+3.Renal function：Cr：1018umo/L， UREA：32.36mmol/L4.biochemistry：T：56.4g/L；Alb：22.8g/L， Ca：1.95mmol/L， P：3.12mmol/LImage examination： ultrasound：双肾积水，chronic cystitis，ascites，prostate hyperplasia conclusion：1.obstruction renal disease （prostate hyperplasia)2.chronic renal insufficient，uremia stage1. What kidney diseases can cause an elevated Ccr? What else besides kidney disease can do this? 2. What does a creatinine clearance tell you?3. what does dilution-concentration test tell you? Key points谢谢谢谢