主任查房武金城

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1、主任查房武金城49/M2012-5-16病例特点中年男性，隐袭起病，慢性病程肾脏受累大量蛋白尿、低白蛋白血症、肾功能受损糖尿病、非活动性HBsAg携带诊断与鉴别诊断ARForA/C急性肾衰竭肾前性肾衰竭肾性肾衰竭肾后性肾衰竭肾小球性肾小管性肾间质性肾血管性无证据无证据肾小球：急进性肾小球肾炎支持：蛋白尿ANA、ANCA-PR3（-）；无明显血尿肾间质：急性间质性肾炎、特发性急肾衰支持点：有可疑用药史、蛋白尿、肾小管损伤证据不支持点：无相应体征、血嗜酸细胞正常、蛋白尿量大肾小管：急性肾小管坏死支持：用药史、有近端肾小管重吸收功能障碍不支持：无明显

2、少尿、无尿及多尿的病程，低比重尿肾血管肾动脉狭窄、血栓肾静脉血栓血栓性微血管病肾脏本病ＮＳ的诊断大量蛋白尿(尿蛋白>3.5ｇ/ｄ)低蛋白血症(血浆白蛋白<30ｇ/Ｌ)水肿高脂血症诊断思路是否ＮＳ否原发性或继发性是继发性原发性推测病理诊断病因诊断有无并发症常见病因及病理类型分类儿童青少年中老年原发性微小病变系膜增生性肾小球肾炎膜性肾病系膜毛细血管性肾小球肾炎局灶性节段性肾小球硬化继发性过敏性紫癜肾炎系统性红斑狼疮肾炎糖尿病肾病乙肝相关性肾小球肾炎过敏性紫癜肾炎肾淀粉样变性乙肝相关性肾小球肾炎骨髓瘤性肾病先天性NS淋巴瘤或实体肿瘤性肾病乙肝相关性肾

3、小球肾炎DKD临床特点JAmSocNephrol,2010,21:556–563ClassII:MesangialExpansion,Mild(IIa)orSevere(IIb)2ClassIV:AdvancedDiabeticGlomerulosclerosis4ClassI:GlomerularBasementMembraneThickening31ClassIII:NodularSclerosis(Kimmelstiel–Wilsonlesions)33DiagramEMofthisglomerulus:themeanwidthofthe

4、GBMwas671nm(meantakenover55randommeasurements).Glomerulusshowingonlymildischemicchanges,withsplittingofBowman’scapsule.NoclearmesangialalterationDiagramthemesangialexpansionexceedthemeanareaofacapillarylumen(IIb)themesangialexpansiondoesnotexceedthemeanareaofacapillarylumen(

5、IIa)InpanelFisaclassIIIKimmelstiel–Wilsonlesion.InpanelH,signsofclassIVDNconsistofhyalinosisoftheglomerularvascularpoleandaremnantofaKimmelstiel–Wilsonlesionontheoppositesiteofthepole.NDRD线索Absenceofdiabeticretinopathy;LoworrapidlydecreasingGFR;Rapidlyincreasingproteinuriaor

6、nephroticsyndrome;Refractoryhypertension;Presenceofactiveurinarysediment;Signsorsymptomsofothersystemicdisease;>30%reductioninGFRwithin2-3monthsafterinitiationofanACEinhibitororARB.AJKD,VOL49,NO2,SUPPL2,FEBRUARY2007http://www.kidney.org/professionals/kdoqi/guideline_diabetes

7、/guide1.htm其他糖尿病病史短尿蛋白分子量测定特点肾脏病理MembranousNephropathy（MN）distinctclinicopathologicentitybyDavidJonesin1957Nephroticglomerulonephritis.AmJPathol.1957;33:313-329.Circulatingautoantibodies(immunoglobulinG4andG1subclasses)interactingwithantigensnativetoorplantedintheGlomerularc

8、apillarywallatthepodocytecellmembrane–basementmembraneInterfacegenerallyare