糖尿病肾病病理特点

cross-sectional area of the glomerulus devoted to the capillary circulation. The mesangial cellularity and matrix are normal.
Slide 1 —Normal glomerulus: Schematized drawing of a normal glomerulus showing epithelial cells in green, endothelial cells in yellow and mesangial cells in red. Note that the glomerular basement membranes (in black) do not
2型糖尿病伴微量白蛋白尿：不典型肾脏改变—小动脉显著透明样变性，而肾小 球以及肾间质改变不明显
Slide 200 —This and the subsequent two slides illustrate the atypical lesions commonly seen in microalbuminuric NIDDM patients. Some of these
美国肾脏基金会肾脏病预后质量倡议(NKF—K／DOQI)指南标准
糖尿病合并肾脏损伤不一定是糖尿病肾病
(1)无糖尿病视网膜病变 (2)GFR较低或迅速下降 (3)蛋白尿急剧增多或有肾病综合征 (4)顽固性高血压 (5)尿沉渣活动表现（血尿、白细胞尿、管型尿） (6)其他系统性疾病的症状或体征 (7)ACEI或ARB开始治疗后2～3个月内肾小球滤过
11 o’clock). It is likely that the glomerular capillary loops retract, depositing the hyaline material along the Bowman’s capsular wall.
入球小动脉透明样变性早期改变：内皮细胞下非细胞均质成份沉积，肾功能尚 正常
Slide 171 —Nodular diabetic glomerulosclerosis (Kimmelstiel-Wilson lesions) in a patient with overt diabetic nephropathy and proteinuria, hypertension, and reduced GFR. Note the palisading of mesangial nuclei around the
patients, as illustrated in this PAS slide, have established arteriolar hyalinosis lesions with little or no glomerular or tubulointerstitial injury.
率下降超过30％
糖尿病出现以下情况考虑活检
糖尿病病程较短 既往有肾脏病病史 肾损害早于糖尿病，糖尿病与肾损害同时
出现，或糖尿病早期出现肾损害 血尿明显 有肾损害而不伴有其他糖尿病微血管
糖尿病肾脏疾病的病理 -- 肾脏大体标本
糖尿病肾病的基本病理变化
光学显微镜检查 ——呈现两种病理类型
入球小动脉与出球小动脉壁透明样变，弥漫性糖尿病结节性肾小球硬化：１ 型糖尿病引起的临床糖尿病肾病之早期
Slide 176 —Arteriolar hyalinosis in both afferent (lower left side) and efferent (lower right side) glomerular arterioles (PAS). Note the diffuse and
光学显微镜检查
2. 结节性肾小球硬化： 肾小球系膜基质增宽及分裂，并且出现
Kimmelstiel-Wilson结节 肾小球基底膜弥漫增厚，球囊滴（透明变性），
纤维蛋白帽（透明变性和脂质沉着），毛细血 管襻微血管瘤，出、入球小动脉透明变性及动 脉硬化 此型为DN特异
结节性肾小球硬化（K-W结节）：伴蛋白尿、高血压及肾小球滤过率下降
periphery of the nodule and the fibrillar nature of the nodular matrix materialHale Waihona Puke Baidu Note also the restriction of glomerular capillary lumenal space (PAS).
糖尿病肾病的发病机制
高血糖
糖化终末产物
PKC↑
多元醇通路 活性↑
高血压、高 血脂、吸烟
肾小球高 滤过肥厚
糖尿病肾病
遗传
氧化应激 TGF-β
Ang-Ⅱ
GH/IGF-Ⅰ NO白介素
糖尿病肾病的自然进程
时间 (年)
0
5
20
30
糖尿病开始 临床前的肾病
蛋白尿开始
终末期肾病
初期肾病
明显肾病
(高滤过,微白蛋白尿,血压升高) (Scr,升高
nodular diabetic glomerulosclerosis in this IDDM patient with early overt nephropathy.
蜡样物质填充于小动脉壁，引起血管腔几乎完全闭塞
Slide 175 —Advanced arteriolar hyalinosis with virtual complete replacement of the vessel wall by hyaline waxy material (PAS).
GFR降低)
结构改变
高血压
(肾小球基底膜增多且系膜扩展)
Adapted from Breyer JA et al. Am J Kid Dis 1992; 20(6): 535.
糖尿病肾脏病变诊断标准
在大部分糖尿病患者中，出现以下任何一条者考虑 其肾脏损伤是由糖尿病引起的 (1)大量白蛋白尿 (2)糖尿病视网膜病变伴微量白蛋白尿? (3)在1O年以上糖尿病病程的l型糖尿病中出现微量 白蛋白尿
弥漫、严重糖尿病肾小球硬化：系膜区基质及细胞显著增加，毛细血管腔 严重受压；该患者肾小球滤过率下降50%，伴显著蛋白尿、严重高血压
Slide 168 —Marked diffuse diabetic glomerulosclerosis. There is extreme expansion of the mesangium with both matrix and cellular material. The capillary lumenal circulation is markedly constricted (PAS). Whereas the
弥漫性轻度糖尿病肾小球硬化：系膜区基质扩张，GBM增厚，毛细血管腔受 压，血管极小动脉壁增厚
Slide 167 —Moderate diffuse diabetic glomerulosclerosis in an insulin-dependent diabetic (IDDM) patient with 16 years’ duration. Note the widening of the glomerular mesangium, the restriction of the glomerular capillary
糖尿病肾病的特征性病理改变
Burton D Rose，MD 2000
糖尿病肾病：肾小球基底膜增厚伴系膜基质扩张
Slide 165 —Diabetic nephropathy: This schematized drawing shows the markedly thickened lamina densa of the GBM and increased mesangial matrix material which are the sine qua non of diabetic renal disease. The subsequent slides (166-202)
Slide 174 —Early glomerular arteriolar hyalinosis in an afferent arteriole. Note the smooth, waxy, homogenous PAS positive material in the
subendothelial space. This IDDM patient had normal renal function.
帽状滴之形成：肾小球毛细血管袢渗出性物质（内皮细胞下透明样物质） 附着与肾小球囊之内侧壁，然后肾小球收缩。小动脉透明样变性（右图）
Slide 179 —Formation of a capsular drop by adhesion of glomerular capillary loops containing subendothelial hyaline (the so-called “exudative lesion”) to Bowman’s capsule (9 o’clock and
糖尿病肾脏疾病
定义
DKD是指由糖尿病引起的慢性肾病，主要包括肾小球 滤过率(GFR)低于60 ml/min/1.73 m2 或尿白蛋白／肌酐比值(ACR)高于30 mg／g持续超过 3个月 糖尿病性肾小球肾病(diabetic glomerulopathy)专 指经肾脏活检证实的由糖尿病引起的肾小球病变
patient in slide 2 had normal renal function, this patient had overt nephropathy with proteinuria, hypertension, and a 50% reduction in GFR.
糖糖尿尿病病肾肾病病的的病病理理变变化化（五）
糖尿病肾病的其他病理变化
帽状滴：透明PAS阳性物质沉积于肾小球囊之内侧壁
Slide 178 —A capsular drop consisting of hyaline PAS positive material deposited on the parietal surface of Bowman’s membrane (9 o’clock).
completely surround capillary loops, and that endothelial cells are in direct contact with mesangial matrix (blue) at the mesangial poles of capillaries.
demonstrate the spectrum of diabetic renal disease (starting with a review of normal glomerular histology), and illustrate distinguishing points between other types of glomerulopathies which may mimic diabetic nephropathy.
1. 弥漫性肾小球硬化： 肾小球系膜基质增宽 肾小球基底膜弥漫增厚 此型表现并非DN特有
Slide 3 —Normal glomerulus: Hematoxylin and eosin stain of a normal glomerulus sectioned through the vascular pole. Note the wide-open capillary lumina and the large percentage of the
circulation, the thickening of the glomerular basement membrane compared to slide 1, and the hyalinosis of the arteriolar wall at the vascular pole (PAS).