激素和免疫抑制剂的使用
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• 微小病变型肾病
(minimal change disease ,MCD)
• 局灶性节段性肾小球硬化
( focal segmental glomerulosclerosis, FSGS)
• 系膜增生性肾小球肾炎
(mesangioproliferative glomerulonephritis）
• 系膜毛细血管性肾小球肾炎
过敏性紫癜性肾炎
除有大量蛋白尿外,如下特征可考虑: (1)最常见于儿童,青年 (2)斑点状紫癜,常见于臀部和下肢,常有腹痛和
关节痛 (3)多数紫癜后4～8周出现肾损害; (4)血小板计数多正常
遗传性疾病（Alport综合征）
除肾病综合征特点外, 符合: (1)有明显的家族病史; (2)30%～50%病人有神经性耳聋, 3%～20%有眼 部异常表现; (3) 肾活检电镜下肾小球基膜的致密层分离,破 碎并有电子致密颗粒沉积
肿瘤相关性肾病
• 骨髓瘤性肾损害
• ①好发于中老年;
• ②骨痛;
• ③蛋白电泳M带;
• ④尿轻链增高
• ⑤骨髓象显示浆细胞异常增生
• 淋巴瘤肾损害： 淋巴结肿大
•
发热、消瘦、肝脾肿大
•
骨穿和淋巴结活检
• 其他实体瘤
肾淀粉样变
(1) 好发于中老年 (2) 多系统累及(心、肾、消化道、皮肤和神经) (3) 继发者常继发于慢性感染、结核、恶性肿瘤等 (4) 肾脏体积增大 (5) 肾活检确诊
• This normal glomerulus is stained with PAS to highlight basement membranes of glomerular capillary loops and tubular epithelium. The capillary loops of this normal glomerulus are well-defined and thin
• This is IgA nephropathy (Berger disease). The IgA is deposited mainly within the mesangium, which then increases mesangial cellularity as shown at the arrow.
(membranoproliferative glomerulonephritis, MPGN)
• 膜性肾病
(membranous glomerulonephritis,MN)
A normal glomerulus is shown diagramatically. The normal anionic charge barrier of slit pores in overlying podocyte cytoplasm prevents protein molecules such as albumin from passing through the endothelium. The normal mesangium contains about 2 to 4 mesangial cells, which have a macrophage-like function.
• This immunofluorescence pattern demonstrates positivity with antibody to IgA. Note that the pattern is that of mesangial deposition in the glomerulus.
Not a disease but a symptom complex
• 步骤２：排除继发性肾病综合征
感染
• 细菌性： 链球菌感染后肾炎 细菌性心内膜炎肾炎等
• 病毒性： 乙肝相关性肾炎
有HBV感染的血清学证据; 有肾病综合征的临床表现; 肾组织有乙肝病毒抗原的沉积
• 寄生虫
狼疮性肾炎(lupus nephritis, LN)
• This is a normal glomerulus by light microscopy. The glomerular capillary loops are thin and delicate. Endothelial and mesangial cells are normal in number. The surrounding tubules are normal. Life is good.
美国风湿病学会（ACR）1997年 • 1．颊部红斑 • 2．盘状红斑 • 3．光过敏 • 4．口腔溃疡 • 5．关节炎 • 6．浆膜炎 • 7．肾脏病变 • 8．神经病变 • 9．血液学疾病 • 10．免疫学异常 • 11．抗核抗体
糖尿病肾病
除肾病综合征之外,有多年的糖尿病病史 或糖尿病的其他器管的微血管病变(如眼底病 变、周围神经炎、心肌病、动脉硬化及冠心病 Hale Waihona Puke Baidu)
• This is focal segmental glomerulosclerosis (FSGS). An area of collagenous sclerosis runs across the middle of this glomerulus. In contrast to minimal change disease, patients with FSGS are more likely to have non-selective proteinuria, hematuria, progression to chronic renal failure, and poor response to corticosteroid therapy
肾病综合征 Nephrotic Syndrome
浙医二院 肾内科 胡颖
诊断和鉴别诊断
• 肾病综合征的诊断思路
• 步骤１ 是不是肾病综合征？
Diagnostic standard
– Marked proteinuria (albuminuria) >3.5 g/24hr – Hypoalbuminemia <30g/L – Edema – Hyperlipidemia
毒素、药物及过敏
(1) 有蜜蜂刺伤、毒蛇咬伤、花粉过敏史,或注射 白喉、百日咳、破伤风疫苗等病史
(2) 长期接触和服用汞、有机金、青霉素、海洛 因、丙磺舒、巯甲丙脯酸、非甾体抗炎药、 华法令、利福平、造影剂等药物,也可引起肾 病综合征
• 步骤3 确定原发性肾病综合征病理类型
原发性肾病综合征的病理类型
(minimal change disease ,MCD)
• 局灶性节段性肾小球硬化
( focal segmental glomerulosclerosis, FSGS)
• 系膜增生性肾小球肾炎
(mesangioproliferative glomerulonephritis）
• 系膜毛细血管性肾小球肾炎
过敏性紫癜性肾炎
除有大量蛋白尿外,如下特征可考虑: (1)最常见于儿童,青年 (2)斑点状紫癜,常见于臀部和下肢,常有腹痛和
关节痛 (3)多数紫癜后4～8周出现肾损害; (4)血小板计数多正常
遗传性疾病（Alport综合征）
除肾病综合征特点外, 符合: (1)有明显的家族病史; (2)30%～50%病人有神经性耳聋, 3%～20%有眼 部异常表现; (3) 肾活检电镜下肾小球基膜的致密层分离,破 碎并有电子致密颗粒沉积
肿瘤相关性肾病
• 骨髓瘤性肾损害
• ①好发于中老年;
• ②骨痛;
• ③蛋白电泳M带;
• ④尿轻链增高
• ⑤骨髓象显示浆细胞异常增生
• 淋巴瘤肾损害： 淋巴结肿大
•
发热、消瘦、肝脾肿大
•
骨穿和淋巴结活检
• 其他实体瘤
肾淀粉样变
(1) 好发于中老年 (2) 多系统累及(心、肾、消化道、皮肤和神经) (3) 继发者常继发于慢性感染、结核、恶性肿瘤等 (4) 肾脏体积增大 (5) 肾活检确诊
• This normal glomerulus is stained with PAS to highlight basement membranes of glomerular capillary loops and tubular epithelium. The capillary loops of this normal glomerulus are well-defined and thin
• This is IgA nephropathy (Berger disease). The IgA is deposited mainly within the mesangium, which then increases mesangial cellularity as shown at the arrow.
(membranoproliferative glomerulonephritis, MPGN)
• 膜性肾病
(membranous glomerulonephritis,MN)
A normal glomerulus is shown diagramatically. The normal anionic charge barrier of slit pores in overlying podocyte cytoplasm prevents protein molecules such as albumin from passing through the endothelium. The normal mesangium contains about 2 to 4 mesangial cells, which have a macrophage-like function.
• This immunofluorescence pattern demonstrates positivity with antibody to IgA. Note that the pattern is that of mesangial deposition in the glomerulus.
Not a disease but a symptom complex
• 步骤２：排除继发性肾病综合征
感染
• 细菌性： 链球菌感染后肾炎 细菌性心内膜炎肾炎等
• 病毒性： 乙肝相关性肾炎
有HBV感染的血清学证据; 有肾病综合征的临床表现; 肾组织有乙肝病毒抗原的沉积
• 寄生虫
狼疮性肾炎(lupus nephritis, LN)
• This is a normal glomerulus by light microscopy. The glomerular capillary loops are thin and delicate. Endothelial and mesangial cells are normal in number. The surrounding tubules are normal. Life is good.
美国风湿病学会（ACR）1997年 • 1．颊部红斑 • 2．盘状红斑 • 3．光过敏 • 4．口腔溃疡 • 5．关节炎 • 6．浆膜炎 • 7．肾脏病变 • 8．神经病变 • 9．血液学疾病 • 10．免疫学异常 • 11．抗核抗体
糖尿病肾病
除肾病综合征之外,有多年的糖尿病病史 或糖尿病的其他器管的微血管病变(如眼底病 变、周围神经炎、心肌病、动脉硬化及冠心病 Hale Waihona Puke Baidu)
• This is focal segmental glomerulosclerosis (FSGS). An area of collagenous sclerosis runs across the middle of this glomerulus. In contrast to minimal change disease, patients with FSGS are more likely to have non-selective proteinuria, hematuria, progression to chronic renal failure, and poor response to corticosteroid therapy
肾病综合征 Nephrotic Syndrome
浙医二院 肾内科 胡颖
诊断和鉴别诊断
• 肾病综合征的诊断思路
• 步骤１ 是不是肾病综合征？
Diagnostic standard
– Marked proteinuria (albuminuria) >3.5 g/24hr – Hypoalbuminemia <30g/L – Edema – Hyperlipidemia
毒素、药物及过敏
(1) 有蜜蜂刺伤、毒蛇咬伤、花粉过敏史,或注射 白喉、百日咳、破伤风疫苗等病史
(2) 长期接触和服用汞、有机金、青霉素、海洛 因、丙磺舒、巯甲丙脯酸、非甾体抗炎药、 华法令、利福平、造影剂等药物,也可引起肾 病综合征
• 步骤3 确定原发性肾病综合征病理类型
原发性肾病综合征的病理类型