Impairment of kidney function and/or kidney structure 肾功能失调或肾结构破乱 Kidney function blood & urine tests 肾功能可通过血检或尿检评估 Abnormal kidney structure 肾结构异常

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2 Impairment of kidney function and/or kidney structure 肾功能失调或肾结构破乱 Kidney function blood & urine tests 肾功能可通过血检或尿检评估 Abnormal kidney structure 肾结构异常

Current Renal Diagnostic Panel 目前肾病诊断指标 Serum

3 Current Renal Diagnostic Panel 目前肾病诊断指标 Serum creatinine concentration 血肌酐浓度 Blood Urea Nitrogen 血尿素氮 Urinalysis 尿常规 Proteinuria (UPC) 蛋白尿 (UPC) Blood pressure 血压 Current Best Test of Overall Kidney Function: Serum/Plasma Creatinine 目前最佳衡量肾整体功能的检测 : 血清 / 血浆肌酐 Screening Tests

4 Clinical Signs of Kidney Disease 肾病的临床症状 Clinical signs 临床症状 Changes in urine production 尿量变化 Polyuria (and polydipsia) 多尿多饮 Oliguria 少尿 Decreased appetite 食欲下降, Anorexia 厌食 Vomiting 呕吐 Lethargy, depression 嗜睡, 抑郁 Weight loss 体重减轻 Acute blindness 急性失明 Physical examination 体检 Dehydration 脱水 Cachexia 恶病质 Lethargy, weakness 嗜睡, 乏力 Pale mucous membranes 粘膜苍白 Small or Large Kidneys 肾脏过大过小 Uremic halitosis & oral ulcers 尿毒症口臭及口腔溃疡 Hypertensive retinopathy 高压性视网膜病变 Hypothermia 低烧

5 Suspect Kidney Disease? Measure Kidney Function 怀疑肾病监测肾功能 Measure GFR(glomerular filtration rate) 肾小球滤过率 Best overall screening test of kidney function (most important) 最重要的指标衡量肾整体功能 Does not test all kidney functions 不需要检测所有肾功能 Detects generalized kidney disease 检测常规的肾病 Clinical tests for GFR: 肾小球滤过率临床检测 Serum creatinine concentration 血肌酐浓度 Blood urea nitrogen concentration 血中尿素氮浓度

6 摄入蛋白质肾排泄肌酐形成

7 [Creatinine] doubles each time GFR drops In half 每当肾小球滤过率减半, 肌酐水平增加两倍

8 Interpretation of Serum Creatinine 血清肌酐分析 Bumpers

9 When the Patient s SCr Exceeds Reference Levels 当患者的血肌酐超过正常水平... At least a 75% reduction in GFR has already occurred 至少肾小球滤过率已经降低 75% 了 Serum creatinine is a relatively insensitive test for very early (mild) loss of kidney function 在肾功能早期损伤时, 血肌酐在测试中相对不敏感 The sensitivity of serum creatinine to changes in GFR increases as loss of kidney function becomes more severe 当肾功能损伤越来越多时, 血清肌酐对肾小球滤过率的变化越来越敏感

10 Limitations of Creatinine 肌酐的局限 Comparing SCr values to the normal range is relatively insensitive as a marker of early (mild) loss of kidney function 在肾功能损伤早期, 用血清肌酐值与正常值区间做比较会相对不灵敏 Comparing SCr values to the patient s own previous SCr values may be quite sensitive as a marker of loss of kidney function 评估肾功能损伤, 用血清肌酐值与病患之前的血清肌酐值做比较会相当灵敏 Need reliable previous value to compare to 需要可靠的之前的数据来比较 SCr may be altered by factors other than GFR 肌酐可由除肾小球滤过率外的其它因素来改变

11 Impact of Muscle Mass on Creatinine 肌肉的多少对肌酐水平的影响 GFR (% of normal)

12 S Cr : Size-Adjusted Ref Intervals 尺寸调整后的参考区间 Size of Dog mg/dl mmol/l Mini (0-10 kg): (42-90) 小型犬 ( ) Medium (11-25 kg): (49-110) 中型犬 ( ) Maxi (26-45 kg): (53-178) 大型犬 ( ) Giant (>45 kg): (78-161) 超大型犬 ( ) Craig et al, 2006

13 Distribution of Plasma Creatinine in 1439 Clinically Healthy Dogs 1439 条健康狗血浆肌酐含量 Geffré, 2009

14 Azotemia Vs Uremia 氮质血症 VS 尿毒症

15 肾前性肾脏性肾后性

16 Kidney Function Tests 肾功能检验

17 Prerenal Azotemia 肾前性氮质血症

18 Prerenal Versus Renal Azotemia 肾前性 vs 肾性氮质血症

Prerenal Azotemia 肾前性氮质血症 Concentrated urine in a patient

病患的浓缩尿和氮质血症通常提示 : 肾前性氮质血症 Dogs: Urine specific gravity

030 Cats: Urine specific gravity (USG) 1.

19 Prerenal Azotemia 肾前性氮质血症 Concentrated urine in a patient with azotemia generally indicates PRERENAL AZOTEMIA 病患的浓缩尿和氮质血症通常提示 : 肾前性氮质血症 Dogs: Urine specific gravity (USG) 狗 : 尿比重 (USG) Cats: Urine specific gravity (USG) 猫 : 尿比重 (USG) Urine specific gravity is the ratio of: 尿比重的比率 : Density of urine Density of water 尿密度 / 水密度

20 Azotemia is renal when: 当是肾性氮质血症的时候 : Failure to achieve minimum urine specific gravity Less than (dogs 1.030) & (cats 1.035) 尿比重低于最低值 In patients with: 患者有 : Azotemia 氮质血症 Impaired renal blood flow 受损的肾血流量 Prerenal azotemia and Renal azotemia may occur together (inadequate concentration) 肾前性氮质血症和肾氮质血症可能同时发生 ( 浓缩能力不足 ) Does not apply to post-renal azotemia 不适用于肾后性氮质血症

21 Renal Azotemia 氮质血症

22 Prerenal Azotemia 肾前性氮质血症 Alternate method of confirming prerenal azotemia: 确认肾前性氮质血症的另一种方法 : Fluid challenge 补充体液 Prerenal azotemia = Fluid Responsive Azotemia 肾前性氮质血症 = 对补液会产生反应的氮质血症 Fluid therapy reduces or corrects the azotemia 液体疗法减少或纠正氮质血症 How? 如何? Measure serum creatinine concentration 测量血清肌酐浓度 Administer fluid volume 给予液体 Recheck creatinine hours later 小时后重新检查肌酐

23 Example: Fluid Challenge 案例 : 液体检测

24 Interpretation 解释 A cat is presented for lethargy and vomiting. He is ~5% dehydrated. His Serum Creatinine is 4.8 mg/dl (normal 1.6 mg/dl). His urine specific gravity is 猫表现出了嗜睡, 呕吐他有约 5% 的脱水血肌酐 4.8 mg/dl( 正常 1.6 mg/dl ) 尿比重 We rehydrate the cat with IV fluids. The SCr is: 我们为猫静脉补液 2.6 mg/dl 24 hours after fluids (hydrated) 补液 24h 后,2.6mg/dl 2.5 mg/dl 48 hours later he is hydrated & eating 补液 48h 后并进食,2.5mg/dl What was the initial cause for his azotemia? 导致氮质血症最初的原因是什么?

25 Combination of Causes for Azotemia 氮质血症组合的成因 Renal azotemia + prerenal azotemia 肾性氮质血症 + 肾前性氮质血症 Urine specific gravity inadequate 尿比重不足 Evidence of concurrent prerenal azotemia 同时有肾前性氮质血症 Partial reduction in azotemia following fluid challenge 补液后氮质血症部分得到缓解 Evidence of dehydration or other cause for impaired kidney blood flow (e.g. low blood pressure, cardiac disease, etc.) 脱水或其他原因导致的肾血流量降低 ( 例如低血压, 心脏病等 ) Can have either renal or prerenal azotemia with postrenal azotemia 可能是肾性或者肾前性氮质血症伴有肾后性氮质血症

Postrenal Azotemia 肾后性氮质血症 Elevated serum creatinine and BUN concentrations 血清肌酐和尿素氮浓度 Due to obstruction of flow of urine 由于尿流梗阻 Urine specific gravity of urine DOES

26 Postrenal Azotemia 肾后性氮质血症 Elevated serum creatinine and BUN concentrations 血清肌酐和尿素氮浓度 Due to obstruction of flow of urine 由于尿流梗阻 Urine specific gravity of urine DOES NOT help recognize postrenal azotemia 尿的比重不能帮助确认肾后性氮质血症 Recognized by confirming obstruction to free-flow of urine in the collecting system 通过确定出肾脏之后尿液的自由流动在哪里受阻从而判断是肾后性氮质血症

27 Potential Causes for BUN 尿素氮升高的可能原因 Increased protein intake 增加蛋白质的摄入量 Infusion of amino acids 氨基酸输注 Gastrointestinal bleeding 消化道出血 Catabolic states 分解状态 Corticosteroids 皮质类固醇 Tetracycline 四环素

28 What Is BUN Good For? 尿素氮的用处? Screening for hepatic failure 检查肝功能衰竭 Urea made in liver 肝脏产生尿素 Decreased liver function less urea produced 肝功能下降, 会使尿素生成减少 Low BUN: Suspect 低尿素氮可以怀疑 : Liver failure 肝功能衰竭 Low protein diet 低蛋白饮食 Starvation 饥饿 Elevated in GI bleeding (high compared to SCr) 胃肠道出血会使尿素氮升高 Association with uremic signs 和尿毒症的临床表现有关

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