1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf

1. 1 尿液常規及生化檢查之臨床應用：特殊個案及研究分析演講者：高雄榮總陳金順醫師時間：112年1月6日12:30 地點：高雄醫師公會大禮堂

2. 2 2 O U T L I N E 01 尿液分析臨床應用之過往歷史 02 尿液分析之介紹、文獻回顧及研究分析 2-1.尿液常規 2-2.尿液生化 04 結論 03 尿液分析之近期進展：精準及智慧醫療

3. 3 3 01 PART 尿液分析臨床應用之過往歷史

4. 4 01.尿液分析臨床應用之過往歷史 Ancient time(古代史): BC: clay tablets Hindu cultures: sweet urine:DM Bubbles: kidney diseases Urine: a filtrate of the humors The middle Ages(中世紀) (AD500-1500) : AD885-955: De urinis: textbook: urine as diagnostic tool AD 1165-1213: Matula (jorden): color, consistency, clarity AD 1275-1328:warned of the dangers of diagnosis based on urine alone The Renaissance(現代史) (1450-1600) : AD1491: Fasciculus Medicinae (Germany) vs Merck Manual Leeches vs Physician: Pisse Phophets Uroscopy is no longer practiced, but urine analysis remains an effective diagnostic tool, with a long and colorful history Kidney International 2007:71:384-387

5. 5 尿液分析是醫院中最常做的檢驗項目之一，臨床上通常將尿液分析應用於疾病篩檢、診斷及追蹤工具 篩檢：篩選腎臟及代謝性疾病（如酸鹼、血壓、糖分異常等…） 診斷：診斷腎臟、泌尿道異常及其他系統性疾病（如內分泌、癌症、感染、紫質症等…） 追蹤：腎臟及代謝性疾病之追蹤工具。 01.尿液分析臨床應用之過往歷史

6. 6 6 02 PART 尿液分析之介紹、文獻回顧及研究分析 2-1.尿液常規 2-2.尿液生化

7. 7 7 尿液之形成 尿液之成分 尿液分析之時機及方法 尿液之分析及判讀 物理特性 化學特性 顯微鏡檢 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

9. 9 9 尿液之形成 腎臟之解剖學 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

10. 1/5 1/5 Cardiac output Renal blood flow GFR 125 cc/min 水+溶質水+溶質過濾吸收分泌排出 Urine 600~1800 cc/day 水+溶質 1/5

12. 12 12 尿液之成分溶質-代謝產物 Carbohydrate Lipid Water & CO2 Mineral Electrolytes Protein Nucleic acid Urea, Creatinine, Uric acid, Other inorganic solutes Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

13. 13 13 有形物質：細胞、圓柱體、結晶、微生物有機體 Urinalysis and Body Fluids, 7th-ed., 2020 尿液之成分 02.尿液分析之介紹、文獻回顧及研究分析尿液常規  尿液成分：預估3,079種成分  尿療法?

14. 14 14 尿液之成分 物理特性  Color  Turbidity  Odor  Specific gravity 尿液常規 化學特性  pH  Glucose  Occult blood  Protein  Ketone  Bilirubin-urobilinogen  Leukocyte  Nitrite 顯微鏡檢  Cell  Cast  Crystal  Microorganism 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

16. 16 16 尿液分析之時機及方法 尿液分析是醫院中最常做的檢驗項目之一，臨床上通常將尿液分析應用於疾病篩檢、診斷及追蹤工具 篩檢：篩選腎臟及代謝性疾病（如酸鹼、血壓、糖分異常等…） 診斷：診斷腎臟、泌尿道異常及其他系統性疾病（如內分泌、癌症、感染、紫質症等…） 追蹤：腎臟及代謝性疾病之追蹤工具。 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

17. 17 17 尿液分析之時機及方法-檢體收集 Urinalysis and Body Fluids, 7th-ed., 2020 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

18. 18 18 尿液分析之時機及方法-檢體保存(1) Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 CLSI (formerly, NCCLS) Guidelines recommend testing urine within two hours of its collection. However, refrigeration or chemical preservation of urine specimens may be utilized if testing or refrigeration within a two-hour window is not possible. 02.尿液分析之介紹、文獻回顧及研究分析尿液常規使用不同試劑保存，因應不同目的。

19. 19 19 尿液分析之時機及方法-檢體保存(1) Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

21. 21 21 尿液之分析及判讀  Color  Turbidity  Odor  Specific gravity 物理特性(Physical Features) 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

22. 22 22 Scand J Clin Lab Invest, 2000; 60: 1-96 Physical Features—Color (1) 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

23. 23 23 Physical Features--Color (2) 尿液之分析及判讀 Scand J Clin Lab Invest, 2000; 60: 1-96 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

24. 24 24 Physical Features--Turbidity 尿液之分析及判讀 Fundamentals of Urine & Body Fluid analysis, 2nd-ed., 2003; p107 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

25. 25 25 Physical Features--Odor 尿液之分析及判讀 Fundamentals of Urine & Body Fluid analysis, 2nd-ed., 2003; p108 02.尿液分析之介紹、文獻回顧及研究分析尿液常規鼠臭皮衣楓糖餿腐爛啤酒花臭腳味薄荷

26. 26 26 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規  The ratio of its weight to that of an equal volume of water at the same temperature 代表腎臟濃縮功能 正常： 1.005 ~ 1.035 異常：< 1.005  尿崩症、抗利尿激素分泌不正常 > 1.035  脫水、少尿症、使用顯影劑等 Physical Features--Specific Gravity (尿比重) Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 尿比重與尿溶解度(osmolality)有一定比例關係( × 40)

27. 27 27 Physical Features --Specific Gravity water diuresis solute diuresis Hyponatremia 02.尿液分析之介紹、文獻回顧及研究分析尿液常規 實驗室：鈉離子 症狀：尿量異常異常

28. 28 28  pH  Glucose  Occult blood  Protein  Ketone  Bilirubin-urobilinogen  Leukocyte  Nitrite 化學特性(Chemical Features) 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

29. 29 29 尿液之分析及判讀 正常範圍：4.0～8.0，平均為6.0。 異常： < 6.0 (酸性尿) 蛋白質攝取較多、水果如Cranberry ，酸血症，泌尿道感染(特別是大腸桿菌)，低血鉀症、飢餓、糖尿病等。 > 7.0 (鹼性尿) 高蔬果飲食、飯後，鹼血症, 因proteus造成的泌尿道感染，尿液放置過久。鹼性體質 vs 酸性體質?? 體內血中PH：7.35~7.45 Robert Oldham Young  1億美金 Chemical Features--pH Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

30. 30 30 Acid-base disturbances: hypokalemic alkalosis with paradoxical aciduria Acidification or alkalinization of urine is associated with specific diseases: renal tubular acidosis Chemical Features--pH 尿液之分析及判讀 (+) (-) pCO2 < 40 mmHg, HCO3 ≤ 22 mmol/l Metabolic acidosis Ketones Acidosis - Gastrointestinal bicarbonate loss (diarrhoea, ureterosigmoidostomy, pancreatic fistula, anion exchange resins, CaCl2/MgCl2 intake) - Various causes (hypoaldosteronism, hyperalimentation, HCl administration) - Diabetic ketoacidosis without hyperglycaemia - Alcoholic ketoacidosis - Fasting - Non-Ketotic hyperosmolar coma - Ketoacidosis associated with hyperglyceamia - Renal tubular acidosis - Interstitial nephritis - Obstructive uropathy - Carboanhydrase inhibitors pCO2 < 40 mmHg, HCO3 ≥ 22 mmol/l Respiratory acidosis Anion gap < 12 Anion gap > 12 Urine pH > 5.5 SOSM > 295mOsm/Kg H2O - Methanol - Ethylene glycol - Paraldehyde - Lactic acidosis - Salicylate intoxication - Renal failure - Alveolocapillary gas exchange diminished - Hypoventilation (CNS-related) - Anatomical reasons - Neuromuscular insufficiency - Airway obstruction No Yes No Yes 02.尿液分析之介紹、文獻回顧及研究分析尿液常規 血中偏酸尿中偏鹼

31. 31 31 尿液之分析及判讀 Chemical Features--Glucose Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

32. 32 32 Chemical Features--Glucose 尿液之分析及判讀 Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

33. 33 33 尿液之分析及判讀 Chemical Features--Occult blood Pseudoperoxidase activity shown by the haem moiety of haemoglobin and of myoglobin Hemoglobin: pre-renal, renal, post-renal, menstruation Myoglogin: muscle necrosis, rhabdomyolysis (alcoholic, neuroleptic malignant syndrome, cocaine abuse), and polymyositis Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

34. 34 34 Hemoglobin vs. Myoglobin Dissolving 2.8 g of ammonium sulfate in 5 ml of urine, followed by filtration or centrifugation  hemoglobin participate, myoglobin doesn’t not Sediment: RBCs exist: Yes Hemoglobin No  Myoglobin Hemoglobin without red cells Myoglobin Hemolysis Cells have been destroyed Chemical Features--Occult blood 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規 OB vs RBC

35. 35 35 尿液之分析及判讀 Chemical Features--Protein Normal protein excretion < 100~150mg/dl  40%: Tamm-Horsfall glycoprotein (uromodulin)  40%: Albumin (distal tubular cast formation)  15%: immunoproteins  5%: other plasma proteins Pathological protein  glomerular: GN (increase permeability)  tubular: Tubulointerstitial disease (decreased reabsorption)  overload: monoclonal gammpathy (increased production) Fundamentals of Urine & Body Fluid analysis, 5th-ed., 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

36. 36 36 尿液之分析及判讀 Chemical Features--Protein Quantitative evaluation Random Up/Ucr 24 hrs DPL Qualitative analysis Selectivity of proteinuria: IgG/transferrin (<0.1, selective) Microalbuminuria Random albumin/ creatinine: 30-300 ug/mg 24 hrs urine: 30-300 mg/day 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

37. 37 37 尿液之分析及判讀 Chemical Features--Ketones Brunzel, Nancy A. Fundamentals of Urine & Body Fluid analysis. 5th-ed. 2022 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

38. 38 38 尿液之分析及判讀 Chemical Features--Bilirubin-urobilinogen Normal Urine urobilinogen: normal (< 1 mg/dl) Urine bilirubin: normal (< 0.02 mg/dl) Prehepatic Urine urobilinogen:  Urine bilirubin: negative Hepatic Urine urobilinogen: normal or  Urine bilirubin:  Postehepatic Urine urobilinogen:  Urine bilirubin:  02.尿液分析之介紹、文獻回顧及研究分析尿液常規

39. 39 39 尿液之分析及判讀 Chemical Features--Leukocyte & Nitrite Leukocyte esterase Esterase activity of granulocytes Nitrite Nitrate WBC: inflammation nitrate reductase G(-): E.coli retention time Nitrite Bacteriuria Leukocyte with bacteriuria: pyelopnephritis, cystitis, urethritis Leukocyte without bacteriuria: trichomonas, mycoses, chlamydia, virus, TB, and mycoplasma Diet 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

40. 40 40  Cell  Cast  Crystal  Microorganism 顯微鏡檢(Urine Microscopy) 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

41. 41 41 Note Before analysis: pH and osmolality should be know higher pH cast decreased  neutrophilic lyse lower osmolality erythrocyte lyse (couple microscopy with dispsticks for hemoglobin and leukocyte esterase) Urine microscopy 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

42. 42 Erythrocyte Cell morphology--regular shape: non glomerular origin --irregular shape: glomerular origin Granulocytes UTI, glomerulonephritis, acute interstitial nephritis, and aseptic cystitis Lymphocytes Chronic inflammatory diseases, viral diseases, renal transplant rejection Macrophage UTI, inflammation of kidney Urine microscopy--Cell 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

43. 43 43 Eosinophili Acute interstitial nephritis, atheroembolic renal diseases Renal tubular cells ATN, AIN, AGN, acute cellular allograft rejection Urothelial cell Deep layer: urolithiasis, bladder cancer, hydronephrosis Superficial layer: UTI Squamous cell vaginal discharge Urine microscopy--Cell 尿液之分析及判讀 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

44. 44 44  Form within the distal tubules and the collecting ducts of the kidneys from the aggregation and transformation into a gel of the fibrils of Tamm- Horsfall glycoprotein. Urine microscopy--Cast 尿液之分析及判讀 American Family Physician, 2005; 71: 6 1153-62 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

45. 45 45 尿液之分析及判讀 Urine microscopy--Crystal In most instances, the finding of crystals is not clinically relevant. Clinical value in subpopulation Recurrent renal stone formers Acute renal failure (calcium oxalate crystalluria) Acute uric acid nephropathy Ethylene glycol poisoning Severe liver disease Tyrosine and leucine crystals Deficinecy of xanthine oxidase Xanthine crystalluria Uric acid Triple phosphate Calcium Oxalate leucine crystals Tyrosine crystals 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

46. 46 46 Urine microscopy--Microorganism 尿液之分析及判讀 Bacteriuria Trichomonas vaginalis Candida Eggs of Schistosoma haematobium Lipid droplet Bacteria UTI GI contamination Bacteriuria without leukocyte: investigation again Yeast Urethral: actual infection (immunosuppressive) Vaginal infection Fat Lipiduria: nephrotic syndrome Trichomona vaginalis  Parasitic gynecological infection Parasites Parasitic infection 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

47. 47 47 Urolithiasis (2019) 47:99–105 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

48. 48 48 Urolithiasis (2019) 47:99–105 02.尿液分析之介紹、文獻回顧及研究分析尿液常規

49. 49 02 PART 尿液分析之介紹、文獻回顧及研究分析 2-1.尿液常規 2-2.尿液生化

50. 50 50 02.尿液分析之介紹、文獻回顧及研究分析尿液生化

51. 51 51 腎臟：電解質異常、酸鹼異常荷爾蒙：血壓異常(續發性高血壓) 血液腫瘤：蛋白質異常毒物：重金屬、藥物 02.尿液分析之介紹、文獻回顧及研究分析尿液生化

52. 52 52 1以鉀離子為例： Input: Redistribution: Output: 2名詞介紹： Spot urine:TTKG FEK 、UK / Ucr 24 hrs urine: 須使用尿中osmolality & Cr 作計算或校正 FE： filtration excretion ratio Filtration GFR × 血中濃度 × 1440min Excretion 尿中濃度 × 一天尿量 Mayo Clin Proc. March 2021;96(3):744-762 02.尿液分析之介紹、文獻回顧及研究分析尿液生化 =

57. 57 57 腎臟基本生理功能及其測定 02.尿液分析之介紹、文獻回顧及研究分析尿液生化

58. 58 58 生理功能基本檢驗血液尿液腎功能腎絲球 eGFR, BUN/Cr Albuminuria 腎小管(近曲小管) Glucose, UA Glucosuria, FEUA 體液平衡（水及鈉） POsm USpGr, UOsm, UNa 代謝性酸中毒 PAG UpH, UAG, Ketones 代謝性鹼中毒及鉀 Mineralocoticoids TTKG, 24 hrs K 內分泌急性腎衰竭 IgX, C3, ANA FENa, Cast 慢性腎衰竭 iPTH, Ca, iP, CO2, Hgb Casts 腎臟基本生理功能及其測定 02.尿液分析之介紹、文獻回顧及研究分析尿液生化

59. 59 59 急性慢性病史系統性疾病藥物感染身體檢查皮膚鞏膜實驗室檢查尿液--U/R：Cast FENa, Uosm 血液--B/R：Hgb --SMA：CO2、Ca、iP --內分泌：iPTH 影像學檢查超音波：Kidney size 腎臟病理學檢查眼底檢查藉由此表之總整分析，快速分析腎病變是急性或慢性 To establish diagnosis, rule out reversible causes 02.尿液分析之介紹、文獻回顧及研究分析尿液生化

60. 60 60 Singapore Med J 2017; 58(5): 267-271 02.尿液分析之介紹、文獻回顧及研究分析尿液生化

61. 61 61 03 PART 尿液分析之近期進展：精準及智慧醫療

62. 62 62 03.尿液分析之近期進展：精準及智慧醫療

63. 63 63 Nature Reviews | Urology volume 19 | April 2022 | 219 03.尿液分析之近期進展：精準及智慧醫療

65. 65 65 npj Digital Medicine (2019) 2:109 03.尿液分析之近期進展：精準及智慧醫療

66. 66 66 Bi et al., 2022, Cell Reports 38, 110271 03.尿液分析之近期進展：精準及智慧醫療

68. 68 68 04 PART 結論 04.結論

69. 70 70

70. 71 71 Hyaline cast Waxy cast Granular cast

71. 72 72 Erythrocyte cast Leukocyte cast

72. 73 73

73. 74 74

74. 75 75

75. 76 76 Calcium Oxalate Triple phosphate Calcium phosphate Uric acid

76. 77 77 Cystine

77. 78 78

78. 79 79

79. 80 80

80. 81 81

81. 82 82

82. 83 83

83. 84 84

84. 85 85

85. 86 86

86. 87 87

87. 88 88

88. 89 89

89. 90 90

90. 91 91

91. 92 92

92. 93 93

93. 94 94 Hoilat GJ, John S.2022 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan– .PMID: 32491371

94. 95 結論

1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf

Du liest eine Vorschau.

Hier ansehen

1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf

Weitere Verwandte Inhalte

Aktuellste (20)

Empfohlen (20)

1120106-尿液常規及生化檢查之臨床應用~特殊個案及臨床分析-陳金順副院長.pdf