從尿液檢查看血尿、蛋白尿與 泌尿道感染 高雄榮民總醫院兒童醫學部 小兒腎臟科 方乃文主治醫師 / 邱益煊主任 2016/ 02/ 26
Outline 1. 一般尿液常規檢查簡介 2. 血尿之評估 3. 蛋白尿之評估 4. 泌尿道感染之評估
Eye
Dipstick
Microscopy
Icon made by [Freepik] from www.flaticon.com
生化項目以及鏡檢正常值 項目
參考值
項目
參考值
Appearance Yellow/ clear
RBC
(0~2) /HPF
SPG
1.005 ~ 1.030
WBC
(0~5) /HPF
PH
5~8
EPI
(0~5) /HPF
PRO
-
CAST
-
SUG
-
Crystal
-
KET
-
OB
-
URO
Normal
BIL
-
NIT
-
LEU
-
Hematuria
Icon made by [Freepik] from www.flaticon.com
OB
RBC
Supernatant ( 離心後上清 液)
色素尿 (-) (-) 紅 溶血 (+) (-) 紅 血尿 (+) (+) 清澈
色素尿 • 藥物 : Rifampin, phenytoin • 食物 : Beets ( 甜菜 ) 火龍果 桑葚
Ref: 1.http://articles.mercola.com/sites/articles/archive/2014/01/25/beets-health-benefits.aspx 2.http://www.frolichawaii.com/stories/our-top-5-pitaya-bowls/ 3.http://askmiko.com/nutrition-facts/10-health-benefits-of-blackberries/
Rhabdomyolysis OB+ RBC -
Hemolysis
Anatomy Bladder Cancer Drug Exercise Factiticous Glomerulopathy Hematology Infection inJury Kidney Stone
Anatomy Bladder Cancer Drug Exercise Factiticous Glomerulopathy Hematology Infection inJury Kidney Stone
Acute or chronic
Gross or Microscopic
Glomerular or non-glomerular
2
單純顯 微鏡下 血尿者 可追蹤
1
需做進一步檢查 : 1.有症狀者 2.有蛋白尿者 3.追蹤時間久者
3 Reference: Uptodate:Evaluation of microscopic hematuria in children
症狀 Deafness
Rash Purpura Arthragia
Dysuria Incontinence Fever
Fever Malaise BW loss
Flank pain
Edema Oligouria HTN Icon made by [Dot on Paper] from www.flaticon.com
檢驗 • • • • • • • • • •
CBC/ DC CRP Na, K, Ca, Cl, BUN,Crea, GPT, Alb (TG, CHOL) HBsAg, HBsAb, AntiHCV Ab ANA, C3 C4, ASLO (PT/aPTT) (IgG IgA IgM) 24Hr urine Cr, protein. U/R U/C. Urine RBC morphology Renal sonography (urine cytology) (KUB, Abd CT, IVP, cystoscopy)
Proteinuria
Icon made by [Freepik] from www.flaticon.com
檢驗結果 Negative Trace 1+ 2+ 3+ 4+
估計量 (mg/dl) 0 15- 30 30-100 100-300 300-1000 >1000
偽陽性 : 濃尿、鹼尿，尿受到顯影劑汙染，尿受到消毒劑 (chlorhexidine/ benzalkonium chloride) 汙染
SPOT Urine Protein/ Cr
24hr Urine Protein
Icon made by [Daniel Bruce] from www.flaticon.com
Pathologic
>1 g/d
Physiologic Normal
小孩 < 150 mg/d 成人 < 300 mg/d
Physiologic (or Intermittent)
Fever
Exercise
Orthostatic
Seizure Icon made by Freepik from www.flaticon.com
GN Proteinuria MCD
Hematuria
MGN FSGS
IgAN LN
Alport
PSGN
FTBM
需進一步檢查 者: 1. 兩次蛋白尿 2. 有症狀
UTI
Icon made by [Freepik] from www.flaticon.com
Sensitivity ( 敏感度 )
LEU NIT WBC
Specificity ( 特異度 )
高 (67%- 94%) 低 低 高 (90-100%) 中 中
sterile Pyuria LEU (+) WBC > 5 /HPF
asymptomatic UTI Bacteriuria >100000 (clean catch) >10000 (urinary catheter) >1000 (supra-pubic puncture)
Sterile pyuria
Asymptomatic bacteriuria
• Previous antibiotics • Systemic inflammation
• Contamination • Colonization
– Roseola infantum – Kawasaki disease
• Near-GU inflammation – Appendicitis
• • • • •
Not bacteria related UTI Foreign body Stone Polycystic kidney etc
When to collect urine
Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011 Sep
Poor feeding Irritability BW loss
Fever
Fever
Dysuria Urgency Frequency
Prolonged jaundice
Icon made by [OCHA] [Dot on Paper] from www.flaticon.com
Nausea Vomiting
Abd/ Flank pain
(Sometimes) Diarrhea
?
NICE guideline for VCUG
ISPN risk factors:
<6m 非典型病菌 / 病程
家族史 (+)
6m~3y 非典型病菌 / 超音波異常 / 家族史 (+) 非典型病程 / 病菌 >3y 不作
嚴重病程 年齡 <6m
Thank you for your attention!