חוברת נפרולוגיה

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1 8002.1.01 1.1 . , " 51-01 " ) (. 3 ) (. , . . )%58(. . . . . . , . . ) afferent (. ) (efferent . ) "( " - ) ( ) " (. . . ) ,(PCT ) , U - ,(TAHL ),(DCT ) (connecting tubule )cortical .(collecting ducts - CCD . . - 081

, - 2-1 - %99 . . . . . -, ) ,(arcuate - . ' -< -< .IVC .EM )A( ) (, . , . . GBM . ) ( - 3 : ) (, ) GBM ( ) , GBM" Foot .(processes . . . ,pores , slit membrane ) '( , . , -081 . 5.1-1 , . : ) (. ) ( ) GBM, (, ) (. Tight junctions . : trans-cellular .para-cellular , . , %001. . , . ) ( ) (. .GBM , . .CO , . - GFR 081-08 .mmhg " . " .

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" ) ( ) ( . " ) ( " ) , (. , , ) ( , . ) ( , , . . , .

, . , . -" ) ( ).(hypertensive nephrosclerosis - Afferent- Efferent. AgII - ,Efferent ACE .

: . , ) (. ,GFR : . , " ) 8-6 ( - 42 . ) (clearance . - GFR . : -42 , . . ) .(BUN , . ) (CR . , )%51-01 (. . , CR , . , 21.0-7.0 %. 3

. , o . , , . o . o , / . , , . %51 . CCT . 42 , CR . . . " , , . 0441 -42 . CCT ) , (. CCT . * / , . ) " GC ( CCT" . (%CCT.male=(140-age)x(weight)/72xPlasma.Cr(mg (%CCT.female=(140-age)x(weight)/85xPlasma.Cr(mg : 02, 07 ", CR 2. CCT 06 /. 09, 05 ", CR 2. CCT 52 /. , !CR , ) (NSAID 09, / . 051 , , . , . 57.0 - 6.0 ) (. , . , , . . CR, ) (, CR, - .CR . ) (, CR, , CR . , , 1.1 CR 2.1 , , 4 5.5 . ) BUN blood urea nitrogen ( . BUN 02-8 "%, 24-51 "%. , . . . o , , " . o - . o . o 4

. , - , . ) (urinalysis . , pH . . , ) GFR CR- (BUN, . , '. : , . ) ,contour (, . . " )( )intra-venous . (pyelography- IVP . : , , Contrast nephrotoxicity - . , MI . .IVP - , , " ) .(retrograde pylography , , . . ) (contrast nephropathy : ) < :(1.5mg/dL ) 5.1( . . 57 , . ' , '. Myeloma , NSAIDS - uricosuria , . . . , , LV .EF - - ) (, . US , . , )%58 (. . 5

, , ) (. . - US , renal artery stenosis ... , . CT , . . CT )- CT 1 "( , ) " .(US )(. , . MRI . MRA magnetic resonance angiography , ) (. , . " . Nephrogenic systemic fibrosis , . MRI MRA . . . )( , . ) , (, . DTPA . DMSA , . . - Renal scintigraphy . ) (, " ,II E . " ACE ) / , CR (. , . , . ) (ACE .

7002.1.01 2.1 - , . , . : . - malignant melanoma . ,hematuria , ) .(rhabdomyalysis, ,cedural . . ) (. , . specific gravity . , . PH PH. 071%. . 051 " , %02 . . , false negative . 6

) ( ,total protein . : , 04 , . , . . , . 1-0 " , 3-2. 4-3 , . . " - . " , . , . " ) (red blood cell casts ) ( , " , ". . : " o o o . : , " , . DD " . 3 . , , , .

8002.1.31 3.1 Diuretics , . ) ,(natriuresis - NaCl. , " ) ADH (aquaretics . , ) . (. . PCT %56 , TAHL %52, DCT %5 CCD %2-1. carbonic anhydrase- .PT , , - .PT - Loop diuretics - TAHL . furosemid ) ( ethecrinic acid ) (. 7

- - .DCT )( , - GFR. - Potassium sparing- CCD ) - (eplerenone amiloride- .triamterene - CCD ) potassium sparing diuretics). Eplerenone , , . - aquaretics .CCD . - PT ) ( ) (secretion . . : 1. ,CHF )(, ) (. 2. " . 3. . 4. .Hypercalciuria 5. acidosis 6. .Renal tubular acidosis RTA 7. .SIADH 8. ) (. 9. . 01. ) - ( - - 11. ,cardiac remodeling . . 21. : - ,TAHL . , . -2) NKCC , (, " . , " ROMK , , ) ( ) (para-cellular . 2 NKCC , . , . , ) (. , ,CCD .ADH . ) ,(isoosmolar ' -- ) (RAAS' ) , , (. , . . . ) " ( , . : 8

,PO . 2-5.1 ) 6 (, RAAS. - torsemide . . - ) (, ) ( . : , ' , ) (. 08 ". " .PO , ) ( ) IV, (. 04 " ,PO " ) CCT (. CCT , . , : . " 42 , . . . , , . .IV . -.IV , . , . - ,RAAS " . ) 1-5.0 " (. ) DCT ( . , , . " , - . , steady state . . , . . - ) (, " ) (, ) ,(hypercalciuria .(RTA(renal tubular acidosis - . : sulfa ), ( ) (, . . ) ,(gout RAAS / . -. 9

' -RAAS ) ,(principal cells ) , . (, , - . , NA . , . barter's syndrome -2) NKCC ( , " - ) ROMK ( ) .(bartin . 4 . . .PT RF, . . - DCT NCCT .NACL .NAKATPASE ,NCCT , . , : ' - ) .(LD . ) ,(diosthiazide . : , ", ) (, . : , , . ) . (. ' -RAAS ) (, , , , . . , 0021, " NACL. ) CCD ( ,ADH . ,DT , ) ( . ) (, . , . . 01

:Potassium sparing diuretics - CCD .(PC (Principal cells - ) , (ENAC ) (, .NaKATPase ) ( . , spironolacton ) ( ) (. ) ( . . - Amiloride . . - CCD -intercalated ( (. . carbonic anhydrase -2 .CO . 4- type Renal tubular acidosis . : ' , , . . " . , . :PCT . - ) (. .NAKATPASE , . , . , 2 CO )" -4CA - .(brush border-2 CO - , 2 CA . )( . , .reclamation - 4CA ) .(3NAHCO . . ) (. : CA 11

- : )(NSAIDS, minoxidil , , .LD PO IV ) (. , . , - CHF , . ,LD %52 , . /Aquaretics: - ADH " 2, 4,3 . 2AP .ADH ADH ) (. ADH ) SIADH (, CHF, . ) aquaporin - ADH ( . : ) (. /. , . . - .CCD - PC )(. ) (. Potassium sparing diuretics . , . . .

2 8002.1.31 1.2 32, ' . " ) (TBW - 24 )%06 07 (. ) (ICF %06 - ,TBW ) (ECF %04 - .TBW %08 -) ECF- 5.31 ( %02 )- 5.3 (.

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. GFR - 021 , -071 . 041 " . 008,32 " ) ,(filtered load 021 " . %56 ) (PCT ) (TAHL %52 ) (DCT %7 ) (CCD %3. -021 " ) , 001 " , 2.1 (. - PCT )3/2 ( .brush border : ,NAKATPASE . .NA NA - , , antiport . :TAHL 2 NKCC , %52 . K" ROMK . . - TAHL %52 . ) (loop diuretics . :DCT NCCT . TAHL DCT , . :CCD principal cell- .intercalated cells .principal cells PC ATP . " NaKATPase . ADH, . ,2V AC 2 . 4,3 . : K" NAKATPASE. PCT - , . %56 . . , . TAHL thin ascending ,2NAKCL %52 . K. , . ,LD . 31

DCT NACL" .NCCT . .

CCD

' - NAKATPASE, ,NA NA NA K K .K NA ) CCD (, K . . ) ATP ,(NAKATPASE . . ,K sparing , . , .NA " . " ADH . ) (ADH ,SIADH LD . : - 531 " . . -. ) (, , . . , . : : . ) (. , , . / , . . : .IV 001 "% - 4.1 " . : 121, BUN 82 0011. ) 092-072 - "(: 8.2 / POsmolality = 2 x [Na] + Glu / 18 + BUN Posmolarity=2x121 +1100/18+28/2.8=242+62+10= 313mosmol/Kg , . , /. , -120meq/L . . - . . " ) ( . , , , , , , .

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, . ) TBNa" (. -". .TBNa , . . " , . TBNa. 1. ), ' (. ) , ( ) 02 " (. ) ( ' )