内科学-慢性肾衰竭-陆福明讲解课件

ChronicRenalFailure陆福明复旦大学附属华山医院肾脏科ChronicRenalFailure陆福明1TheimportanceofChronicRenalFailureWorldwide,theprevalenceofCRFisincreasingbymorethan5%annuallyThecostofrenalreplacementtherapyhasanincreasingimpactonhealtheconomicsinbothdevelopedanddevelopingcountriesTheimportanceofChronicRena2PlasmaCreatinineandGFRNormalGFR100-125ml/min/1.73m2GFRdeclinesbyabout1ml/min/1.73m2/yearPlasmacreatinineconcentrationcanbeusedtomonitorrenalfunctionwhenGFR<50ml/minMassscreeningofplasmacreatininecannotprovideearlydetectionofrenaldiseasesinthegeneralpopulationPlasmaCreatinineandGFRNorma3内科学-慢性肾衰竭-陆福明讲解课件4内科学-慢性肾衰竭-陆福明讲解课件5CausesofCRFGlomerulardiseasesaccountfor60%ofCRFDiabeticnephropathyaccountfor10-15%ofCRF(inUSAabout50%)Hypertension:10-15%Polycystickidneydiseases:5%Obstructiveuropathy:3-4%Lupusnephropathy:2-3%UnderminedOrigin:5-10%CausesofCRFGlomerulardiseas6EvolutionofCRFGlomerulardiseaseswillbedecreasedDiabeticandhypertensivenephropathy↑Chronicnephrotoxicitybyenvironmentalpollutants,drugsandherbs↑IncidenceofESRD:100-200permillionEvolutionofCRFGlomerulardis7ClinicmanifestationofCRFDeteriorationofrenalfunctionisinvariableonceGFRisreducedbymorethan25%Serialplotsofthereciprocalofcrvs.timefollowsastraightlineOftenremainasymptomaticwhenGFR=25%UraemicsyndromeClinicmanifestationofCRFDet8内科学-慢性肾衰竭-陆福明讲解课件9ClinicalDiagnosisofCRFAcuteorchronic?OftenpresentsacutelywhenGFRsuddenlydropsfrom20%to10%orlessToassesstheseverityofrenalimpairmentToelucidatethecausesofrenalfailureToascertainwhethertherenalfailureisacute,oracute-on-chronicToassessthepatientforrenalreplacementtherapyClinicalDiagnosisofCRFAcute10ClinicalInvestigationsThehistoryshouldincludeadiligentsearchforpotentialnephrotoxicagentsApositivefamilymayindicateheredofamilialdiseasesPallor,scratchmarks,peripheraloedemaandpalpablemassesintheabdomenAfullexaminationisimportant,especiallyinpatientswithdiabetesClinicalInvestigationsThehis11CommonInvestigationsRenalfunctionprofileUrinalysisQuantitationofproteinuriaDeterminationofcreatinineclearanceLiverfunctionprofileHepatitisBandCstatusCommonInvestigationsRenalfun12CommonInvestigationsSerologicaltestsuchasanti-nuclearantibodies,complements,immunoglobulinlevels,C-reactiveproteinandanti-neutrophilcytoplasmantibodiesLipidprofileUltrasonogramofkidneysformeasurementofkidneysizeandexclusionofstructuralabnormalitiesDopplerexaminationofrenalarterieswhenindicatedCommonInvestigationsSerologic13ManagementofCRFTreatmentofprimarydiseaseTreatmentofhypertensionUsingACEIorangiotensin-IIreceptorblockersAvoidingnephrotoxicagentsLowdietaryproteinintakePhosphatecontrolEarlycorrectionofaneamiaManagementofCRFTreatmentof14TreatmentofHypertensionThetargetofbloodpressure:<130/80mmHgMultipleagentsarerequiredACEI,ARB,B-B,CCB,α-B，diureticsBloodpressurecontrolledfor24hrTreatmentofHypertensionThet15UsingACEIorARBACEIcancausesanunacceptablecoughinasubstantialnumberofpatientsTheriskofhyperkalaemiaissmallthoughreal.ARFcanbehappenedinpatientswithsevererenalarterystenosis.UsingACEIorARBACEIcancaus16AvoidingnephrotoxicAgentsNon-steroidalanti-inflammatorydrugsareusedtooliberallyHerbs:patientsoftenresorttoalternativemedicineandingestawidecombinationofherbswhichleadstoarapiddemiseofremainingkidneyfunction.AvoidingnephrotoxicAgentsNon17ManagementofCRFUrinaryobstructionandinfectionshouldbetreatedpromptlyFluidsoverloadingshouldbeavoidedEarlyreferredtonephrologist(GFR<30ml/min)ManagementofCRFUrinaryobstr18ManagementofCRFPhosphatebindersaregivenwitheachmealtobinddietaryphosphatesinthegutCalciumsupplementationisneededActiveVitaminDmetabolitesareprescribedwhenPTHishighManagementofCRFPhosphatebin19ManagementofCRFMetabolicacidosisiscorrectedwithsodiumbicarbonateErythopoietincancorrectsearlyanaemia,improvescardiovascularfunctionandpreservesresidualrenalfunctionManagementofCRFMetabolicaci20ManagementofCRFProteinrestrictioncanslowdowntheprogressionofrenalfailure.However,severemalnutritionshouldbecarefullyavoided65%ofthedietaryproteinintakeshouldbeintheformofhighbiologicalvalueproteinManagementofCRFProteinrestr21ManagementofCRFVegetableproteinmaybebeneficialinearlystagesofCRFSaturatedfatsmustbeavoidedLipidabnormalitiesmustbegivendueattentionLowsodiumdietaryintakeManagementofCRF22ManagementofCRFCardiovascularmortalityisthemostimportantcauseofdeathAnti-lipidtreatmentshouldbegivenearlyAspirinwillabeneficialimpactonsurvivalSmokingshouldbeavoidedPotassiumintakeshouldbereducedwheninESRDManagementofCRFCardiovascula23RenalReplacementTherapyAthoroughdiscussioninvolvingthepatientandhisfamilyonthedifferenttreatmentoptionsismandatoryKidneytransplantationpresentsthebestmeansofrehabilitation,especiallywhenitisperformedpre-emptivelyRenalReplacementTherapyAtho24RenalReplacementTherapyIntegratedapproachintheoverallmanagement:Peritonealdialysiscanbeconsideredasinitialdialytictherapy,whilehaemodialysisisreservedforpatientswhoareunabletoperformPD,PriortokidneytransplantationRenalReplacementTherapyInteg25RenalReplacementTherapyIncrementaldialysis:thedoseofdinlysisisdecidedbasedontheamountofresidualrenalfunctionRenalReplacementTherapyIncre26THANKS！THANKS！27ChronicRenalFailure陆福明复旦大学附属华山医院肾脏科ChronicRenalFailure陆福明28TheimportanceofChronicRenalFailureWorldwide,theprevalenceofCRFisincreasingbymorethan5%annuallyThecostofrenalreplacementtherapyhasanincreasingimpactonhealtheconomicsinbothdevelopedanddevelopingcountriesTheimportanceofChronicRena29PlasmaCreatinineandGFRNormalGFR100-125ml/min/1.73m2GFRdeclinesbyabout1ml/min/1.73m2/yearPlasmacreatinineconcentrationcanbeusedtomonitorrenalfunctionwhenGFR<50ml/minMassscreeningofplasmacreatininecannotprovideearlydetectionofrenaldiseasesinthegeneralpopulationPlasmaCreatinineandGFRNorma30内科学-慢性肾衰竭-陆福明讲解课件31内科学-慢性肾衰竭-陆福明讲解课件32CausesofCRFGlomerulardiseasesaccountfor60%ofCRFDiabeticnephropathyaccountfor10-15%ofCRF(inUSAabout50%)Hypertension:10-15%Polycystickidneydiseases:5%Obstructiveuropathy:3-4%Lupusnephropathy:2-3%UnderminedOrigin:5-10%CausesofCRFGlomerulardiseas33EvolutionofCRFGlomerulardiseaseswillbedecreasedDiabeticandhypertensivenephropathy↑Chronicnephrotoxicitybyenvironmentalpollutants,drugsandherbs↑IncidenceofESRD:100-200permillionEvolutionofCRFGlomerulardis34ClinicmanifestationofCRFDeteriorationofrenalfunctionisinvariableonceGFRisreducedbymorethan25%Serialplotsofthereciprocalofcrvs.timefollowsastraightlineOftenremainasymptomaticwhenGFR=25%UraemicsyndromeClinicmanifestationofCRFDet35内科学-慢性肾衰竭-陆福明讲解课件36ClinicalDiagnosisofCRFAcuteorchronic?OftenpresentsacutelywhenGFRsuddenlydropsfrom20%to10%orlessToassesstheseverityofrenalimpairmentToelucidatethecausesofrenalfailureToascertainwhethertherenalfailureisacute,oracute-on-chronicToassessthepatientforrenalreplacementtherapyClinicalDiagnosisofCRFAcute37ClinicalInvestigationsThehistoryshouldincludeadiligentsearchforpotentialnephrotoxicagentsApositivefamilymayindicateheredofamilialdiseasesPallor,scratchmarks,peripheraloedemaandpalpablemassesintheabdomenAfullexaminationisimportant,especiallyinpatientswithdiabetesClinicalInvestigationsThehis38CommonInvestigationsRenalfunctionprofileUrinalysisQuantitationofproteinuriaDeterminationofcreatinineclearanceLiverfunctionprofileHepatitisBandCstatusCommonInvestigationsRenalfun39CommonInvestigationsSerologicaltestsuchasanti-nuclearantibodies,complements,immunoglobulinlevels,C-reactiveproteinandanti-neutrophilcytoplasmantibodiesLipidprofileUltrasonogramofkidneysformeasurementofkidneysizeandexclusionofstructuralabnormalitiesDopplerexaminationofrenalarterieswhenindicatedCommonInvestigationsSerologic40ManagementofCRFTreatmentofprimarydiseaseTreatmentofhypertensionUsingACEIorangiotensin-IIreceptorblockersAvoidingnephrotoxicagentsLowdietaryproteinintakePhosphatecontrolEarlycorrectionofaneamiaManagementofCRFTreatmentof41TreatmentofHypertensionThetargetofbloodpressure:<130/80mmHgMultipleagentsarerequiredACEI,ARB,B-B,CCB,α-B，diureticsBloodpressurecontrolledfor24hrTreatmentofHypertensionThet42UsingACEIorARBACEIcancausesanunacceptablecoughinasubstantialnumberofpatientsTheriskofhyperkalaemiaissmallthoughreal.ARFcanbehappenedinpatientswithsevererenalarterystenosis.UsingACEIorARBACEIcancaus43AvoidingnephrotoxicAgentsNon-steroidalanti-inflammatorydrugsareusedtooliberallyHerbs:patientsoftenresorttoalternativemedicineandingestawidecombinationofherbswhichleadstoarapiddemiseofremainingkidneyfunction.AvoidingnephrotoxicAgentsNon44ManagementofCRFUrinaryobstructionandinfectionshouldbetreatedpromptlyFluidsoverloadingshouldbeavoidedEarlyreferredtonephrologist(GFR<30ml/min)ManagementofCRFUrinaryobstr45ManagementofCRFPhosphatebindersaregivenwitheachmealtobinddietaryphosphatesinthegutCalciumsupplementationisneededActiveVitaminDmetabolitesareprescribedwhenPTHishighManagementofCRFPhosphatebin46ManagementofCRFMetabolicacidosisiscorrectedwithsodiumbicarbonateErythopoietincancorrectsearlyanaemia,improvescardiovascularfunctionandpreservesresidualrenalfunctionManagementofCRFMetabolicaci47ManagementofCRFProteinrestrictioncanslowdowntheprogressionofrenalfailure.However,severemalnutritionshouldbecarefullyavoided65%ofthedietaryproteinintakeshouldbeintheformofhighbiologicalvalueproteinManagementofCRFProteinrestr48ManagementofCRFVegetableproteinmay