内科学教学课件：CHRONIC RENAL FAILURE (CRF)

CHRONICRENALFAILURE

(CRF)ChronicrenalfailurefeaturesCommon

finalofchronickidneydiseasesProgressiverenalinsufficiencyovermonthstoyearsManifestationofuremia,metaboliteretentionHypertensioninthemajority,AnemiaUnbalanceoffluid,electrolyte,acid-base.BroadcastsinurinarysedimentarecommonBilateralsmallkidneysonultrasoundEvidenceofrenalosteodystrophyGeneralconsiderationsCausesofCRF:glomerulonephritis

diabetesmellitushypertensionlupusnephritiscysticdiseasesurologicstonerenaltubulointerstitialothercauses

ChronickidneydiseaseCKDisdefinedas1)kidneydamageorglomerularfiltrationrate(GFR)<60mL/min/1.73m(2)for3monthsormore,irrespectiveofcause.2)Kidneydamage(structureandfunction)includerelatedbloodtestandurinalysisabnormalities,pathologicalinjury,imagingabnormalities.PhaseDescriptionGFR(ml/min/1.73m2)123a3b45GFRnormalor≥90GFRmildly60~89GFRmild-moderatelyGFRmoderared-severely45~5930~44GFRseverely15~29ESRD＜15ordialysisPhasesofchronickidneydisease(K/DOQIbyAmericaNKF)phaseScr(μmol/L)Ccr(ml/min)compensatoryphaseazotemiarenalfailureuremia＜178

＞50178-45050~25451-70625~10

＞707＜10

Phasesofchronicrenalinsufficiency(ofChina)MechanismsofchronicrenalfailureMechanismsofdiseaseprogression1.Nephronhyperfiltration2.Nephronhypermetabolism3.Phenotypic

switchofrenaltubularepithelial

cell4.

Cytokines,

tissuefactor5.OthermechanismsMechanismsofchronicrenalfailure

Irreversiblechronicrenaldisease→reductioninrenalmass→hypertrophy，hyperfiltration→aburdenontheremainingnephrons→glomerulisclerosisandtubuler-interstitialfibrosis→chronicrenalfailurerenin-angiotensionsystem，Ang-Ⅱ

→Hypertensionandglomeruli-HBP肾小球硬化形成机制MechanismsofuremicsymptomsRenalexcretionandmetabolicfunctiondicrease2.Uremictoxinsretention3.Endocrinefunctiondisorder4.OtherfactorsClinicalfindingsOnphysicalexamination

appearingchronicallyillhypertensionrales,cardiomegaly,edemaapericardialfrictionrub.mentalstatusLaboratoryfindings:ElevationsofBUN,Scr,Ccr,eGFRAnemiaMetabolicacidosisHyperphosphatemia,hypocalcemia,hyperkalemiaIsosthenuriaiftubularconcentratinganddilutingabilityareimpaired;broadwaxycastsIMAGINGSmallbilateralkidneysCRFNormalorevenlargekidneys↓adultpolycystickidneydiseasediabeticnephropathy,HIV-associatednephropathy,multiplemyeloma,amyloidosis,obstructiveuropathyRenalosteodystrophycomplicationsHyperkalemiadecreasedsecretionofpotassiumwiththedecreaseofGFRHappenuntiltheGFRislessthan25ml/min.

complicationsHyperkalemiaendogenouscauses:hemolysisandtrauma,hypoaldosteronism,acidosisstates,

potassium

excretion↓exogenouscauses:dietcontaininganabundantofpotassium,drugsthatblockK+secretion(triamterenespironolactone,NSAIDS,ACEI)

blood

transfusioncomplicationsAcid-BaseDisorders

Damagekidneysareunabletoexcreteenoughacidgeneratedbymetabolismofdietaryproteins.Thislimitsproductionofammonia(NH3)andbufferingofH+intheurine.Howtojudge?BloodgasanalysisPH,HCO-3,BE,PCO2complicationsHypertensionhypertensionisthemostcommoncomplicationofend-stagerenaldisease.causesofhypertension:SaltandwaterretentionvolumeoverloadHyperreninemicstates(RASSactivation)ExogenouserythropoietinadministrationcomplicationsPericarditis

Thecauseisbelievedtoberetentionofmetabolictoxins.symptoms:chestpainandfeversigns:africtionrubmaybeauscultatedchestradiography:plicationsCongestiveheartfailureCausesinclude:extracellularfluidoverloadhypertensionanemiaarteriovenousfistulafordialysis

uremiatoxinswhichwillaffectthemyocardiuminfectioncomplicationsAnemia

causes:erythropoietinproductioniron-deficiency,ferroussulfatedeficiency,Vitamin-deficiencylow-gradehemolysisduetouremiatoxins,Bonemarrowsuppressionbloodlossfromplateletdysfunctionorhemodialysis

complicationsCoagulopathy

becauseofdysfunctionofplateletabnormaladhesivenessandaggregation,bleedingtimebeingprolonged.treatmentisrequiredonlyinpatientswhoaresymptomatic.DplicationsDigestivesystemcomplication

anorexia,nausea,vomiting,andepigastricpain.Gastrointestinalbleedingisalsocommon(hematemesis,melena,hematochezia),plicationsNeurologiccomplicationUremicencephalopathyoccuruntilGFR≤15ml/min.Patientsmaypresentwithdifficultyinconcentratingandcanprogresstolethargy,confusion,andcoma.neuropathycomplicationsDisorderofMineralMetabolismHyperphosphatemiahypocalcemiaOsteodystrophy:OsteitisfibrosacysticaOsteomalaciacomplicationsEndocrineDisordersCirculatinginsulinlevels↑,becauseofdecreasedrenalinsulinclearanceGlucoseintolerancecanoccurwhenGFRislessthan20ml/Lduetoperipheralinsulinresistance.Gonadaldysfunction,including:decreasedlibidoandimpotence.DiagnosisIsitrenalfailure?Serumcreatinine,Ccr,eGFR--yesCRForARF?

AppearingchronicallyillAnemiaBilateralsmallkidneysRenalosteodystrophy

(Ca、P、iPTH、Angiosteosis)DiagnosisFundamentalCausesofCRFCGN,DN,LN,HBP-GN,etc.Arethereworseningfactors?

Infection,HypovolemiaNephrotoxins,HypertensionTiredness,pregnancyCongestiveheartfailureurinarytractobstructionTreatmentObjectiveTreatmentoffundamentaldiseaseandworseningfactorsofCRF，

protect

residual

nephronsTreatmentMeasurestoretardthediseaseprogressionDietaryManagementProteinrestrictionnondialysispatients0.6g/kg/ddialysispatients1g/kg/dSaltandwaterrestrictionPotassiumrestrictionPhosphorusrestrictionMagnesiumrestrictionProtein

content50gpig9gAnegg6.5gMilk220ml

6.6g50gfish10g50gBeltFish9g50gFlour

4.5g50gBeef

10g50grice

3.5gBeancurd50g

5.5gTreatment:HypertensionAntihypertensiveobjectiveIfnon-dialysis,BP≤130/80mmHgIfdialysis,BP≤140/90mmHgDrugs:ACEI/ARBCCB

β-blocker;α-blockerDiureticVasodilator

TreatmentControlbloodglucose,lipid,UricAcidReduceurinaryprotein

TreatmentofComplicationHyperkalemia

Inacutecases:

CardiacmonitoringCalciumchlorideInsulinadministrationwithglucoseBicarbonateAnorallyorrectallyadministeredionexchangeresinanemergentdialysisifnecessary(k＞

6.5mmol/L)

MetabolicacidosisBasesupplementsincludesodiumbicarbonate,AdministrationofalkalidividedintotwodosesperdayDialysismaybeneededinseveremetabolicacidosisRecombinanterythropoietin(EPO)staredon50units/kg1-2/week.EPOcancauseorworsenhypertensionIronsupplementationitisgiveniftheserumferritin＜100μg/mlFerroussulfate,325mg/dayFolinicacidandVitaminsupplementationAdequatedialysisAnemiatreamentDialysiscanalleviatethesymptoms.Ifgastrointestinalbleedingoccur,patientsshouldbetreatedaggressively.CoagulopathytreamentRenalreplacetreatmentindication

Uremicsymptomssuchaspericarditis,encephalopathy,orcoagulopathy.FluidoverloadunresponsivetodiuresisRefractoryhyperkalemiaSeveremetabolicacidosis(PH＜7.20）RenalreplacetreatmentIndication

GFR＜10ml/minorserumcreatinine＜707μmol/L.UremicsymptomsDiabeticsshouldstartearlier,generallywhentheGFRreaches15ml/minorserumcreatinineis530μmol/L.HemodialysisHemodialysisrequiresaconstantflowofbloodalongonesideofsemi-permeablemembranewithdialysateontheother.HemodialysisDiffusionandconvectionallowthedialysatetoremoveunwantedsubstancesfromthebloodwhileaddingbackneededcomponents.Requirethreetimesaweek.sessionslast3-5hours.血液透析Peritonealdialysistheperitonealmembraneisthedialyzer.dialysateenterstheperitonealcavitythroughacatheter.PeritonealdialysisThemostcommonkindofperitonealdialysisiscontinuousambulatoryperitonealdialysis(CAPD)Itscontinuousnatureminimizesthesymptomaticswingsobservedinhemodialysispatients.ThemostcommoncomplicationofPDisperitonitis.Kidneytransplantation

Asuccessfulkidneytransplantationcanleadtoanormalrenalfunctionincludingendocrinefunctionandmetaboli