内科学慢性肾功能衰竭(英文)

ChronicRenalFailure

AnatomyoftheKidneyFIBROUSCAPSULECORTEXPYRAMIDPAPILARENALCALYXRENALPELVISRENALARTERYRENALVEINURETERChronicrenalfailure

1.DefinitionandStages

2.Etiology

3.Pathogenesis

※4.ClinicalManifestations

※5.TherapyDefinition

CRFisa

permanent,usuallyprogressive

diminution

inrenalfunctiontoadegreethathasdamagingconsequencesforthepatient.

Itischaracterizedbyanincreasing

inability

ofthekidneytomaintainnormallowlevels

oftheproductsofproteinmetabolism(suchasurea),normalbloodpressureandhematocrit,andsodium,water,potassium,andacid-basebalance.DefinitionChronicKidneyDisease,CKDRenalFailureWhatisCKD?1.AnatomicalorStructuralDefectExample:Abnormalimagingstudy(i.e.PolycysticKidneyDisease),AbnormalRenalBiopsyorProteinuria(spoturineprotein/creatinineratio>30mg/g)2.FunctionalComponentExample:AbnormaleGFR(LoworHigh)3.TimeComponent≥3monthsdurationrequired※StagesCKDstagesDescriptioneGFRRange(ml/min/1.73m2)Population(1,000’s)Population(%)1KidneydamagewithnormalorincreaseGFR≥905,9003.3%2MildlydecreasedGFR60-895,3003.0%3ModeratelydecreasedGFR30-597,6004.3%4SeverelydecreasedGFR15-294000.2%5KidneyFailure<153000.1%-AdaptedfromNHANESIII(2000)estimatedGlomerularFiltrationRate(eGFR)MDRDEquation：

aMDRD-GFR(ml/min/1.73m2)=186×[Scr]-1.154×[Age]-0.203×0.742[iffemale]Cockcroft-GaultEquation： Ccr（ml/min）=(140-age)×IBW（kg）×(0.85female)

72×Scr（mg/dl）SCr

unitmg/dl，1mg/dl=88.4umol/L

Etiology1.CausesofCKDandCRFDiabeticnephropathyHypertensivenephropathyOriginalorsecondaryglomerulonephritisChronicTubulointerstitialNephritisInheritedkidneydiseasesEtiology※2.MostcommoncausesofCKDandCRFinChina:GlomerulardiseasesDiabeticnephropathyHypertensivenephropathyCausesofend-stagerenaldiseaseintheUnitedStates.

(USRDS2005AnnualDataReport)

Etiology3.RiskFactorsKidneyDiseaseOutcomeQualityInitiative:K/DOQIclinicalpracticeguidelinesforchronickidneydisease:Evaluation,classification,andstratification.AmJKidneyDis39:S1–246,2002.

※PathogenesisPathogenesisofchronicrenalfailurePathogenesisoftheuremicsyndrome

PathogenesisPathogenesisofglomerulosclerosisHypothesisAuthor(s)※Glomerularhyperfiltration/hyperperfusionHostetterandBrenner1981※GlomerularhypertensionAndersonandBrenner1985NephrotoxicityoflipidsMoorheadetal.1982SimilaritieswithatherosclerosisEINahas1988DiamondandKamovsky1988GlomerularhypertrophyFogoandIchikawa1991NephrotoxicityofproteinuriaRemuzziandBertani1990GrowthfactorsPlatelet-derivedgrowthfactorTransforminggrowthfactorJohnsonetal.1994Borderetal.1993Mesangial/myofibroblastdifferentiationJohnsonetal.1994PodocyteinjuryKriz1996PathogenesisPathogenesisoftubulo-interstitialfibrosisHypothesisAuthor(s)AdaptivetubularhypermetabolismHarrisandSchrier1998NephrotoxicityoflipidsMoorheadetal.1982NephrotoxicityofproteinuriaRemuzziandBertani1990NephrotoxicityofcalciumandphosphateAlfrey1988NephrotoxicityofironHarrisandAlfrey1994NephrotoxicityofoxygenfreeradicalsNathetal.1994TubularcellsandfibrosisKuncioandNeilson1991TubulartransdifferentationOkada,Strutz,andNielson1994

hyperperfusionGCPlossofnephronadaptionofremainingnephronsglomhypertrophy

liferation,focalGS,proteinuria

tubu-inters.atrophyESRDglomdisvascdistubu-intersdisnephroarteriolosclerosisHBP+hyperlipidemiaatherosclerosisRenovascularrenalfailureCaPPTHAquiredrenalcysticdiseasePathogenesis

UremicToxinsProductsofproteinmetabolism

urea:50mmol/L sympt:malaise,vomiting,bleeding,headache guanidinecompounds(methylguanidine) sympt:anorexia,vomiting,pruritus,twitch,unconsciousnessMiddlemolecularweightsolutes: MW500-5000PTH uremicperipheralneuropathy,disorderoflipidmetabolism,renalosteodystrophy,CVDOthers:β-MG,VitAEndocrine–metabolicdisorderErythropoietin--anemia1,25(OH)2D3--RenalosteodystrophyInsulinresistance—diabetesPathogenesisPathogenesisDisorderofnutrition&metabolismCatabolicmetabolism:Anabolicmetabolism:Intake:255075100eGFRClinicalmenifestionsAzotemiastageRenalFailureUremiaAsymptomaticstageClinicalManifestationsGastroenterologicmanifestations

prominentandfrequentlyencounteredanorexia

nausea,vomiting,diarrhea

uremicgastroenteritis

pepticulcer,bleeding

unpleasant,metallictaste(uremicfetor)

ManifestationsManifestations—NervousSystemAbnormalities

●

centralnervousEarlyuremia

Anorexia

Malaise

InsomniaDiminishedattentionspanDecreasedlibidoModerateuremia

Emesis

Decreasedactivity

Easyfatigability

Decreasedcognition

ImpotenceAdvanceduremia

Severeweaknessandfatigue

Disorientation

Confusion

Asterixis

Stupor,seizures,comaManifestationsperipheralnervous

restlesslegsyndromeparesthesias

motorweakness

paralysisCardiovascularandpulmonarydiseasemaincauseofdeathforpatientswithchronickidneydiseaseandESRD

hypertensioncongestiveheartfailure

pericarditis

atherosclerosis

respiratorysystemsymptomsManifestationsManifestationsHematologicanemia(GFR<30-40ml/min) EPO,inhibitorfactor,shortenofRBClifespan,shortofmaterials,lossbleedingdiathesisgastrointestinal,vaginal,pericardial,intracranialleukocyteabnormalitiesDermatologicmanifestations

pallor,hyperpigmentation,pruritusManifestationsManifestationsNephroticfaciesAnemiafaciesRenalosteodystrophy

high-boneturnoverdis:osteitisfibrosacystica,

osteoporosis,osteosclerosis

low-boneturnoverdis:osteomalacia, osteopenia

mixedManifestations

Manifestations

Boneturnover,mineralization,andvolume(TMV)classificationsystemforbonehistomorphometryFluid,electrolyteandacid-basedisturbance

sodiumandwaterpotassium

metabolicacidosis

abnormalitiesofcalcium,phosphateandvitaminDmetabolismManifestationsMetabolicdisturbance

carbohydratemetabolismglucosetoleranceisreducedinsulinresistancehyperlipidemia:triglycerideManifestationsManifestationsEndocrineabnormalitiesInfection

cellularimmunefunctionisdepressedDiagnosis&Differentialdiagnosis

HistoryPhysicalexaminationLab(urinanalysis,renalfunction,biochemicalanalysisofblood)

Urineroutine：1.protein2、redbloodcells

X-ray,ultrasound,radiorenogramGeneralRecommendations(1)ThefollowinggeneralrecommendationscanbemadeforthemanagementofpatientswithprogressiveCRF.1、Frequentclinicfollow-upisrequiredwithparticularattentiontothedetection,monitoring,andtreatmentofhypertension.Emphasisshouldalsobeonasimultaneousreductionofproteinuria(evidence-basedstatement).2、ItisreasonabletoadvisepatientswithprogressiveCRFtoavoidahigh-proteindiet,butcautionshouldbeexertedwhenrecommendingdietaryproteinrestrictionwithitsinherentriskofundernutrition.Itmaybebettertostartdialysisafewmonthsearlierandbewellnourishedthanriskmalnutritionwithitsassociatedincreasedmorbidityandmortalityondialysis.GeneralRecommendations(2)3、AttentionshouldbepaidtothemanagementofthecomplicationsofCRFincludingmetabolicacidosis,hypocalcemia,andhyperphosphatemiawiththeassociatedrenalosteodystrophy(evidence-basedstatement).4、Potentialnephrotoxinsshouldbeavoidedincludingnonsteroidalanti-inflammatoryagents;ACEIandARBshouldalsobeusedwithcarefulmonitoring.DiettherapyEnoughcalorieintake:126-147KJ（30~35Kcal）Lowproteindiet:0.4-0.6g/kg/d,60%highqualityproteinEssentialaminoacidsupplement-ketoacidsupplementVitaminsupplement:folicacid,VitC,VitB6,VitDTreatmentofcomplications

CardiovascularHypertension:1-4stageTarget:Upro<1g/d<130/80mmHg >1g/d<125/75mmHg5stage<140/90mmHgRx: restrictionofsodium(6~8g/d) ACEIorARB CCB diureticHeartfailureRestrictionofwaterandsodiumLargedoseoffurosemideVasculardilation(sodiumnitroprusside)DigoxinsBloodpurificationCorrectionofelectrolytesandacid-basedisturbanceImprovementofanemiaPerica