内科学慢性肾衰竭

内科学慢性肾衰竭内科学慢性肾衰竭第1页TheimportanceofChronicRenalFailureWorldwide,theprevalenceofCRFisincreasingbymorethan5%annuallyThecostofrenalreplacementtherapyhasanincreasingimpactonhealtheconomicsinbothdevelopedanddevelopingcountries内科学慢性肾衰竭第2页PlasmaCreatinineandGFRNormalGFR100-125ml/min/1.73m2GFRdeclinesbyabout1ml/min/1.73m2/yearPlasmacreatinineconcentrationcanbeusedtomonitorrenalfunctionwhenGFR<50ml/minMassscreeningofplasmacreatininecannotprovideearlydetectionofrenaldiseasesinthegeneralpopulation内科学慢性肾衰竭第3页内科学慢性肾衰竭第4页内科学慢性肾衰竭第5页CausesofCRFGlomerulardiseasesaccountfor60%ofCRFDiabeticnephropathyaccountfor10-15%ofCRF(inUSAabout50%)Hypertension:10-15%Polycystickidneydiseases:5%Obstructiveuropathy:3-4%Lupusnephropathy:2-3%UnderminedOrigin:5-10%内科学慢性肾衰竭第6页EvolutionofCRFGlomerulardiseaseswillbedecreasedDiabeticandhypertensivenephropathy↑Chronicnephrotoxicitybyenvironmentalpollutants,drugsandherbs↑IncidenceofESRD:100-200permillion内科学慢性肾衰竭第7页ClinicmanifestationofCRFDeteriorationofrenalfunctionisinvariableonceGFRisreducedbymorethan25%Serialplotsofthereciprocalofcrvs.timefollowsastraightlineOftenremainasymptomaticwhenGFR=25%Uraemicsyndrome内科学慢性肾衰竭第8页内科学慢性肾衰竭第9页ClinicalDiagnosisofCRFAcuteorchronic?OftenpresentsacutelywhenGFRsuddenlydropsfrom20%to10%orlessToassesstheseverityofrenalimpairmentToelucidatethecausesofrenalfailureToascertainwhethertherenalfailureisacute,oracute-on-chronicToassessthepatientforrenalreplacementtherapy内科学慢性肾衰竭第10页ClinicalInvestigationsThehistoryshouldincludeadiligentsearchforpotentialnephrotoxicagentsApositivefamilymayindicateheredofamilialdiseasesPallor,scratchmarks,peripheraloedemaandpalpablemassesintheabdomenAfullexaminationisimportant,especiallyinpatientswithdiabetes内科学慢性肾衰竭第11页CommonInvestigationsRenalfunctionprofileUrinalysisQuantitationofproteinuriaDeterminationofcreatinineclearanceLiverfunctionprofileHepatitisBandCstatus内科学慢性肾衰竭第12页CommonInvestigationsSerologicaltestsuchasanti-nuclearantibodies,complements,immunoglobulinlevels,C-reactiveproteinandanti-neutrophilcytoplasmantibodiesLipidprofileUltrasonogramofkidneysformeasurementofkidneysizeandexclusionofstructuralabnormalitiesDopplerexaminationofrenalarterieswhenindicated内科学慢性肾衰竭第13页ManagementofCRFTreatmentofprimarydiseaseTreatmentofhypertensionUsingACEIorangiotensin-IIreceptorblockersAvoidingnephrotoxicagentsLowdietaryproteinintakePhosphatecontrolEarlycorrectionofaneamia内科学慢性肾衰竭第14页TreatmentofHypertensionThetargetofbloodpressure:<130/80mmHgMultipleagentsarerequiredACEI,ARB,B-B,CCB,α-B，diureticsBloodpressurecontrolledfor24hr内科学慢性肾衰竭第15页UsingACEIorARBACEIcancausesanunacceptablecoughinasubstantialnumberofpatientsTheriskofhyperkalaemiaissmallthoughreal.ARFcanbehappenedinpatientswithsevererenalarterystenosis.内科学慢性肾衰竭第16页AvoidingnephrotoxicAgentsNon-steroidalanti-inflammatorydrugsareusedtooliberallyHerbs:patientsoftenresorttoalternativemedicineandingestawidecombinationofherbswhichleadstoarapiddemiseofremainingkidneyfunction.内科学慢性肾衰竭第17页ManagementofCRFUrinaryobstructionandinfectionshouldbetreatedpromptlyFluidsoverloadingshouldbeavoidedEarlyreferredtonephrologist(GFR<30ml/min)内科学慢性肾衰竭第18页ManagementofCRFPhosphatebindersaregivenwitheachmealtobinddietaryphosphatesinthegutCalciumsupplementationisneededActiveVitaminDmetabolitesareprescribedwhenPTHishigh内科学慢性肾衰竭第19页ManagementofCRFMetabolicacidosisiscorrectedwithsodiumbicarbonateErythopoietincancorrectsearlyanaemia,improvescardiovascularfunctionandpreservesresidualrenalfunction内科学慢性肾衰竭第20页ManagementofCRFProteinrestrictioncanslowdowntheprogressionofrenalfailure.However,severemalnutritionshouldbecarefullyavoided65%ofthedietaryproteinintakeshouldbeintheformofhighbiologicalvalueprotein内科学慢性肾衰竭第21页ManagementofCRFVegetableproteinmaybebeneficialinearlystagesofCRFSaturatedfatsmustbeavoidedLipidabnormalitiesmustbegivendueattentionLowsodiumdietaryintake内科学慢性肾衰竭第22页ManagementofCRFCardiovascularmortalityisthemostimportantcauseofdeathAnti-lipidtreatmentshouldbegivenearlyAspirinwillabeneficialimpactonsurvivalSmokingshouldbeavoidedPotassiumintakeshouldbereducedwheninESRD内科学慢性肾衰竭第23页RenalReplacementTherapyAthoroughdiscussioninvolvingthepatientandhisfamilyonthedifferenttreatmentoptionsismandatoryKidneytransplantationpresentsthebestmeansofrehabilitation,especiallywhenitisperformedpre-emptively内科学慢性肾衰竭第24页RenalReplacementTherapyIntegratedapproachintheoverallmanagement:Peritonealdialysiscanbeconsideredasinitialdialyticth