慢性肾功能衰竭Chronic-Renal-Fai课件

ChronicRenalFailure(CRF)ShanghaiRuijinHospitalaffiliatedtoShanghaiSecondMedicalUniversity,Dept.ofNephrologyQianYingCRFDefinition:

finalstageofnumorousrenaldiseasesresultingfromprogressivelossofglomerular,tubularandendocrinefunctioninbothkidneys.Thisleadstodisturbedexcretionofendproductsofmetabolismdisturbedeliminationofelectrolytesandwaterdisturbedsecretionofhormones(eg.Erythropoietin,renin,prostaglandins,activeformofvitaminD)CRFRegionalandracialincidenceofCRFBritain70-80/permillionChina100/permillionUSA60-70/permillionCRFEtiologydiabeticnephropathy,

hypertensiveglomerularsclerosis,chronicGNchronicGN,obstructivenephropathy,diabeticnephropathyoverseaschinaCRFPathogenesis(unknown)uremictoxinssmallmolecularweight:urea,creatinine,uricacid,guanidine,phenol,amines,indolesmiddlemolecularweight:PTHlargemolecularweight:2-MGCRFMajorhypothesisintactnephronhypothesisfinalcommonpathway(hemodynamicallymediatedglomerularinjury)CRFglomerularinjuryadaptivesinglenephronhyperfiltrationglomerularcapillaryplasmaflow,hydraulicpressureIntactnephronhypertrophyandsclerosisCRFTrade-offhypothesisCRFCalcium

phostate

PTHSHPTbone,heart,blood,nervesinjuryHypertensionandcompensatoryhypertrophyofglomeruliHypermetabolismofrenaltubulicytokinesandlipiddisturbancesCRFStage1:thenormalstageofrenalfunction

GFR>70

ml/min,BUN<6.5mmol/L,

Scr<110umol/LStage2:imcompensationstageofrenal

GFR50-70ml/min,6.5<BUN<9mmol/L,

110<Scr<178umol/L

noanysignsandsymptomsexceptfortheunderlyingdisordersCRFStage3:azotemicstage

GFR<50ml/min,BUN>9mmol/LScr>178umol/Ltheremaybeslightfatigue,anorexiaandanemiaStage4:uremicstage

GFR<25ml/min,BUN>20mmol/L

Scr>445umol/L

aconstellationofuremicsyndromemayappearinthisstageCRF

Signsandsymptomsofuremia

GeneralGastrointestinaltractNeuropathyBoneBloodElectrolytedisordersHeartSkinMusclesInfectionLungEndocrineandmetabolicCRFCRFCardiovasculardisordersHypertension80%WaterandsodiumretentionAlterationsofRAAS

Glomerularcapillarypressure>systemicarterialpressureCRFAtherosclerosishypertriglycerid,hypercholesterolemiavascularcalcificationinadequateperfusionofthelimbsCRFPericarditisUremicDialysisassociatedSignsandsymptomsChestpainFrictionrubPericardialeffusionandtamponadeCRFHematologicdisordersAnemia,bleeding,granulocyte,plateletdysfunctionCauses:RelativedeficiencyoferythropoietinDecreasederythropoietinproductionReducedredcellsurvivalIncreasedbloodlossFolateandIrondeficiencyHypersplenismCRFNeuropathyCentralnervoussystem

Tiredness,insomnia,agitation,irritability,

depression,regression,rebellionPeripheralnervoussystem

Restlesslegsyndromethepatient’slegsarejumpyduringthenight,painfulparesthesisofextremities,twitching,lossofdeeptendonreflexes,musclarweakness,sensorydeficitsCRFRenalosteodystrophyTypeI:

highturn-overbonediseaseTypeII:lowturn-overbonediseaseTypeIII:mixtureCRFCausesofrenalosteodystrophy1,25(OH)2D3calciumphosphateSHPTmalnutritionironandaluminumoverloadCRFCRFWater,electrolyteandacid-basedisturbancespotassiumsodiumcalciumphosphateMetabolicacidosismagnesiumCRFDiagnosisofhyperkalemiaPlasmaK>5.5mmol/LPlasmaK>7.0mmol/LcardiacarrestCRFCRFCausesofhyperkalemiaIncreasedintake:rapidadminstrationofKbymouthorintravenouslyDrugscontainingK(chinesemedicalherbs)ImpairedexcretionChronicrenalfailure(GFR<15ml/min)CRFCausesofhyperkalemiaShiftofKoutofcellsMetabolicacidosisTissuebreakdownBleedingintosofttissues,GItractorbodycavities

Hemolysis

CatabolicstatesCRFDiagnosis:CasehistoryPhysicalexaminationLaboratorystudiesincludingurinalysis,renalfunctiontests,biochemicalanalysisofbloodX-ray,ultrosoundandradiorenogramCRFTreatmentofCRFNon-dialysisdialysisCRFNon-dialysisDiettherapyTreatmentofreversiblefactorsTreatmentoftheunderlyingdiseaseTreatmentofcomplcationsofuremiaChinesemedicalherbsCRFDiettherapyProteinrestriction(0.5-0.8mg/kg/d)Adequteintakeofcalories(30-35kcal/kg/d)Fluidintake:urinevolume+500mlLowphosphatediet(600-1000mg/d)SupplementofEAA(ketosteril)CRFReversiblefactorsinCRFHypertensionReducedrenalperfusion(renalarterystenosis,hypotension,sodiumandwaterdepletion,poorcardiacfunction)UrinarytractobstructionInfectionNephrotoxicmedicationsMetabolicfactors(calciumphosphateproducts)CRFManagementofcomplicationsofuremiaHyperkalemiaIdentifytreatablecausesInject10-20ml10%calciumgluconate50%gluconate50-100mli.v.+insulin6-12uInfusion250ml5%sodiumbicarbonateUseexchageresinHemodialysisorperitonealdialysisCRFCardiaccomplicationsDiureticsDigitalisTreathypertensiondialysisCRFAntihypertensivetherapyTargetbloodpressure130/85mmHgACEinhibitorsAngiotensionIIreceptorantagonistsCalciumantagonists-blockersvesodialatorsCRFTreatmentofanemiaRecombinanthumanerythropoietin(rhEPO)2000-3000uBIWHTargethemoglobin10-12g/Lhemotocrit30-33%CRFSideeffectsofrhEPOHypertensionHypercoagulationThrombosisoftheAVFCRFrhEPOresistantIrondeficiencyActiveinflamationMalignancySecondaryhyperparathyroidAluminumoverloadPureredcellaplasiaCRFTreatmentofrenalosteodystropyLowphosphatedietCalciumcarbonate(1-6g/d)VitaminD(0.25ug/dforprophylactic,0.5ug/dforsymptomatic,pulsetherapy2-4ug/dforseverecases)parathyroidectomyCRFRenalreplacementtherapyHemodialysisPeritonealdialysisRenaltransplantationCRFIndicationsofHDGFR<10ml/mintheuremicsyndromehyperkalemiaacidosisfluidoverloadHemodialysisHemodialysis弥散Diffussion渗透DialysisHemodialysis超滤Ultrofiltration对流Conduction正压负压ContraindicationsofHDShokeSeverecaidioccomplicationsSeverebleedingmalignency,sepsispoorc