慢性肾衰竭的管理

慢性肾衰竭的管理

ManagementofChronicRenalFailure

1肾脏之正常生理学

NormalPhysiologyoftheKidney2肾脏之正常生理学

NormalPhysiologyoftheKidney3正常肾结构/RenalstructureApproximately200,000tinystructures(nephrons)inthekidneyseliminatewasteproductsandregulateelectrolytesinthebody.nephronKidneysection4肾脏之正常生理学

NormalPhysiologyoftheKidney精密复杂的过滤及废弃物处理中心:Sophisticatedfiltrationandwastedisposalunit:代谢废弃物的排除Excreteswasteproductsofmetabolism调节体液、电解质及酸-硷平衡Regulatesfluid,electrolyte,andacid-basebalance贺尔蒙（激素）的制造Produceshormones5肾衰竭的定义

Definition-RenalFailure6肾衰竭的定义

Definition-RenalFailure

由于肾脏没有办法维持正常的排泄和内分泌等生理调节功能而导至体内氮溶解物的滞留，加上体液、电解质、酸碱度等的失衡而表现的临床惩状。

Clinicalsyndromethatoccurswhenthekidneysarenolongerabletomaintaintheirregulatory,excretory,andendocrinefunctions,resultinginretentionofnitrogenoussolutesandderangementsoffluid,electrolyte,andacid-basebalance.7

慢性肾衰的发病情况

Epidemiology8肾衰与年龄的关系9犬最常见五种

Top5ConditionsCited癌症心脏病肾病肝病癫痫病10猫最常见五种

Top5ConditionsCited猫传染性腹膜炎糖尿病心脏病肾病/泌尿道疾病癌症11慢性肾衰病因

Varietyofcauses12慢性肾衰的病因

CRF=lossoffunctionalunitsofthekidneys尿结石/urinarycalculi感染因素/infection:leptospirosis,pyelonephritis…寄生虫/parasiticinfestation:babesiosis中毒/intoxication免疫紊乱/immunitarydisorders肿瘤/tumoursPathologicAnatomyENVN13肾脏病之危险因子

KidneyDiseaseRiskFactors老化 Advancingage高血压 Hypertension

药物治疗 Drugtherapy感染症 Infection品种/家族 Breed/family14慢性肾衰与猫的品种

RelationshipbetweenCRFandBreeds易发生慢性肾衰的品种：MaineCoonAbyssinianSiameseRussianBlueBurmeseBalineseTheMaineCoon,Abyssinian,Siamese,RussianBlue,Burmese,andBalineseappeartobemorelikelytodevelopCRFthanotherbreeds.15慢性肾衰的症状

CRFClinicalsigns1617肾衰的症状/CRFClinicalsigns多饮/多尿*

PU/PD食欲不振*

PoorAppetite精神沉郁*

Lethargy体重减轻*

WeightLoss视网膜的变化

RetinalChanges忽然丧失视力

SuddenBlindness毛色暗淡*

DullCoat18身体检查/PhysicalExam呕吐/腹泻*

Vomiting/diarrhea缺水状态*

Dehydrated囗臭、咀部溃疡*

Halitosis,MouthUlcers肾部大小改变 ChangeinKidneySize呼吸加深 Increaseddepthofrespiration贫血Anemia神经性征兆 NeurologicalSigns癫痫

Seizures*一般观察CommonFindings19橡皮下颌骨

“Rubber”Jaw20低钾血症/Hypokalemia21肾衰的症状/CRFClinicalsigns临床症状Clinicalsigns:lowspecificity最终阶段Terminalstage(n=26)尿毒症阶段Uraemicstage(n=39)猫肾衰的临床症状Clinicalsignsobservedinrenaldeficientcats22发病机制/Mechanism23肾脏病发病特点

KidneyDisease

在例行血检中检查出以前,有75%以上的肾功能早已经丧失了。

Atearliestdetectionbyroutinebloodtesting,morethan75%ofthekidney’sfunctionalcapacityislost.24肾脏病的四个阶段

FourStagesofKidneyDisease肾单元的丧失Lossofnephrons肾保留能力丧失Lossofrenal

reserve肾功能不全Renal

insufficiency中度肾衰竭Renal

failure重度肾衰竭AdvancedRenalfailure<66%>66%>75%>90%25肾衰病理结果

CRF:pathologicalconsequencesPathologicAnatomyENVN排毒能力下降/Lowerabilitytoexcretetoxicsubstances尿浓缩能力下降/Lowerabilitytoconcentrateurine激素分泌紊乱/Hormonaldisturbances26肾脏排除毒物能力下降（1）

lowerabilitytoexcretetoxicsubstancesBloodsericconcentration血中氮产物升高nitrogenby-products尿素urea肌酐creatinine...血磷升高phosphates淀粉酶升高Amy27肾脏排除毒物能力下降（2）

lowerabilitytoexcretetoxicsubstances警示症状Alarmingsignsfortheowner难闻的气味badbreath唾液中尿素ureainsaliva冷漠、食欲降低apathy,lowappetite体重下降weightloss28尿浓缩能力下降

lowerabilitytoconcentrateurine结果Consequences尿量增加increasedurinaryvolume尿丢失urinaryloss蛋白proteins(theratioalbumine/globulinedrops)电解质紊乱HCO3-,K+…(electrolyticimbalances)29肾脏丧失浓缩尿的能力（1）

thekidneylosesitsabilitytoconcentrateurineFunctionaltissue

33%Evolutionofurinaryspecificgravityincats30

尿浓缩能力下降（2）

lowerabilitytoconcentrateurine重要症状Alarmingsignsfortheowner多饮多尿«

Polyuro-polydipsia

»syndrome犬明显mainlyobviousindogs消化紊乱Digestivedisturbances脱水perturbationofthehydratationstatus31激素紊乱/hormonaldisturbances促红细胞生成素下降Erythropoietinsynthesis贫血anemia活性维生素减少ActivationofvitaminD钙代谢紊乱perturbationsofcalciummetabolism甲状旁腺分泌增加Secretionofparathormon骨溶解bonedemineralization神经问题nervoustroubles…photo:B.Carriere32维生素D代谢图

VitaminDMetabolism33CRF:associatedrisksAnatPathoENVN逐渐发展尿毒症症状Evolutiontowardsuraemicsyndrome消化道症状digestivesigns血管紊乱Vasculardisorders高血压hypertension磷积聚

Accumulationofphosphorus磷在肾积聚phosphorusdepositinthekidney钙释放（橡皮鄂）calciumrelease(rubberjawdisease)34RenalC/FlimittheriskofdigestivedisturbancesWhy?

gastro-intestinaldisordersarefrequentlyobservedinCRFstudyon132renaldeficientcats厌食anorexia: 80%(ulceration,stomatitis)呕吐vomiting: 52%便秘constipation: 24%腹泻diarrhoea:3%Lulich199235血磷升高的原因

Whydoesthephosphorusaccumulateintheblood?肾小球虑过机能下降Diminutionoftheglomerularfiltrationrate(GFR)肾脏排除磷减少Diminutionofthequantityofphosphorusexcretedbythekidney造成血液中的磷增加Augmentationofphosphorusintheblood36血磷增加的后果

Phosphorusaccumulation:consequences肾排磷能力下降renalexcretionofphosphorusactivevitDCaabsorptionCalcium（Ca）(intheblood)Phosphorus（Pi）parathormonsynthesis(PTH)eliminationofP,Cabonereleasingosteoporosisrisk,calciumdepositinkidneys（骨质疏松、肾钙化）aggravationofCRF(glomerularsclerosis)（肾衰恶化）37限制磷摄入可以延长患猫生命

Phosphorusrestrictionimproveslifeexpectancy38限制磷摄入可以延长患犬生命

Phosphorusrestrictionimproveslifeexpectancy39减缓肾衰的发展

Slowingdownevolutionofthedisease减少磷的积聚Limitationofphosphorusaccumulation40肾脏病的诊断

DiagnosisofKidneyDisease41肾脏病的诊断

DiagnosisofKidneyDisease

1.病历 History2.身体检查 PhysicalExam3.全血细胞数 CBC4.血清生化学 SerumBiochemistry5.尿液分析 Urinalysis

6.影像分析 Imaging

7.其他测试 Othertests

42全血细胞数/CBC贫血（非再生性）Anemia(nonregenerative)轻微的白血细胞增多与淋巴细胞减少症MildLeukocytosis&Lymphopaenia43血清生化学/Biochemistry尿素氮的增加(10-30mg/dl)

IncreasedBUN(10-30mg/dl)肌酸酐的增加(0.5-1.6mg/dl)IncreasedCreatinine(0.5-1.6mg/dl)高磷酸盐血症 Hyperphosphatemia高或低钾血症 HypoorHyperkalemia44InternationalRenalInterestSociety(IRIS)classification

ofstagesofrenaldiseaseandrenalfailureindogs

（Plasmacreatinineconcentration）StagesofcaninerenaldiseaseandfailureIIIIIIIVμmol/L<125125to180181to440>440mg/dL<1.41.4to2.02.1to5.0>5.045InternationalRenalInterestSociety(IRIS)classification

ofstagesofrenaldiseaseandrenalfailureinCats

（Plasmacreatinineconcentration）StagesoffelinerenaldiseaseandfailureIIIIIIIVμmol/L<140140to250251to440>440mg/dL<1.61.6to2.82.8to5.0>5.046尿液分析/DiagnosticTests-Urinalysis尿比重 Specificgravity(USG)酸碱度

pH沉积物

Sediment蛋白尿

Proteinuria细菌尿

Bacteruria血尿

Hematuria白细胞尿

Lucosuria47尿液比重/UrineSpecificGravity尿液比重USG犬只

Dog猫只Cat

正常值Usual1.035-1.0451.055-1.065肾病值RenalDisease1.010-1.0201.015-1.03048各式手提析光仪

HandHeldRefractometers49尿试纸可用来测试

UrineDipstixMeasures胆红素 Bilirubin血

Blood葡萄糖

Glucose酮

Ketones白细胞 Leukocyte亚硝酸盐 Nitrite酸碱度 pH蛋白 Protein比重（不准确）Specificgravity(notreliable)尿素原 Urobilinogen50各类尿试纸/UrineDipstix

51影像分析/ImagingＸ光照片

X-rays

可用来评估肾脏形状，大小，位置以及肾结石的存在

Evaluatekidneysize,shape,andpositionaswellasthepresenceofnephroliths52正常/NormalAppearence肾石/Nephroliths53肾肿瘤/RenalTumours54影像分析/Imaging超声波造影

Ultrasound

可用来评估肾脏结构

Evaluaterenalarchitecture55多囊肾病/PolycysticKidneyDisease56其他诊断化验

OtherDiagnosticTests蛋白/肌酸酐比例–

对诊断肾衰竭相当有用(<1.0)

Protein/CreatinineRatio–VeryusefultodiagnoseRenalInsufficiency(<1.0)血压--BloodPressure

组织活检--Biopsy肾小球体滤过率-肌酐廓清率

GlomerularFiltrationRate–CreatinineClearance57肾脏病的检查

ScreeningforRenalDisease©2002HeskaCorporation早期后期比重血液尿素氮尿毒症微量尿蛋白肾单元损坏的新指标：蛋白尿健全肾单元数量等渗尿肾单元损伤初期58肾衰的治疗

ManagementofChronicRenalFailure59慢性肾衰竭的初期药物管理

InitialMedicalManagementofChronicRenalFailure尽可能去除病因

--Removethecause,ifpossible停止有损害性的药物--Discontinueinjuriousdrugs治疗

尿道炎-DetectandtreatUTI(urinarytractinfection)调节电解质和酸碱平衡--Correctelectrolyteimbalances补充血浆量-Expandplasmavolume,ifcontracted控制高血压--ControlHypertension60输液疗法/IVFluidTherapy方法视电解质的平衡状态而定

TypedependsonElectrolyteBalance乳酸复方氯化纳或复方氯化纳溶液

LactatedRingersorRingers每公斤体重3.5-5mmol亳克分子碳酸氢盐3.5-5mmolBicarbonate/kg治疗至少24至72小时Treatmentfor24-72hoursatleast61利尿/UrineOutput利尿剂 Diuretics

呋喃苯胺酸Frusemide2-6mg

毫克/

kgIV

静脉注射肾血管舒张剂RenalVasodilatingAgent

多巴胺Dopamine

/３–羟酪胺

每分钟1-2mg

微克/

km

/

minIV

静脉注射62剌激食欲/AppetiteStimulation安定 Diazepam维生素B VitaminB63慢性肾衰的医学管理

MedicalManagementofCRF

促蛋白合成甾类

（类固醇）

AnabolicSteroids

对贫血和蛋白分解都有益处

BenefitforAnaemia&ProteinCatabolism

提高精神与饮食欲

ImprovedDemeanour&Appetite64胃肠道药物

GastrointestinalDrugs止吐药Antiemetics 氯普胺，灭吐灵，胃复安Metoclopramide每公斤0.2

-

0.4mg

/

kgqid

一天四次H2拮抗剂H2Antagonists

西米替丁，Cimetidine

每公斤5–10

mg

/

kgq6-8hr

每６–８小时65慢性肾衰的医学管理

MedicalManagementofCRF

用肠内磷结合因子来控制高磷酸盐血症

Controlhyper-phosphatemiawithintra-intestinalphosphatebinders氢氧化铝AluminumHydroxide(Amphogel) 每日经口服用(30-100mg/kg/dayPO)炭酸钙CalciumCarbonate

每日经口服用(90-150mg/kg/dayPO)66慢性肾衰的医学管理

MedicalManagementofCRF用促红素去控制贫血情AdministerErythropoietintomanageanemia-每星期3次血细胞比容（HCT）<20,treat3X/week用合成维生素D去减低甲状旁腺激素SyntheticVitaminD(Calcitrol)toreduceparathyroidhormone经口服每公斤

1.5-3.5mg/kgPO67血管收缩素转换抑制因子

AngiotensinConvertingEnzymeInhibitorsEnalapril0.5mg/kgPOq24hrBenzapril

(Fortekor5½tab/day/cat)68慢性肾衰竭营养管理的目标

GoalsofNutritionalManagementinChronicRenalFailure“…饮食管理的目的是透过以下的方法使生命的质与量都获得最美好的延伸“...thegoalsofdietarymanagementaretomaximizethequalityandquantityoflifeby确保适当的能量摄取,

ensuringadequateintakeofenergy,抑制尿毒症的发展及

limitingtheextentofuremiaand延缓肾脏疾病的进行.”

slowingtherateofprogressionofrenaldisease.”Ettinger,Feldman,TextbookofVeterinaryInternalMedicine,Volume2,200069慢性肾衰竭(CRF)的诊断DiagnosisofCRF始动饮食管理InitiateDietaryManagement监察对食物的反应MonitorResponsetoFood不适当的营养InadequateNutritionAdaptedfrom:Ettinger,FifthEdition,Vol.2(2000)p.1648Fig.169-3慢性肾衰的饮食管理

DietaryManagementofCRF如需要的话:

从代谢方面调理缺乏食欲的问题，始动尿毒性胃炎治疗，建议导管喂食IfNeeded:Correctmetaboliccausesforinappetence,Initiatetherapyforuremicgastritis,Considertubefeeding70慢性肾衰竭之营养管理

NutritionalManagementofChronicRenalFailure以控制食物中的磷含量来延缓肾脏病及控制高磷血症

Slowprogressionofkidneydiseaseandcontrolhyperphosphatemiabydietaryphosphorousrestriction增加食物中的缓冲物质

帮助预防代谢性酸血症