医学课件慢性肾功能衰竭张玖强

慢性肾功能衰竭 Chronic Renal Failure 整理：张玖强 Phase of Chronic Kidney Failure GRFGRF (Ccr ml/min)(Ccr ml/min) CrCr( (mol/L)mol/L) Early Early PhasePhase 50205020 Normal 2035%Normal 2035% 186442186442 Failure Failure PhasePhase 20102010 Normal 1020%Normal 1020% 450770450770 End PhaseEnd Phase770770 Etiological Factors Primary Chronic Glomerunephritis（6070%） Obstructive nephropathy Diabetic nephropathy Lupus nephritis Hypertension nephropathy Polycystic Kidney Nephron damage Glomerulosc lerosis Uremia Pathogenesis Mechanism of CRF deteriorating n Health survive nephron - trade-off hypothesis n Glomerulus Hyperfiltration Hypothesis Pathogenesis Mechanism of CRF deteriorating n Renal tubule Hypermetabolism hypothesis Reneal tubule lesion 、Interstitial inflammation and fibrosis。 n Other Angiotensin II、Transforming growth factor, ECM Lipid metabolism disorder, LDL, Protein filter 增生硬化性肾小球肾炎，代偿肥大增生硬化性肾小球肾炎，代偿肥大(H) (H) 与萎缩与萎缩(A)(A)区域相间存在区域相间存在 ( HE, 40 )( HE, 40 ) Pathogenesis Occurrence Mechanism of Various kinds in Uremia Kidney Principal Function Maintenance wate ,electrolure,acid-base equilibration； Eliminating metabolism refuse； Endocrine function： Erythropoietin, 1-hydroxylase; Degradation pheromone：Insulin and so on; PathogenesisPathogenesis Occurrence Mechanism of Occurrence Mechanism of Various kinds in UremiaVarious kinds in Uremia 1. 1. Water-Electrolyte and Acid-base Water-Electrolyte and Acid-base dysequilidrium;dysequilidrium; 2. 2. Metabolism refuse retentionMetabolism refuse retention，Endocrine Endocrine hormones savings, causing uremia symptom.hormones savings, causing uremia symptom. Clinical situation n Sodium dysequilibrium Desiccation Edema Low sodium（Dilution） High sodium n K dysequilibrium Water-Electrolyte and Acid-base Water-Electrolyte and Acid-base dysequilibriumdysequilibrium n Acidosis：Common death cause n Calcium and Phosphorus dysequilibrium Low Calcium：1,25(OH)2D3 High Phosphorus： n Hypermagnesemia Clinical situationClinical situation Water-Electrolyte and Acid-base Water-Electrolyte and Acid-base dysequilibriumdysequilibrium n Cardia-blood vessel systemic symptoms Hypertension Cardia-insufficiency Pericarditis Atherosclerosis n Respiratory systemic symptoms Respiratory profound Uremic pneumonia Pleurisy Clinical situationClinical situation Each systemic symptomsEach systemic symptoms n Blood systemic manifestation Anemia ：EPO ，RBC destruction and so on Hemorrhagic tendency Leucocyte abnormilly n Nervus-Muscular systemic manifestation Muscle spasm Coma Peripheral nervous lesion Clinical situationClinical situation Each systemic symptomsEach systemic symptoms n Gastrointestinal manifestation Appetite descent Nausea and Vomiting Gastrointestinal hemorrhage n Skin manifestation Uremia Facial Features Skin to tickle Clinical situationClinical situation Each systemic symptomsEach systemic symptoms n Renal Osteodystrophy Clinical Manifestation 10% X-ray 40% Bone biopsy 90% Osteitis fibrosa (纤维性骨炎) Renal Osteomalacia (肾性骨软化症) Osteoporosis (骨质疏松) Renal Osteosclerosis (肾性骨硬化症) Clinical situationClinical situation Each systemic symptomsEach systemic symptoms n Endocrine disturbance Plasm1,25(OH)2D3 , Renin , PTH, Estrin (雌激素) Testosterone (睾丸素) n Easy combine infection Common infection in Lung and Urinary tract n Metabolism disturbance Hypothermia (体温过低), Carbohydrate Metabolism disturbance Sugar Tolerance decrease, Hyperuricemia, Lipo-Metabolism Disorder Clinical situationClinical situation Each systemic symptomsEach systemic symptoms Diagnosis n Diagnosis of Background Disease based Earlier Period：Imagelogy，Renal Biopsy Late Period：Difficult for diagnosis backgound disease n Finding Facts of deteriorating in CFR Deteriorate Facts: Hypovolemia；Infection ； Urinary tract obstruction； Congestive heart failure ; Severity arrhythmia； Blood pressure fluctuation Treatment I Therapeutics of background disease and deteriorate agent. Treatment II Slowing Development in CRF n Diet Treatment n Essential Amino Acid n Angiotensin-Converting Enzyme Inhibitor Angiotensin II receptor 1 antagonist Blood creatinine 350mol/L， Blood creatinine elevating over than 30% stop using 。 n Other Anti lipideomia Treatment III Complication Treatment nWater-Electrolyte imbalance nMetabolic Acidosis nCalcium-Phosphorum metabolism imbalance nCardia-bl