慢性肾功能衰竭chronic renal failure（crf）课件

Chronic Renal Failure(CRF) Shanghai Ruijin Hospital affiliated to Shanghai Second Medical University, Dept.of Nephrology Qian Ying CRF Definition: final stage of numorous renal diseases resulting from progressive loss of glomerular, tubular and endocrine function in both kidneys. This leads to disturbed excretion of end products of metabolism disturbed elimination of electrolytes and water disturbed secretion of hormones(eg. Erythropoietin, renin, prostaglandins, active form of vitamin D) CRF Regional and racial incidence of CRF Britain 70-80/per million China 100/per million USA 60-70/per million CRF Etiology diabetic nephropathy, hypertensive glomerular sclerosis, chronic GN chronic GN, obstructive nephropathy, diabetic nephropathy overseas china CRF Pathogenesis (unknown) uremic toxins small molecular weight: urea, creatinine, uric acid, guanidine, phenol, amines, indoles middle molecular weight: PTH large molecular weight: 2-MG CRF Major hypothesis intact nephron hypothesis final common pathway (hemodynamically mediated glomerular injury) CRF glomerular injury adaptive single nephron hyperfiltration glomerular capillary plasma flow, hydraulic pressure Intact nephron hypertrophy and sclerosis CRF Trade-off hypothesis CRF Calcium phostate PTH SHPT bone,heart,blood,nerves injury Hypertension and compensatory hypertrophy of glomeruli Hypermetabolism of renal tubuli cytokines and lipid disturbances CRF Stage 1: the normal stage of renal function GFR70 ml/min, BUN9 mmol/L Scr178 umol/L there may be slight fatigue,anorexia and anemia Stage 4: uremic stage GFR20 mmol/L Scr445 umol/L a constellation of uremic syndrome may appear in this stage CRF Signs and symptoms of uremia General Gastrointestinal tract Neuropathy Bone Blood Electrolyte disorders Heart Skin Muscles Infection Lung Endocrine and metabolic CRF CRF Cardiovascular disorders Hypertension 80% Water and sodium retention Alterations of RAAS Glomerular capillary pressure systemic arterial pressure CRF Atherosclerosis hypertriglycerid, hypercholesterolemia vascular calcification inadequate perfusion of the limbs CRF Pericarditis Uremic Dialysis associated Signs and symptoms Chest pain Friction rub Pericardial effusion and tamponade CRF Hematologic disorders Anemia, bleeding, granulocyte, platelet dysfunction Causes: Relative deficiency of erythropoietin Decreased erythropoietin production Reduced red cell survival Increased blood loss Folate and Iron deficiency Hypersplenism CRF Neuropathy Central nervous system Tiredness, insomnia, agitation, irritability, depression, regression, rebellion Peripheral nervous system Restless leg syndrome the patients legs are jumpy during the night, painful paresthesis of extremities, twitching, loss of deep tendon reflexes , musclar weakness, sensory deficits CRF Renal osteodystrophy vType I: high turn-over bone disease vType II: low turn-over bone disease vType III: mixture CRF Causes of renal osteodystrophy 1, 25(OH)2D3 calcium phosphate SHPT malnutrition iron and aluminum overload CRF CRF Water, electrolyte and acid-base disturbances potassium sodium calcium phosphate Metabolic acidosis magnesium CRF Diagnosis of hyperkalemia Plasma K5.5mmol/L Plasma K7.0mmol/L cardiac arrest CRF CRF Causes of hyperkalemia sIncreased intake: rapid adminstration of K by mouth or intravenously sDrugs containing K(chinese medical herbs) sImpaired excretion Chronic renal failure(GFR15ml/min) CRF Causes of hyperkalemia sShift of K out of cells Metabolic acidosis Tissue breakdown Bleeding into soft tissues, GI tract or body cavities Hemolysis Catabolic states CRF Diagnosis: Case history Physical examination Laboratory studies including urinalysis , renal function tests , biochemical analysis of blood X-ray, ultrosound and radiorenogram CRF Treatment of CRF Non-dialysis dialysis CRF Non-dialysis Diet therapy Treatment of reversible factors Treatment of the underlying disease Treatment of complcations of uremia Chinese medical herbs CRF Diet therapy Protein restriction (0.5-0.8mg/kg/d) Adequte intake of calories(30- 35kcal/kg/d) Fluid intake:urine volume +500ml Low phosphate diet(600-1000mg/d) Supplement of EAA(ketosteril) CRF Reversible factors in CRF Hypertension Reduced renal perfusion (renal artery stenosis, hypotension , sodium and water depletion, poor cardiac function) Urinary tract obstruction Infection Nephrotoxic medications Metabolic factors(calcium phosphate products ) CRF Management of complications of uremia Hyperkalemia Identify treatable causes Inject 10-20ml 10% calcium gluconate 50% gluconate 50-100ml i.v.+insulin 6-12u Infusion 250ml 5% sodium bicarbonate Use exchage resin Hemodialysis or peritoneal dialysis CRF Cardiac complications Diuretics Digitalis Treat hypertension dialysis CRF Antihypertensive therapy Target blood pressure 130/85mmHg ACE inhibitors Angiotension II receptor antagonists Calcium antagonists -blockers vesodialators CRF Treatment of anemia Recombinant human erythropoietin(rhEPO) 2000-3000u BIW H Target hemoglobin 10-12g/L hemotocrit 30-33% CRF Side effects of rhEPO Hypertension Hypercoagulation Thrombosis of the AVF CRF rhEPO resistant Iron deficiency Active inflamation Malignancy Secondary hyperparathyroid Aluminum overload Pure red cell aplasia CRF Treatment of renal osteodystropy Low phosphate diet Calcium carbonate (1-6g/d) Vitamin D (0.25ug/d for prophylactic, 0.5ug/d for symptomatic, pulse therapy 2-4ug/d for severe cases) parathyroidectomy CRF Renal replacement therapy Hemodialysis Peritoneal dialysis Renal transplantation CRF Indications of HD GFR10ml/min the uremic syndrome hyperkalemia acidosis fluid overload Hemodialysis Hemodialysis 弥散 Diffussion 渗透 Dialysis Hemodialysis 超滤 Ultrofiltration 对流 Conduction 正压 负压 Contraindications of HD Shoke Severe caidioc complications Severe bleeding malignency , sepsis poor condition in vascular system CRF Indicatio