慢性肾功能衰竭课件_33

慢性肾功能衰竭 Chronic Renal Failure Peng Youming, MD,PhD 中南大学湘雅二医院中南大学湘雅二医院 彭佑铭彭佑铭 概 述 概 述 概 述 概 述 慢性肾脏疾病定义慢性肾脏疾病定义 标准标准 1 1、肾脏损伤（肾脏结构或功能异常）、肾脏损伤（肾脏结构或功能异常） /= 3/= 3个月个月, , 可以有或无可以有或无GFRGFR下降下降, ,可表现为下面任何一条可表现为下面任何一条: : 肾脏病理学检查异常肾脏病理学检查异常 肾脏损伤的指标：包括血、尿成分异常或肾脏损伤的指标：包括血、尿成分异常或 影像影像 学检查异常学检查异常 2 2、 GFR/= 3 /= 3个月个月, , 有或无肾有或无肾 脏损伤证据脏损伤证据 概 述 概 述 CKD ESRD 1 million 20 million 慢性肾脏疾病的发病率占普通人群的10%左右 概 述 慢性肾脏疾病分期慢性肾脏疾病分期 阶段描述GFRml/min/1.73m2 处理方案 CKD危险增加/=90，有危险因素筛查，减少危险因素 1肾脏损伤肾脏损伤 GFR正常 或增加 /=90诊诊断治疗疗，减少CVD危险险，延缓缓 进进展 2轻轻度下降60 - 89评评估进进展 3中度30 - 59治疗疗并发发症 4重15 - 29替代治疗疗准备备 5肾肾衰竭770 慢性肾衰竭的分期 概 述 Etiological Factors Primary Chronic Glomerunephritis （60% ） Diabetic nephropathy Hypertension nephropathy Obstructive nephropathy Lupus nephritis Polycystic Kidney Nephron damage Glomerulosclerosis Uremia 病 因 各种病因所占CKD的比重 病 因 病 因 病 因 病 因 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 ) 病 因 Pathogenesis Mechanism of CRF deteriorating n Health survive nephron - trade-off hypothesis n Glomerulus Hyperfiltration Hypothesis 发病机制 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 发病机制 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; 发病机制 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 dysequilidriumdysequilidrium; ; 2. 2. Metabolism refuse retentionMetabolism refuse retention，Endocrine Endocrine hormones savings, causing uremia symptom.hormones savings, causing uremia symptom. 发病机制 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 临床表现 n Acidosis：Common death cause n Calcium and Phosphorus dysequilibrium Low Calcium High Phosphorus n Hypermagnesemia Clinical situationClinical situation Water-Electrolyte and Acid-base Water-Electrolyte and Acid-base dysequilibriumdysequilibrium 临床表现 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 临床表现 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 临床表现 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 临床表现 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 临床表现 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 临床表现 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 诊 断 Treatment I Therapeutics of background disease and deteriorate agent. 治 疗 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 治 疗 III Complication Treatment nWater-Electrolyte imbalance nMetabolic Acidosis nCalcium-Phosphorum metabolism imbalance nCardia-blood vessel and lung complication nBloo