【持续性肾脏替代治疗crrt英文精品课件】肾脏替代治疗病人的管理

Nur4206Managementofpatientswithrenal urinarydisorders ByLindaSelf FunctionsoftheKidney RegulationofwaterexcretionRegulationofelectrolytefunctionRegulationofacid basebalance retainHCO3 andexcreteacidinurineRegulationofbloodpressure RAASRegulationofRBCsVitaminDsynthesis FunctionsofKidneycont SecretionofprostaglandinEandprostacyclinwhichcausevasodilation importantinmaintainingrenalbloodflowExcretionofwasteproducts body smainexcretoryorgan Urea creatinine phosphates uricacidandsulfates Drugmetabolites Physiology PathophysiologyRenin angiotensinsystem Hormonesinfluencingrenalfunction Renin raisesBPBradykinins increasebloodflowandvascularpermeabilityErythropoietinADHAldosterone promotessodiumreabsorptionandpotassiumexcretionNatriuretichormones releasedfromthecardiacatriaandbrain Riskfactorsforrenalorurologicdisorders HypertensionDiabetesmellitusImmobilizationParkinson sdiseaseSLEGoutSicklecellanemia multiplemyelomaBPHPregnancySCI GerontologicConsiderations GFRdecreasesfollowing40yearswithayearlydeclineofabout1mL minRenalreservedeclinesMultiplemedicationscanresultintoxicmetabolitesDiminishedosmoticstimulationofthirstIncompleteemptyingofbladderUrinaryincontinence DiagnosticEvaluation Urinalysisandculture Sp Gravity 1 005 1 020Microscopicexaminationforprotein RBCs ketones glycosuria presenceofbacteria generalappearanceandodorLeukocyteesterase enzymefoundinWBCsNitrites bacteriaconvertnitratestonitritesOsmolality accuratemeasurementofthekidney sabilitytoconcentrateurine Normalrangeis500 1200mOsm kg Cultureimportantin Id ingpathogen Urinetests Albuminuria albumininurinenotmeasurablebydipstickNormalvaluesinfreshlyvoidedsampleshouldrangebetween2 0 20formenand2 8 28forwomen Higherlevelsindicatemicroalbuminuria Canalsobedeterminedby24hspecimen RenalFunctiontests Urineosmolality indicationofconcentratingability changesseenearlyindiseaseprocessesCreatinineclearance testsclearanceofcreatinineinonemin ReflectsGFR Serumcreatinine measureseffectivenessofrenalfunction 0 6to1 2mg dLUreanitrogen alsoindicatorofrenalfunction 7 18mg dL Measuresrenalexcretionofureanitirogen abyproductofproteinmetabolism Isnotalwayselevatedwithkidneydisease Notbestindicatorofrenalfunction Renalfunctiontestscont Livermustfunctionproperlytoproduceureanitrogen BUNlevelsindicatetheextentofrenalclearanceofthisnitrogenouswasteproduct MayseeelevationofBUNwithbleedingintotissuesorfromrapidcelldestructionfrominfection steroids RenalFunctionTests RatioofBUNtocreatininedistinguishesbetweenrenalandnon renalfactorscausingelevationsDehydrationcanaffecttheBUNWhenbloodvolumeisdown orBPislow BUNlevelrisesmorerapidlythancreatininelevel GFR VolumeoffluidfilteredfromrenalglomerularcapillariesintoBowman scapsuleperunitoftimeGenerallyexpressedinml minuteNormalGFRgenerallyis125mL minute CalculationofGFR complexanddifferingformulas Cockcraft GaultformulaModificationofDietinRenalDiseaseStudyGroupformula MDRD SchwartzformulaStarlingequation creatininelevel Nocommonpathologiccondition otherthanrenaldisease increasestheserumcreatininelevelSerumcreatininedoesnotincreaseuntilatleast50 ofrenalfunctionislost CreatinineClearance Isacalculatedmeasureofglomerularfiltrationrate Isbestindicatorofoverallkidneyfunction Basedon24hoururinecollectionMidwaywillobtainserumcreatinine Serumcreatininelevelsvarywithage genderandbodymusclemassCalculate VolumeofurineXurinecreatinine Dividedbyserumecreatinine ImagingStudies KUBUltrasonographyCTMRINuclearscansIVurography IVP NPObefore Bowelprep Nephrotoxicagent Metformin VCUG UrologicEndoscopicProcedures CystoscopyUreteralbrushbiopsyKidneybiopsyUrodynamictests cystometrogram Measuresdetrusormusclefunction GlomerularDiseases Antigen antibodycomplexesforminbloodandbecometrappedinglomerularcapillariesInduceaninflammatoryresponseManifestedbyproteinuria hematuria decreasedGFRandalterationinexcretionofsodiumAcuteandchronicglomerulonephritisNephroticsyndrome AcuteGlomerulonephritis Infectiouscauses Staph klebsiella CMV mono hepB mycoplasma groupAbeta hemolyticstrep ClinicalManifestationsofacuteglomerularnephritis HematuriaEdemaAzotemia accumulationofnitrogenouswastesUrineappearancemaybecolacoloredHypertensionHypoalbuminemiaHyperlipidemiaRisingBUNandcreatinine Complications HypertensiveencephalopathyHeartfailureRapiddeclineinrenalfunctioncanoccurtoESRD Management Treats ssuchaselevatedBPCheckGFRby24hurineforcreatinineclearanceANATreatstreptococcalinfectionwithantibiotics preferablyPCNCorticosteroidsImmunosuppressantsLimitdietaryprotein increaseCHORestrictsodiumMayprogresstochronicglomerulonephritis willtreatasinCKD NephroticSyndrome IsnotaspecificglomerulardiseaseIsasyndromewithaclusteroffindingsthatinclude Markedincreaseinproteininurine especiallyalbumin HypoalbuminemiaEdemaHighserumcholesterolandLDL NephroticSyndrome AconditionofincreasedglomerularpermeabilityResultsinmassiveproteinlossOftenlinkedgeneticallyorr timmune inflammatoryprocessCausedbychronicglomerulonephritis diabetesmellituswithglomerulosclerosis amyloidosis lupus multiplemyelomaandrenalveinthrombosisMajormanifestationisedemaHallmarkisalbuminuriaexceeding3 5g day NephroticSyndrome Sequenceofeventsinnephroticsyndrome Complicationsofnephroticsyndrome MassiveproteinuriaHypoalbuminemiaEdemaLipiduriaHyperlipidemiaIncreasedcoagulationRenalinsufficiency Treatmentofnephroticsyndrome RenalbiopsytodeterminespecificcauseSteroidsImmunosuppressiveagentsACEIscandecreaseproteinuriaCholesterolloweringagentsHeparintoreducecoagulabilityLimitsodiumintake AcuteRenalFailure ReversibleclinicalsyndromewherebythereissuddenandpronouncedlossofkidneyfunctionOccursoverhourstodaysResultsinkidneysfailuretoexcretenitrogenouswastes CausesofAcuteRenalFailure IntrarenalactualparenchymaldamageProlongedrenalischemiafrommyoglobinuria rhabdo trauma burns hemoglobinuria transfusionreaction hemolyticanemia Nephrotoxicagentslikeaminoglycosides radiopaquecontrast heavymetals solvents NSAIDs ACEIs acuteglomerulonephritis CausesofAcuteRenalFailure Prerenal60 70 ofcasesVolumedepletionasseeninhemorrhage renallossesfromdiuretics GIlossesfromvomiting diarrheaImpairedcardiacoutput2ndarytoMI heartfailure dysrhythmias cardiogenicshockVasodilationfromsepsis anaphylaxis antihypertensivemeds Causesofacuterenalfailure PostrenalUrinarytractobstructionbycalculi tumors BPH bloodclots PhasesofAcuteRenalFailure InitiationoccurswiththeinsultOliguriawithurinaryoutputlessthan400ml 24h risingpotassium BUN Cr Notresponsivetofluidchallenges Diuresisperiod gradualincreaseinurinaryoutput Beginningrecovery RenalfunctiongraduallyimprovesRecovery maytake3 12months Mayhavepermanentreductioninfunctioningof1 3 KeyfeaturesofARF Prerenal hypotension tachycardia decreasedCO decreasedurinaryoutput lethargyintrarenalandpostrenal oliguriaoranuria hypertension tachycardia SOB orthopnea n v generalizededemaandweightgain lethargy confusion Nonoliguricformalsoexists Phasesaresimilar LaboratoryProfileofARF ElevatedBUNandcreatinineSodiumretentionbutmaybedeceptiveduetowaterretentionPotassiumincreasedPhosphorusincreasedCalciumdecreasedH HdecreasedSp Gravitydecreasedandfixed Management Objectives RestorenormalchemicalbalanceandpreventcomplicationsuntilrestorationofrenalfunctionIdentifyandtreatunderlyingcauseMaintainfluidbalance wts serialCVPreadings BP strictI OMaygiveMannitol LasixorEdecrinMayneedtemporarydialysis Management Ifprerenal fluidchallengesanddiureticstoenhancerenalbloodflowOliguricrenalfailure lowdosedopamine Calciumchannelblockersmaybeusedtopreventinfluxofcalciumintokidneycells maintainscellintegrityandincreaseGFR Management Hyperkalemia closelymonitorelectrolytesKayexalate Sorbitol mayneedFlexisealIVdextrose insulinandcalciummayhelpshiftK CautiousadministrationofanymedicationthatcanbenephrotoxicMonitorABGsandacid basebalanceMonitorphosphatelevels NutritionalTherapy AzotemiaanduremiaaredirectlyrelatedtotherateofproteinbreakdownDietaryproteinsareindividualizedtoeachpatient Isacatabolicstateandifinsufficientintake patientmayloseupto0 5 1poundsdaily EncouragehighCHO Proteinneedsfornon dialysispatientsneed0 6g kgofbodyweightDialysispatientswillneed1 1 5g kgFluidrestriction urinevolumeplus500ml Roleofnurse MonitorfluidandelectrolytebalanceReducemetabolicdemandsPromotepulmonaryfunctionPreventinfectionProvideskincareProvidesupport ChronicRenalFailure End stagerenaldisease Progressive irreversibedeteriorationinrenalfunctionCausation 1diabetesmellitus hypertension glomerulonephritis pyelonephritis polycystickidneydisease vasculardisorders othersUremia collectionofnitrogenouswastesnormallyexcretedbythekidneys S Sinclude HA seizures coma dryskin rapidpulse elevatedBP scantyurine laboredbreathing Kidneychanges Nephronshypertrophyandworkharderuntil70 80 ofrenalfunctionislostNephronscouldonlycompensatebydecreasingwaterreabsorptionthus Hyposthenuria lossofurineconcentratingabilityoccursPolyuria increasedurineoutputThenisosthenuria fixedosmolalityGradualdeclineinurinaryoutput StagesofRenalFailure GFRgreaterthanorequalto90mL min 1 73m2 Kidneydamagew normalorincreasedGFRGFR 60 89 milddecreaseinGFRGFR 30 59 moderatedecreaseinGFRGFR 15 29 severedecreaseinGFRGFR 15 Kidneyfailure ClinicalManifestations EverybodysystemisaffectedCV hypertension RAAS heartfailure pulmonaryedema pericarditis MIPulm crackles Kussmaul pleuriticpainDerm severepruritus uremicfrost ureacrystals GI n v anorexia uremicfetor ammoniaodortobreath constipationordiarrheaNeurologic LOCchanges confusion seizures agitation neuropathies RLS ClinicalManifestations Hematologic anemia thrombocytopeniaMusculoskeletal musclecramps renalosteodystrophy bonepain bonefracturesMetabolicchanges ureaandcreatinine sodium potassium acid base calciumandphosphorus MedicalManagement Calciumandphosphorusbinders Calciumcarbonate calciumacetateAntihypertensivesAntiseizure valiumordilantinErythropoietinIronsupplementsDiet CHOandfat vitamins restrictprotein DialysisTherapies Indications UremiaPersistenthyperkalemiaUncompensatedmetabolicacidosisFluidvolumeexcessUremicencephalopathyRemovetoxicsubstances Dialysis Basedonprinciplesofdiffusion osmosisandultrafiltrationDiffusion removaloftoxinsandwastes Movefrombloodtodialysate Osmosis excesswaterisremoved Goesfromareaofhighersoluteconcentration blood tolowerconcentration dialysate Ultrafiltration watermovesfromhighpressureareatolowerpressure Appliedbynegativepressure moreefficientthanjustbyosmosis Complicationsofdialysis ASHDDisturbancesoflipidsworsenedbydialysisAnemiaandfatigueGastriculcersRenalosteodystrophySleepproblemsHypotensionMusclecrampsDysrhythmiasDialysisequilibriumfromcerebralfluidshifts DialysisDisequilibriumSyndrome CausedbyrapiddecreaseinfluidvolumeandbloodureanitrogenlevelsduringHDChangeinurealevelscancausecerebraledemaandincreasedICPNeurologiccomplicationsinclude HA vomiting restlessness decreasedLOC seizures comaordeathCanbepreventedbystartingHDforshortperiodsandlowbloodflows Formsofdialysis HemodialysisInICUswherepatientistoounstabletohavehemodialysis canhaveCRRTPeritonealdialysis KidneyTransplantation MoresuccessfulifdonebeforedialysisHLAandABOcompatibilityDonorkidneyplacediniliacfossaPatientmustbefreefrominfectionSimilarcareforpatientpost opasanysurgery KidneyTransplantation Post op assessfors sofrejectionsuchasoliguria edema fever increasingbloodpressure weightgainandswellingortendernessovertransplantedareaMonitorcreatininelevel inthoseoncyclosporine maybetheonlys sMonitorWBCsMonitorurinaryoutput mayneedhemodialysistemporarily 2 3weeksmayinitiallyhaveATN DiabeticNephropathy Occursintypes1and2Severityofdiabeticrenaldiseaseisrelatedtoextent durationandeffectsofatherosclerosis htnandneuropathy Diabeticnephropathy MicrovascularcomplicationofdiabetesFirstmanifestationispersistentalbuminuriaDiabeticpatientsarealwaysconsideredtobeatriskforrenalfailureAvoidnephrotoxicagentsanddehydration Stagesofprogressionoftype1diabeticrenaldisease Stage1 attimeofdiagnosisofdiabetes KidneysizeandGFRareincreased Bloodsugarcontrolcanreversethechanges Stage2 2 3yearsafterdiagnosis Basementmembranechangesresultinlossoffiltrationsurfaceareaandscarformation Thesechangesarecalledglomerulosclerosis Stagescont Stage3 7 15yearsafterdiagnosis Microalbuminuriaispresent GRFmaybenormalorincreased Stage4 albuminuriaisdetectablebydipstick GRFdecreased BPisincreased Retinopathyispresent StageV GFRdecreasesatanaveragerateof10ml min year Lowerurinarytractinfections CystitisUreterovesicalreflux Lowerurinarytractinfections Ifbacteriuria followingshouldhaveculturesdone AllmenAllchildrenPatientswithdiabeticsThosewithrecentinstrumentationThosehospitalizedorwholiveinlongtermcarePregnantwomenSexuallyactivePostmenopausal Factorscontributingtourinarytractinfections ObstructionStonesDiabetesmellitusGenderAge anticholinergics neuromuscularconditions hypoestrogenismSexualactivityAlkaloticurineVesicoureteralreflux MostcommonorganismisE coliOthercausativeorganismsare S saprophyticus K pneumoniae ProteusandEnterobacter Treatment Bactrim Macrodantin Cipro LevaquinFluids avoidurinaryirritantsHygienePrevention Upperurinarytractinfections AcutepyelonephritisWillhavefever chills leukocytosis bacteriuriaandpyuriaCVAtendernessUSorCTtor oanyobstructionUrineC S Tx HydrationAntiemeticsTwoweekcourseofantibioticssuchasBactrim Cipro gentamycinw orw oampicillin 3rdgenerationcephalosporinPregnantwomenhospitalizedfor2 3daysf ucultureintwoweeks AdultVoidingDysfunction Stressincontinence invol lossofurinew activitiesthatincreaseintraabdominalpressureUrgeincontinence unabletosuppresssignalfrombladdertobrainOverflowincontinence whenbladderisdistended willhavesmallamountofincont FunctionalincontinenceasseeninAlzheimer sReflexincontinenceasseeninSCIpatientsMixed stressandurgeNeurogenicbladder lesionofnsleadstourinaryincontinence Neurogenicbladder MaybecausedbyMS SCI HNP spinaltumor spinabifida diabetesSpastic uppermotorneuronlesionFlaccid lowermotorneuronlesion FillsthenhaveoverflowincontinenceAssessbycheckingresiduals I O UA assessingsensoryawarenessTx urecholine surgery intermittentcaths S Pcaths Factorscontributingtourinaryincontinenceintheelderly DiureticsCNSdepressantswhichaffectLOCCVAsParkinson sDepressionandalteredself esteemInabilitytoambulatesafelyAssistanceproductscostprohibitiveforpatientUTI PharmacologicManagement TCAsAnticholinergics Sudafed Detrol DitropanEstrogeninwomen TherapyforIncontinence WeightlossinobeseFluidmanagementTransvaginalortransrectalele