肾内科课件crf

1、chronic renal failure (c r f) panlingchronic renal failure featurescommon final of chronic kidney diseasesprogressive renal insufficiency over months to yearsmanifestation of uremia, metabolite retentionhypertension in the majority , anemiaunbalance of fluid ,electrolyte,acid-base.broad casts in uri

2、nary sediment are commonbilateral small kidneys on ultrasoundevidence of renal osteodystrophy general considerationscauses of crf: glomerulonephritis diabetes mellitus hypertension lupus nephritis cystic diseases urologic stone renal tubulointerstitial other causes chronic kidney disease ckd is defi

3、ned as1) kidney damage or glomerular filtration rate (gfr) 60 ml/min/1.73 m(2) for 3 months or more, irrespective of cause. 2)kidney damage (structure and function) include related blood test and urinalysis abnormalities ,pathological injury ,imaging abnormalities.phasedescription gfr(ml/min/1.73m2)

4、123a3b45gfr normal or 90gfr mildly6089gfr mild-moderatelygfr moderared-severely 45593044gfr severely 1529esrd15 or dialysisphases of chronic kidney disease (k/doqi by america nkf)phasescr(mol/l)ccr (ml/min)compensatory phaseazotemiarenal failureuremia17850178-4505025451-7062510 707 10 phases of chro

5、nic renal insufficiency ( of china )mechanisms of chronic renal failuremechanisms of disease progression1. nephron hyperfiltration 2. nephron hypermetabolism3. phenotypic switch of renal tubular epithelial cell4. cytokines, tissue factor5. other mechanismsmechanisms of chronic renal failure irrevers

6、ible chronic renal disease reduction in renal mass hypertrophy， hyperfiltration a burden on the remaining nephrons glomeruli sclerosis and tubuler-interstitial fibrosis chronic renal failurerenin-angiotension system， ang- hypertension and glomeruli-hbp肾小球硬化形成机制mechanisms of uremic symptoms1. renal e

7、xcretion and metabolic function dicrease2. uremic toxins retention3. endocrine function disorder4. other factorsclinical findingson physical examination appearing chronically ill hypertension rales, cardiomegaly, edema a pericardial friction rub. mental statuslaboratory findings:elevations of bun,sc

8、r,ccr,egfranemiametabolic acidosishyperphosphatemia, hypocalcemia, hyperkalemiaisosthenuria if tubular concentrating and diluting ability are impaired; broad waxy casts imagingsmall bilateral kidneys crf normal or even large kidneys adult polycystic kidney disease diabetic nephropathy, hiv-associate

9、d nephropathy, multiple myeloma, amyloidosis, obstructive uropathy renal osteodystrophycomplicationshyperkalemiadecreased secretion of potassium with the decrease of gfr happen until the gfr is less than 25 ml/min. complicationshyperkalemiaendogenous causes: hemolysis and trauma, hypoaldosteronism,

10、acidosis states, potassium excretion exogenous causes: diet containing an abundant of potassium , drugs that block k+ secretion( triamterene spironolactone, nsaids, acei) blood transfusioncomplicationsacid-base disorders damage kidneys are unable to excrete enough acid generated by metabolism of die

11、tary proteins. this limits production of ammonia(nh3) and buffering of h+ in the urine. how to judge?blood gas analysis ph,hco-3, be,pco2complicationshypertension hypertension is the most common complication of end-stage renal disease.causes of hypertension: salt and water retention volume overloadh

12、yperreninemic states(rass activation) exogenous erythropoietin administration complicationspericarditis the cause is believed to be retention of metabolic toxins. symptoms : chest pain and fever signs: a friction rub may be auscultated chest radiography: an enlarged cardiac silhouette pericarditis i

13、s an indication for initiation of plicationscongestive heart failurecauses include:extracellular fluid overloadhypertensionanemiaarteriovenous fistula for dialysis uremia toxins which will affect the myocardiuminfectioncomplicationsanemia causes:erythropoietin production iron-deficiency, ferrous sul

14、fate deficiency, vitamin- deficiencylow-grade hemolysis due to uremia toxins, bone marrow suppressionblood loss from platelet dysfunction or hemodialysis complicationscoagulopathy because of dysfunction of platelet abnormal adhesiveness and aggregation , bleeding time being prolonged.treatment is re

15、quired only in patients who are symptomatic. dialysis can improve the bleeding plicationsdigestive system complication anorexia, nausea, vomiting , and epigastric pain. gastrointestinal bleeding is also common ( hematemesis, melena, hematochezia ), which is frequently due to erosive gastritis or pep

16、tic ulcer plicationsneurologic complicationuremic encephalopathy occur until gfr 15 ml/min. patients may present with difficulty in concentrating and can progress to lethargy, confusion, and coma. neuropathycomplicationsdisorder of mineral metabolismhyperphosphatemiahypocalcemiaosteodystrophy:osteit

17、is fibrosa cysticaosteomalaciacomplicationsendocrine disorderscirculating insulin levels , because of decreased renal insulin clearanceglucose intolerance can occur when gfr is less than 20ml/l due to peripheral insulin resistance.gonadal dysfunction, including: decreased libido and impotence. diagn

18、osis is it renal failure? serum creatinine , ccr , egfr -yes crf or arf? appearing chronically ill anemia bilateral small kidneys renal osteodystrophy (ca、p、ipth、 angiosteosis)diagnosis fundamental causes of crf cgn,dn, ln,hbp-gn, etc. are there worsening factors? infection,hypovolemia nephrotoxins,

19、 hypertension tiredness,pregnancy congestive heart failure urinary tract obstructiontreatment objective treatment of fundamental disease and worsening factors of crf， protect residual nephronstreatmentmeasures to retard the disease progressiondietary managementprotein restriction nondialysis patient

20、s 0.6g/kg/d dialysis patients 1g/kg/dsalt and water restrictionpotassium restrictionphosphorus restrictionmagnesium restriction protein content 50g pig 9g an egg 6.5g milk 220ml 6.6g 50g fish 10g50g belt fish 9g50g flour 4.5g 50g beef 10g50g rice 3.5gbean curd 50g 5.5gtreatment:hypertensionantihyper

21、tensive objective if non-dialysis,bp 130/80mmhg if dialysis,bp 140/90mmhgdrugs: acei/arb ccb -blocker; -blocker diuretic vasodilator treatmentcontrol blood glucose,lipid, uric acidreduce urinary protein treatment of complication hyperkalemia in acute cases: cardiac monitoring calcium chloride insuli

22、n administration with glucose bicarbonate an orally or rectally administered ion exchange resin an emergent dialysis if necessary(k 6.5mmol/l ) metabolic acidosis base supplements include sodium bicarbonate, administration of alkali divided into two doses per day dialysis may be needed in severe met

23、abolic acidosis recombinant erythropoietin (epo)stared on 50 units/kg 1- 2/week. epo can cause or worsen hypertensioniron supplementationit is given if the serum ferritin 100g/mlferrous sulfate, 325mg/dayfolinic acid and vitamin supplementationadequate dialysisanemia treament dialysis can alleviate

24、the symptoms. if gastrointestinal bleeding occur, patients should be treated aggressively. coagulopathy treamentrenal replace treatmentindication uremic symptoms such as pericarditis, encephalopathy, or coagulopathy.fluid overload unresponsive to diuresisrefractory hyperkalemia severe metabolic acid

25、osis (ph7.20）renal replace treatment indication gfr 10ml/min or serum creatinine 707mol/l.uremic symptoms diabetics should start earlier, generally when the gfr reaches 15ml/min or serum creatinine is 530mol/l.hemodialysis hemodialysis requires a constant flow of blood along one side of semi-permeab

26、le membrane with dialysate on the other. hemodialysis diffusion and convection allow the dialysate to remove unwanted substances from the blood while adding back needed components.require three times a week.sessions last 3-5 hours .血液透析peritoneal dialysisthe peritoneal membrane is the dialyzer.dialy

27、sate enters the peritoneal cavity through a catheter. peritoneal dialysisthe most common kind of peritoneal dialysis is continuous ambulatory peritoneal dialysis (capd)its continuous nature minimizes the symptomatic swings observed in hemodialysis patients.the most common complication of pd is peritonitis. kidney transplantation a successful kidney transplantation can lead to a normal renal function including endocrine function and metabolic function. transplant rejection is the main complicat