肾内科课件crf

1、CHRONIC RENAL FAILURE (C R F) PanLing,Chronic renal failure features,Commonfinal of chronic kidney diseases Progressive renal insufficiency over months to years Manifestation of uremia, metabolite retention Hypertension in the majority , Anemia Unbalance of fluid ,electrolyte,acid-base. Broad casts

2、in urinary sediment are common Bilateral small kidneys on ultrasound Evidence of renal osteodystrophy,General considerations,Causes of CRF: glomerulonephritis diabetes mellitus hypertension lupus nephritis cystic diseases urologic stone renal tubulointerstitial other causes,Chronic kidney disease,CK

3、D is defined as 1) 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.,Phase,Description,GFR(ml

4、/min/1.73m2),1,2,3a 3b,4,5,GFR normal or,90,GFR mildly,6089,GFR mild-moderately GFR moderared-severely,4559 3044,GFR severely,1529,ESRD,15 or dialysis,Phases of chronic kidney disease (K/DOQI by America NKF),phase,Scr(mol/L),Ccr (ml/min),compensatory phase,azotemia,renal failure,uremia,178,50,178-45

5、0,5025,451-706,2510,707, 10,Phases of chronic renal insufficiency ( of China ),Mechanisms of chronic renal failure,Mechanisms of disease progression 1. Nephron hyperfiltration 2. Nephron hypermetabolism 3. Phenotypicswitch of renal tubular epithelialcell 4. Cytokines, tissue factor 5. Other mechanis

6、ms,Mechanisms of chronic renal failure,Irreversible chronic renal disease reduction in renal mass hypertrophy， hyperfiltration a burden on the remaining nephrons glomeruli sclerosis and tubuler-interstitial fibrosis chronic renal failure renin-angiotension system， Ang- Hypertension and glomeruli-HBP

7、,肾小球硬化形成机制,Mechanisms of uremic symptoms Renal excretion and metabolic function dicrease 2. Uremic toxins retention 3. Endocrine function disorder 4. Other factors,Clinical findings,On physical examination appearing chronically ill hypertension rales, cardiomegaly, edema a pericardial friction rub.

8、mental status,Laboratory findings:,Elevations of BUN,Scr,Ccr,eGFR Anemia Metabolic acidosis Hyperphosphatemia, hypocalcemia, hyperkalemia Isosthenuria if tubular concentrating and diluting ability are impaired; broad waxy casts,IMAGING,Small bilateral kidneys CRF Normal or even large kidneys adult p

9、olycystic kidney disease diabetic nephropathy, HIV-associated nephropathy, multiple myeloma, amyloidosis, obstructive uropathy Renal osteodystrophy,complications,Hyperkalemia decreased secretion of potassium with the decrease of GFR Happen until the GFR is less than 25 ml/min.,complications,Hyperkal

10、emia endogenous causes: hemolysis and trauma, hypoaldosteronism, acidosis states, potassiumexcretion exogenous causes: diet containing an abundant of potassium , drugs that block K+ secretion( triamterene spironolactone, NSAIDS, ACEI) bloodtransfusion,complications,Acid-Base Disorders Damage kidneys

11、 are unable to excrete enough acid generated by metabolism of dietary proteins. This limits production of ammonia(NH3) and buffering of H+ in the urine. How to judge?,Blood gas analysis PH,HCO-3, BE,PCO2,complications,Hypertension hypertension is the most common complication of end-stage renal disea

12、se. causes of hypertension: Salt and water retention volume overload Hyperreninemic states(RASS activation) Exogenous erythropoietin administration,complications,Pericarditis The cause is believed to be retention of metabolic toxins. symptoms : chest pain and fever signs: a friction rub may be auscu

13、ltated chest radiography: an enlarged cardiac silhouette pericarditis is an indication for initiation of hemodialysis.,complications,Congestive heart failure Causes include: extracellular fluid overload hypertension anemia arteriovenous fistula for dialysis uremia toxins which will affect the myocar

14、dium infection,complications,Anemia causes: erythropoietin production iron-deficiency, ferrous sulfate deficiency, Vitamin- deficiency low-grade hemolysis due to uremia toxins, Bone marrow suppression blood loss from platelet dysfunction or hemodialysis,complications,Coagulopathy because of dysfunct

15、ion of platelet abnormal adhesiveness and aggregation , bleeding time being prolonged. treatment is required only in patients who are symptomatic. Dialysis can improve the bleeding time.,complications,Digestive system complication anorexia, nausea, vomiting , and epigastric pain. Gastrointestinal bl

16、eeding is also common ( hematemesis, melena, hematochezia ), which is frequently due to erosive gastritis or peptic ulcer disease.,complications,Neurologic complication Uremic encephalopathy occur until GFR 15 ml/min. Patients may present with difficulty in concentrating and can progress to lethargy

17、, confusion, and coma. neuropathy,complications,Disorder of Mineral Metabolism Hyperphosphatemia hypocalcemia Osteodystrophy: Osteitis fibrosa cystica Osteomalacia,complications,Endocrine Disorders Circulating insulin levels , because of decreased renal insulin clearance Glucose intolerance can occu

18、r when GFR is less than 20ml/L due to peripheral insulin resistance. Gonadal dysfunction, including: decreased libido and impotence.,Diagnosis,Is it renal failure? Serum creatinine , Ccr , eGFR -yes CRF or ARF? Appearing chronically ill Anemia Bilateral small kidneys Renal osteodystrophy (Ca、P、iPTH、

19、 Angiosteosis),Diagnosis,Fundamental Causes of CRF CGN,DN, LN,HBP-GN, etc. Are there worsening factors? Infection,Hypovolemia Nephrotoxins, Hypertension Tiredness,pregnancy Congestive heart failure urinary tract obstruction,Treatment,Objective Treatment of fundamental disease and worsening factors o

20、f CRF， protect residualnephrons,Treatment,Measures to retard the disease progression Dietary Management Protein restriction nondialysis patients 0.6g/kg/d dialysis patients 1g/kg/d Salt and water restriction Potassium restriction Phosphorus restriction Magnesium restriction,Proteincontent,50g pig 9g

21、,An egg 6.5g,Milk 220ml 6.6g,50g fish 10g,50g Belt Fish 9g,50g Flour 4.5g,50g Beef 10g,50g rice 3.5g,Bean curd 50g 5.5g,Treatment:Hypertension,Antihypertensive objective If non-dialysis,BP 130/80mmHg If dialysis,BP 140/90mmHg Drugs: ACEI/ARB CCB -blocker; -blocker Diuretic Vasodilator,Treatment,Cont

22、rol blood glucose,lipid, Uric Acid Reduce urinary protein,Treatment of Complication,Hyperkalemia,In acute cases: Cardiac monitoring Calcium chloride Insulin administration with glucose Bicarbonate An orally or rectally administered ion exchange resin an emergent dialysis if necessary(k 6.5mmol/L ),M

23、etabolic acidosis,Base supplements include sodium bicarbonate, Administration of alkali divided into two doses per day Dialysis may be needed in severe metabolic acidosis,Recombinant erythropoietin (EPO) stared on 50 units/kg 1- 2/week. EPO can cause or worsen hypertension Iron supplementation it is

24、 given if the serum ferritin 100g/ml Ferrous sulfate, 325mg/day Folinic acid and Vitamin supplementation Adequate dialysis,Anemia treament,Dialysis can alleviate the symptoms. If gastrointestinal bleeding occur, patients should be treated aggressively.,Coagulopathy treament,Renal replace treatment,i

25、ndication Uremic symptoms such as pericarditis, encephalopathy, or coagulopathy. Fluid overload unresponsive to diuresis Refractory hyperkalemia Severe metabolic acidosis (PH7.20）,Renal replace treatment,Indication GFR 10ml/min or serum creatinine 707mol/L. Uremic symptoms Diabetics should start ear

26、lier, 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-permeable membrane with dialysate on the other.,Hemodialysis Diffusion and convection allow the dialysate to remove unwanted substances fr

27、om the blood while adding back needed components. Require three times a week.sessions last 3-5 hours .,血液透析,Peritoneal dialysis the peritoneal membrane is the dialyzer. dialysate enters the peritoneal cavity through a catheter.,Peritoneal dialysis The most common kind of peritoneal dialysis is conti

28、nuous 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 mai