内科学教学课件：Chronic Renal Failure.ppt

Chronic Renal Chronic Renal FailureFailureDefinition Chronic renal failure (CRF) is a pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron number and function and frequently leading to end-stage renal disease (ESRD). CRF is divided into 4 stages supposed the normal CRF is 100%:1: 50%

 Pathophysiology 1: glomerular hypererfusion, hypertension, hyperflitration: 2: the rennin-angiotensin axis ↑→ glomerular hypertension → hypertrophy and sclerosis. AT-Ⅱ → TGF- β (the decisive medium )↑and ECM ↑ → sclerosis3: uremic toxicity may contribute to some of the clinical abnormalities, the renal production of EPO is impaired. Clinical Manifestation 1. Water, electrolyte, and acid-base disorders(1)Sodium and water retention, the concentrate of sodium decrease because of dilution (2) Patassium homeostasis:A: Hyperkalemia: Reason: augmented dietary intake, transfusion of stored red blood cells, metabolic acidosis, ACEI and k-sparing diuretics. The ECG is a convenient method to probe that.B: Hypokalemia: Reason: markedly reduced dietary k+ intake, excessive diuretic therapy or gastrointestinal losses, tubulointerstitial nephritisClinical Manifestation(3) Metabolic acidosis: HCO3-<15mmol/l, nausea, vomit, coma, shock, heat failure, respire deeply and slowly. (4) Disorders of calcium and phosphate. Phosphate↑→ calcium phoshate↑→ calcium ↓ 1,25-(OH)2D3↓→ calcium↓→ PTH↑(5) magnesemia Clinical Manifestation2．metabolic disturbance of protein, carbohydrate, fat and vitamins。

body temperature ↓about 1℃ caused by lower BMR hypothermiaClinical Manifestation3. Cardiovascular and pulmonary symptoms: most reason to death. (1) Hypertention and left ventricular hypertrophy(2)Heart failure:(3) cardiomyopathies(4) Pericarditis (5) Arteriosclerosis 4 Respiratory symptoms: respiration deeply and slowly, pulmonary edema, uremia pneumonia. Respiratory symptoms Clinical Manifestation5. Gastrointestinal symptoms: Anorexia appeared first. Alimentary canal hemorrhage or ulcer occur more frequently. Hepatitis and hepatic cirrhosis. :↓Clinical Manifestation6. Blood system symptoms:(1)Anemia: a.insufficient production of EPO by the diseased kidneys.b. iron and folate and protein deficiency. c: blood loss in dialysis and biochemical test. d: shortened RBC survival. e: toxin inhibit bone marrow. e: toxin inhibit bone marrowf: hemorrhage(2) Hemorrhage (3) Abnormal WBCAnemia: Clinical Manifestation7. Neuromuscular abnormalities: Early manifestations include mild disturbances in memory and concentration and sleep disturbances. The Rest less legs syndrome. 8. Endocrine-metabolic disturbances: Rise: rennin, PTH, insulin. Descend: EPO, 1, 25-(OH)D3, estrogen levels in woman, 尿毒症面容Clinical Manifestation9. Renal osteodystrophy: osteitis fibrosa, renal osteomalacia, osteoporosis, renal osteopetrosis.10. Skin symptoms: (1).itching may be caused by PTH. (2). uremia face11. Infection Deteriorating factors: 1 blood volume,2 infection, 3 urinary tract obstruction, 4 heat failure and serious arrhythmia. 5 renal toxic drug. 6 stressing condition. 7 hypertention. 8. ionic disorder phosphate↑calcium↑Diagnosis•Acute progression of CRF •Acute on chronic renal failureTreatment1. Treat the primary disease and correct deteriorating factors.2. Delay the development of renal failure in the early stageBasic countermeasure1.Insist on etilogical treatment2.Avoid or eliminate risk factors of CRF about acute exacerbation3．Block or inhibit the gradually developmental path on nephron injury Specific measure of prevention and cure１．Control hypertension efficiently in time ２．Unique action of ACEI and ARB: Reducing body and intraglomerular hypertension and proteinuia. ACEI and ARB. If Scr is more than 350μmol/l, it is controversial to do that unless the patient has receive blood dialysis treatment. ACEI and ARB.３．Regiment blood glucose４．Control proteinuriaSpecific measure of prevention and cureDiet therapy1) Protein restriction: GFR<50m1／min，limit proteinNon-DM: CKD1~CKD2 intake protein : 0.8g／kg.d CKD3 0.6g／kg.d DM: proteinuria intake protein : 0.8g／kg.d GFR decrease 0.6g／kg.d 2) High energy, Energy requirement in the range of 30~35kcal/kg.d are recommended. Rich vitamin B and C, folic acid. 3) Water, sodium, potassium, and phosphorus should be regulated. 4) EAA and α-ketoglutaric acid may be administrated Specific measure of prevention and curePharmacotherapy about CRF 1) Water and Electrolyte disturbancea. Disorders of water and sodium: GRF<25mi/min, limit the intake of sodium, lasix 20mg tid po Specific measure of prevention and cureb. Hyperkalemia: [k+]>6.5mmol/l●5%natriibicarbonat 100ml st iv in 5 minutes ● 10%calcium gluconate 20ml st iv ●　loop diuretic ● 50% glucose 50-100ml and insulin 6-12U st iv ● take orally　kayexalate 　● dialysisSpecific measure of prevention and curec.Metabolic acidosis: 5%natriibicarbonat is applied to raise [HCO3] to 17.1 mmol/l, must prevent hypocalcaemia convulsion by using 10% calcium gluconate.d. disorders of calcium and phosphate: GFR<30mi/min, calcium carbonate 0.5~ 2.0 tid tid po .Obviously low calcium, replenish calcitriol 0.25μg/d, 2~4 weeks.Specific measure of prevention and cure2) Cardiovascular and pulmonary disordera. Hypertension: most of them is volume-depended, thus limiting water and sodium is advisable, dehydrating drug or filtration is commonly recommended. ACEI is favorite .Blood pressure should be controlled at least the level of 130/80mmHg. Proteinuria >1g/d, blood pressure should be further reduced to 125/75mmHg. But hyperkalemia must noticed. b. Pericarditis should be dialyzed actively qd 1 weeks c. Heat failure treatment specially focus on eliminating of water and Na. Loop diuretics are higher doses required. Dialyze. d. Uremia pneumonia is sensitive to dialysis.Specific measure of prevention and cure3) Blood system complication Anemia could be ameliorated by EPO, in same time, folic acid (10mg, tid, po) vitamin B12(50μg, tid, po ) and iron EPO: starting dosage: 80-120U/kg.per week 2-3 times /week ih Target hemoglobin: 110-120g/l, HCT>0.33-0.66, The side effect: hypertension（1）初始剂量皮下给药剂量：100~120IU/Kg/W，每周2~3 次。

静脉给药剂量：120~150IU/Kg/W，每周3 次•初始剂量选择要考虑患者的贫血程度和导致贫血的原因，对于Hb<7g/dl 的患者，应适当增加初始剂量•对于非透析患者或残存肾功能较好的透析患者，可适当减少初始剂量•对于血压偏高、伴有严重心血管事件、糖尿病的患者，应尽可能的从小剂量开始使用rHuEPO 2）剂量调整rHuEPO 治疗期间应定期检测Hb 水平：诱导治疗阶段应每2～4 周检测一次Hb 水平；维持治疗阶段应每1～2 月检测一次Hb 水平应根据患者Hb 增长速率调整rHuEPO 剂量：初始治疗Hb 增长速度应控制在每月1～ 2g/dl 范围内稳定提高，4 个月达到Hb 靶目标值如每月Hb 增长速度<1g/dl ，除外其它贫血原因（见附录：EPO 抵抗原因），应增加rHuEPO 使用剂量25% ；如每月Hb 增长速度>2g/dl ，应减少rHuEPO 使用剂量25%~50% ，但不得停用•维持治疗阶段，rHuEPO 的使用剂量约为诱导治疗期的2/3 若维持治疗期Hb 浓度每月改变>1g/dl ，应酌情增加或减少rHuEPO 剂量25% Specific measure of prevention and cure4) Infection: Antibiotics dose should be calculate according to the GFR. Minimi nephrotoxicity antibiotics 5) Neuromuscular: dialysis to full, kidney transplant, 1, 25 -(OH)2D3, EPO6) Others: insulin dose decreased gradually, itching can not be alleviated satisfactorily, forbid pregnancy.Specific measure of prevention and cure7) oral adsorbing treatment and cathartic treanment： Oxytarch and CharcoAid , rheum Administration of drugs: regulate the dose according to the Ccr8) Follow-up at least every 3 months口服吸附疗法和导泻疗法 •大黄大黄•蒲公英蒲公英•黄芪　黄芪　Specific measure of prevention and cureSubstitute treatment1) Blood dialysis: three times per week, 4-6 hours/times2) CAPD: fit for old patient, cardiovascular patient, DM, kid and the people who can not possess a-v fistulae. 2L/times q6h 3) Renal dialysis: 腹膜透析血液透析肾移植•陈××，男，46岁，反复眼睑及双下肢水肿、尿蛋白升高伴镜下血尿15年，血压升高6年，近2天开始出现发热、呼吸困难、咳嗽、尿量减少，浮肿加重，恶心呕吐。

既往无糖尿病病史体格检查：T 37.℃ Bp 170/105mmHg，皮肤粘膜苍白，眼睑及球结膜水肿，双肺呼吸音粗，双肺底可闻及干湿啰音，心界向左扩大，HR116次/分，心律齐，腹软，肝脾未及，双下肢凹陷性浮肿辅助检查：HB 60g/l，WBC 7.7×109/L, 血肌酐1228µmol/l，肌酐清除率6.5 ml/min , HCO313mmol/l，k+ 5.0mmlo/l，血钙1.95 mmlo/l，胸片左心室扩大，肺淤血。