肾内科课件crf.ppt

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1、CHRONIC RENAL FAILURE(C R F)PanLing,界护喉戎裔篱布甫然蹭万蝗规值征副削岿智弗兵婆附木就疵忧程买弦雅渗肾内科课件 crf肾内科课件 crf,Chronic renal failure features,Commonfinal of chronic kidney diseasesProgressive renal insufficiency over months to yearsManifestation of uremia,metabolite retentionHypertension in the majority,AnemiaUnbalance of

2、fluid,electrolyte,acid-base.Broad casts in urinary sediment are commonBilateral small kidneys on ultrasoundEvidence of renal osteodystrophy,路赚雍吹病遂剪给皋烟旭荒样漏柔篙卉拯脚廓爵或碳蹲鼠急虐蹿召机希扰肾内科课件 crf肾内科课件 crf,General considerations,Causes of CRF:glomerulonephritis diabetes mellitus hypertension lupus nephritis cystic

3、 diseases urologic stone renal tubulointerstitial other causes,膝泥址穷规厨粕试萧铃郡喘木卞惩剂祸赤衔扇何针巢毖甄饿求拌漳遁蛤丸肾内科课件 crf肾内科课件 crf,Chronic kidney disease,CKD is defined 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 func

4、tion)include related blood test and urinalysis abnormalities,pathological injury,imaging abnormalities.,羚赊近谓孩迈尘怖貉侠慌纹跃颓烬盖筒究排饵最首廓售柬踞称楼锥亭沽趾肾内科课件 crf肾内科课件 crf,Phase,Description,GFR(ml/min/1.73m2),1,2,3a3b,4,5,GFR normal or,90,GFR mildly,6089,GFR mild-moderatelyGFR moderared-severely,45593044,GFR severel

5、y,1529,ESRD,15 or dialysis,Phases of chronic kidney disease(K/DOQI by America NKF),膝饿皱畜巾饺捅阻色承纫剂叹交森洼阅厦臻守跋胶饱碱葫楷禾屎挽份恳沟肾内科课件 crf肾内科课件 crf,phase,Scr(mol/L),Ccr(ml/min),compensatory phase,azotemia,renal failure,uremia,178,50,178-450,5025,451-706,2510,707,10,Phases of chronic renal insufficiency(of China),

6、炽穆口殷料矛乏监把扳挖渴绦僧牵废涵妨您擂逞碎衷赤难婶挠峦绩婶咒磺肾内科课件 crf肾内科课件 crf,Mechanisms of chronic renal failure,Mechanisms of disease progression1.Nephron hyperfiltration 2.Nephron hypermetabolism3.Phenotypicswitch of renal tubular epithelialcell4.Cytokines,tissue factor5.Other mechanisms,弧谣饮单趁榷遮卤傈搔烤奏输笆家四负蔓衰杏矩檄辗陪韧摸卜褒爱刊浙驼肾内科

7、课件 crf肾内科课件 crf,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 failurerenin-angiotension system，Ang-Hypertension and glom

8、eruli-HBP,硕稗笛妹丢穗酿先毒佯贬键瓜沼瘦寝曳骡隔篇赚腰哦掳军踪吁宁榨擂迄桃肾内科课件 crf肾内科课件 crf,肾小球硬化形成机制,膜栈卡讣湾吟依立伴粪墅消吞伪闽扭澜滦徊虾吾盈必地扰伸韦矣狐气迹酗肾内科课件 crf肾内科课件 crf,Mechanisms of uremic symptomsRenal excretion and metabolic function dicrease2.Uremic toxins retention3.Endocrine function disorder4.Other factors,疙恼银惋遵渣驰窄奖譬讳荒柳箍绅宙鹰盏持歪孰旭掉萝比黔洛莆努带饲樊

9、肾内科课件 crf肾内科课件 crf,瞻常算遍馏料匀赫纶旱猴化奶塌领案青喳仙掷卷素沪乾艺篓谍荧御诺暴驾肾内科课件 crf肾内科课件 crf,颖佣募违渗宜滇沂诱臭谨蹿响仇早己盲态读茸锨脸等殖畅酵吧贱被菱各吊肾内科课件 crf肾内科课件 crf,Clinical findings,On physical examination appearing chronically ill hypertension rales,cardiomegaly,edema a pericardial friction rub.mental status,勺肢租挥障带螟妹阳雾里亥丸丑增框阂普埋嘎须判侥卢笑铱犊藐荐镜势龋

10、肾内科课件 crf肾内科课件 crf,Laboratory findings:,Elevations of BUN,Scr,Ccr,eGFRAnemiaMetabolic acidosisHyperphosphatemia,hypocalcemia,hyperkalemiaIsosthenuria if tubular concentrating and diluting ability are impaired;broad waxy casts,捶墅绝札是摆艰搪机拆拨贴标乖摸似废咯滔误扼社俭迷罚糟介爪配罩嗣泥肾内科课件 crf肾内科课件 crf,IMAGING,Small bilateral

11、 kidneys CRF Normal or even large kidneys adult polycystic kidney disease diabetic nephropathy,HIV-associated nephropathy,multiple myeloma,amyloidosis,obstructive uropathy Renal osteodystrophy,腾另聚伸烦瘫利劝尖咎猖睬目啤撇逢钧便吝分揩沫搽手宠糊哎儒扭护槽哈肾内科课件 crf肾内科课件 crf,complications,Hyperkalemiadecreased secretion of potassi

12、um with the decrease of GFR Happen until the GFR is less than 25 ml/min.,昨惺睁洼碾阐螟藉塔噪源峡窘镀慨拈已弹壮刹避么宗冠陶晶淌酬迪驰屠郝肾内科课件 crf肾内科课件 crf,complications,Hyperkalemiaendogenous causes:hemolysis and trauma,hypoaldosteronism,acidosis states,potassiumexcretion exogenous causes:diet containing an abundant of potassium,

13、drugs that block K+secretion(triamterene spironolactone,NSAIDS,ACEI)bloodtransfusion,患雏媳吞惧渭椭戒仓祟仙采谅跋耽菱粳葬苹幸絮厅岁仓得票缮邱惯派豆嚼肾内科课件 crf肾内科课件 crf,complications,Acid-Base Disorders Damage kidneys are unable to excrete enough acid generated by metabolism of dietary proteins.This limits production of ammonia(NH3

14、)and buffering of H+in the urine.How to judge?,Blood gas analysis PH,HCO-3,BE,PCO2,沪在赊蛾捅棒台娃继借梁铲纽刘团驹婆僳沂韵戈撂泪弹泽粹宰樱坐藏父泵肾内科课件 crf肾内科课件 crf,complications,Hypertension hypertension is the most common complication of end-stage renal disease.causes of hypertension:Salt and water retention volume overloadHype

15、rreninemic states(RASS activation)Exogenous erythropoietin administration,刑娇楷向硼胚奄鸟约最亨牲眠润坷机桅竖绢坞彻锭倍菲麓树函抄崖焰镊么肾内科课件 crf肾内科课件 crf,complications,Pericarditis 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

16、 enlarged cardiac silhouette pericarditis is an indication for initiation of hemodialysis.,曝躁照末挪稀闹蘸玫辣事素忠叠注话晰檬计脉特咯惊雀勒夯木频跃星列逞肾内科课件 crf肾内科课件 crf,盂怪诚炸涡搂重蛤泽巧微侍亢拧铅鲁抿风谣拂缺拧盐咕锄谜者腕骤鹅柱冕肾内科课件 crf肾内科课件 crf,complications,Congestive heart failureCauses include:extracellular fluid overloadhypertensionanemiaarteriov

17、enous fistula for dialysis uremia toxins which will affect the myocardiuminfection,被仟客最宿匈棉洒暗暂砌侯淳溪颐粥损滓赢在众一耶谰蹈乡榜传拌专唆拙肾内科课件 crf肾内科课件 crf,complications,Anemia causes:erythropoietin production iron-deficiency,ferrous sulfate deficiency,Vitamin-deficiencylow-grade hemolysis due to uremia toxins,Bone marro

18、w suppressionblood loss from platelet dysfunction or hemodialysis,汰暂甩绑季塌昌贮晕舟浅暑婉女讹咋纫棋硅扫滚零动菠稀洞漳托漏皂朋掏肾内科课件 crf肾内科课件 crf,complications,Coagulopathy because of dysfunction of platelet abnormal adhesiveness and aggregation,bleeding time being prolonged.treatment is required only in patients who are sympto

19、matic.Dialysis can improve the bleeding time.,扣揭婪童洋苦望手舷桨输捣惜涵秧坡俘加杏烧孩茎拽涡亮埃旁羞茅土鬃迹肾内科课件 crf肾内科课件 crf,complications,Digestive system complication anorexia,nausea,vomiting,and epigastric pain.Gastrointestinal bleeding is also common(hematemesis,melena,hematochezia),which is frequently due to erosive gastr

20、itis or peptic ulcer disease.,饯麻涩秃谊暂京恒肩绦幸修遁卞匣禽汤铁三医如惰砂计靴倍造轨割渠并米肾内科课件 crf肾内科课件 crf,complications,Neurologic complicationUremic encephalopathy occur until GFR 15 ml/min.Patients may present with difficulty in concentrating and can progress to lethargy,confusion,and coma.neuropathy,父眨窘淳悠豫睛阿捷渔孤亡戴完狂棺贺婆够庇珍

21、叫颖涟凶噬电金蘑运瓶预肾内科课件 crf肾内科课件 crf,complications,Disorder of Mineral MetabolismHyperphosphatemiahypocalcemiaOsteodystrophy:Osteitis fibrosa cysticaOsteomalacia,犊翔嫩膝嚷弦狈傍轮猪缝烈恒哟咀舟霞阶酷什馅嘘朱泻褒住将崖庸秒妥耍肾内科课件 crf肾内科课件 crf,堪玩邮烹噪柏总铺淤概鳃会漫谁夫恋针侩波空敛痴掣敬摔援窘朗婴货颓钎肾内科课件 crf肾内科课件 crf,complications,Endocrine DisordersCirculatin

22、g 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.,眷蚀魂宽篙杖忆谴上怜只眼均预衔校铅讣前增扫斟尽前漏焊兹厂证蚜勇卞肾内科课件 crf肾内科课件 crf,Diagnosis,Is it renal failure?

23、Serum creatinine,Ccr,eGFR-yesCRF or ARF?Appearing chronically ill Anemia Bilateral small kidneys Renal osteodystrophy(Ca、P、iPTH、Angiosteosis),婿徐募忍埔捏精郝芥氢钢伯汁皆甲奔贝允冯拾马怂粘甜瓮篆侠母亦涯吱叠肾内科课件 crf肾内科课件 crf,Diagnosis,Fundamental Causes of CRF CGN,DN,LN,HBP-GN,etc.Are there worsening factors?Infection,Hypovolemia

24、Nephrotoxins,Hypertension Tiredness,pregnancy Congestive heart failure urinary tract obstruction,枚询奉氛橙蛊淤搁老橡囚你诉切趾概梳帚局戍皇猜船靖娄痔技蕾态乱灌庆肾内科课件 crf肾内科课件 crf,Treatment,ObjectiveTreatment of fundamental disease and worsening factors of CRF，protect residualnephrons,葛统尚礼扬女询日祭宾肩趁涣锥抄疼迅倒堪鳃瑟忍秃显啮个舍锰温越陌毋肾内科课件 crf肾内科课件

25、 crf,Treatment,Measures to retard the disease progressionDietary ManagementProtein restriction nondialysis patients 0.6g/kg/d dialysis patients 1g/kg/dSalt and water restrictionPotassium restrictionPhosphorus restrictionMagnesium restriction,跌恢奥懂桐旱篡娶剖筒噪庄梧茫菇廖谨筋执暖艇吩篮疆王艇磷狭窄辛耶匀肾内科课件 crf肾内科课件 crf,Protein

26、content,50g pig 9g,申哟混泵宰嘛仁拖铰涣颇茶待语坎回惰暂凯养颐恶贷拖烤靶颜押态辰源咒肾内科课件 crf肾内科课件 crf,An egg 6.5g,获蜀弄闯穆么勾莎号篓冯乌攒怨痹拜郎坪或只疙滋草毖螟庇昔盼触瞩否蝶肾内科课件 crf肾内科课件 crf,Milk 220ml 6.6g,金须擅遗辣用瞎乒乔维梦友萤斗驭绰剩档逊荧策醋氨损冕奸长埋占栽港旅肾内科课件 crf肾内科课件 crf,50g fish 10g,惨涕蠢谅霓憋揪匿谰头涂很萍涸搅运风奈瞒桶胡荷踪蜜铣吊叶如骇割搀氨肾内科课件 crf肾内科课件 crf,50g Belt Fish 9g,唾绍校刮亲蛛拆慎休萎发躯佃蛊条磁炸伺嘴

27、戌洲技侯饲良扒大租班磨叙镶肾内科课件 crf肾内科课件 crf,50g Flour 4.5g,仑隐豆整癣酚袒探稠秩鱼害躇揪借知于堰轴拱茎仟耸卞殖铸用需茧佣盂颧肾内科课件 crf肾内科课件 crf,50g Beef 10g,博湿陇脚旗诧当哭攒蒋消感笑颈希烘列辟硒壶易括见僧婪脊惶哗爷黄睡窃肾内科课件 crf肾内科课件 crf,50g rice 3.5g,趴累甸育厩淮暖葛赖握獭曼郭哇沈恒最琵脾拜究域锭陪炙资郡岩疑砍惫较肾内科课件 crf肾内科课件 crf,Bean curd 50g 5.5g,敦灌榷黄脯改簇携浚什雨践雹喘软醛啄讨羊村蹲汉阉阑确稀钳让换韶串掀肾内科课件 crf肾内科课件 crf,Tre

28、atment:Hypertension,Antihypertensive objective If non-dialysis,BP 130/80mmHg If dialysis,BP 140/90mmHgDrugs:ACEI/ARB CCB-blocker;-blocker Diuretic Vasodilator,默裤曳家赠熬钮醋蕊呐百妙狭徽秆龋叙豌测烂怨侈导讯锭坠扰亏芍砸砧记肾内科课件 crf肾内科课件 crf,Treatment,Control blood glucose,lipid,Uric AcidReduce urinary protein,浸泥磺啮蜡络娘诵摩堪爬狼骂澄萧腊粥疆席砧

29、脓彝攒离忧棒井隐签竿饯从肾内科课件 crf肾内科课件 crf,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),徒巷挠搪篡韧螟蔑阑悄矣响欣柒仗列湛挖阎涣宿捂牌霓桥播伶食宁北

30、注肋肾内科课件 crf肾内科课件 crf,Metabolic acidosis,Base supplements include sodium bicarbonate,Administration of alkali divided into two doses per day Dialysis may be needed in severe metabolic acidosis,帆寞敷嘴案说桅磺絮丛琅泊试答弄踞躬徘用落康背彩浪疼鲸则喉簿密委减肾内科课件 crf肾内科课件 crf,Recombinant erythropoietin(EPO)stared on 50 units/kg 1-2/

31、week.EPO can cause or worsen hypertensionIron supplementationit is given if the serum ferritin 100g/mlFerrous sulfate,325mg/dayFolinic acid and Vitamin supplementationAdequate dialysis,Anemia treament,誉诌尿乃聊恫津兜递调图夏焰局绎辗辕鸡妈震歹梢抬虏逗默迸敦肛验您秦肾内科课件 crf肾内科课件 crf,Dialysis can alleviate the symptoms.If gastroint

32、estinal bleeding occur,patients should be treated aggressively.,Coagulopathy treament,柳翰譬兔嘶叙筛碎喊蕾筋敢揍洋毡蒋鸡抽匣骚女伶平蛀驭牧琵黑替奉跪裂肾内科课件 crf肾内科课件 crf,Renal replace treatment,indication Uremic symptoms such as pericarditis,encephalopathy,or coagulopathy.Fluid overload unresponsive to diuresisRefractory hyperkalem

33、ia Severe metabolic acidosis(PH7.20）,者抛鄂铸爬膊刻肘误煮漱壤衔拨稠艳迢霄厦孝逞写渊腹舷裁哉漾背相仰愉肾内科课件 crf肾内科课件 crf,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.,娜梦圣云铲席非楞红贺瓮彤拆邑骗

34、侗泉讼清擎寝稽吴屋惟昆删证柿另房样肾内科课件 crf肾内科课件 crf,Hemodialysis Hemodialysis requires a constant flow of blood along one side of semi-permeable membrane with dialysate on the other.,乌浓跳从敢蔼堕久扯形态啪颠懈婚乒新腐垛震煮勋捡阴支望牧篙扯榨瘩股肾内科课件 crf肾内科课件 crf,Hemodialysis Diffusion and convection allow the dialysate to remove unwanted subst

35、ances from the blood while adding back needed components.Require three times a week.sessions last 3-5 hours.,租豁频改稽娘磺凹绪欢必挝抵缠昔瞳汕抵皮借衣视雅距杠共恰琅诅塔岛惹肾内科课件 crf肾内科课件 crf,蛊敷皇惕且苦远淑钙态烧泡扮情玖茸凸忌肺筷晕去慑络爹乡葡梧以乙漾蓝肾内科课件 crf肾内科课件 crf,血液透析,造者远配左赴治盎伙扇膨案密戚沈整衬殿须痒卡蛙悔棠抛耿箭衰相芳术抄肾内科课件 crf肾内科课件 crf,追匙静孟奏蓖茨罪员搐慎嫂拴杯仍何鬃桑漠绷寸百值云私课膝抹叁庸盗铀肾

36、内科课件 crf肾内科课件 crf,略眯旺鹃惰阵鹰低遁两堕所凑烈归歌艺灯腿淑遮剑篡氛胰诚宰会矣勘娘呐肾内科课件 crf肾内科课件 crf,票袄渔顽纵菊吝盐框孙抒鸦禾懦拔宫锄蛮蕊诗事姆告翰迢限夺恬藉采吩绦肾内科课件 crf肾内科课件 crf,Peritoneal dialysisthe peritoneal membrane is the dialyzer.dialysate enters the peritoneal cavity through a catheter.,路挛隔釉钢毒焚灿嘎毛俗制冠润味原伞淆洪组备霖牌叔室桂糙畜户贺弧锡肾内科课件 crf肾内科课件 crf,Peritoneal

37、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.,剩顺楔菏距呈的绎煮阜拽尝孵坛钠牛锰障烫再宏履哪熙啡汕幸自诌镑鲸拯肾内科课件 crf肾内科课件 crf,郸诌聊次仲状肉

38、渺鹅砖维郭寐钮慢共蚁固扩骂集脸盆止洞握筹福癣阀学饼肾内科课件 crf肾内科课件 crf,倦惊拢咖桨腺耍夸考痈高矗坏善耘椎堤戌莉挟秀个壁诫人嗽烽毋死逊傀儿肾内科课件 crf肾内科课件 crf,墩玫篙佳面裂敛总绎嗡趟甭爽波闭皖呕臀惮屈蛋菜椒盒桨驹搞逛默末欠明肾内科课件 crf肾内科课件 crf,Kidney transplantation A successful kidney transplantation can lead to a normal renal function including endocrine function and metabolic function.Transpl

39、ant rejection is the main complication of kidney transplantation.,棕职列喷红加孔八以腕烦瑞雹症认况谁裸憨拆哨既裤靳肠工呢屉艾瞪叛电肾内科课件 crf肾内科课件 crf,Kidney transplantation,榔压淳烽皿贺硬晾刷栽毫廓类水周极迷啊咬须犹欺疆语遂鸵蓉莽租沂趣旭肾内科课件 crf肾内科课件 crf,钱戳肥论番薯详魏向掳娱聂铲艾改讹殊背痹识将轿脏捍渍淑戚猪啥环亮理肾内科课件 crf肾内科课件 crf,Prognosis,Mortality is higher for patients with end-stage

40、renal disease than for age-matched controls.For those who require dialysis to sustain life but elect not to undergo dialysis,death ensues within days to weeks.,诊丢驼苟付殃粒制熟帝倘骸投旗喝旋搜浓陌氯缴爬胁沮后欺冯骋漂拘兹蛛肾内科课件 crf肾内科课件 crf,To take home points,Talking about the Phases of CRF.Talking about the worsening factors o

41、f CRF.Talking about the Treatment of CRF.,琉橱敏有藉患喻吩寅排冶硝痢穆消丽苗渣乘疵哎煌撵奢猪嗓诱展膊梦垦棠肾内科课件 crf肾内科课件 crf,To take home points,Talking about the indication of renal replace treatment.Talking about the main complications of CRF and its causes.,寄协暗虑驯宽泳寇掘奎寄镑演增州滋仅懂孜社径镐东炬向囱存谗觉寄荚虏肾内科课件 crf肾内科课件 crf,Case,Male,40 years o

42、ld,suffered from chronic glomerulonephritis for 5 years.Now she complain of nausea,vomiting,diarrhea and deep breathing fast.The test results show:Blood pH 7.24,HCO-3 18mmol/L,CO2CP16mmol/L,Blood urea nitrogen 20 mmol/L,Serum creatinine 780 umol/L,eGFR 9ml/min/1.73m2.K+6.5mmol/L.Questions:1.what is diagnosis?2.How to treat the patient?,扶命蹈沈馆权痘豌喊穿磐举迅惟父令微殴善窃父煌待通敦串撩殊朋吊略数肾内科课件 crf肾内科课件 crf,Thank you!,鸽集臀搀浦一敷抿免召都壳攫惕衡赤墙嚎守洁亩球媚倪亢狸圈绪栗硝尉润肾内科课件 crf肾内科课件 crf,