内科学-慢性肾衰竭课件.ppt

Chronic Renal FailureChronic Renal Failure陆福明陆福明复旦大学附属华山医院肾脏科复旦大学附属华山医院肾脏科The importance of Chronic The importance of Chronic Renal FailureRenal Failuren nWorldwide,the prevalence of CRF is increasing by more than 5%annuallyn nThe cost of renal replacement therapy has an increasing impact on health economics in both developed and developing countriesPlasma Plasma CreatinineCreatinine and and GFRGFRn nNormal GFR 100-125ml/min/1.73m2n nGFR declines by about 1ml/min/1.73m2/yearn nPlasma creatinine concentration can be used to monitor renal function when GFR50ml/minn nMass screening of plasma creatinine cannot provide early detection of renal diseases in the general population Causes of CRFCauses of CRFn nGlomerularGlomerular diseases account for 60%diseases account for 60%of CRFof CRFn n Diabetic nephropathy account for Diabetic nephropathy account for 10-15%of CRF(in USA about 50%)10-15%of CRF(in USA about 50%)n nHypertension:10-15%Hypertension:10-15%n nPolycystic kidney diseases:5%Polycystic kidney diseases:5%n nObstructive Obstructive uropathyuropathy:3-4%:3-4%n nLupus nephropathy:2-3%Lupus nephropathy:2-3%n nUndermined Origin:5-10%Undermined Origin:5-10%Evolution of CRFEvolution of CRFn nGlomerular diseases will be decreasedn nDiabetic and hypertensive nephropathyn nChronic nephrotoxicity by environmental pollutants,drugs and herbsn nIncidence of ESRD:100-200 per millionClinic manifestation of CRFClinic manifestation of CRFn nDeterioration of renal function is invariable once GFR is reduced by more than 25%n nSerial plots of the reciprocal of cr vs.time follows a straight linen nOften remain asymptomatic when GFR=25%n nUraemic syndromeClinical Diagnosis of CRFClinical Diagnosis of CRFn nAcute or chronic?Acute or chronic?n nOften presents acutely when GFR Often presents acutely when GFR suddenly drops from 20%to 10%or suddenly drops from 20%to 10%or lesslessn nTo assess the severity of renal To assess the severity of renal impairmentimpairmentn nTo elucidate the causes of renal To elucidate the causes of renal failurefailuren nTo ascertain whether the renal failure To ascertain whether the renal failure is acute,or acute-on-chronicis acute,or acute-on-chronicn nTo assess the patient for renal To assess the patient for renal replacement therapy replacement therapy Clinical InvestigationsClinical Investigationsn nThe history should include a diligent The history should include a diligent search for potential search for potential nephrotoxicnephrotoxic agentsagentsn nA positive family may indicate A positive family may indicate heredofamilialheredofamilial diseases diseasesn nPallor,scratch marks,peripheral Pallor,scratch marks,peripheral oedemaoedema and palpable masses in the and palpable masses in the abdomenabdomenn nA full examination is important,A full examination is important,especially in patients with diabetes especially in patients with diabetes Common InvestigationsCommon Investigationsn nRenal function profilen nUrinalysisn nQuantitation of proteinurian nDetermination of creatinine clearancen nLiver function profilen nHepatitis B and C statusCommon InvestigationsCommon Investigationsn nSerological test such as anti-nuclear Serological test such as anti-nuclear antibodies,complements,antibodies,complements,immunoglobulin levels,C-reactive immunoglobulin levels,C-reactive protein and anti-protein and anti-neutrophilneutrophil cytoplasm cytoplasm antibodiesantibodiesn nLipid profileLipid profilen nUltrasonogramUltrasonogram of kidneys for of kidneys for measurement of kidney size and measurement of kidney size and exclusion of structural abnormalitiesexclusion of structural abnormalitiesn nDoppler examination of renal arteries Doppler examination of renal arteries when indicatedwhen indicatedManagement of CRFManagement of CRFn nTreatment of primary diseasen nTreatment of hypertensionn nUsing ACEI or angiotensin-II receptor blockersn nAvoiding nephrotoxic agentsn nLow dietary protein intaken nPhosphate controln nEarly correction of aneamiaTreatment of HypertensionTreatment of Hypertensionn nThe target of blood pressure:130/80mmHgn nMultiple agents are requiredn nACEI,ARB,B-B,CCB,-B，diureticsn nBlood pressure controlled for 24hrUsing ACEI or ARBUsing ACEI or ARBn nACEI can causes an unacceptable cough in a substantial number of patientsn nThe risk of hyperkalaemia is small though real.n nARF can be happened in patients with severe renal artery stenosis.Avoiding Avoiding nephrotoxicnephrotoxic Agents Agentsn nNon-steroidal anti-inflammatory drugs are used too liberallyn nHerbs:patients often resort to alternative medicine and ingest a wide combination of herbs which leads to a rapid demise of remaining kidney function.Management of CRFManagement of CRFn nUrinary obstruction and infection should be treated promptlyn nFluids overloading should be avoided n nEarly referred to nephrologist(GFR30ml/min)Management of CRFManagement of CRFn nPhosphate binders are given with each meal to bind dietary phosphates in the gutn nCalcium supplementation is neededn nActive Vitamin D metabolites are prescribed when PTH is highManagement of CRFManagement of CRFn nMetabolic acidosis is corrected with sodium bicarbonaten nErythopoietin can corrects early anaemia,improves cardiovascular function and preserves residual renal functionManagement of CRFManagement of CRFn nProtein restriction can slow down the progression of renal failure.However,severe malnutrition should be carefully avoidedn n65%of the dietary protein intake should be in the form of high biological value proteinManagement of CRFManagement of CRFn nVegetable protein may be beneficial in early stages of CRFn nSaturated fats must be avoidedn nLipid abnormalities must be given due attentionn nLow sodium dietary intakeManagement of CRFManagement of CRFn nCardiovascular mortality is the most important cause of deathn nAnti-lipid treatment should be given early n nAspirin will a beneficial impact on survival n nSmoking should be avoidedn nPotassium intake should be reduced when in ESRDRenal Replacement TherapyRenal Replacement Therapyn nA thorough discussion involving the patient and his family on the different treatment options is mandatoryn nKidney transplantation presents the best means of rehabilitation,especially when it is performed pre-emptivelyRenal Replacement TherapyRenal Replacement Therapyn nIntegrated approach in the overall management:n nPeritoneal dialysis can be considered as initial dialytic therapy,while haemodialysis is reserved for patients who are unable to perform PD,Prior to kidney transplantationRenal Replacement TherapyRenal Replacement Therapyn nIncremental dialysis:the dose of dinlysis is decided based on the amount of residual renal functionnTHANKS！