肾内科课件crf.ppt

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 urinary 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 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 function)include related blood test and urinalysis abnormalities,pathological injury,imaging abnormalities.PhaseDescription GFR(ml/min/1.73m2)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 chronic 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 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 glomeruli-HBP肾小球硬化形成机制Mechanisms of uremic symptoms1.Renal excretion 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,Scr,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-associated 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/plicationsHyperkalemiaendogenous causes:hemolysis and trauma,hypoaldosteronism,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 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,PCO2complicationsHypertension hypertension is the most common complication of end-stage renal disease.causes of hypertension:Salt and water retention volume overloadHyperreninemic 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 is 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 sulfate 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 required 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 peptic 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:Osteitis 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.Diagnos