1、Chronic Renal Failure(CRF)Shanghai Ruijin Hospital affiliated to Shanghai Second Medical University,Dept.of NephrologyQian YingCRFDefinition:final stage of numorous renal diseases resulting from progressive loss of glomerular,tubular and endocrine function in both kidneys.This leads todisturbed excr
2、etion of end products of metabolismdisturbed elimination of electrolytes and waterdisturbed secretion of hormones(eg.Erythropoietin,renin,prostaglandins,active form of vitamin D)CRFRegional and racial incidence of CRF Britain 70-80/per million China 100/per million USA 60-70/per millionCRFEtiology d
3、iabetic nephropathy,hypertensive glomerular sclerosis,chronic GN chronic GN,obstructive nephropathy,diabetic nephropathyoverseaschinaCRFPathogenesis(unknown)uremic toxins small molecular weight:urea,creatinine,uric acid,guanidine,phenol,amines,indoles middle molecular weight:PTH large molecular weig
4、ht:2-MGCRFMajor hypothesis intact nephron hypothesis final common pathway (hemodynamically mediated glomerular injury)CRFglomerular injuryadaptive single nephron hyperfiltrationglomerular capillary plasma flow,hydraulic pressureIntact nephron hypertrophy and sclerosisCRF Trade-off hypothesis CRF Cal
5、cium phostate PTH SHPT bone,heart,blood,nerves injury Hypertension and compensatory hypertrophy of glomeruli Hypermetabolism of renal tubuli cytokines and lipid disturbancesCRF Stage 1:the normal stage of renal function GFR70 ml/min,BUN6.5 mmol/L,Scr110 umol/L Stage 2:imcompensation stage of renal G
6、FR 50-70 ml/min,6.5 BUN 9 mmol/L,110 Scr 178 umol/L no any signs and symptoms except for the underlying disordersCRF Stage 3:azotemic stage GFR9 mmol/L Scr178 umol/L there may be slight fatigue,anorexia and anemia Stage 4:uremic stage GFR20 mmol/L Scr445 umol/L a constellation of uremic syndrome may
7、 appear in this stageCRFSigns and symptoms of uremiaGeneralGastrointestinal tractNeuropathyBoneBloodElectrolyte disordersHeartSkinMusclesInfectionLungEndocrine and metabolicCRFCRFCardiovascular disorders Hypertension 80%Water and sodium retention Alterations of RAAS Glomerular capillary pressure sys
8、temic arterial pressureCRFAtherosclerosishypertriglycerid,hypercholesterolemiavascular calcificationinadequate perfusion of the limbsCRFPericarditis Uremic Dialysis associatedSigns and symptoms Chest pain Friction rub Pericardial effusion and tamponade CRFHematologic disorders Anemia,bleeding,granul
9、ocyte,platelet dysfunctionCauses:Relative deficiency of erythropoietin Decreased erythropoietin production Reduced red cell survival Increased blood loss Folate and Iron deficiency HypersplenismCRFNeuropathy Central nervous system Tiredness,insomnia,agitation,irritability,depression,regression,rebel
10、lion Peripheral nervous system Restless leg syndrome the patients legs are jumpy during the night,painful paresthesis of extremities,twitching,loss of deep tendon reflexes,musclar weakness,sensory deficitsCRFRenal osteodystrophyvType I:high turn-over bone diseasevType II:low turn-over bone diseasevT
11、ype III:mixtureCRFCauses of renal osteodystrophy 1,25(OH)2D3 calcium phosphate SHPT malnutrition iron and aluminum overloadCRFCRFWater,electrolyte and acid-base disturbances potassium sodium calcium phosphate Metabolic acidosis magnesium CRFDiagnosis of hyperkalemia Plasma K5.5mmol/L Plasma K7.0mmol
12、/L cardiac arrestCRFCRFCauses of hyperkalemiasIncreased intake:rapid adminstration of K by mouth or intravenouslysDrugs containing K(chinese medical herbs)sImpaired excretion Chronic renal failure(GFR15ml/min)CRFCauses of hyperkalemiasShift of K out of cells Metabolic acidosis Tissue breakdown Bleed
13、ing into soft tissues,GI tract or body cavities Hemolysis Catabolic statesCRFDiagnosis:Case historyPhysical examinationLaboratory studies including urinalysis,renal function tests,biochemical analysis of bloodX-ray,ultrosound and radiorenogramCRFTreatment of CRFNon-dialysisdialysisCRFNon-dialysis Di
14、et therapy Treatment of reversible factors Treatment of the underlying disease Treatment of complcations of uremia Chinese medical herbsCRFDiet therapy Protein restriction(0.5-0.8mg/kg/d)Adequte intake of calories(30-35kcal/kg/d)Fluid intake:urine volume+500ml Low phosphate diet(600-1000mg/d)Supplem
15、ent of EAA(ketosteril)CRFReversible factors in CRF Hypertension Reduced renal perfusion(renal artery stenosis,hypotension,sodium and water depletion,poor cardiac function)Urinary tract obstruction Infection Nephrotoxic medications Metabolic factors(calcium phosphate products)CRFManagement of complic
16、ations of uremia Hyperkalemia Identify treatable causes Inject 10-20ml 10%calcium gluconate 50%gluconate 50-100ml i.v.+insulin 6-12u Infusion 250ml 5%sodium bicarbonate Use exchage resin Hemodialysis or peritoneal dialysisCRFCardiac complications Diuretics Digitalis Treat hypertension dialysisCRFAnt
17、ihypertensive therapyTarget blood pressure 130/85mmHg ACE inhibitors Angiotension II receptor antagonists Calcium antagonists-blockers vesodialatorsCRFTreatment of anemia Recombinant human erythropoietin(rhEPO)2000-3000u BIW H Target hemoglobin 10-12g/L hemotocrit 30-33%CRFSide effects of rhEPO Hype
18、rtension Hypercoagulation Thrombosis of the AVFCRFrhEPO resistant Iron deficiency Active inflamation Malignancy Secondary hyperparathyroid Aluminum overload Pure red cell aplasiaCRFTreatment of renal osteodystropyLow phosphate dietCalcium carbonate(1-6g/d)Vitamin D(0.25ug/d for prophylactic,0.5ug/d
19、for symptomatic,pulse therapy 2-4ug/d for severe cases)parathyroidectomyCRFRenal replacement therapy Hemodialysis Peritoneal dialysis Renal transplantationCRFIndications of HD GFR10ml/min the uremic syndrome hyperkalemia acidosis fluid overloadHemodialysisHemodialysis弥散弥散 Diffussion渗透渗透 DialysisHemo
20、dialysis超滤超滤 Ultrofiltration对流对流 Conduction正压正压负压负压Contraindications of HDShokeSevere caidioc complicationsSevere bleedingmalignency,sepsispoor condition in vascular systemCRFIndications of CAPDqchildqold people with cardiovascular diseaseqdibetic nephropathyqtrouble of AVFChoice of HD or CAPDpoorbe
21、tterEcnomic situationpoorgoodVascular conditionBleedingNo bleedingBloodyesnoCardiovascular diseaseeldlyyoungAgePDHD治疗CRFIndications of RT maitenance dialysis patients without contraindications of RT age60 yearsCRFPrognosis5-year survival-Home HD 80%-RT 60%-Hospital HD 60%-CAPD 50%CRFDrug dosing in CRFRedused dose and adminstration interval Ccr(ml/min)=(140-years old)body weight(kg)/72Scr(mg/dl)for female:0.85Acute heart failure in uremia(key treatment?)DiureticsDigitalisTreat hypertensiondialysis
