泌尿系统课件：CKD english version 2013.ppt

1、CKDDefinitionEtiologyPathophysiologyClinical menifestationsManagementTreatment to delay progressionTreatment to prevent complicationsTreatment to replace renal functionIn 1999, the NKF approved a proposal for K/DOQI,K/DOQI, （Kidney Disease Outcomes Quality Initiative） The purpose was to develop clin

2、ical practice guidelines for the spectrum of kidney diseases.CKD is defined as either Kidney damage or GFR 902Mild GFR60-893Moderate GFR30-594Severe GFR15-295Kidney Failure 15 or dialysis Primary CareFocus is here!Causes of CKDGlomerulonephritis Primary glomerular disease: -IgA nephropathy, FSGS, MN

3、, MPGN, etc Secondary glomerular disease: - Diabetic nephropathy -Post-infectious Glomerulonephritis - Systemic diseases - AmyloidosisVascular disease Ischemic renal disease, Hypertensive nephrosclerosis, Renal artery stenosisTubulointerstitial disease TIN ,UTI, Drug toxicity, IdopathicObstructive n

4、ephropathies Prostatic disease, Urinary stones, Retroperitoneal fibrosis/tumorHereditary disease Polycystic kidney disease, Alport syndrome Causes of ESRD in the USA: Prevalent Counts and AdjustedRates by Primary Diagnosis2006 ADR: USRDS Pathophysiology of CKD Pathophysiology of CKDHemodynamics chan

5、ges of glomerularsProteinuriaRAASHypertensionHyperlipidemiaTubulointerstitial injuryProtein in dieturemiatoxin MalnutritionEndocrine disorders Trade-off hypothesis RENAL INJURYReduction in nephron massGlomerular capillary hypertensionIncreased glomerular permeability to macromolecules Increased filt

6、ration of plasma proteinsProteinuriaExcessive tubular protein reabsorptionTubulointerstitial inflammationRENAL SCARRING PROGRESSIVE RENAL DAMAGE: The Final Common PathwayIncreased BPLead to dysfunction of all organ systemsGastrointestinal symptom -Appetite,Nausea, Vomting, Uremic fetor, mucosal ulce

7、ration, Gastrointestinal hemorrhage Cardiovascular system -HTN,CHF, Coronary atherosclerosis ,Pericarditis ,Hematological system - Anemia ,BleedingRespiratory system -uremic pneumonia Neural and muscular - Fatigue, coma and seizures, Sleep disturbances Restless legs, Peripheral neuropathySkin White

8、crystals in and on skin (uremic frost), dry scaly skin, easy bruisingBone disease PO4, Ca, PTH ， Osteomalacia, adynamic bone disease, metastatic calcifications, mixed bone disease Endocrine disorders Insulin resistance, growth retardation, hypogonadism, impotence, infertilityInfectionsMetabolic acid

9、osis Water-electrolyte imbalance Na / , K / , Ca ,P GFR Vit D 代谢 Ca吸收 血清HPO4 血清Ca+ PTH 破骨 Ca+和HPO4-从骨重吸收骨营养不良CaHPO4产物转移性钙化肾性骨营养不良：肾性骨营养不良：儿童手指骨膜下吸收（箭头）儿童手指骨膜下吸收（箭头）肾性骨营养不良：肾性骨营养不良：转移性钙化转移性钙化laboratory testing and special checkingWho should we screen ?What should we screen ?YESNORisk Factor Reduction

10、Determine Stage of CKD Determine underlying cause Identify revisible factors for progression Identify complications Patient meets definition of CKD ?Diagnosis procedureProtein restriction0.8 g/kg/d (Stages 1- 2)0.6 g/kg/d (Stages 3) plus Ketosteril 0.4 g/kg/d (Stages 4-5) plus Ketosteril Energy inta

11、ke RDA ( recommended dietary allowance ) depends on energy expenditure 30-35 kcal/kg/d when GFR 1.0 g/d, BP 125/75mmHgIf Protein 1.0 g/d, BP 130/80mmHgIf CKD stage 5 , BP 140/90mmHg (From WHO and ISH)For Adults with Stage 3 CKD: Assess Hemoglobin level If anemia (HgB 12g/dl) RBC indices/CBC Reticulo

12、cyte count Iron studies Test for occult GI bleeding as indicated Medical evaluation of comorbid conditions Erythropoetin levels are usually NOT indicated. Fe DeficiencyFe Deficiency Ferritin 100 ng/ml and FeSat 20 % Start oral. May require parenteral replacement.Erythropoietin Stimulating Agents (ES

13、A)Epo Usual dose: 100-120 IU/(Kg.W) SQ 120-150 IU/(Kg.W) IV Starting dose :80-120 IU/(Kg.W )Monthly monitoring of Hgb, iron stores.Monthly adjustments in EPO dose and frequency to meet target Hgb 11-13g/dl ,HCT 33-36% Pay attention to resistance of EPOOsteitis fibrosis cystica, is major form of bone

14、 disease.Check indices of bone and mineral metabolism at GFR 70pg/ml, CKD 4 PTH110pg/ml, CKD 5 PTH300pg/ml, -not use if ca x p55 mg2/dl2Avoid acidosis, HCO3 23 mEq/l PO4 Goal 2.7 4.6 mg /dl Calcium Goal 8.4 9.5 mg/dlCa x PO4 Goal 55 mg2/dl2Frequency of testingStage 3: q 12 monthsStage 4: q 3 monthsc

15、orrect water-electrolyte imbalancecorrect water-electrolyte imbalance -Hyperkalemia, Metabolic acidosis ,edemaControl infectionsControl infectionsCardiovascular disease prevention (lipids, Cardiovascular disease prevention (lipids, etcetc) )Evacuation from Evacuation from intestinesintestines（活性炭，氧化

16、淀粉，大黄制剂，中药保留灌肠）（活性炭，氧化淀粉，大黄制剂，中药保留灌肠）Renal replacementRenal replacement -dialysis, renal transplantion Dialysis Hemodialysis(HD) Peritoneal Dialysis (PD)Diabetics kidney disaese Ccr 6 mg/dL (530 umol/l)Nondiabetics kidney disaese Ccr 8 mg/dL (707umol/l)It may be necessary to initiate dialysis earlie

17、r if there are otherwise uncorrectable symptoms or signs of renal failure such as nausea and vomiting, weight loss, intractable CHF or hyperkalemia. severe hyperkalemia k 6.5 mmol/l acute pulmonary edema, refractory to diuretics severe metabolic acidosis ,HCO312mmol/l, PH7.2Dialysate inflow tubeDial

18、ysate outflow tubeBlood inflow tubeBlood outflow tube10,000 hollow fibers (large surface area)Diffusion:Toxins are removed from the blood through diffusion.Ultrafiltration: There is higher pressure in blood compartment than in the dialysate compartment. Excess water is removed from the blood with a

19、certain amount of filtration.Convection: This forces water and any other molecules small enough to pass through the membrane to evacuate the blood.Blood circulates outside the body and passed through the dialyzerComes into contact with a counter flow of dialysate solutionBlood is injected with hepar

20、in, ananticoagulant.Blood is then returned back to the body through the artery.Dialysis frequencyTime 4-6h, 3 / WDialysis disequilibrium syndrome FeverCVDFirst-use syndrom Others4647The abdominal cavity, hold the large organs of the digestive system, is lined by the peritoneum.In PD, special fluid i

21、s instilled through a permanent catheter in the lower abdomen.48An osmotic pressure gradient is applied by the addition to the dialysis fluid of an osmotic agent which will “suck” fluid from the blood.In most cases glucose is used to create the osmotic pressure.49The driving force is the concentrati

22、on gradient between the PD fluid and the blood Fluid is removed by ultrafiltration driven by an osmotic pressure gradient .Waste products present in the blood will diffuse from the blood vessels into the “cleaner” dialysis fluid.bacterial peritonitis peritoneal fibrosis Metabolic disordermechanical

23、complications of catheters such as malfunction, migration, or kinksManagement of Patients with Chronic Kidney DiseaseB lo o d gluco se co ntro lB P C o ntro lA R B sA C E Inhibito rsInte rve ntio ns tha t de la y pro gre ssio nR e duce d F unctio ning a nd W e ll-be ingM a lnutritio nO ste o dystro

24、phyA ne m iaP re ve ntio n o f U re m ic C o m plica tio ns(G F R 60 cc/m in/1.73 m 2)C a rdio va scula r D ise a seM o difca tio n o f C o m o rbidityP re -e m ptive T ra nspla nta tio nK idne y T ra nspla nt E va lua tio nT im e ly D ia lysis Initia tio nT im e ly D ia lysis A cce ss P la ce m e ntC ho ice o f D ia lysis M o da lityE duca tio nA n E S R D C linicP re pa ra tio n fo r R e na l R e pla ce m e nt T he ra py(G R F 30 cc/m in/1.73m 2)E a rly D e te ctio n o f C K D