NYHA 1) 2) DM, 2; 3) HTN; 4) CKD

Transcription

1 急慢性腎衰竭 腎臟科邱炳芳 1 case This 84 y/o man with a history of 1) heart failure, NYHA FcIII; 2) DM, type 2; 3) HTN; 4) CKD satge IV 5) dyslipidemia; 6) ischemic heart disease; 7) PAOD was readmitted to ER on 12/25 with pain on urination and fever as high as 38.4 for one day. His last hospital stay on 11/13 was due to ARF 2nd to simvastatin-associated rhabdomyolysis complicated with R't exudative pleual effusion requiring CT insertion. After discharge on 12/14, he was in a relatively stable condition until last night when he was found to have fever as high as He also developed shortness of breath with dysuria, frequency, and urgency. There was no nausea, vomiting, flank pain, or loss of appetite. On arrival in ER, urinalysis revealed pyuria and bacteriuria with occult blood 2(+). He was transferred to Neph ward with the tentative Dx of UTI.

2 PE BT:38.4, HR: 110 min, RR:24, BP:90/60 Cons:drowsy Neck: JVE:- Chest: BS: coarse crackle HS: RHB, S3:- Ext: edema, pedal Lab WBC:13000, Seg:90%,band:6% Hb: 8.2 BUN:105.9 Cr: 5.0, Na:128, K:4.6 U/A: SG:1.015, protein: 75, Nitrite:+, WBC esterase:++, RBC: HPF, WBC: HPF, bacteria: ++ ABG: PH:7.37, PO2: 65, PCO2 : 35, HCO3: 19

3 BUN Cr Renal sonography: Size: Rt/Lt : 8.0/8.5 Echogenicity: Gr II Imp: chronic renal parenchymal disease

4 Question: Acute? on chronic renal failure Pre-renal / renal intrinsic azotemia Shock : septic or cardiogenic Fluid or diuretics Dialysis? Etiology of CKD Renal perfusion=20% C.O. 8

5 腎臟的功能 排除水分與代謝廢物 維持水分 電解質 ( 鈉鉀鈣鎂磷 ) 及酸鹼平衡 調節血壓 製造活性賀爾蒙 維生素 D 紅血球生成素腎素 前列腺素等 代謝賀爾蒙 (insulin etc) 9 急性腎衰竭 10

6 急性腎衰竭的定義 腎功能快速的喪失導致代謝廢物在體內的累積 什麼是腎功能? 快速是指多快? 什麼代謝廢物? 定義 : 1. 腎功能急速降低 ( 幾小時至數週 ) : 腎絲球 : 過濾 -GFR;CCR(BUN,Cr ) 腎小管 : 尿液濃縮, 電解質, 酸鹼值 2. 代謝廢物 : 含氮廢物,K, 代謝酸, 水和鹽 3. 平衡喪失 : water, Na, K, Ca, Mg,PO 4 3+, 酸鹼值 12

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8 4. 急性腎衰竭的臨床表現 含氮廢物 : 胃腸道症狀 :Nausea, vomiting, hiccup, foul taste, dry crusted mouth,gi bleeding 皮膚 :itching, 神經症狀 :Drowsiness, clouding of consciousness, neuropathy, Coma 心臟 : 心包膜積水 15 代謝酸 Kussmaul respiration( 代償性呼吸快且深 ) Hyperreflexia hypotension 16

9 K 肌肉 :Weakness, lassitude, paralysis, 心臟 :EKG changes with tall T waves, widening of QRS complex, increased PR interval, sine wave pattern, cardiac arrest, VT 17 水和鹽 積水 : Pulmonary edema peripheral edema Ascites pleural effusion 18

10 5. 急性腎衰竭原因 : 1. 腎前因素 (55-60%) : decrease in renal perfusion pressure. 2. 腎後因素 (5-10%) :obstruction of urine flow. 3. 腎內因性因素 :disease process that directly injures the kidneys. 19 A. 腎前性 Post open- heart bypass 20

11 B 腎後因素 : 雙側腎臟 significant renal failure 尿量起伏 輸尿管 膀胱 尿道 21 C 腎因性因素 : vascular factors Interstitium tubular 22

12 常見腎毒性藥物 : Aminoglycoside :Gentamicin, amikin NSAID, COX-II inhibitors Amphotericin-B Cyclosporin / tacrolimus Contrast media Rifampin Acyclovir cisplatinum 23 病史及理學檢查 尿鈉排泄分率 6: 診斷 : 尿液鏡檢 影像學檢查 切片 24

13 a 病史及理學檢查 intravascular volume depletion: drop in weight, flat neck veins, orthostatic hypotension Cardiac dysfunction: edema, pulmonary rales, S3 gallop insults associated with ATN: hypotension, surgery, transfusion reactions, dye exposure Urinary obstruction: anuria, intermittent anuria, or large swings in urine flow rate 25 b Urinalysis 尿液鏡檢 所有急性腎衰竭患者均須執行 red blood cell casts glomerulonephritis, vasculitis, malignant hypertension white blood cell casts--pyelonephritis and allergic interstitial nephritis,leukemia or lymphoma infiltration Granular cast ATN (muddy brown), glomerulonephritis, vasculitis, interstitial nephritis Ocult blood hematuria,hemolysis,rhabodomyolysis 26

14 c Urinary index prerenal failure tubular necrosis Urinary sodium <20 >40 Urine osmolarity >500 <350 Urine/plasma urea >8 <3 Urine/plasma creatinine >40 <20 Urine/plasma osmolarity >1.5 <1.1 FeNa <1 >2 Renal failure index <1 >2 Renal failure index=[urinary sodium] x [lasma creatinine] /urinary creatinine. limitation:diuretics, acute on chronic renal failure 急性腎衰竭的處理 治療原發疾病 Do no harm 維持適當體液狀態 ( 避免脫水 ) 避免腎毒性藥物 飲食 : 限蛋白含量, 低鉀 低鎂 低磷 限鈉及水 楊桃 腎臟替代療法 :Renal replacement therapy 28

15 A.(>6 to 6.5 meq/l) 緊急處理 EKG calcium gluconate bolus glucose and insulin Kayexalate hemodialysis 高血鉀 B.Tall T wave(ii, III V 2 -V 4 ;T>R in any lead) QRS widening & P-R interval shortening sine wave 29 B. 飲食中鉀限定小於 50meq/day C. 其他如盤尼西林 G 鉀, 磷酸鉀, 乳酸林格氏液 D. ACE-I,Baktar,NSAID, COX-2 inhibitor,digoxin,, CsA / Tacrolimus, non-selective β-blocker, spironolactone, heparine 30

16 腎臟替代療法 : Indication( 什麼情況需要透析 ) 1. fluid overload 肺水腫 2. Hyperkalemia 內科治療無效時 3. Metabolic acidosis PH<7.2 PH<7.2,HCO3 HCO3 < 10meq/L 4. uremic complications --pericarditis --encephalopathy, convulsion,neuropathy neuropathy --bleeding 5. Acute uric acid nephropathy 6. Oliguria (< ml/day) 31 腎臟替代療法種類 : 腹膜透析 Peritoneal dialysis 間歇式血液透析 Intermittent hemodialysis 連續性腎臟替代療法 Continuous renal replacement therapy: -slow continuous ultrafilltration CAVH / CAVHD / CVVHDF CVVH / CVVHD / CVVHDF Hybrid dialysis 32

17 33 Continuous renal replacement therapy(crrt) 連續性腎臟替代療法 適應症 急性腎衰竭合併心臟衰竭 急性腎衰竭合併腦水腫 急性腎衰竭合併高代謝率需大量點滴輸液或全靜脈營養 急性腎衰竭合併低血壓 34

18 Hybrid dialysis 35 Hybrid therapies in ICU Designed for patients hemodynamically unstable (ICU). Extended time to increase the dose of dialysis Low efficency on solute clearences Conventional HD machines. Hybrid therapy between IHD and CRRT. Blood pump speeds (QB) and Dialysate flow (QD) intermediate between IHD & CRRT.

19 Hybrid therapies in ICU EDD ( Extended daily dialysis ) SLEDD ( Slow Low-efficient Daily Dialysis ) SLEDD-f (Sustained Low-efficiency Daily Diafiltration )

20 緩慢低效率每日血液透析過濾治療 Sustained low efficiency daily dia-hemofiltration (SLEDD-f) 適應症 : 1. 生命徵象不穩定, 且必要為接受過透析治療者 2. 嚴重心臟衰竭合併肺水腫之病患 3. 開心手術數日內併發急性腎衰竭之病患 Chronic kidney disease 40

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22 What can we do for Pt with CKD? Ensure the natural course of CKD Prevent long term complication from CKD and slow down the worsening rate Preparation for access for renal replacement therapy 43 long term complication from CKD Renal anemia Renal bone disease (osteodystrophy) Dyslipidemia Avoid drug: baclofen, star-fruit 44

23 Interventions to slow the progression of kidney disease should be considered in all patients with chronic kidney disease Strict glucose control in diabetes Strict blood pressure control Angiotensin-converting enzyme inhibition or angiotensin-2 receptor blockade. Dietary protein restriction Lipid-lowering therapy Partial correction of anemia. 45 Renal Replacement Therapy for ESRD Intermittent hemodialysis Peritoneal dialysis Transplantation

24 conclusion 確立腎衰竭診斷 辨別急慢性 治療 :general and RRT 47