核心課程編號 :B37 腎衰竭 陳金順醫師 / 蘇士傑醫師 102 年 03 月 26 日第四版王涵恩醫師 1041015
學習目標 PGY 知識 1. 急性腎衰竭及慢性腎衰竭的鑑別診斷 2. 慢性腎臟疾病持續進行的因素及防治 3. 腎切片的處置 UGY 知識 1. 急性腎衰竭病因 2. 急性腎衰竭的自然病史 初步評估及治療 併發症 3. 慢性腎病的常見病因 4. 慢性腎衰竭導致次發性副甲狀腺機能亢進及 骨病變 5. 慢性腎衰竭導致貧血的病理生理學 6. 尿毒症的病態生理學及臨床表現 7. 腎衰竭的診斷流程 8. 腎衰竭相關的實驗室檢查 腎切片及影像檢 查 : 檢查時機及判讀 9. 血液透析及腹膜透析的基本原理及併發症 10. 高血壓 糖尿病及高血鉀症的處理 技能 1. 腎衰竭相關的病史詢問 2. 腎衰竭相關的身體檢查
ITE 考題
急性 V.S. 慢性腎衰竭 Acute Renal Failure (ARF): a.abrupt onset b.potentially reversible Chronic Renal Failure (CRF): a.progresses over at least 3 months b.permanent- non-reversible damage to nephrons
急性腎衰竭 Acute Renal Failure 定義 : 腎功能急速 ( 幾小時 幾天到幾星期 ) 下降, 因而產生症狀或併發症 氮血症 (Azotemia): 血中尿素氮 (BUN) 上升, 常合併肌酸苷 (Creatinine) 昇高 寡尿 (Oliguria):<400 ml/day 或 < 20 ml/hr 無尿 (Anuria): <100 ml/day
急性腎衰竭之病因
Acute Renal Failure Pre-Renal Azotemia Intrinsic Causes Post-Renal ( 含 Intratubular obstruction) Acute Tubular Necrosis (ATN) Interstitial Nephritis Acute GN Ischemia (Renal hypoperfusion) Nephrotoxin Vascular 急性腎衰竭的鑑別診斷
腎衰竭併發症 腎臟功能喪失時, 會導致 : 水份 鹽份累積在體內, 造成水腫 高血壓 鉀離子排不出, 造成高血鉀, 嚴重時可能發生心律不整 甚至致死 排酸功能變差, 誘發酸中毒 代謝的廢物無法排出, 造成尿毒症 造血功能喪失, 產生貧血 磷酸根不能排出, 引起血鈣降低, 造成骨骼病變
Probable Causes of Acute Renal Failure Based on the Findings of the History History Review of systems Pulmonary system Sinus, upper respiratory or pulmonary symptoms Cardiac system Symptoms of heart failure Intravenous drug abuse, prosthetic valve or valvular disease Gastrointestinal system Diarrhea, vomiting or poor intake Colicky abdominal pain radiating from flank to groin Genitourinary system Symptoms of benign prostatic hypertrophy Musculoskeletal system Bone pain in the elderly Trauma or prolonged immobilization Skin Rash Constitutional symptoms Fever, weight loss, fatigue or anorexia Past medical history Multiple sclerosis, diabetes mellitus or stroke Past surgical history Recent surgery or procedure Medication history ACEI, NSAID, antibiotics or acyclovir (Zovirax) Probable causes of acute renal failure Pulmonary-renal syndrome or vasculitis Decreased renal perfusion Endocarditis Hypovolemia Urolithiasis Obstruction Multiple myeloma or prostate cancer Rhabdomyolysis (pigment nephropathy) Allergic interstitial nephritis, vasculitis, SLE, atheroemboli or TTP Malignancy or vasculitis Neurogenic bladder Ischemia, atheroemboli, endocarditis or exposure to contrast agent Decreased renal perfusion, ATN or allergic interstitial nephritis
Probable Causes of Acute Renal Failure Based on the Physical Findings Physical examination Vital signs Temperature Blood pressure Weight loss or gain Mouth Jugular veins Pulmonary system Heart Abdomen Pelvis Rectum Skin Probable causes of acute renal failure Possible infection Hypertension: nephrotic syndrome or malignant hypertension Hypotension: volume depletion or sepsis Hypovolemia or hypervolemia Dehydration Hypovolemia or hypervolemia Signs of congestive heart failure New murmur of endocarditis or signs of congestive heart failure Bladder distention suggesting urethral obstruction Pelvic mass Prostate enlargement Rash of interstitial nephritis, purpura of microvascular disease, livedo reticularis suggestive of atheroembolic disease, or splinter hemorrhages or Osler's nodes of endocarditis
高危險群病人 High-Risk Setting
危險因子 Risk Factors
異常及診斷流程 急性腎衰竭 Acute renal failure FE Na Urine osmolality Urine casts
急性腎衰竭與寡尿的診斷流程 Acute Renal Failure(oliguria) Acute on CRF Pre-Renal Azotemia Intrinsic Causes Post-Renal ( 含 Intratubular obstruction) Acute Tubular Necrosis (ATN) Interstitial Nephritis Acute GN Ischemia (Renal hypoperfusion) Nephrotoxin Vascular 急性腎衰竭的鑑別診斷
相關檢驗及檢查 急性腎衰竭之診斷
慢性腎衰竭之病因
Signs & Symptoms of CKD
尿毒症的病生理與臨床表現 腎臟功能喪失時, 會導致 : 水份 鹽份累積在體內, 造成水腫 高血壓 鉀離子排不出, 造成高血鉀, 嚴重時可能發生心律不整 甚至致死 排酸功能變差, 誘發酸中毒 代謝的廢物無法排出, 造成尿毒症 造血功能喪失, 產生貧血 磷酸根不能排出, 引起血鈣降低, 造成骨骼病變
Pathophysiology of CKD Progressive destruction of nephrons leads to: a. Decreased glomerular filtration, tubular reabsorption & renal hormone regulation b. Remaining functional nephrons compensate c. Functional and structural changes occur d. Inflammatory response triggered e. Healthy glomeruli so overburdened they become stiff, sclerotic and necrotic
Structural Changes of CKD Epithelial damage Glomerular and parietal basement membrane damage Vessel wall thickening Vessel lumen narrowing leading to stenosis of arteries and capillaries Sclerosis of membranes, glomeruli and tubules Reduced glomerular filtration rate Nephron destruction Healthy Glomerulus Damaged Glomerulus
Stages of Chronic Kidney Disease
CKD and sonogram Kidney sonogram common finding 1. Decreased bilateral renal size 2. Decreased in cortex thickness 3. Irregular cortex surface 4. Increase cortex echogenicity
Patients in stge 1 to 4 Treatment of CKD Reduce risk factors for progression (hypertension, diabetes) Provide interventions that delay progression Management of secondary complications fluid and electrolyte abnormalities, anemia, hyperphosphatemia, hyperparathyroidism, metabolic acidosis, malnutrition Renal replacement - hemodialysis, peritoneal dialysis
CKD and hyperparathyroidism
FGF23 parathyroid interaction in CKD
Pathogenesis of Renal Anemia EPO deficiency Hemolysis Absolute iron deficiency Functional iron deficiency Folic acid deficiency Carnitine deficiency Chronic inflammation Aluminium intoxication External blood loss Drugs Hyperparathyroidism with myelofibrosis Bone-marrow suppression induced by retained toxic metabolites
腎臟切片適應症 原因不明之腎病症候群 原因不明或少尿期病程太長之急性腎衰竭 不明原因且持續蛋白尿 因為腎絲球腎炎所引起之快速進行性腎衰竭 反覆發作且併有蛋白尿, 腎絲球性血尿或兩者同時存在且原因不明之腎臟疾病 追蹤腎臟移植後之排斥情形不明原因之移植腎功能衰退時 全身系統性疾病懷疑併有腎侵犯時之診斷
腎臟切片禁忌症絕對禁忌症 體質有出血傾向或凝血機能障礙之患者 ( 服用抗凝血藥物需停藥一周以上 ) 病人無法合作 病人只有單一腎臟 高血壓控制不良者相對禁忌症 極度肥胖 兩側腎臟萎縮變小 水腎 腎膿瘍 腎盂腎炎或腎臟感染 惡性腎臟腫瘤或巨大的腎囊腫 有腎血管炎合併血管瘤
腎臟切片術後照顧 需在病床上躺臥至術後至少 6 小時 術後觀察排尿情形, 通常有血尿, 一至三天內會自行消失, 若症狀持續, 必要時追蹤超音波檢查 切片側可能會有腰痠或不舒服的感覺, 在數天內通常會消失, 若症狀持續, 必要時追蹤超音波檢查 極少數病患會有血壓降低甚至休克的情形發生 大多是太緊張使副交感神經亢進, 血管擴張而使血壓下降, 只需支持性治 但需要特別注意的是, 低血壓是否是因為產生大量內出血所致的休克, 此時就需緊急處理 術後 7 天內避免劇烈運動 衝撞 搬抬重物 或劇烈咳嗽 二個月內應避免劇烈運動或提重物, 以預防穿刺傷口出血 其他可能併發症 : 腎周邊血腫 出血 感染 神經損傷
CKD 血壓控制 Target blood pressure 130/80mmHg Lifestyle modifications + pharmacological therapy Cacium channel blocker Central alpha-2 agonist ACEI / ARB Diuretic B-blocker (if no contraindication)
口服血糖藥於慢性腎臟病之使用
高血鉀處理
腎臟替代治療 Renal Replacement Therapy 血液透析 (Hemodialysis) 腹膜透析 (Peritoneal dialysis) 腎臟移植 (Renal transplantation)
血液透析之原理 擴散 / 廓清 Diffusion / Clearance 超過濾 / 對流 Ultrafiltation / Convection
擴散 / 廓清 Diffusion / Clearance 溶質之自由移動 血中尿毒經透析膜的擴散作用之大小, 與其濃度差 膜的表面積大小 膜之擴散係數有關 膜之擴散係數又由材質 溫度 及介面電荷反應所決定
血液透析 Hemodialysis
血液透析設備 血液透析機 透析器 / 人工腎臟 (Dialyzer; Artificial Kidney) 血管通路 (Vascular access)
血液透析之適應症
緊急血液透析之適應症 A Acidosis E Electrolyte imbalance, esp. HyperK + HyperCa 2+ I Intoxication O Fluid Overload U Uremic symptoms, esp. Encephalopathy, Pericarditis
血液透析之併發症 Hypotension Chest pain Muscle cramping Nausea / vomitting Seizure Disequilibrium syndrome
腹膜透析 Peritoneal dialysis
腎臟移植 Renal transplantation
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