015esavs-貓病專題ii-3尿毒癥性并發(fā)癥

FelineChronicKidneyUremicDipl.ECVIM-CA Diagnosticandtherapeutic診斷和治療identifyunderlyingdiseases+specificrenoprotectivetxtoslowdietarymodification飲食的改antihypertensivetherapy降壓治ACEinhibitors血管緊張素Ⅰ轉(zhuǎn)化酶抑制symptomatictxofuremicclinicalsignsduetoaccumulationofuremic尿毒癥毒素的積累導(dǎo)致臨床癥anumberofmetabolitesresponsible,e.g.PTH,phospate,certainaminoacids,…..canbeexpectedwitha3foldorhigherelevationBUNand可以通過尿素氮和肌酐增長(zhǎng)3倍或者更高H2OandelectrolyteHypo/hyperkalemia低/高鉀血癥MetabolicacidosisEndocrineInsulin 胰島素抵抗 HematologicAnemia WBCdysfunction

Neurologicsigns神經(jīng)癥CNS:lethargy,Uremicencephalopathies GIsigns消化道癥 Nausea,vomiting Hyperacidity,胃酸過多，潰Hypertension高血壓Cardiomyopathies心肌病CongestiveheartfailureGIsignsuremic尿毒癥性口GIsigns消化道癥Panorexia,vomitingstimulationofCRTZbyuremicuremicgastropathyhyperacidityrenalgastrinexcretion)胃酸過多癥（腎胃泌素分atrophyglandularcellsuremicvasculitis尿毒癥性血管mucosaledema粘膜水backdiffusionofgastricacid胃酸向后擴(kuò)uremicenterocolitisPantacidicsPH2blocker(Ranitidin,PH2阻滯劑（雷尼替丁，法莫替丁Omeprazol0,5–1mg/kg0,51mg/kgAntiemeticsMetoclopramidMaropitant胃復(fù)安，H1-blockerH1appetitanregendeMedikamenteCyproheptadin(1-4mg/catSIDorBID)Mirtazapin(1/5Tbl15mgq72hrsfeedingtubefluidlossand體液流失和脫ifPUisnotcompensatedbyPDinadaquatenotenoughwatersourcesadditionallossesviatheGIConsequencesof脫水hypovolemia血容量過decreasedkidneyperfusion腎臟的灌注降progressionofnephropathy腎病的發(fā)Fluidtherapyi.v.fluids(pufferedvolumereplacementincreaseoralfluiduptake增加口服液fluidviafeedingtube通過飼管喂液metabolicacidosis代~10%ofcatsinstageIIIof~10%處于慢性腎臟疾病III~50%ofcatsinstageIIIof~50的貓?zhí)幱诼阅I臟疾病IIIElliotetal.,JSAPanorexia,lethargy,nausea,protein Therapykidneydietsodiumbicarbonateorallyorini.v.potassiumcitrateMetabolicacidosis代3413,6-16,5reducedabilityofthekidneytoexcretereducedfiltrationofphosphatesandlossof20to30%ofcatswith20to30pathomechanism?clinicalconsequences:Lethargymuscularweakness(K+<3PD/PUmetabolicácidosisArrhythmiasinterstitialnephritisHypokalemia:低血鉀癥：治supplementationofIVfluidswith靜脈輸液補(bǔ)充oralpotassiuminitially:2-4mmol/cat最初：2-4mmol/catmaintenance維持劑量1-2mmol/catHypokalemia:低血鉀癥：治Serum[K+]<2,1-2,6-3,1-3,6-[K+]inmmol/l68*Notmorethan0,5mmol/kg/hK+的輸液速率不可大于DiBartola:Fluidtherapyinsmallanimalpractice,↑PCa++Phosphate磷酸鹽的滯controlindicated StageIIIVindogsandIIIVtargetPhosphorusconcentrationto Targetrangesfor磷的目標(biāo)范StageII:<1.45mmol/l(4.5階段II1.45mmol/l(4.5StageIII:<1.6 (5.0階段III:<1.6 (5.0StageIV:<1.9 (6.0階段IV:<1.9 (6.0normal

0,97–2,362.5–7,3Monitorevery3to6Monitorevery3to6每3-6月觀察一磷酸鹽的管CKDStagesCKDStagesII–2–62-6Therapyfor高磷酸鹽血癥的治phosphorusrestrictedintestinalphosphatebindingcalciumcarbonat(Ipakitine?腎康)90-150mg/kg/dPOwithaluminiumhydroxid(Ulcogant?)氫氧化10-30mg/kgPOTIDwithsevelamerhydorchlorid30-100drugscanbecombined藥物可以進(jìn)行組allowslowerdosesofeachdrugexceptforcalcium-citrateandaluminiumseveremaystartwithaluminiumthenmovetowardsotherGIphosphorus消化道磷粘結(jié)AlwayswithNotbetween腎性甲狀旁腺機(jī)能亢進(jìn)Pin100%ofdogswith患有慢性腎臟疾病的狗100%發(fā)Gerberetal.,in75.9%ofdogswith患有慢性腎臟疾病的狗75.9%發(fā)Cortadellasetal.,Pin84%ofcatswith患有慢性腎臟疾病的狗84%發(fā)Barberetal.,↑↓↓(VitDreceptor（維生素D受體活化PsuppressiveeffectonparathyroidPregulationofcalciumandphosphorusabsorption(intestine,bone)PimprovedsurvivalofdialysisPantiinflammatoryeffectsPantithromboticeffectsPinhibitionofvascularcalcificationPnegativeeffecton PCalcitriolindogswithCKDStage3and對(duì)患有慢性腎臟疾病3和4期的犬運(yùn)用骨化三Polzinetal.,Pplacebo-controlledstudyP37dogswithCKD37Pcalcitrioldose2.5ng/kg骨化三醇的劑量2.5PdoseadjustedbasedoniCa++andPTHPdose↓ifiCa++>1.45如果iCa++1.45mmol/lPdose↑ifPTH>13如果甲狀旁腺素13pmol/lPmediansurvival365daysfordogsinthecalcitriolgroupvs.250daysfordogreceivingplaceboCalcitriolindogswithCKDStage3and對(duì)患有慢性腎臟疾病3和4期的犬運(yùn)用骨化三Polzinetal.,low-dosecalcitrioleffectiveinnormalizingPTH低劑量的骨化三醇有助于使甲狀旁腺激素水平正常calcitriolsignificantlyreduces骨化三醇大大的減小 Pmediansurvival365daysfordogsinthecalcitriolgroupvs.250daysfordogreceivingplaceborenoprotectiveeffectof骨化三醇有腎臟保護(hù)作用Calcitriolindogswith對(duì)患有慢性腎臟疾病的犬運(yùn)用骨化三requireseffectivephosphorus 高磷酸鹽血高鈣血goodownermonitorCa,iCa,P,PTHandadjustdosage 2,4,在第2,4,8,…周 Ca,iCa,P,PTH以及調(diào)整劑2.5–3.5ng/kg/day(atnightonanempty2.53.5ng/kg/day（夜晚空腹給藥narrowtherapeuticPifcalcitriolinduceshypercalcemiabeforePTHis如果骨化三醇在甲狀旁腺激素正常之前導(dǎo)致了血鈣過Ppulsetherapy:twicedailydosegivenq48脈沖療法：每天兩次的劑量，給予間隔48小PmonitorasCalcitriolin骨化三醇在貓上的運(yùn)用1randomizedcontrolledclinical1組隨機(jī)對(duì)照臨40stablecatswithclinicallystableCKD Polzinetal.,nocleardifferencetoplacebonaturalhistoryofCKDinlong-termCanJVetResHpercalcemiaincatswith慢性腎臟疾病的貓患有高鈣血ionizedhypercalcemiain~30%ofpossible↑c(diǎn)alciumreleasefrombonedueto↑c(diǎn)alciuresisdueto鈣的下降是由于reducedavailabilityofacalcitriolinducedcalciumreceptorofdistaltubularcells(atinterstitialsideofHpercalcemiaincatswith慢性腎臟疾病的貓患有高鈣血treatmentoptions治療選Calcitriol(withnormal tightmonitoringofCa++緊 stopifCa++ 如果Ca++Biphosphonatese.g.alendronate例如 510mg/catonceaweek5–10mg/只貓，每周一次sideeffect:esophagealWhatcausesanemiain什么導(dǎo)致慢性腎臟疾病中的貧impairedRBCproduction紅細(xì)胞生成受iatrogeniccauses醫(yī)源性原bloodloss血液的損HemolysisFactorspromotinganemiaof慢性腎臟疾病中促進(jìn)貧血的因促血紅細(xì)胞生長(zhǎng)素生成受iron 鐵缺acuteandchronicinflammatory急性以及慢性的炎癥條severe嚴(yán)重的甲狀旁腺功能亢aluminiumtoxicityfolatedeficiency葉酸缺decreasedsurvivalofredblood紅細(xì)胞的存活下HormoneReplacement激素替代療binanthumanerythropoetin(rHu重組人促紅細(xì)胞生長(zhǎng)素（rHuEPOveryeffective100U/kg3100U/kg3x/thenAntibodyreactionsto重組人促紅細(xì)胞生長(zhǎng)素的抗體反inabout30%ofdogsand在大約30%的犬hematocrit titerconversionfrom4to20效價(jià)轉(zhuǎn)換從4到20 Indicationsfor重組人紅細(xì)胞生長(zhǎng)素的適應(yīng)hematocrit<20血細(xì)胞比容20clinicalsignsduetoanemia由于出現(xiàn)貧血導(dǎo)致的臨床癥othercausesforanemiaruled-outorcorrectedwithoutadequateimprovement排除或者糾正貧血的其他原因，但是沒有足夠的改Darbepoetinalfa促紅血球生成素similartorHuEPO與重組人紅細(xì)胞生長(zhǎng)素a相BUT但extendedhalf半衰期延等價(jià)的紅血球生成能maybelesstreatmentprotocol治療草案startwith0.25μg/kgSQmonitorHct每 血細(xì)胞比transitiontomaintenancetxwhendesiredHctrangereached當(dāng)紅細(xì)胞比容達(dá)到理想范圍，轉(zhuǎn)變?yōu)榫S持劑Therapeuticgoals治treatmenttargetrange治療目標(biāo)范dogs37–45cats30–40

狗3745貓3040

aimforlowendoftargetrangemaintenancetherapy Vintarget

modifydosageand/orfrequencyasneededto VintargetrangeTransitiontomaintenance過渡到維持劑PCVintargetrange紅細(xì)胞壓積在目標(biāo)范changefrequencytoq2PCVattopoftarget紅細(xì)胞壓積到達(dá)目標(biāo)范圍的頂decreasefrequencytoq3PCVabovetargetrange紅細(xì)胞壓積超過目標(biāo)范discontinuetemporarilybeginagainatlowerExpectedresponse預(yù)targetrangereachedin~3to6在3到6周到達(dá)目標(biāo)范inadequateresponseby812weeks→increasedosageby258-12周反應(yīng)不充分→增加25%劑量Ptargetrangeovershoot→withholddrugfor1week,restartwithlowerdosage超過目標(biāo)范圍→停止用藥一周，PlagtimebetweenadministrationandPdon′tadjustdosetoo不要經(jīng)常調(diào)整劑Pnomoreoftenthanevery3–4不要超過每34Maintenancetherapytypicalmaintenancedosage:0,25–0,5μg/kgevery2–3week常用維持劑量：0,250,5μg/kg，每2-3monitorCBCandHct每 全血細(xì)胞計(jì)數(shù)和紅細(xì)胞比monitorblood血~monthlyduring~q3monthsduring維持治療每3IronSupplementation補(bǔ)veryoftendeficientironstoresin ↑needsforironwithironsupplementationessential(atleastduringPirondextranIM(50–300mg)右旋糖酐鐵肌注（50–300mg）Pdogs10–20mg/kgoncefollowedbyoraltherapywithferrous狗：每次10–20mg/kg，伴隨口服硫酸亞鐵Pcats:50mgIMq3–4Pferroussulfate硫酸亞Pdogs:100–300mg(totaldose)POper狗：100–300mg（總劑量）口服，每天Pcats:50–100mg(totaldose)POper貓：50–100mg（總劑量）口服，每CluesforAntibody抗體形成的提rapiddecline Vwhileonmaintenance當(dāng)維持劑量治療時(shí)，紅細(xì)胞壓積急速下↓inreticulocyte網(wǎng)織紅細(xì)胞計(jì)數(shù)下noresponseto↑dosageandiron對(duì)劑量增加和補(bǔ)充鐵沒有反bonemarrowM:Eratio>骨髓M:EInadequateResponseantibody抗體形failuretorecognizeallcausesfor不能識(shí)別貧血的所有原irondeficiency缺infections(relativeiron（相對(duì)缺鐵Neoplasia腫nutritionaldeficiencies(folate,Long-T