肾替代性治疗大全.ppt

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Renal Replacement Therapy (RRT) 腎替代性治療 By R4董國盈 Acute Kidney Injury (AKI) [Acute Renal Failure ARF] Prevention Identification of high-risk patients for pharmacologic agents-induced nephrotoxicity iodinated radiocontrast medium, NSAIDs Aggressive surveillance for nephrotoxin-induced renal dysfunction cisplatin, amphotericin B, aminoglycoside Use of volume expansion in selected clinical settings Hyperpigmenturia: hemoglobinuria, myoglobinuria Crystaluria: uric acid, acyclovir, methotrexate, sulfonamides Minimalization of catheters use to avoid nosocomial sepsis Etiology Treatment Correct postrenal factor Correct prerenal factor Treat underlying sepsis Stop nephrotoxic drugs Guide of Volume Expansion CVP 8-14 cm H2O PAWP 12-16 mmHg Urine output 0.5-1.0ml/kg/hour Weighing the patient daily Insensible water loss from the skin and respiratory tract (500 ml/day) Conservative Measurement Fluid balance Careful monitoring of I/O and body weight Fluid restriction (usually less than 1 L/day in oliguric ARF) Total intake urine output + extrarenal losses Electrolytes and acid -base balance hyperkalemia hyponatremia Keep serum bicarbonate 15 hyperphosphatemia Treat hypocalcemia only if symptomatic Conservative Measurement Uremia-nutrition Restriction protein but maintain caloric intake Carbohydrate ≥ 100gm/day to minimize ketosis and protein catabolism Drug Review all medication, Stop magnesium-containing medication Adjusted dosage for renal failure, Readjust with improvement of GFR Dietary modification Total caloric intake– 35~ 50 kcal/kg/day to avoid catabolism Salt restriction– 2~4 g/day Potassium intake– 40 meq/day Phosphorus intake– 800 mg/day Renal Replacement Therapy Indications for Renal Replacement Therapy Prophylactic dialysis: BUN 80-100 mg/dl , creatinine 8-10 mg/dl Volume overloading with refractory to diuretics Pulmonary edema Hyperkalemia 6.5 mEq/l Severe metabolic acidosis 7.1 Uremic pericarditis Uremic encephalopathy: coma, seizure

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