獸醫(yī)師貓傳染病專題等多個文件-015esavs-貓病ii7急性腎衰

AcuteRenalRoswitha2yrs,fBengalcat?Delilah“,2yrs,孟加拉貓”Delilah“，2歲，雌cesareansection3daysago三天 txwithamoxicillin-clavulanicacidand術(shù)后阿莫西林克拉維酸鉀和卡洛芬治didwelluntilyesterdaykittensdon′tdrinkDelilahanorexicDelilahvomitedtwicewith Bengalcat?Delilah“,2J,phys.depressed,temp.35,7°C,MM沉郁，體溫35.7°C，黏膜蒼periph.lnn.WNL,HR200/min,RR體表 dehydration5%painfulonabdominalpalpationshinyhaircoatgoodBCS被毛有光澤，BWqueen4kg母貓體重：4BWkittens:130gand120g幼貓體重：130克和120CBCDelilah血常規(guī)RBC40-WBCHct0,3-MCV40-180-lymphocytes1-segm.neutroph.3-bands0-retikulocytes42.000/μl→regenerative42.000/微升→MicrocytosisSerumchemistry生化700-580-585-6190-2426-5357-5,263,7-2,630-Venousbloodgas–血氣－電解CO2mm~Phosphat0,97-PotassiumCalcium++ChlorideUrinalysis尿檢+++Epithelial0-0-3-Problemlist問題列表proteinuria,glucosuria,pyuria,→acutekidneydisease,acuteAclinicalconditioninwhichthekidneyssuddenlyandoftencatastrophicallyfailtomeettheirexcretory,metabolicandendocrineneeds MRapidonsetofazotemiaandMSuddenincreaseordecreaseinwaterintakeandAcuterenalfailuredegenerationornecrosisoftubularcells,lossoftightjunctionsandbackleakageoftubularfluidintointerstitialtissuearterialvasoconstrictionand ysis?尿檢+++Epithelial0-0-3-Typicallab.abnormalitiesinacuterenalfailure急性腎衰 檢查中的典型發(fā)Granularorhyalinecasts(30–40%ofAcuterenalfailurepredisposingconditions20%ofcardiacoutputforrenal20％的心臟輸出給予腎臟灌highmetabolicrateofproximal近球小管的高新陳代謝bigsurfaceareaofglomerulumaccumulationofcertaintoxinsintubular腎小管細胞內(nèi)某些毒素的積formationoftoxicsubstancesviametabolismofsubstates(e.g.(例：乙二醇PhasesofAcuteKidney急性腎損傷的階InitiationExtensionMaintenanceRecoveryPhasesofAcuteKidney急性腎損傷的階Initiationofparenchymaldamage實質(zhì)損傷開始ExtensionExtensionofparenchymaldamage實質(zhì)損傷擴大letalletalinjury致Subletalinjurymaintenancemaintenancedweeks)保Recovery(weeks-恢復(fù)（數(shù)周－數(shù)月FullFullchronnephropathy慢ClassificationofAKI–急性腎損傷的分serum-－肌urine尿生Loss失permanentrenalfailurefor>4性腎衰>4(=Endstagerenal腎病末permanentrenalfailurefor>3性腎衰>3個ClassificationofAKI–急性腎損傷的分Serum-Urine尿生－肌風1,5–2foldincreaseincomparedtobasic肌酐是正常值的1.5－2<0,5ml/kg/hfor6小于0.5ml/kg/h達6小損2–3foldincreasein肌酐是正常值的2－3<0,5ml/kg/hfor12小于0.5ml/kg/h達12小3foldincreaseincreatinine<0,3ml/kg/hfor24h衰creatinine>4mg/dlwithincrease ≥0,5anuriafor12小于0.3ml/kg/h達24小肌酐是正常值的3倍以上或者肌酐或者無尿達12小大于4mg/dl并伴有0.5mg/dl增Bellomoetal.,ProposedstagingsystemfordogsandcatswithCowgillUrinary尿液生物標mayofferadditionaltoolforearlyrecognitionofkidney可能提供另外的方法來識別早期的腎臟疾earlydiagnosisofkidneydiseaseinassociationwithotherdisorders(D.m.,UTI,hyperthyroidism)與其他疾病有關(guān)的腎臟疾病的早期診斷( Future未來的研AcuteRenalischemiahypoxiaMostcommon最常見的原dogsInfektions （鉤端螺旋體catsAcuteRenalFailureRiskfactors急性腎衰的風險因

AcuteRenalFailure急性腎衰病因drugs(aminoglykosides,NSAIDs,咪唑硫嘌呤

AcuteRenalFailure急性腎衰病因ethyleneglycollilies(cats)百合花（貓raisinsandgrapesvitaminD petfood(melamine,cyanuric 胺，三聚酸NSAIDnephrotoxicityindogsand犬貓的非皮質(zhì)激素類抗炎藥腎毒primarilyin2settings兩 togetherwithotherriskfactor與其他風險因素一NSAIDs非皮質(zhì)激素類抗炎藥毒hemodynamicallymediatedacuterenal血液動力學介導的急性腎acuteinterstitialnephritis/nephrotic急性間質(zhì)腎炎/腎病綜合renalpapillary 壞NSAID非皮質(zhì)激素類抗炎藥分non-selectiveNSAIDs非選擇性非皮質(zhì)激素類抗炎藥（阿司匹林COX-2preferentialNSAIDs(Carprofen,環(huán)氧化酶2（卡洛芬，美洛西康COX-2selectiveNSAIDs(Coxibs)(dogs:deracoxib,firocoxib,mavacoxibcats/dogs:robenacoxib)環(huán)氧化酶2選擇性非皮質(zhì)激素類抗炎藥（考昔類NSAIDsandthe非皮質(zhì)激素類抗炎藥和腎decreased↓GFR24–48hpostadministrationofcarprofenandketoprofeninnormaldogsForsythetal.,2000,noalterationinGFRaftermeloxicaminhealthyandconsciouscats(iohexolclearance)健康和神志清醒的貓給予美洛西康后，腎小球濾過率沒有改Godmanetal.,2009,環(huán)氧化酶2構(gòu)noobviousadvantageregardingrenalside關(guān)于腎臟副作用沒有明顯優(yōu)COX-2inhibitorsalsoinducerenal環(huán)氧化酶2抑制劑也誘導腎constitutiveCOX-2inthe環(huán)氧化酶2在腎臟中的結(jié)avoidanceofCOX1-suppression避免抑制環(huán)氧化酶↓GIsideeffects(GIirritation/ulceration, et降低胃腸道影響（胃腸道刺激/潰瘍，血小板抑制advantageregardingrenalsideeffectsnot關(guān)于腎臟副作用似乎沒有優(yōu)nodifferenceinanti-inflammatoryor gesicefficacybetweenCOXnon-selectiveandCOX-2selective抗炎或者鎮(zhèn)痛效果在環(huán)氧化酶非選擇性和選擇性環(huán)氧化NSAIDToxicity非皮質(zhì)激素類抗炎藥毒dogsprobablymoresusceptiblethanunipapillarykidney widedistributionofCOX-2indogsincludingrenalinterstitial犬環(huán)氧化酶2的廣泛分布包括 間質(zhì)細normallylowCOX-2levelsthatgreatlyincreasewith正常情況下低濃度環(huán)氧化酶2在容量損耗時能大量增COX-2constitutivelyexpressedatseveral環(huán)氧化酶結(jié)構(gòu)表達于各個位Cats?貓Possible可能的解dosage劑量inappropriate不正常的給 與麻醉相obesity肥胖ISFM/AAFP lowriskforAKI mendationsare如果Guidelinesfor用于貓的指導方riskfactorsforrenaltoxicityinhumanspresumedtoapplyincatsdehydrationcongestiveheartfailureoccultrenaldiseaseitantdrugtherapy(diuretics,ACEGuidelinesfor用于貓的指導方monitoringofBUNandCreatinine(pretxandafterstartoftx)alwayswithfood–withheldiffoodisnot總是和食物一起–如果不吃食則不給riskfactorsaddressedbeforetxnotusedincatswithrenalandcardiac有腎病和心臟病的貓不使incatswithstablekidneyClinical臨床結(jié)GIsymptomsrespsymptomshematologicabnormalitiesneurologicsignsLilyintoxication百合catstoxinunknowninleafsandflowers在葉子和花alsotoxicforthepancreas對于胰腺 Lilyintoxication百合MEarlysignswithinhours早期指征（數(shù)小時內(nèi)MGIsigns胃腸MSalivation流MWithin5days5天內(nèi)Mrenomegaly腎腫大Lilyintoxication百合MEarlyrecognitionMGastrointestinaledecontaminationMWithin6hours→↓riskfortubular6小時內(nèi)→降低腎小管壞死的風MMorethan18hours–tubularnecrosis長于18小時－腎小管可能壞MFluidtherapyMIfoliguricoranuric→Ethyleneglycolintoxication乙二 診metabolicacidosis(withincreasedanion代謝性 （增加的陰離子隙renalazotemiahypocalcemiacalciumoxalatmonohydrate草酸鈣一水合物結(jié)EGlevelsinbloodor乙二醇在血液和尿液的濃hyperechoickidneysonB超腎臟回聲增Hyperechoic腎臟回聲增Ethyleneglycolintoxicationclinicalsigns乙二 臨床指shortlyafteringestion(1h):ataxia,staggering立刻咽下后（1小時）：共濟失調(diào)，蹣跚步after12–24hrs:cardiopulmonary12－24小 after1to3days:signsofrenalfailure(oftenoliguricand1到3天后：腎衰指征（經(jīng)常少尿和致命Ethyleneglycolintoxication乙二 within2hrsafter inducevomitingactivatedcharcoalenemasEthyleneglycol Antidot–乙二 解毒劑－甲吡within32hrsafter Fomepizole(4-Methylpyrazol)5%dog:initially20mg/kgslowlyi.v首先20mg/kgafter12hrsand24hrs15mg/kg12和2415mg/kgafter36hrs5mg/kgi.v36小時后5mg/kgcat125mg/kgi.vinitially首先125mg/kgthen3times32mg/kgq12hEthyleneglycolintoxicationAntidot–Ethanol乙二 解毒劑–乙ethanol2020dog:5,5ml/kgq4hrsi.v.(55,5ml/kgq6hrsi.v.(4犬：5.5ml/kg每4小時靜脈給藥（共5次5.5ml/kg每6小時靜脈給藥（共4次cat:5ml/kgq6hrsi.v.(5treatments)5ml/kgq8hrsi.v.(4treatments)貓：5ml/kg每6小時靜脈給藥（共5次5ml/kg每8小時靜脈給藥（共4次sideeffectsofethanolCNSdepression,中樞神經(jīng)抑制，呼吸抑Bilateralureteral輸尿管兩側(cè)堵Bilateralureteral輸尿管兩側(cè)堵Clinicalconsequencesof急性腎損傷的臨床結(jié)↓clearanceofsubstances(BUN,creatinine,phosphate,drugs,etc.)物質(zhì)的清除率減少（尿素氮，肌酐，磷酸鹽，藥物等regulatoryorgan(fluidbalance,electrolytesandbase,blood調(diào) endocrineorganTherapeuticguidelinesfor急性腎衰的治療指導方stopfurthertoxinexposure停止進一 在毒物restorationoffluiddeficitsmonitoringofurineoutputantidote(ethyleneglycol)解毒（乙二醇symptomatictherapyadequatenutritionAcuterenalfailure急性腎衰的治discontinuealldrugswhicharepossibly停止所有可能有腎毒性的藥stopresorptionof停止腎毒性物質(zhì)的吸Acuterenalfailure急性腎衰的治restorefluiddeficits補充correctdehydration糾optimizevolumestatus(Ringer-Lactat,isotonicNaCl,Normosol（乳 液，等滲生理鹽水 液 ectrolytebalanceacid-baseCalculationoffluid計算液體需要maintenance+deficit+additionalmaintenance:40-60mL/kg/24hor1-2ml/kg/h維持：40-60ml/kg/24h或者1-2ml/kg/hdeficit:calculationbasedonseverityofadditionallossesurineGItract,….)Restorefluid補充液體不example:4kgcat,estimatedtobe8%Calculatedeficit44kgx810x0,080,32amountoffluidinliters的液體量Addmaintenancefluids22fora4kgcat8ml/h對于4kgRestorefluid恢復(fù)液體不replacecalculatedfluidvolumeover2-6在2-644hourwindow320ml/4按4小時計80ml/h+8ml/h→88reassesspatientassessdiuresisFluidtherapyMaintenance輸液治療維持量的需healthyoliguricpolyuricurin健康動物，urine少尿動物，urine多尿動物，1-2<>2-4Insensible無感損202020尿液損4010160Total總體需6030180Monitoringofurine監(jiān)測尿生成indwellingurinarycatheterandclosed留置導尿管和封閉系bodyweightMeasurementof?Insand輸入和排出的測avoidunderestimationoffluid避免低估液體的需toavoidvolume避免液體過Inductionof誘導利onlyifdiuresisisinadequateafterrestorationofhydrationandvolumefurosemide(2-4mg/kgq6-8（2-4mg/kg每6-8小時dopaminDTI(1-3mannitolDTI(0,5–1g/kg甘露醇衡量靜脈給藥（0.5-1g/kgCVPin貓 靜脈betterassessmentofintravascularvolumecardiacfunctionpreventionofoverhydration(CVP<7mm 靜脈壓<7mm Mcentralvenous MtipjustatbeforerightatriumMmanualorelectronicdeviceFurtherassessmentofvolumestatus容量數(shù)據(jù)的進一步評 靜脈Clinicalsignsof補液過量的臨床指increasedlungsoundstachycardiarestlessnesschemosisnasaldischargeSupportive支持治TherapyofGIsymptomsantiemeticse.g 止吐藥，例：胃復(fù)H2-Blocker,e.g.ranitidine,H2受體阻斷劑，例：雷尼替丁，法莫替Antibiotics(Leptospirosis,抗生素（鉤端螺旋體病，腎盂腎炎HypertensionCa++-channelblockers(amlodipin)鈣離子泵阻斷劑（氨氯地平ACE-inhibitors(e.g.血管緊張素轉(zhuǎn)化酶抑制劑（苯那普利NUTRITIONvitalparameters(HR,RR,T,BW,blood生命體征（心律，呼吸率，體溫，體重，血壓urineproductionelektrolytes(sodium,potassium,calcium,電解質(zhì)（鈉，鉀，鈣，磷serumchemistry(BUN,creatinine,TP, urinalysistoxins(18/32cats)(Lilyingestion9,NSAIDs4,ethyleneglycol2,misc.3)(18/32貓攝入百合9非皮質(zhì)激素類抗炎乙二2,prob.pyelonephritis(10/32)疑似腎盂腎炎ischemia(anesthesia2,hypovolemia17/32cats53 17/32貓（53%）(9/17withand8/17withoutazotemiaafter(9/17伴有氮血癥8/17沒有氮血癥10/32euthanized5/32died10/32安negativeprognosticparameter預(yù)后不良potassiumalbuminandbicarbonatoliguria/anuria少尿/withoutprognosticinfluence對預(yù)后無initiallevelsofBUNandcreatinine“Allnon-oliguriccatssurvived,andallcatsthatdiedwereanuricoroliguric.” PrognosisSurvivalrate3725/70幸存率37negativeprognostic 預(yù)后不良的因↑age↓bodytemperatureon↓albumin,↓LDHand↓glucoseon nodecreaseinBUNandcreatininewithin3nosignificantinfluenceonprognosis對預(yù)后沒有明顯影severityinBUNandcreatinineincreaseatLeeetal.,JVIM?Delilah“wholebloodtransfusion(Hct12%→21全血輸血（血細胞比容Txofdehydrationover2to6治療脫水超過2-6小Txofmetabolic治療代謝性urineproduction?Delilah“symptomatictherapyforGIerosions/ulceration(H2blocker,sucralfat,maropitant)胃腸道腐蝕/潰瘍對癥治Follow-up追蹤daydaydayBUNHctCauseofAKIinDelilah急性損傷的原ARF–急性腎衰－治atleast5to6daysofintensive至少5到6天強化治reductionofi.v.fluidsifdiuresisisadequate如果利尿充足減少靜脈輸液，并BUNandphosphatlevelsdecreasegradualdecreasefluids(25%pernovomitinganddiarrhea沒 腹clinicalimprovementoftheARF–急性腎衰－治noresponsetofluidtherapyand對于輸液治療和利尿沒有反→considerhemodialysisorperitoneal In