心力衰竭伴肾功能不全的早期识.pptVIP

心力衰竭和肾功能衰竭常常同时存在，而且心力衰竭可引起肾功能衰竭，反之亦然。心力衰竭可直接或通过激活神经内分泌机制导致肾脏低灌注[。联合治疗（例如利尿剂和ACI抑制剂导致肾小球出球小动脉扩张，非甾体抗炎药通过抑制肾小球入球小动脉扩张）可加重肾功能衰竭。起初，肾血流自动调节和肾小球出球小动脉收缩可以代偿肾脏低灌注，但是到了后期肾功能主要依赖肾小球入球血流，因此在严重急性心力衰竭病人常见肾功能衰竭和少尿尿液分析结果受肾功能衰竭的病因影响很大。当肾功能衰竭继发于低血压，尿钠/钾比率小于1急性肾小管坏死的诊断可根据尿钠增加、尿氮浓度减少和尿沉淀物检查结果判断。CriticalCareMedicineandTraumaMedicalManagementofAcuteHeartFailureMaryO.Gray,MD,FAHAAssociateProfessorofMedicineUniversityofCalifornia,SanFranciscoStaffCardiologistandTrainingFacultyDivisionsofCardiologyandClinicalPharmacologySanFranciscoGeneralHospitalmgray@medsfgh.ucsf.eduAcuteDecompensatedHeartFailure.VolumeOverload.Tachyarrhythmias.CardiogenicShockVolumeOverload.Diuretics.VasodilatorsVolumeOverload.Leftventriculardiastolicdysfunction.Riskfactors:LVH,female,age70,hypertension,coronarydisease,diabetes.AcuteHFprecipitants:Pain,anemia,tachycardia,cardiacischemiaorinfarctionDiuretics:loopthiazidespironolactoneDosessufficienttoinducediuresisthatwilloptimizevolumestatusandrelievethesignsandsymptomsofcongestionwithoutexcessivelyrapidreductionsinintravascularvolumethatmayresultinhypotension,renaldysfunction,orboth.Circulation2009;119:e391-e479Diuretics:.HeartFailureClinicalResearchNetwork:NationalHeart,Lung,BloodInstitute.DiureticOptimizationStrategiesEvaluationDOSEStudy—Braunwaldetal.CircHeartFail2009;2:56-62Diuretics:DOSEStudy.Hypothesis1“Lowintensification”furosemide(1xchronicoraldose)ismoreefficacious(withregardtoreliefofsymptoms)andsafer(withregardtochangesinrenalfunction)comparedto“highintensification”furosemidetherapy(2.5xthechronicoraldose)inpatientswithADHF.Diuretics:DOSEStudy.Hypothesis2Continuousinfusiondiuretictherapyismoreefficacious(withregardtoreliefofsymptoms)andsafer(withregardtorenalfunction)when