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心功能不全. (Cardiac insufficiency ). 华中科技大学同济医学院病理生理系. Clinical example. 病史: 患风湿性心脏病 10 余年。近 3 月来出现心慌、闷气 , 伴浮肿、腹胀,不能平卧。

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(Cardiac insufficiency)


Clinical example

103,

, ,, 36/, , 130/, (110/80mmHg)IV6cm


heart failure

()


  • (Cardiac insufficiency )

  • heart failure)


(Causes and predisposing

factors of heart failure)


(Causes)


()

(Impaired myocardium)


()

(Overload for myocardium)


(Predisposing factors)


(Classification of heart failure)


  • (left-sided heart failure)

  • (right-sided heart failure)

  • (whole heart failure)


  • (systolic heart failure)

  • (diastolic heart failure)


(low-output heart failure)

(high-output heart failure)



  • :

(acute heart failure)

(chronic heart failure)


  • :

(mild heart failure)

(moderate heart failure)

(severe heart failure)


(Mechanisms of heart failure)



Ca2+

Ca2+

ATP



1.

(Injuries of myocardial contractile protein)



TNF

IL-1

IL-6

IFN

OFR

NO

ATP

[H+]


2.

(Disorder of myocardial energy metabolism)


O2

VitB1

ATP

(1)

(impaired energy production)

:


ATP:

Ca2+

Ca2+

Ca2+

Ca2+


(2)

(impaired energy utilization)

ATP:

V1 ():

V2 ():

V3 ():

ATPV1 V3


ATP

(3)

(reduced energy reserve)

(CP)

CP


3.

(Impaired excitation-contraction coupling)

Ca2+

Ca2+

Ca2+


(1)Ca2+

  • Ca2+

  • ATP Ca2+

P-PLA

PLA

Ca2+


Ry-

H +

Ca2+

  • Ca2+

    Ca2+

  • Ca2+

Ry-

Ca2+

H +


(2) Ca2+

H+

+

K+

Ca2+

cAMP

ATP

Ca2+


  • 1-

  • K+Ca2+


(3) Ca2+

H+Ca2+,troponinCa2+


4.

(Imbalance growth of myocardial hypertrophy)

  • ,

  • ATP

  • Ca2+


Ca2+

Ca2+

(Impaired myocardial diastolic properties)


Ca2+

Ca2+ATP

Na+ - Ca2+

Ca2+

Ca2+

Ca2+


  • -

ATP

, ,

--p-V


dv/dp

dv/dp

V

dv/dp



(Compensatory mechanisms to cardiac insufficiency)


-


-

  • --


Ag II

ET




1.


(>150/):


0

1.7

2.1

2.2

3.65 m

Lmax

Normal

Frank-Starling

2 .


  • 2.2m

  • 2.2m


3.



,CO

,,


*

*

*

*


ADH

  • ,

()


()

()

()


(Consequences of

the pumping dysfunction)


(syndrome of low output)

:

  • (cardiac output,CO)

  • (ejection fraction)

  • (ventricular filling)

  • (heart rate)


:


  • (syndrome of venous congestion)

  • :

  • (systemic congestion)

  • (pulmonary congestion)


()

(Systemic congestion)

CVP>16 cmH2O



() (Pulmonary congestion)

PCWP>18 mmHg


: (dyspnea)

:


:

  • (dyspnea on exertion)

  • (orthopnea)

  • (paroxysmal nocturnal dyspnea)


:


:

  • ,


:


(Pathophysiological basis of

prevention and treatment

for heart failure )



Clinical example

103,

, ,, 36/, , 130/, (110/80mmHg)IV6cm



1.

2.

3.

4.ATP

5.

6.


Respiratory Failure


PiO2 150mmHg

ventilation

PAO2 100

PACO2 40

gas exchange

PvO2 40mmHg

PvCO2 46mmHg

PaO2 100mmHg

PaCO2 40mmHg


Process of external respiration


PaO2

60mmHg

Hypoxemic PaCO2 I

Hypercapnic 50mmHgII


3000mPaO2 60mmHg

PiO2

PaO2

Everest


ventilatory disorder

1restrictive

1

2

3 RDS

4


2obstructive

dyspnea







0

0

+5

+10

+10

+20

+20

+20

+30

+20

+20

+20

+35

+25

+20

+20

+20

+20

Unit: cmH2O


PaCO2

PaO2

PaCO2

0.863VCO2

VA

PACO2 =


diffusion disorder

1

2

+

PaO2

PaCO2


PCO2( kPa )

PO2

13.33

PaO2

PvCO2

10.67

6.13

8.00

PvO2

5.33

PaCO2

2.67

0.75 s

0

0.50

0.25


10cmH2O

4L

VA

VA/Q

0.8

=

=

Q

5L

3

0.6

- 2.5cm H2O

Ventilation-perfusion imbalance


4L

VA

0.8

=

=

Q

5L

Ventilation-perfusion imbalance

VA Q VA/Q

1

10

3

0.6

3

6


VA/Q 0.8 0.8 =0.8

PaCO2 N

CaCO2 N

1functional shunt

PaO2 ?

CaO2


2

dead space like

?


2

dead space like


1PaCO2

2 ,


anatomic shunt


ARDS


PaO2 60mmHg

30mmHg

PaCO2 50mmHg

80mmHg

COPDPaO2 pH

PaCO275-110mmHg

III


Hepatic insufficiency








  • -6-



Ald


ADH

ADH





  • intestinal endotoxenia

1

1

2,

2


1.

2.

3.ECICAM-1

4.

,EC




Hepatic encepholopathy

:


=



ammonia intoxication hepothesis


  • 80%




ATP


6-

6-

NAD

NAD

NADH

NADH

A

A

-

+

+

ATP

NAD

NADH

-

-

-

NADH

+NH3

NAD

+NH3

ATP

1.

2.


  • 1. 20%

  • 3.


False neurotransmitter hepothesis





CHOHCH2NH2

CHOHCH2NH2

HO

HO

CHOHCH2NH2

CH2CH2NH2

HO

HO

HO


Hepatic failure

Nomal


Plasma amino acid imblance hepothesis


  • BCAA/AAA (decrease from 33.5 to 0.6 1.2)

  • BCAA/AAA


BCAA

BCAA/AAA

AAA

/

AAA


FNT

FNT

5-

5-

-

-

FNT

5-



  • 1. +

  • BCAA/AAA

  • 3. + BCAA


GABA

GABA hepothesis


  • GABA

  • GABA


Cl-

Cl-

Cl-

GABA

Cl-


GABAGABA



BCAA/AAA

(+)

GABA

(+)

GABA

GABA

-




Chronic Renal Failure


Chronic Renal Failure



Causes of CRF: Obstruction/reflux



,

1.

2.

3.

4.

CRI


30%

25% 30%

20%25%

20%


?

  • ,

  • : , , NPN


GFR


CRI,,,,?


1.

Intact nephron Hypothesis

GFR

GFR


GFR

2. Trade-off Hypothesis

PTH


3. Glomerular HyperfiltrationHypothesis


4.-

CRI

--


CRI


()

1.:

Normal: 1500ml/

1000ml/ 500ml/

nocturia),

polyuria) >2000ml/d,

<400ml/d


2. , 1.008-1.012N1.002-1.035

3.

,

,


()

1.: azotemia)

GFR

NPN>40mg/dl


GFR BUN

40% Normal

20% 200mg/dl

=Cr*/Cr

:BUNCr


2.

AG

CRI:

(,)

AG

CRI:


3.

:

,

,


CRI

,

,,


GFR

VitD3


GFR

PTH


CRI


GFR

renal hypertension

-

PGA2 E2

-


1.25-(OH)2VitD3

GFR

PTH


Uremia


Uremia


1

2


PTH


-

CRF


PaCO2

PaCO2


1 ()

(1)

(2)

(3)


2.

( )

PTH


PTH


1.

.


2.

ATP

-

-


3.

1

2

3


4.500-5000

1

2

3

4


5.PTH

1

2

3

4



XX 68 80118

:,3,,10.:3,,,,.,,.

..,,,,,,,,,,150ml.:13,. :,,T37,R 130/min,,P 90/min,

Bp 160/90mmHg,,,,,,.:RBC 200/cmm,Hb 6g%,12.8/cmm,

92.2mg%,11.2mg%,

K+ 5.9%mEq/L,Na+ 123mEq/L,Ca2+ 7mg/L,7mg/dL,

1.010,(++)


  • ARF

  • ?

  • ,?

  • ?

  • 7.

  • 8. ,,,

  • 9. ?

  • 10.,

  • 11.

  • 12.,



Renal Insufficiency(RI)

Renal failure(RF)





  • H+ K + NH3


  • 125OH)2VitD3

  • PTH


:


Acute renal insufficiency ARI


GFR


  • (prerenal ARI)

  • (postrenal ARI )

  • (intrarenal ARI )


GFR

RAA&ADH

1. Prerenal ARI :vascular



GFR

2. Postrenal ARI :obstructive


3.Intrarenal ARI : parenchymal

GFR

()


Acute Tubular Necrosis : ATN

  • S3mTAL

ATNARF75%


Etiology of ATN

1. renal ischemia:

110-8mmHg

2S3,mTAL

31mmol NaCl30umol


2.Nephrointoxincation :

:

:


GFR

1.

2.

3.

4.


ATN




ATN

GFR

GFR


133Xe,RBF

?


(1)

(2)

(3)


  • 80mmHg<BP<160mmHg:RBF.GFR

  • 50mmHg<BP<70mmHg:RBF,GFR1/2-2/3

  • BP<=40mmHg:RBF,GFR


  • -()

  • PGs


GFR

AT


A1R

A2R

AT

GFR



GFR


1


2

  • ATP

GFR


GFR

ARI


ARI

(oliguria stage)

(diuresis stage)

(recovery stage)


816

1.

2.

3.

4.

5.


1.

2.

1GFR

2

3

4


ARI


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