急性肾衰竭 急性肾衰竭 acute renal failure ( arf ). definitions and incidence acute...
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急性肾衰竭急性肾衰竭
Acute Renal Failure
( ARF )
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DEFINITIONS AND DEFINITIONS AND INCIDENCEINCIDENCE
Acute renal failure (ARF) is a syndrome characterized by rapid decline in glomerular filtration rate(GFR) and retention of nitrogenous waste products such as blood urea nitrogen (BUN) and creatinine.
ARF complicates approximately 5% of hospital admissions and up to 30% of admissions to
intensive care units.
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CLASSIFICATIONCLASSIFICATION
Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia
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ETIOLOGY OF ARFETIOLOGY OF ARF
Prerenal Azotemia Intravascular Volume Depletion
Decreased Cardiac Output
Systemic Vasodilatation
Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)
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ETIOLOGY OF ARFETIOLOGY OF ARF
Postrenal Azotemia
Ureteric Obstruction
Bladder Neck Obstruction
Urethral Obstruction
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ETIOLOGY OF ARFETIOLOGY OF ARF
Intrinsic Renal Azotemia
Diseases Involving Large Renal Vessels
Diseases of Glomeruli And Microvasculature
Acute Tubule Necrosis
Diseases of the Tubulointerstitium
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急性急性肾小管坏死肾小管坏死
Acute Tubule Necrosis
( ATN )
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ETIOLOGY OF ATNETIOLOGY OF ATN
Renal Ischemia ( 50% ) Nrphrotoxins ( 35% ) Exogenous
Endogenous
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PATHOPHYSIOLOGY OF ATNPATHOPHYSIOLOGY OF ATN
Intrarenal Vasoconstriction
Tubular Dysfunction
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Role of Hemodynamic alterations Role of Hemodynamic alterations in ATNin ATN
Reduction in Total Renal Blood Flow Regional Disturbance in Renal Blood Flow and Oxygen Supply Edothelin (ET) / NO (EDNO) Other Endothelial Vasoconstrctors The Tubulo-glomerular Feed Back
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Role of Tubule DysfunctionRole of Tubule Dysfunction in ATN in ATN
Two Major TubularAbnormalities:
Obstrction
Backleak
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Metabolic Responses of Metabolic Responses of Tubule cells to InjuryTubule cells to Injury
ATP Depletion Cell Swelling Intyacellular Free Calcium↑ Intyacellular Acidosis Phospholipase Activation Protease Activation Oxidant Injury Inflammatory Respose
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PathologyPathology
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Clinical Presentation of ATNClinical Presentation of ATN
The Clinical Course of ATN : The Initiation Phase
The Maintenance Phase
The Recovery Phase
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The Initiation PhaseThe Initiation Phase
GFR↓
Lasting Hours or Days
Evidence of true Volume Depletion
Decreeced Effective Circulatory Volume
Treatment with NSAIDs or ACEI
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The Maintenance PhaseThe Maintenance Phase
GRR 5 ~ 10 ml/minLasting 1 ~ 2 WeeksOliguric ARF high catabolismNonoliguric ARFUremic Syndrome
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High Catabolic StateHigh Catabolic State
Daily Increase in BUN >10.1~17.9 mmol/L
Daily Increase in Serum Creatinine >176.8μmol/L
Daily Increase in Serum Potassium >1~2 mmol/L
Daily Decrease in Serum HCO 3 - >2 mmol/L
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The Uremic SyndromeThe Uremic Syndrome
General Complications of ARF : Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
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The Uremic SyndromeThe Uremic Syndrome Homeostatic Disorder of water , Electr
olyte and Acid-alkali Balance : Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
Hyperphosphatemia
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The Recovery PhaseThe Recovery Phase
The Period of Repair and Regeneration
of Renal Tissue:
Gradual Increase in Urine Output
“Post-ATN” Diuresis
Fall in BUN and Scr
Recovery of GFR/ Tubule function
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Lab ExaminationLab Examination
Blood Routine Test and Chemistry Assays:
Animia, RBC ↓, Hb ↓
BUN and Scr↑
Na + ↓ , K +↑ ,Ca2 +↓, P3+ ↑
pH ↓ , AG ↑ , HCO3- ↓
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Lab ExaminationLab Examination
Diagnostic Index Prerenal Renal Specific Gravity > 1.020 ~ 1.010
Osmolality(mOsm/Kg H2O) > 500 ~ 300
Urinary Na+ (mmol/L) < 10 > 20
Ucr/Scr > 40 < 20
UUN/BUN > 8 < 3
BUN/Scr > 20 < 10-15
Renal Failure Index < 1 > 1
Fractional Excretion of Na+ < 1 > 1
Urine Sediment Hyaline Brown ranular
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Lab ExaminationLab Examination
Radiologic Evaluation: Plain Abdominal film
Renal Ultrasonography
IVP
Renal angiography Renal Biopsy
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Diagnosis DifferentiationDiagnosis Differentiation :: prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosis
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Management of ARF Management of ARF (( 一一 ))
Correction of Reversible causes
Prevention of additional Injury
Maintaining Fluid balance
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Management of ARF (Management of ARF ( 二二 ))
Maintaining Fluid balance
Fluid Intake : 500ml + The Amount of Urine in The Preceding 24 Hours
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Management of ARF (Management of ARF ( 三)三)
Nutrition Enegy Intake:147kj/d
Dietary Protein: 0.8g/kg.d
CRRT ( fluid > 5L/d)
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Management of ARF (Management of ARF ( 四)四) Hyperkalemia K+<6mmol/L Restriction of Dietary Potassium Intake K+-Binding Ion Exchange Resins K+>6mmol/L 10%Calcium Gluconate 10-20ml 5% Sodium Bicarbonate 100-200ml 20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h Dialysis
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Management of ARF (Management of ARF ( 五)五)
Metabolic Acidosis HCO3
- < 15mmol/L :
5% Sodium Bicarbonate 100-250ml
Dialysis
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Management of ARFManagement of ARF
Other Electrolyte Disorder
Infection
Hart failure
Dialysis