急性肾衰竭
DESCRIPTION
急性肾衰竭. Acute Renal Failure ( ARF ). DEFINITIONS AND INCIDENCE. 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. - PowerPoint PPT PresentationTRANSCRIPT
急性肾衰竭急性肾衰竭
Acute Renal Failure
( ARF )
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.
CLASSIFICATIONCLASSIFICATION
Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia
ETIOLOGY OF ARFETIOLOGY OF ARF
Prerenal Azotemia Intravascular Volume Depletion
Decreased Cardiac Output
Systemic Vasodilatation
Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)
ETIOLOGY OF ARFETIOLOGY OF ARF
Postrenal Azotemia
Ureteric Obstruction
Bladder Neck Obstruction
Urethral Obstruction
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
急性急性肾小管坏死肾小管坏死
Acute Tubule Necrosis
( ATN )
ETIOLOGY OF ATNETIOLOGY OF ATN
Renal Ischemia ( 50% ) Nrphrotoxins ( 35% ) Exogenous
Endogenous
PATHOPHYSIOLOGY OF ATNPATHOPHYSIOLOGY OF ATN
Intrarenal Vasoconstriction
Tubular Dysfunction
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
Role of Tubule DysfunctionRole of Tubule Dysfunction in ATN in ATN
Two Major TubularAbnormalities:
Obstrction
Backleak
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
PathologyPathology
Clinical Presentation of ATNClinical Presentation of ATN
The Clinical Course of ATN : The Initiation Phase
The Maintenance Phase
The Recovery Phase
The Initiation PhaseThe Initiation Phase
GFR↓
Lasting Hours or Days
Evidence of true Volume Depletion
Decreeced Effective Circulatory Volume
Treatment with NSAIDs or ACEI
The Maintenance PhaseThe Maintenance Phase
GRR 5 ~ 10 ml/minLasting 1 ~ 2 WeeksOliguric ARF high catabolismNonoliguric ARFUremic Syndrome
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
The Uremic SyndromeThe Uremic Syndrome
General Complications of ARF : Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
The Uremic SyndromeThe Uremic Syndrome Homeostatic Disorder of water , Electr
olyte and Acid-alkali Balance : Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
Hyperphosphatemia
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
Lab ExaminationLab Examination
Blood Routine Test and Chemistry Assays:
Animia, RBC ↓, Hb ↓
BUN and Scr↑
Na + ↓ , K +↑ ,Ca2 +↓, P3+ ↑
pH ↓ , AG ↑ , HCO3- ↓
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
Lab ExaminationLab Examination
Radiologic Evaluation: Plain Abdominal film
Renal Ultrasonography
IVP
Renal angiography Renal Biopsy
Diagnosis DifferentiationDiagnosis Differentiation :: prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosis
Management of ARF Management of ARF (( 一一 ))
Correction of Reversible causes
Prevention of additional Injury
Maintaining Fluid balance
Management of ARF (Management of ARF ( 二二 ))
Maintaining Fluid balance
Fluid Intake : 500ml + The Amount of Urine in The Preceding 24 Hours
Management of ARF (Management of ARF ( 三)三)
Nutrition Enegy Intake:147kj/d
Dietary Protein: 0.8g/kg.d
CRRT ( fluid > 5L/d)
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
Management of ARF (Management of ARF ( 五)五)
Metabolic Acidosis HCO3
- < 15mmol/L :
5% Sodium Bicarbonate 100-250ml
Dialysis
Management of ARFManagement of ARF
Other Electrolyte Disorder
Infection
Hart failure
Dialysis