急性肾衰竭ARF.ppt

急性肾衰竭,AcuteRenalFailure（ARF）,.,DEFINITIONSANDINCIDENCE,Acuterenalfailure(ARF)isasyndromecharacterizedbyrapiddeclineinglomerularfiltrationrate(GFR)andretentionofnitrogenouswasteproductssuchasbloodureanitrogen(BUN)andcreatinine.ARFcomplicatesapproximately5%ofhospitaladmissionsandupto30%ofadmissionstointensivecareunits.,.,CLASSIFICATION,PrerenalazotemiaIntrinsicrenalazotemiaPostrenalazotemia,.,ETIOLOGYOFARF,PrerenalAzotemia,IntravascularVolumeDepletionDecreasedCardiacOutputSystemicVasodilatationRenalVasoconstrictionPharmacologicAgents(ACEIorNSAIDs),.,ETIOLOGYOFARF,PostrenalAzotemiaUretericObstructionBladderNeckObstructionUrethralObstruction,.,ETIOLOGYOFARF,IntrinsicRenalAzotemiaDiseasesInvolvingLargeRenalVesselsDiseasesofGlomeruliAndMicrovasculatureAcuteTubuleNecrosisDiseasesoftheTubulointerstitium,.,急性肾小管坏死,AcuteTubuleNecrosis（ATN）,.,ETIOLOGYOFATN,RenalIschemia（50%）Nrphrotoxins（35%）ExogenousEndogenous,.,PATHOPHYSIOLOGYOFATN,IntrarenalVasoconstrictionTubularDysfunction,.,RoleofHemodynamicalterationsinATN,ReductioninTotalRenalBloodFlowRegionalDisturbanceinRenalBloodFlowandOxygenSupplyEdothelin(ET)/NO(EDNO)OtherEndothelialVasoconstrctorsTheTubulo-glomerularFeedBack,.,RoleofTubuleDysfunctioninATN,TwoMajorTubularAbnormalities:ObstrctionBackleak,.,MetabolicResponsesofTubulecellstoInjury,ATPDepletionCellSwellingIntyacellularFreeCalciumIntyacellularAcidosisPhospholipaseActivationProteaseActivationOxidantInjuryInflammatoryRespose,.,Pathology,.,ClinicalPresentationofATN,TheClinicalCourseofATN：TheInitiationPhaseTheMaintenancePhaseTheRecoveryPhase,.,TheInitiationPhase,GFRLastingHoursorDaysEvidenceoftrueVolumeDepletionDecreecedEffectiveCirculatoryVolumeTreatmentwithNSAIDsorACEI,.,TheMaintenancePhase,GRR510ml/minLasting12WeeksOliguricARFhighcatabolismNonoliguricARFUremicSyndrome,.,HighCatabolicState,DailyIncreaseinBUN10.117.9mmol/LDailyIncreaseinSerumCreatinine176.8mol/LDailyIncreaseinSerumPotassium12mmol/LDailyDecreaseinSerumHCO32mmol/L,.,TheUremicSyndrome,GeneralComplicationsofARF：GastrointestinalCardiovascularRespiratoryNeurologicHematologicInfectious,.,TheUremicSyndrome,HomeostaticDisorderofwater，ElectrolyteandAcid-alkaliBalance：VolumeOverloadMetabolicAcidosisHyperkalemiaHyponatremiaHypocalcemiaHyperphosphatemia,.,TheRecoveryPhase,ThePeriodofRepairandRegenerationofRenalTissue:GradualIncreaseinUrineOutput“Post-ATN”DiuresisFallinBUNandScrRecoveryofGFR/Tubulefunction,.,LabExamination,BloodRoutineTestandChemistryAssays:Animia,RBC,HbBUNandScrNa，K,Ca2，P3+pH，AG，HCO3,.,LabExamination,DiagnosticIndexPrerenalRenalSpecificGravity1.0201.010Osmolality(mOsm/KgH2O)500300UrinaryNa+(mmol/L)20Ucr/Scr408201FractionalExcretionofNa+1UrineSedimentHyalineBrownranular,.,LabExamination,RadiologicEvaluation:PlainAbdominalfilmRenalUltrasonographyIVPRenalangiographyRenalBiopsy,.,DiagnosisDifferentiation：,prerenalazotemiapostrenalazotemiaGlomerulonephritis/VasculitisHUS/TTPInterstitialNephritisRenalArteryThrombosisRenalveinthrombosis,.,ManagementofARF(一),CorrectionofReversiblecausesPreventionofadditionalInjuryMaintainingFluidbalance,.,ManagementofARF(二),MaintainingFluidbalanceFluidIntake：500ml+TheAmountofUrineinThePreceding24Hours,.,ManagementofARF(三）,NutritionEnegyIntake:147kj/dDietaryProtein:0.8g/kg.dCRRT(fluid5L/d),.,ManagementofARF(四）,HyperkalemiaK+6mmol/L10%CalciumGluconate10-20ml5%SodiumBicarbonate100-200ml20%Glucose3ml/kg.h+Insulin0.5U