急性肾衰竭-内科学课件

1、 急性肾衰竭 Acute Renal Failure （ARF） 急性肾衰竭 Acute Renal FailDEFINITIONS AND INCIDENCEAcute 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 appr

2、oximately 5% of hospital admissions and up to 30% of admissions to intensive care units.DEFINITIONS AND INCIDENCEAcuCLASSIFICATION Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia CLASSIFICATION Prerenal azotETIOLOGY OF ARF Prerenal Azotemia Intravascular Volume Depletion Decreased Card

3、iac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)ETIOLOGY OF ARF PrerenETIOLOGY OF ARF Postrenal Azotemia Ureteric Obstruction Bladder Neck Obstruction Urethral ObstructionETIOLOGY OF ARFETIOLOGY OF ARF Intrinsic Renal Azotemia Diseases Involving Large R

4、enal Vessels Diseases of Glomeruli And Microvasculature Acute Tubule Necrosis Diseases of the Tubulointerstitium ETIOLOGY OF ARF Intrin急性肾小管坏死 Acute Tubule Necrosis （ATN）急性肾小管坏死 Acute Tubule ETIOLOGY OF ATN Renal Ischemia（50%） Nrphrotoxins （35%） Exogenous Endogenous ETIOLOGY OF ATN Renal IschemPATHO

5、PHYSIOLOGY OF ATN Intrarenal Vasoconstriction Tubular DysfunctionPATHOPHYSIOLOGY OF ATN IntrarRole of Hemodynamic alterations in 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-

6、glomerular Feed BackRole of Hemodynamic alteration Role of Tubule Dysfunction in ATN Two Major TubularAbnormalities: Obstrction Backleak Role of Tubule Dysfunction iMetabolic Responses of Tubule cells to Injury ATP Depletion Cell Swelling Intyacellular Free Calcium IntyacellularAcidosis Phospholipas

7、e Activation Protease Activation Oxidant Injury Inflammatory ResposeMetabolic Responses of TubulePathologyPathologyClinical Presentation of ATN The Clinical Course of ATN： The Initiation Phase The Maintenance Phase The Recovery PhaseClinical Presentation of ATN The Initiation PhaseGFRLasting Hours o

8、r DaysEvidence of true Volume DepletionDecreeced Effective Circulatory VolumeTreatment with NSAIDs or ACEIThe Initiation PhaseGFRThe Maintenance PhaseGRR 5 10 ml/minLasting 1 2 WeeksOliguric ARF high catabolismNonoliguric ARFUremic SyndromeThe Maintenance PhaseGRR 5 1High Catabolic StateDaily Increa

9、se in BUN 10.117.9 mmol/LDaily Increase in Serum Creatinine 176.8mol/LDaily Increase in Serum Potassium 12 mmol/LDaily Decrease in Serum HCO 3 2 mmol/LHigh Catabolic StateDaily IncrThe Uremic Syndrome General Complications of ARF： Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic In

10、fectiousThe Uremic Syndrome GenThe Uremic Syndrome Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance： Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia HyperphosphatemiaThe Uremic Syndrome HomeostaThe Recovery Phase The Period of Repair and Regeneration of Ren

11、al Tissue: Gradual Increase in Urine Output “Post-ATN” Diuresis Fall in BUN and Scr Recovery of GFR/ Tubule functionThe Recovery Phase The PeriLab Examination Blood Routine Test and Chemistry Assays: Animia, RBC , Hb BUN and Scr Na ，K,Ca2，P3+ pH ，AG ，HCO3 Lab Examination Blood RoutineLab Examination

12、 Diagnostic Index Prerenal Renal Specific Gravity 1.020 1.010 Osmolality(mOsm/Kg H2O) 500 300 Urinary Na+ (mmol/L) 20 Ucr/Scr 40 8 20 10-15 Renal Failure Index 1 Fractional Excretion of Na+ 1 Urine Sediment Hyaline Brown ranular Lab Examination Diagnostic ILab Examination Radiologic Evaluation: Plai

13、n Abdominal film Renal Ultrasonography IVP Renal angiography Renal Biopsy Lab Examination Radiologic Diagnosis Differentiation： prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosis Diagnosis DifferentiatioMana

14、gement of ARF (一) Correction of Reversible causes Prevention of additional Injury Maintaining Fluid balanceManagement of ARF (一) CorrecManagement of ARF (二) Maintaining Fluid balance Fluid Intake ： 500ml + The Amount of Urine in The Preceding 24 HoursManagement of ARF (二) M Management of ARF (三） Nutrition Enegy Intake:147kj/d Dietary Protein: 0.8g/kg.d CRRT ( fluid 5L/d) Management of ARF (三） NutrManagement of ARF (四） Hyperkalemia K+6mmol/L 10%Calcium Gluconate 10-20ml 5% Sodium Bicarbonate 100-200ml 20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h DialysisManagement of ARF (四