急性肾衰竭.ppt
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急性肾衰竭
Acute Renal Failure
(ARF)
DEFINITIONS AND INCIDENCE
* Acute renal failure (ARF) is a syndrome characterized by rapid declinein glomerular filtration rate(GFR)and retentionof nitrogenous waste products such as blood ureanitrogen (BUN) and creatinine.
*ARF complicates approximately 5% of hospitaladmissions and up to 30% of admissions to
intensive care units.
CLASSIFICATION
* Prerenal azotemia
* Intrinsic renalazotemia
* Postrenal azotemia
ETIOLOGY OF ARF
Prerenal Azotemia
ETIOLOGY OF ARF
Postrenal Azotemia
*Ureteric Obstruction
* Bladder Neck Obstruction
* Urethral Obstruction
ETIOLOGY OF ARF
Intrinsic Renal Azotemia
*Diseases Involving Large Renal Vessels
* Diseases of Glomeruli And Microvasculature
* Acute TubuleNecrosis
* Diseases of the Tubulointerstitium
急性肾小管坏死
Acute Tubule Necrosis
(ATN)
ETIOLOGY OF ATN
* RenalIschemia(50%)
* Nrphrotoxins(35%)
Exogenous
Endogenous
PATHOPHYSIOLOGY OF ATN
*Intrarenal Vasoconstriction
*Tubular Dysfunction
Role of Hemodynamic alterations
in ATN
*Reduction in Total Renal Blood
FlowRegional Disturbance in
Renal BloodFlow and Oxygen
Supply
* Edothelin (ET) / NO (EDNO)
* Other Endothelial Vasoconstrctors
* The Tubulo-glomerular Feed Back
Role of Tubule Dysfunction
in ATN
Two Major TubularAbnormalities:
Obstrction
Backleak
Metabolic Responses of
Tubule cells to Injury
*ATP Depletion
*Cell Swelling
*Intyacellular Free Calcium↑
*Intyacellular Acidosis
*Phospholipase Activation
*Protease Activation
*Oxidant Injury
*Inflammatory Respose
Pathology
Clinical Presentation of ATN
The Clinical Course of ATN：
The Initiation Phase
The MaintenancePhase
The Recovery Phase
The Initiation Phase
* GFR↓
* Lasting Hours or Days
* Evidence of true Volume Depletion
* Decreeced Effective Circulatory Volume
* Treatment with NSAIDs or ACEI
The Maintenance Phase
* GRR 5 ~ 10 ml/min
* Lasting 1 ~ 2 Weeks
* Oliguric ARF
* high catabolism
* Nonoliguric ARF
* Uremic Syndrome
High 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 Syndrome
General Complications of ARF：
Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
The Uremic Syndrome
Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance：
Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
Hyperphosphatemia
The 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 Examination
Blood Routine Test and Chemistry Assays:
Animia,RBC ↓, Hb ↓
BUN and Scr↑
Na + ↓ ，K+↑,Ca2+↓，P3+ ↑
pH ↓，AG ↑，HCO3- ↓
Lab Examination
Diagnostic IndexPrerenalRenal
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 SedimentHyaline Brown ranular
LabExamination
*Radiologic Evaluation:
Plain Abdominal film
Renal Ultrasonography
IVP
Renalangiography
*Renal Biopsy
DiagnosisDifferentiation：
prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosis
Management of ARF(一)
* Correction of Reversible causes
* Prevention of additional Injury
* Maintaining Fluid balance
Management of ARF (二)
Maintaining Fluid balance
Fluid Intake ：
500ml + The Amount ofUrine
in The Preceding 24 Hours
Management of ARF (三)
Nutrition
* Enegy Intake:147kj/d
* Dietary Protein:0.8g/kg.d
* CRRT ( fluid > 5L/d)
Management of ARF (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 Bicarbonate100-200ml
20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h
Dialysis
Management of ARF (五)
Metabolic Acidosis
HCO3-<15mmol/L :
5% Sodium Bicarbonate 100-250ml
Dialysis
Management of ARF
* Other Electrolyte Disorder
*Infection
*Hart failure
*Dialysis
急性肾衰竭
Acute Renal Failure
(ARF)
DEFINITIONS AND INCIDENCE
* Acute renal failure (ARF) is a syndrome characterized by rapid declinein glomerular filtration rate(GFR)and retentionof nitrogenous waste products such as blood ureanitrogen (BUN) and creatinine.
*ARF complicates approximately 5% of hospitaladmissions and up to 30% of admissions to
intensive care units.
CLASSIFICATION
* Prerenal azotemia
* Intrinsic renalazotemia
* Postrenal azotemia
ETIOLOGY OF ARF
Prerenal Azotemia
ETIOLOGY OF ARF
Postrenal Azotemia
*Ureteric Obstruction
* Bladder Neck Obstruction
* Urethral Obstruction
ETIOLOGY OF ARF
Intrinsic Renal Azotemia
*Diseases Involving Large Renal Vessels
* Diseases of Glomeruli And Microvasculature
* Acute TubuleNecrosis
* Diseases of the Tubulointerstitium
急性肾小管坏死
Acute Tubule Necrosis
(ATN)
ETIOLOGY OF ATN
* RenalIschemia(50%)
* Nrphrotoxins(35%)
Exogenous
Endogenous
PATHOPHYSIOLOGY OF ATN
*Intrarenal Vasoconstriction
*Tubular Dysfunction
Role of Hemodynamic alterations
in ATN
*Reduction in Total Renal Blood
FlowRegional Disturbance in
Renal BloodFlow and Oxygen
Supply
* Edothelin (ET) / NO (EDNO)
* Other Endothelial Vasoconstrctors
* The Tubulo-glomerular Feed Back
Role of Tubule Dysfunction
in ATN
Two Major TubularAbnormalities:
Obstrction
Backleak
Metabolic Responses of
Tubule cells to Injury
*ATP Depletion
*Cell Swelling
*Intyacellular Free Calcium↑
*Intyacellular Acidosis
*Phospholipase Activation
*Protease Activation
*Oxidant Injury
*Inflammatory Respose
Pathology
Clinical Presentation of ATN
The Clinical Course of ATN：
The Initiation Phase
The MaintenancePhase
The Recovery Phase
The Initiation Phase
* GFR↓
* Lasting Hours or Days
* Evidence of true Volume Depletion
* Decreeced Effective Circulatory Volume
* Treatment with NSAIDs or ACEI
The Maintenance Phase
* GRR 5 ~ 10 ml/min
* Lasting 1 ~ 2 Weeks
* Oliguric ARF
* high catabolism
* Nonoliguric ARF
* Uremic Syndrome
High 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 Syndrome
General Complications of ARF：
Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
The Uremic Syndrome
Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance：
Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
Hyperphosphatemia
The 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 Examination
Blood Routine Test and Chemistry Assays:
Animia,RBC ↓, Hb ↓
BUN and Scr↑
Na + ↓ ，K+↑,Ca2+↓，P3+ ↑
pH ↓，AG ↑，HCO3- ↓
Lab Examination
Diagnostic IndexPrerenalRenal
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 SedimentHyaline Brown ranular
LabExamination
*Radiologic Evaluation:
Plain Abdominal film
Renal Ultrasonography
IVP
Renalangiography
*Renal Biopsy
DiagnosisDifferentiation：
prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosis
Management of ARF(一)
* Correction of Reversible causes
* Prevention of additional Injury
* Maintaining Fluid balance
Management of ARF (二)
Maintaining Fluid balance
Fluid Intake ：
500ml + The Amount ofUrine
in The Preceding 24 Hours
Management of ARF (三)
Nutrition
* Enegy Intake:147kj/d
* Dietary Protein:0.8g/kg.d
* CRRT ( fluid > 5L/d)
Management of ARF (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 Bicarbonate100-200ml
20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h
Dialysis
Management of ARF (五)
Metabolic Acidosis
HCO3-<15mmol/L :
5% Sodium Bicarbonate 100-250ml
Dialysis
Management of ARF
* Other Electrolyte Disorder
*Infection
*Hart failure
*Dialysis
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