急性肾衰竭

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 z Prerenal azotemia z Intrinsic renal azotemia z Postrenal azotemia ETIOLOGY OF ARFETIOLOGY OF ARF Prerenal Azotemia ƒ Intravascular Volume Depletion ƒ Decreased Cardiac Output ƒ Systemic Vasodilatation ƒ Renal Vasoconstriction ƒ 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 z Renal Ischemia（50%） z Nrphrotoxins （35%） Exogenous Endogenous PATHOPHYSIOLOGY OF ATNPATHOPHYSIOLOGY OF ATN z Intrarenal Vasoconstriction z Tubular Dysfunction Role of Role of Hemodynamic Hemodynamic alterations 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 ATNin 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 z GFR↓ z Lasting Hours or Days z Evidence of true Volume Depletion z Decreeced Effective Circulatory Volume z Treatment with NSAIDs or ACEI The Maintenance PhaseThe Maintenance Phase z GRR 5 ~ 10 ml/min z Lasting 1 ~ 2 Weeks z Oliguric ARF z high catabolism z Nonoliguric ARF z Uremic Syndrome High Catabolic StateHigh Catabolic State zDaily Increase in BUN >10.1~17.9 mmol/L zDaily Increase in Serum Creatinine >176.8μmol/L zDaily Increase in Serum Potassium >1~2 mmol/L zDaily Decrease in Serum HCO 3 －>2 mmol/L The The UremicUremic SyndromeSyndrome General Complications of ARF： Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectious TheThe UremicUremic SyndromeSyndrome Homeostatic Disorder of water， Electrolyte 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 z Other Electrolyte Disorder z Infection z Hart failure z Dialysis 急性肾衰竭 DEFINITIONS AND INCIDENCE CLASSIFICATION� ETIOLOGY OF ARF� ETIOLOGY OF ARF ETIOLOGY OF ARF� 急性肾小管坏死 ETIOLOGY OF ATN PATHOPHYSIOLOGY OF ATN� Role of Hemodynamic alterations �in ATN Role of Tubule Dysfunction� in ATN Metabolic Responses of �Tubule cells to Injury Pathology Clinical Presentation of ATN The Initiation Phase The Maintenance Phase High Catabolic State The Uremic Syndrome The Uremic Syndrome The Recovery Phase Lab Examination Lab Examination� Lab Examination� Diagnosis Differentiation： Management of ARF (一) Management of ARF (二) Management of ARF (三） Management of ARF (四） Management of ARF (五） Management of ARF