教学课件 急性肾衰竭null 急性肾衰竭 急性肾衰竭 Acute Renal Failure
(ARF)DEFINITIONS AND INCIDENCEDEFINITIONS AND INCIDENCEAcute renal failure (ARF) is a syndrome characterized by rapid decline in glomerular filtration rate(GFR) and retention of nitrogenous waste...
null 急性肾衰竭 急性肾衰竭 Acute Renal Failure
(ARF)DEFINITIONS AND INCIDENCEDEFINITIONS 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 approximately 5% of hospital admissions and up to 30% of admissions to
intensive care units.
CLASSIFICATION
CLASSIFICATION
Prerenal azotemia
Intrinsic renal azotemia
Postrenal azotemia
ETIOLOGY OF ARF
ETIOLOGY 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 ARF
ETIOLOGY OF ARF
Intrinsic Renal Azotemia
Diseases Involving Large Renal Vessels
Diseases of Glomeruli And Microvasculature
Acute Tubule Necrosis
Diseases of the Tubulointerstitium
急性肾小管坏死急性肾小管坏死 Acute Tubule Necrosis
(ATN)ETIOLOGY OF ATNETIOLOGY OF ATN Renal Ischemia(50%)
Nrphrotoxins (35%)
Exogenous
Endogenous
PATHOPHYSIOLOGY OF ATN
PATHOPHYSIOLOGY OF ATN
Intrarenal Vasoconstriction
Tubular DysfunctionRole of Hemodynamic alterations
in ATNRole 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-glomerular Feed Back
Role of Tubule Dysfunction
in ATN Role of Tubule Dysfunction
in ATN Two Major TubularAbnormalities:
Obstrction
BackleakMetabolic Responses of
Tubule cells to InjuryMetabolic Responses of
Tubule cells to Injury ATP Depletion
Cell Swelling
Intyacellular Free Calcium↑
Intyacellular Acidosis
Phospholipase Activation
Protease Activation
Oxidant Injury
Inflammatory ResposePathologyPathologyClinical Presentation of ATNClinical Presentation of ATN The Clinical Course of ATN:
The Initiation Phase
The Maintenance Phase
The Recovery PhaseThe Initiation PhaseThe Initiation PhaseGFR↓
Lasting Hours or Days
Evidence of true Volume Depletion
Decreeced Effective Circulatory Volume
Treatment with NSAIDs or ACEI
The Maintenance PhaseThe Maintenance PhaseGRR 5 ~ 10 ml/min
Lasting 1 ~ 2 Weeks
Oliguric ARF
high catabolism
Nonoliguric ARF
Uremic SyndromeHigh Catabolic StateHigh Catabolic StateDaily 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/LThe Uremic SyndromeThe Uremic Syndrome General Complications of ARF:
Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
The Uremic SyndromeThe Uremic Syndrome Homeostatic Disorder of water,Electrolyte and Acid-alkali Balance:
Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
HyperphosphatemiaThe 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 functionLab ExaminationLab Examination Blood Routine Test and Chemistry Assays:
Animia, RBC ↓, Hb ↓
BUN and Scr↑
Na + ↓ ,K+↑,Ca2+↓,P3+ ↑
pH ↓,AG ↑,HCO3- ↓Lab Examination
Lab 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 Examination
Lab Examination
Radiologic Evaluation:
Plain Abdominal film
Renal Ultrasonography
IVP
Renal angiography
Renal Biopsy Diagnosis Differentiation: Diagnosis Differentiation: prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosisManagement of ARF (一)Management of ARF (一) Correction of Reversible causes
Prevention of additional Injury
Maintaining Fluid balance
Management of ARF (二)Management of ARF (二) Maintaining Fluid balance
Fluid Intake :
500ml + The Amount of Urine
in The Preceding 24 Hours
Management of ARF (三) Management of ARF (三) Nutrition
Enegy Intake:147kj/d
Dietary Protein: 0.8g/kg.d
CRRT ( fluid > 5L/d)Management of ARF (四)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 Bicarbonate 100-200ml
20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h
Dialysis Management of ARF (五) Management of ARF (五) Metabolic Acidosis
HCO3-< 15mmol/L :
5% Sodium Bicarbonate 100-250ml
DialysisManagement of ARFManagement of ARF Other Electrolyte Disorder
Infection
Hart failure
Dialysis
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