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教学课件 急性肾衰竭

2011-07-25 31页 ppt 137KB 144阅读

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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...
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 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 null
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