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...
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
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 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
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