医学培训课件 急性肾衰竭.ppt

AcuteKidneyInjury-Acuterenalfailure,JiangHuajun.M.D,Ph.DDept.ofNephrology,UnionHospital.HUSTdrhuajunjiang,TheEarlyReportofARF,“Thediseaseseemsingeneraltocomeonsuddenly.Thepeculiarsymptomisasuddendiminutionofsecretionofurine,whichsoonamountstoacompletesuspensionofit.Theafflictionisprobablyatfirstconsideredasretention;butthecatheterbeingemployed,thebladderisfoundtobeempty.afterseveraldays,thepatientbeginstotalkincoherently,andshowsatendencytostupor.Thisincreasesgraduallytoperfectcoma,whichinafewdaysmoreisfatal.”JohnAbercombie(17801828)sudden(i.e.,hourstodays)reductioninurinevolume,Profile,Rapiddecreaseinrenalfunctionoverdaystoweeks,causingaaccumulationofnitrogenousproductsintheblood.Oftenresultsfrommajortrauma,illness,orsurgerybutinsomecasesiscausedbyarapidlyprogressive,intrinsicrenaldisease.Symptomsincludeanorexia,nausea,andvomiting,progressingtoseizuresandcomaiftheconditionisuntreated.Fluid,electrolyte,andacid-basedisordersdevelopquickly.Diagnosisisbasedonlaboratorytestsofrenalfunction,includingserumcreatinine,renalfailureindex,andurinarysediment.Othertestsareneededtodeterminethecause.Treatmentisdirectedatthecausebutalsoincludesfluidandelectrolytemanagementandsometimesdialysis.,Epidemiology,Variable(inconsistentdefinitions,differentpopulation)Basedonnewdefinition,AKIoccursapproximately7%inhospitalizedpatientsMortality:Variabledependonetiology,TheModernUnderstandingofARF,ARFtoAKIDefinitionisbasedonabsoluteincreaseinserumcreatinine(Scr)andoliguria,NewconceptsinDefinition,Whatsthenewdefinition?Earlysingle-centerandmulticenterCohortstudies,administrativedatabasestudiesDefinitionsweredifferentHouetal.AmJMed74:243248,1983,NewconceptsinDefinition,TheSecondInternationalConsensusConferenceoftheAcuteDialysisQualityInitiative(ADQI)Group.CritCare.2004;8:R204-R212.,De,DecreaseinGFR,RIFLEcriteria,NewconceptsinDefinition,AnnewpreciseoperationaldefinitionofAKIisintendedtoemphasizethereversiblenatureofmostrenalinsults.,AcuteKidneyInjuryNetwork:reportofaninitiativetoimproveoutcomesinacutekidneyinjury.CritCare.2007;11:R31.,AKINcriteria,In48hours,NewconceptsinDefinitionKDIGOcriteria,NewconceptsinDefinition,NewBiomarkersCystatinCNeutrophilgelatinaseassociatedlipocalin(NGAL)Kidneyinjurymolecule-1Interleukin18,Pathophysiology,EndothelialinjuryfromvascularperturbationsDirecteffectofnephrotoxinsAbolishmentofrenalautoregulationFormationofinflammatorymediators,Pathophysiology,TubularobstructionnecrosisandapoptosisoftubularcellsIncreasedtubuloglomerularfeedbackelevatedintracellularcalciumlevelsfromtubulardamagecauseaseriesofcellular-levelalterations,Etiology,Pre-renalUnderperfusionofkidneysresultsfromvolumedepletion,fluidsequestration,orinadequateperfusionpressures(heartfailure,cirrhosis,orsepsis)hypoperfusionoffunctioningkidneyleadstoenhancedreabsorptionofNaandwater,resultinginoliguriawithhighurineosmolalityandlowurineNa.,Etiology-prerenal,Etiology,Renal（tubular,interstitial,glomerular,vascular）TubuleATNIschemia(prolongedorsevereprerenalstate)Nephrotoxic,Etiology,InterstitiumAcuteinterstitialnephritis(AIN)-druginduced-certaininfections：pyelonephritis,papillarynecrosis-neoplasticdisorders,Etiology,GlomerulusPrimaryInfectiousRheumatologicVasculiticantineutrophiliccytoplasmicantibodyantinuclearantibodytestantistreptolysinOcomplementlevelsc-reactiveproteincryoglobulinerythrocytesedimentationratehepatitispanel(ie,specificallyforhepatitisBandC)renalbiopsy,Etiology,Postrenal(10%ofAKI)Urinarytractobstructions(withinoroutside)stones,tumors,retroperitonealfibrosisUltrasonography,Etiology-postrenal,CausesExamplesTubularprecipitationuricacid(tumorlysis),sulfonamides,acyclovir,methotrecxate,Caoxalate(ethyleneglycolingestion),myelomaprotein,myoglobinUreteralobstructionIntrinsic:calculi,clots,slougherrenaltissue,fungusball,edema,malignancy,congenitaldefectsExtrinsic:malignancy,retroperitonealfibrosis,ureteraltraumaduringsurgeryorhighimpactinjuryBladderobstructionMechanical:prostatichypertrophyorcancer,bladdercancer,urethralstrictures,phimosis,urethralvalves,obstructedindwellingurinarycatheterNeurogenic:anticholinergics,upperorlowermotorneuronlesion,Symptomsandsigns,Oftheunderlyingillnessorsurgicalprocedurethatprecipitatedrenaldeterioration.Uremiasymptoms:anorexia,nausea,vomiting,weakness,myoclonicjerks,seizures,confusionandcoma.PE:edema,palpablebladderetc.,Diagnosis,SuspectedwhenurineoutputfallsorserumBUNandScrriseSeekanunderlyingcauseLaboratorytests:CBC,BUN/Scr,electrolytes,urinetestsandotherneededbycausedetermination,DiagnosticEvaluation,IndexPrerenalPostrenalATNAGNU/Posmolality>1.511.511.511.5UrineNa(mmol/L)40>400.04>0.022>2<1,AdaptedfromMillerTR,etal:urinarydiagnosticindicesinacuterenalfailure.,U/P:urine/plasmaRenalfailureindex:U/PNa+U/Pcreatinine,SpecialScenarios,Contrast-inducednephropathy(CIN)increaseinserumcreatininelevelsthatis25%orhigher(0.5mg/dL)within72hoursofcontrastmediaadministrationriskfactorsforCINincludeolderage,diabetes,underlyingchronicCKD,multiplemyeloma,andvolumedepletion.Vasomotoralterations,freeradicalformationprehydration,temporarydiscontinuationofACEinhibitors,angiotensinreceptorblockers,anddiuretics,SpecialScenarios,Sepsis19%inmoderatesepsis,23%inseveresepsis,and51%insepticshockAKI+sepsis:70%mortalityrateversus45%amongpatientswithAKIalonenitricoxidesynthases,cytokines,chemokines,andadhesionmoleculesearlygoal-directedtherapy,hemodialysis,Treatment,VariedanddependonetiologicfactorsPrerenalazotemiafromvolumedepletionisusuallyresponsivetoisotonicsalinerepletionATNrequiresthediscontinuationofnephrotoxicagents,maintenanceofoptimumhemodynamics,andclosesurveillanceforcomplicationsofrenaldysfunction(eg,acidosis,electrolyteabnormalities)Postrenaletiologiesdictateobstructionremoval,Treatment,EmergencytreatmentLife-threateningcomplicationsPulmonaryedema:O2,IVvasodilatorsHyperkalemia:IVinfusionof10%Cagluconate10ml,dextrose50g,insulin510units.Severeacidosis(pH<7.2)IVNaHCO3(<150mEqin1Lof5%D/W),Treatment,FluidcontrolDailywaterintake=sensibledehydrationvolume(previous24hours)+insensibledehydrationendogenicwater(1gprotein:0.4ml;lipid:1ml;glucose:0.6ml)insensibledehydrationendogenicwater5001000ml/d,Treatment,Numerouspharmacologicagents:insulin-likegrowthfactor1,thyroxine,atrialnatriureticpeptide,dopamine,andloopdiuretics,effectiveinpreventingoramelioratingexperimentalAKI.noneofthesesubstanceshasbeentranslatedsuccessfullytoclinicalpractice.clinicalmanagementofAKIisprimarilysupportive,Treatment:Nutritionalsupport,NUTRITIONALSTATUSINAKIPatientswithAKIintheICU,evenmorethanothercriticallyillpatients,areatriskofnutritionaldepletionevaluationinthisclinicalconditionisdifficultasmostofthecommonlyutilizedtraditionalnutritionaltoolsareoftenmisleadingprotein-energywasting(PEW)aconditionofdecreasedbodystoresofproteinandenergyfuelstores(i.e.,leanbodymassandfatmasses)biochemical(suchasalbuminorprealbumin),bodyweightloss,decreasedmusclemasslowenergyandproteinintakes,InternationalSocietyofRenalNutritionandMetabolism(ISRNM),Treatment:Nutritionalsupport,AKIisassociatedwithalterationsofwater,electrolyteandacid-basemetabolism,andalsowithspecificchangesinprotein,carbohydrateandlipidmetabolismhyperglycemiaandinsulinresistanceproteolysisofskeletalmuscleproteinswithincreasedaminoacidturnoverandnegativenitrogenbalancealteredlipidmetabolismTG,VLDLTC,HDL,LDL,Treatment:Nutritionalsupport,NUTRIENTREQUIREMENTSINAKIMacronutrientsdependsmoreontheseverityofunderlyingdisease,preexistingnutritionalstatusandacute/chroniccomorbidities,thanonAKIitself,Treatment:Nutritionalsupport,GOALSOFNUTRITIONALSUPPORTINAKIensurethedeliveryofenergyandproteininsuchamountsastopreventprotein-energywastingpreserveleanbodymassandnutritionalstatusavoidfurthermetabolicderangementsandcomplicationsimprovewoundhealingsupportimmunefunctionandtoreducemortality,Treatment:replacementtherapy,RRTisthecentralcomponentofcareforpatientswithsevereAKI.generallyacceptedindicationsforRRTincludevolumeoverload,hyperkalemia,metabolicacidosis,andoverturemicsymptoms,Treatment:replacementtherapy,Fordecades,continuousrenalreplacementtherapies(CRRTs)suchascontinuousvenovenoushemofiltration(CVVH)werethoughttoofferbettercardiovascularstability,resultinginbettersurvival,incriticallyillpatientsthanconventionalintermittenthemodialysis(IHD)challengedbyobservationsthatifIHDisperformedwithlowbloodflowandultrafiltrationratesatthestartofthetreatment,reduceddialysatetemperaturealongwithothermeasurescontrolledstudiesandmeta-analysishavenotrevealedadefinitiveadvantageintermsofpatientsurvivalforCRRTascomparedwithIHD.,Treatment:replacementtherapy,themethodforRRTshouldbebasedontheclinicalsituation,physicianproficiencywiththeavailabletechniquesandlogisticalcapacityoftheICUanddialysispersonnel.BothconventionalIHDandCRRTshavecertainadvantages,butalsoseveraldisadvantages,Conclusion,remainsaubiquitousmedicalconditionandisassociatedwithahighrateofmortalityclinicalmanagementofAKIremainslargelysupportiveFutureresearchintothemechanismsandpathophysiologyaswellasthefoundofnewbiomarkers.,Thanksforyourattention,