ARF中国医科大肾病课件.ppt

急性肾衰竭急性肾衰竭 Acute Renal Failure （ARF）DEFINITIONS AND INCIDENCEqAcute 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.q ARF complicates approximately 5%of hospital admissions and up to 30%of admissions to intensive care units.CLASSIFICATIONl Prerenal azotemia l Intrinsic renal azotemial Postrenal azotemia ETIOLOGY OF ARF Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)ETIOLOGY OF ARF Postrenal Azotemiaq Ureteric Obstructionq Bladder Neck Obstructionq Urethral ObstructionETIOLOGY OF ARF Intrinsic Renal Azotemia v Diseases Involving Large Renal Vesselsv Diseases of Glomeruli And Microvasculaturev Acute Tubule Necrosisv Diseases of the Tubulointerstitium 急性急性肾小管坏死肾小管坏死 Acute Tubule Necrosis （ATN）ETIOLOGY OF ATNl Renal Ischemia（50%）l Nrphrotoxins （35%）Exogenous Endogenous PATHOPHYSIOLOGY OF ATNl Intrarenal Vasoconstrictionl Tubular DysfunctionRole of Hemodynamic alterations in ATNv Reduction in Total Renal Blood Flow Regional Disturbance in Renal Blood Flow and Oxygen Supplyv Edothelin(ET)/NO(EDNO)v Other Endothelial Vasoconstrctorsv The Tubulo-glomerular Feed Back Role of Tubule Dysfunction in ATN Two Major TubularAbnormalities:Obstrction BackleakMetabolic Responses of Tubule cells to Injuryq ATP Depletionq Cell Swellingq Intyacellular Free Calciumq IntyacellularAcidosisq Phospholipase Activationq Protease Activationq Oxidant Injuryq Inflammatory ResposePathologyClinical Presentation of ATN The Clinical Course of ATN：The Initiation Phase The Maintenance Phase The Recovery PhaseThe Initiation PhaselGFRlLasting Hours or DayslEvidence of true Volume DepletionlDecreeced Effective Circulatory VolumelTreatment with NSAIDs or ACEIThe Maintenance PhaselGRR 5 10 ml/minlLasting 1 2 WeekslOliguric ARF lhigh catabolismlNonoliguric ARFlUremic SyndromeHigh Catabolic StatelDaily Increase in BUN 10.117.9 mmol/LlDaily Increase in Serum Creatinine 176.8mol/LlDaily Increase in Serum Potassium 12 mmol/LlDaily Decrease in Serum HCO 3 2 mmol/LThe Uremic Syndrome General Complications of ARF：Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic InfectiousThe Uremic Syndrome Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance：Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia HyperphosphatemiaThe 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 Examination Blood Routine Test and Chemistry Assays:Animia,RBC,Hb BUN and Scr Na ，K,Ca2，P3+pH，AG，HCO3 Lab Examination Diagnostic Index Prerenal Renal Specific Gravity 1.020 1.010 Osmolality(mOsm/Kg H2O)500 300 Urinary Na+(mmol/L)20 Ucr/Scr 40 8 20 10-15 Renal Failure Index 1 Fractional Excretion of Na+1 Urine Sediment Hyaline Brown ranular Lab Examinationv Radiologic Evaluation:Plain Abdominal film Renal Ultrasonography IVP Renal angiographyv Renal Biopsy Diagnosis Differentiation：prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosisManagement of ARF (一一)q Correction of Reversible causes q Prevention of additional Injuryq Maintaining Fluid balanceManagement of ARF(二二)Maintaining Fluid balance Fluid Intake：500ml+The Amount of Urine in The Preceding 24 Hours Management of ARF(三）三）Nutritionq Enegy Intake:147kj/dq Dietary Protein:0.8g/kg.dq CRRT(fluid 5L/d)Management of ARF(四）四）Hyperkalemia 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）五）Metabolic Acidosis HCO3 15mmol/L:5%Sodium Bicarbonate 100-250ml DialysisManagement of ARFl Other Electrolyte Disorderl Infectionl Hart failurel Dialysis