内科学 急性肾衰竭顾勇精.ppt

内科学内科学 急性肾衰竭顾勇急性肾衰竭顾勇第1页，本讲稿共39页ARFD1.Definition and conceptD2.Pathogenesis D3.Pathology and pathophysiologyD4.Acute tubular necrosisD5.Special type of ARFD6.Handling of ARF第2页，本讲稿共39页Definition of ARFDSyndromeDQuick decline of GFR A series of clinical manifestationDAccumulation of nitrogen-containing tastes第3页，本讲稿共39页Incidence of ARFDCommon hospitalization：5%DICU：30%Hou SH et al.Am J Med.1983；74：243第4页，本讲稿共39页Features of ARFDKidney：complete restoration of functionDHigh incidence of complicationDHigh morbidity&mortalityDOther organs damage第5页，本讲稿共39页Classification of ARFDPrerenal：Hypoperfusion,functionality：55%-60%DRenal：35%-40%DPostrenal：urinary tract：5%第6页，本讲稿共39页Causes of prerenal ARFDLow volume:bleeding,lost from G-I,kidney,skin,third spaceDLow cardiac output:myocardium,valve,DSystemic vasodilatation:medicine,infection,allergy,liver failureDRenal arterial systole：shock,medicine,liver failure第7页，本讲稿共39页Renal ARFDRenal great vesselsDGlomeruleDAcute tubular necrosis：ischemia/poisoning DTubules and interstitium第8页，本讲稿共39页Postrenal ARF Position:DUreterDbladder neckDAnterior urethraCause：Stone,coagulated blood,Crystal,edema,deligationTumor,fibrosis,stenosis,prostate gland etc.第9页，本讲稿共39页ATNDPathologyDPathophysiologyDCourse of diseaseDDiagnosis and differential diagnosisDComplication第10页，本讲稿共39页Decline of GFR in ARFDAbnormal renal hemodynamicsDTubular impairment:obstruction,back flow第11页，本讲稿共39页Factors involved in renal hemodynamicsDEndothelin：increasing receptor blockingDEDNO：decreasingDOthers：Platelet Activating Factor(PAF)AdenosineDMedulla edemaDTubuloglomerular feedback:TGF第12页，本讲稿共39页Tubular impairmentDObstruction：lCaducous epithelial cells and components lCastDBack flow:Impaired integrity of epithelial cellsAccording to histology:tubular cells fall off and necrosis,cast第13页，本讲稿共39页Metabolic change after tubular cell damageDDecreased ATPDCellular swellingDIncreased intracellular calciumDIntracellular acidosisDActivation of phosphatidaseDActivation of proteaseDOxidative stress第14页，本讲稿共39页Consequence of damaged tubular cellslIntactlSublethallDeath:Apoptosis/necrosisDDepend on:different site,toxin concentration,time第15页，本讲稿共39页Necrosis Apoptosis in ARFDNecrosis：lcellular swelling,chondriosome changelDestroy membranous IntegritylRelease protein lysaselperipheral cell damage/inflammationDApoptosis：lActive energy consumption processlcell nucleus shrinkagesmall DNA fragment lcell membrane：blebbing but integrity lapoptotic body phagocytosislNo peripheral cell damage and inflammation.Depend on severity of impairment第16页，本讲稿共39页Repair,Regeneration and Recovery DRecovery of Sublethal cellsDScavenge necrotic cells and intracavitary castsDRegeneration of epithelial cells:replace necrotic and caducous cellsDTubular epithelial cells integrity and function restoration第17页，本讲稿共39页Course of ATNDInitiation:no parenchyma impairmentDMaintenance:parenchyma impairment:1-2 weeks,may be 11 monthsDRecovery第18页，本讲稿共39页Diagnosis and differential diagnosis of ATNDDiagnosis:medical history,physical examination,Urine Analysis,blood test Other examinations past medical history,drug historyDDifferential diagnosis:Acute or Chronic Classification Causes第19页，本讲稿共39页Special type of ARFDTumor Renal transplantationDPregnancy Lung diseasesDOperation on vessels of heart Liver diseasesDNephrotic Syndrome Drugs第20页，本讲稿共39页Why kidney easy to be damaged by drugs?DLarge volume of blood flow:25-30%heart stroke volumeDActive metabolism DLargest endothelial cell surfaceDRich enzymatic systemDTranscellular transportDConcentration functionDMuch oxygen consumption,little oxygen supply(medulla)第21页，本讲稿共39页Complication of ARF(1)DMetaboliclHyperkalemialMetabolic acidosislHyponatremialHyponatremialHyperphosphatemialHypermagnesemialHyperuricemiaDCardiovascularlPulmonary edemalArrhythmiaslPericarditislPericardial effusionlHypertensionlMyocardial infarctionlPulmonary embolismlPneumonitisDGastrointestinallNausealVomitinglMalnutritionlGastritislGastrointestinal ulcerslGastrointestinal bleedinglStomatitis or gingivitislParotitis or pancreatitis第22页，本讲稿共39页Complication of ARF(2)DNeurologiclNeuromuscular irritabilitylAsterxislSeizureslMental status changeslSomenolencelComaDHematologiclAnemialBleedingDInfectiouslPneumonialWound infections lIV infectionsl SepticemialUrinary tract infectionDOtherlHiccupslDecreased insulin catabolismlMild insulin resistancelElevated PTHlReduced 1,25-dihydroxy-and 25-hydroxycitamin DlLow total T3/T4lNormal free thyroxine第23页，本讲稿共39页Handling of ARF（1）DPrerenalDRenal effective perfusionDFluid supplement:Whole blood,plasma,crystal fluidDHeart:volume load,arrhythmiaDCirrhosisDOthers第24页，本讲稿共39页Handling of ARF(2)DRenal：DPrevention：lPrerenal factors:volume,cardio-respiratory functionlUse of drugsEspeciallylVasoactive agentlDiureticlOthers第25页，本讲稿共39页DopamineD1-3ug/kg/minDIncrease RPF and GFRDPerspective study：not provedDArhythmia/myocardial ischemia第26页，本讲稿共39页ANPDIncrease GFR:expansion of afferent arteriole of glomerulus/increased kfDInhibit sodium transport,decrease oxygen consumptionDExperiments showed effectiveDNot clinically confirmed第27页，本讲稿共39页DiureticDLarge doseDDecrease volume loadDMortality and dialysis rate unchangedDMannitol：lNo clinical evidencelIncrease the volumelLow sodium（shift）第28页，本讲稿共39页OthersDGrowth factor:Insulin-Like G-FDEndothelin receptor antagonistDRGD polypeptide:inhibit tubular obstructionDATP supplementDScavenge ROSDLeukocyte adhension inhibiting：lAnti-CD18lAnti-ICAM-1lAnti-P-selectinDON RESEARCH NOW第29页，本讲稿共39页Special treatment of ARF(not ATN)DCorticosteroidDImmunosuppressive agent DPlasmapheresisDAntiplateletDBlood pressure control第30页，本讲稿共39页Complication treatmentDMetabolism：water-electrolyte,acid-base balanceDNutritionDAnaemia第31页，本讲稿共39页DialysisDQuestions：lPrognosis？lStyle？lDosage？lIndication？第32页，本讲稿共39页Dialysis DPeritoneal dialysisDAcute intermittent hemodialysisDChronic continuous hemofiltration/hemodialysis第33页，本讲稿共39页Postrenal ARFDPrinciple：To relieve obstruction as soon as possible DNephrologist,Urol and Radiol：Work hand in hand第38页，本讲稿共39页Prognosis of ARFDNo obvious changes in mortalityDage,multi-organ involved DPrimary diseases：l gynecology：15%lpoisoning：30%ltrauma/major operation：60-90%DExtent of increase in urine volume and ScrD50%remain dysfunction第39页，本讲稿共39页