急性肾衰竭—内科学课件.ppt

1、 Acute Renal Failure （ARF）qAcute 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 admiss

2、ions to intensive care units.l Prerenal azotemia l Intrinsic renal azotemial Postrenal azotemia Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)Postrenal Azotemial Ureteric Obstructionl Blad

3、der Neck Obstructionl Urethral Obstruction Intrinsic Renal Azotemia l Diseases Involving Large Renal Vesselsl Diseases of Glomeruli And Microvasculaturev Acute Tubule Necrosisv Diseases of the Tubulointerstitium Acute Tubule Necrosis （ATN）l Renal Ischemia（50%）l Nrphrotoxins （35%）Exogenous Endogenous

4、 l Intrarenal Vasoconstrictionl Tubular Dysfunctionv 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 Two Major TubularAbnormalities:Obstrction Backleakq ATP Depl

5、etionq Cell Swellingq Intyacellular Free Calciumq IntyacellularAcidosisq Phospholipase Activationq Protease Activationq Oxidant Injuryq Inflammatory Respose The Clinical Course of ATN：The Initiation Phase The Maintenance Phase The Recovery PhaselGFRlLasting Hours or DayslEvidence of true Volume Depl

6、etionlDecreeced Effective Circulatory VolumelTreatment with NSAIDs or ACEIlGRR 5 10 ml/minlLasting 1 2 WeekslOliguric ARF lhigh catabolismlNonoliguric ARFlUremic SyndromelDaily Increase in BUN 10.117.9 mmol/LlDaily Increase in Serum Creatinine 176.8mol/LlDaily Increase in Serum Potassium 12 mmol/LlD

7、aily Decrease in Serum HCO 3 2 mmol/L General Complications of ARF：Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectious Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance：Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatem

8、ia 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 Blood Routine Test and Chemistry Assays:Animia,RBC,Hb BUN and Scr Na ，K,Ca2，P3+pH，AG，HCO3 Diagnostic Index Prerenal Renal Specific Gravity

9、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 v Radiologic Evaluation:Plain Abdominal film Renal Ultrasonography IVP Renal angiographyv Renal Biopsy prerenal azotemia post

10、renal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosisq Correction of Reversible causes q Prevention of additional Injuryq Maintaining Fluid balance Maintaining Fluid balance Fluid Intake：500ml+The Amount of Urine in The Preceding 24

11、 Hours Nutritionl Enegy Intake:147kj/dl Dietary Protein:0.8g/kg.dl CRRT(fluid 5L/d)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 Metabolic Acidosis HCO3 15mmol/L:5%Sodium Bicarbonate 100-250ml Dialysisl Other Electrolyte Disorderl Infectionl Hart failurel Dialysis