肾病课件——急性肾衰竭(英文)(PPT 31页)

1、 急性肾衰竭 Acute Renal Failure （ARF）第1页，共31页。DEFINITIONS AND INCIDENCEAcute 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% o

2、f hospital admissions and up to 30% of admissions to intensive care units.第2页，共31页。CLASSIFICATION Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia 第3页，共31页。ETIOLOGY OF ARF Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstri

3、ction Pharmacologic Agents (ACEI or NSAIDs)第4页，共31页。ETIOLOGY OF ARF Postrenal Azotemia Ureteric Obstruction Bladder Neck Obstruction Urethral Obstruction第5页，共31页。ETIOLOGY OF ARF Intrinsic Renal Azotemia Diseases Involving Large Renal Vessels Diseases of Glomeruli And Microvasculature Acute Tubule Ne

4、crosis Diseases of the Tubulointerstitium 第6页，共31页。急性肾小管坏死 Acute Tubule Necrosis （ATN）第7页，共31页。ETIOLOGY OF ATN Renal Ischemia（50%） Nrphrotoxins （35%） Exogenous Endogenous 第8页，共31页。PATHOPHYSIOLOGY OF ATN Intrarenal Vasoconstriction Tubular Dysfunction第9页，共31页。Role of Hemodynamic alterations in ATN Re

5、duction 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第10页，共31页。 Role of Tubule Dysfunction in ATN Two Major TubularAbnormalities: Obstrction Backleak第11页，共31页。Metabolic

6、 Responses of Tubule cells to Injury ATP Depletion Cell Swelling Intyacellular Free Calcium IntyacellularAcidosis Phospholipase Activation Protease Activation Oxidant Injury Inflammatory Respose第12页，共31页。Pathology第13页，共31页。Clinical Presentation of ATN The Clinical Course of ATN： The Initiation Phase

7、 The Maintenance Phase The Recovery Phase第14页，共31页。The Initiation PhaseGFRLasting Hours or DaysEvidence of true Volume DepletionDecreeced Effective Circulatory VolumeTreatment with NSAIDs or ACEI第15页，共31页。The Maintenance PhaseGRR 5 10 ml/minLasting 1 2 WeeksOliguric ARF high catabolismNonoliguric AR

8、FUremic Syndrome第16页，共31页。High Catabolic StateDaily Increase in BUN 10.117.9 mmol/LDaily Increase in Serum Creatinine 176.8mol/LDaily Increase in Serum Potassium 12 mmol/LDaily Decrease in Serum HCO 3 2 mmol/L第17页，共31页。The Uremic Syndrome General Complications of ARF： Gastrointestinal Cardiovascular

9、 Respiratory Neurologic Hematologic Infectious第18页，共31页。The Uremic Syndrome Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance： Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatemia第19页，共31页。The Recovery Phase The Period of Repair and Regeneration

10、 of Renal Tissue: Gradual Increase in Urine Output “Post-ATN” Diuresis Fall in BUN and Scr Recovery of GFR/ Tubule function第20页，共31页。Lab Examination Blood Routine Test and Chemistry Assays: Animia, RBC , Hb BUN and Scr Na ，K,Ca2，P3+ pH ，AG ，HCO3 第21页，共31页。Lab Examination Diagnostic Index Prerenal Re

11、nal 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 第22页，共31页。Lab Examination Radiologic Evaluation: Plain Abdominal film Renal Ultrasonography IVP Rena

12、l angiography Renal Biopsy 第23页，共31页。 Diagnosis Differentiation： prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosis第24页，共31页。Management of ARF (一) Correction of Reversible causes Prevention of additional Inj

13、ury Maintaining Fluid balance第25页，共31页。Management of ARF (二) Maintaining Fluid balance Fluid Intake ： 500ml + The Amount of Urine in The Preceding 24 Hours第26页，共31页。 Management of ARF (三） Nutrition Enegy Intake:147kj/d Dietary Protein: 0.8g/kg.d CRRT ( fluid 5L/d)第27页，共31页。Management of ARF (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第2