外科学教学课件急性肾衰竭与急性肾损伤

1、 急性肾衰竭 （Acute Renal Failure ARF）女性患者，28岁，G2P0。因孕26+6周,以“腹胀、无尿3天入院。既往左肾结石病史,无心肺相关疾病。入院查体:T37.5,P 110/min,BP 140/90 mmHg。腹部皮肤紧张、发亮、腹壁皮下静脉可见,宫高28 cm,腹围89 cm,子宫壁紧张,有压痛,胎心率正常,双肾区叩击痛。实验室及仪器检查：B超示双肾积水,双侧输尿管上段扩张12 mm,膀胱未探及。胎儿发育正常。 尿素氮15.8 mmol/L,肌酐631mol/L。病例问题：患者出现腹胀，无尿的原因？如果你是首诊医师，妇产科 or 泌尿外科 or肾内透析科？定义：

2、各种原因引起的肾功能损害，在短时间（几小时或几日）内出现血中氮质代谢产物积聚，水电解质和酸碱平衡失调及全身并发症，是一种严重的临床综合征。Definition： ARF is defined as a rapid reduction in renal function characterized by progressive azotemia (best measured clinically by serum creatinine SCr), which may or may not be accompanied by oliguria. This abrupt decline in ren

3、al function occurs over the course of hours to days and results in the failure to excrete nitrogenous wastes from the plasma or to maintain normal volume and electrolyte homeostasis. Clinical markers of ARFReduced GFRRaised Serum.Creatinine 急性肾衰竭的临床指标肾小球率过滤降低血肌酐的升高 少尿：400ml/24hr 无尿：800ml/24hr，而血BUN、

4、Cr进行性增高 Oliguria: Urine volume 400ml per day in adults.Anuria: Urine volume 800ml per day.急性肾衰竭肾前性肾性肾后性Acute Renal FailurePre-renalIntrinsicPost-renal分 类Classfication 病因 Etiology1.肾前性：血容量不足全身疾病心脏疾病 有效血容量肾血流低灌注功能性肾功能不全、急性肾小管坏死。1 Prerenal Causes: Any disorders such as severe hemorrhage, shock, hypovol

5、emia etc.decrease the blood supply to the nephron. Ultimately, functional disorders(ATN, Acute Tubular Necrosis) develop secondary to renal ischemia or depression of glomerular filtration or both. 2.肾后性：早期解除梗阻，可恢复肾功能Intra-luminal结石血块Papillary necrosisIntra-mural 尿道狭窄 前列腺增生前列腺癌 膀胱肿瘤 Radiation fibrosi

6、s盆腔肿物Prolapsed uterusRetroperitoneal fibrosis 3.肾性： 肾实质缺血肾毒素：氨基糖甙类抗生素、四氯化碳、重金属（汞、铅、砷）放射造影剂过敏，蛇毒和蕈毒等。 两者共同作用：广泛烧伤、挤压伤、感染性休克、肝肾综合症。(3)Intrarenal causes: Severe renal ischemia Renal poisoning Carbon tetrachloride, heavy metals such as mercury etc, X-ray contrast media, mushroom poisoning, various medic

7、ations which are used as antibiotics These two causes usually act together.Renal / Intrinsic AKITubularGlomerularVascularInterstitialATNIschemia (50%)Toxins (30%)Ac. Interstitial nephritisDrug induced - NSAIDs,antibioticsInfiltrative -lymphomaGranulomatous- sarcoidosis, tuberculosisInfection related

8、 - post-infective, pyelonephritisVascular occlusions- Renal artery occlusion - Renal vein thrombosis- Cholesterol emboliAc.GN post-infectious, SLE,ANCA associated,anti-GBM diseaseHenoch-Schnlein purpuraCryoglobulinaemia,Thrombotic microangiopathy TTPHUS5%85%8 -12% 2%N Engl J Med 1996;334 (22):1448-6

9、0发病机理 Pathogenesis 肾缺血肾毒素导致肾小管上皮细胞变性和坏死。Renal ischemia due to vasoconstriction ATN(Acute Tubular NecrosisATN的病理生理变化:肾小管上皮的损伤和修复去极化反应正常上皮肾小管上皮细胞移行再分化分化坏死细胞脱落之肾小管堵塞缺血/ 再灌注损伤坏死Adhesion moleculesNa+/K+-ATPase增殖再生Clinical findings（一）少尿或无尿期三高三低三中毒一倾向 (1)Oliguria or anuria phaseUsually lasting for a period

10、 from one to two weeks, the average duration is between 5 and 6 days临床表现 临床表现一、水、电解质和酸碱平衡紊乱1.水中毒：Na、水摄入过多 内生水450-500ml/24hr。高血压、脑水肿、肺水肿、心力衰竭。恶心、呕吐、头晕、嗜睡的昏迷。1.Water, electrolyte and acid-base disturbances A:Hypervolemia: without restriction of fluid taking. Its manifestations are circulatory overload

11、, such as pulmonary edema, brain edema, high blood pressure, heart failure. The patient can feel nausea, vomiting, dizzy, even coma.临床表现2.高血钾： 90%K+由肾排泄主要死亡原因。心律失常、心脏骤停Q-T间期缩短、T波高峰；QRS间期延长，PR间期增宽，P波降低。B:Hyperkalemia: Normally, 90% K+ are excreted by the kidney. When blood potassium reached to 6-6.5m

12、mol/L, cardiac arrhythmias, cardiac arrest can be caused, ECG changes include peaked T wave ,prolonged P-R interval, widening of QRS complex, etc.临床表现3.高镁血症： 血镁-与血钾呈平行改变。 神经肌肉传导障碍:低血压、呼吸抑制、肌力减弱、昏迷、心跳骤停 ECG：P-R间期延长、QRS增宽、T波增高。C: Hypermagnesemia: Hypermagnesemia is caused by reduction of GRF. Hypermag

13、nsemia decreases neuromuscular irritability, it caused muscle weakness, drowsiness and coma. ECG changes include prolonged P-R interval etc.临床表现4.高磷血症和低钙血症：60%-80%的磷转向肠道排泄，形成不溶性磷酸钙，影响钙的吸收，出现低钙血症低钙抽搐 加重低钾对心肌的毒性作用D: Hyperphosphatemia and Hypocalcemia: 60%-80% phosphate are excreated from intestine and

14、 combined with calcium to form nonabsorbable compounds. Therefore absorption of calcium is diminished and hypocalcemia is caused. The effects of hypocalcemia are muscle tetany etc.临床表现5.低Na血症： 呕吐、腹泻、出汗等使Na流失。输入无钠或少钠液代谢障碍“钠泵”效应下降细胞内Na不能泵出细胞外液Na下降。肾小管功能障碍，Na再吸收下降。E: Hyponatremia:a: Excessive amounts o

15、f sodium lost by vomiting, diarrhea and sweating.b: Excessive fluid intake with water only.c: Abnormal Na+ distribution.d: Decreased Na+ reabsorption by the renal tubule.临床表现6.低氯血症： Cl-、Na+具有相同比例下丢失。F: Hypochloremia The causes resulting in hyponatremia also cause hyochloremia. 临床表现7. 酸中毒： （1）乏氧代谢增加，

16、酸性代谢产物。 （2）肾小管功能损害、丢失硷基 胸闷、气急、恶心、呕吐、软弱、嗜睡及昏迷，并有血压下降，心律失常，甚至心跳骤停。G: Metabolic acidosis a: Retention of sulfates and phosphates as the consequence of reduced GRF. b: Renal tubule failed to reabsorb or regenerate bicarbonate.Clinical manifestation: Nausea, vomiting, weakness, even coma, low blood press

17、ure, cardiac arrhythmias, cardiac arrest. 临床表现二、.尿毒症： 蛋白质代谢产物不能经肾排出，含氮物质积 聚于血中，氮质血症。血酚、胍等毒性物质增加，形成尿毒症。 恶心、呕吐、头痛、烦燥、倦怠无力、意识模糊，昏迷。 Azotemia and uremia 临床表现三、 出血倾向：1.血小板质量下降。2.毛细血管脆性增加。3.多种凝血因子减少 Hemorrhage tendency A: Abnormal platelet function or quantity. B: Increased blood capillaries fragility. C:

18、 Prolonged prothrombin time(PT). 临床表现（二）多尿期： 少尿或无尿7-14日，如24小时尿量增加至 400ml以上，即为多尿期的开始，历时14天。早期多尿后期多尿(2)Diuresis phaseAfter oliguria lasting for 7-14 days, the production of more than 400ml of urine per day indicate the beginning of diuresis phase, Normally the urine volume can reach to 3000ml per day

19、and lasting for 14 days. 临床表现1三种形式：突然增加：5-7天 1500ml 预后好逐步增加：7-14 200-500ml/日 缓慢增加：500- 700ml停滞，预 后差A.There are three catergories of the urine volume increasing in this phase: A: Increasing suddenly, 1500ml B: Increasing gradually, 200-500ml per day C: Increasing slowly, 500ml-700ml 临床表现2低K+、低Na+、 低C

20、a+、低Mg+3 脱水 4 感染Because azotemia and water, electrolyte disturbance also exist in this phase, it has been pointed out that approximately 25% of the deaths in ARF occurred following the onset of the diuresis. The main complications are hypokalemia and infection. 诊断 Diagnosis（一）病史及体格检查 1 有无急性肾小管坏死的病因。

21、2 有无肾前性因素。3 有无肾后性因素。 (1). History and physical examination A: prerenal causes B: postrenal causes C: Intrarenal causes 诊断 （二）尿量及尿液检查 1 尿量：留置尿管，记录每小时尿量 2 尿比重及渗透压：低而固定1.010-1.014，酸性、等渗尿。 3 镜检：肾前、后性：早期一般无管型。肾性：肾衰管型。 4. 物理性状(2)Urine detection A: Urine volume B: Urine specific gravity C:Urine RT and micr

22、ocopic findings 诊断 （三）血液检查 1.血常规 2.肾功能指标3. 测定电解质、血浆HCO3-或PH值(3)Renal functionA: blood urea nitrogen(BUN) and serum creatinine(Cr)B: Urine sodiumC: Urine osmolalityD: Urine urea concentration(4)Electrolyte, Co2cp, PH （四）鉴别诊断(differential diagnosis) 1.肾前性与肾性ARF的鉴别: 补液试验2.肾性与肾后性ARF的鉴别The differential d

23、iagnosis of ARF and hypovolemia Oliguria phase of ARF Hypovolemia Urine volume after infusion 1.020 Urine sediment tubular epithelial cells and casts (-) Urine sodium concentration (mmol/L) 40 20Urine urea and blood plasma urea ratio 10:1 Urine creatinine and blood plasma creatinine ratio 30:1 Serum

24、 potassium Increased markedly Increased slowly Hematocrit(Hct),Blood plasma protein decreased Increased 治疗 Treatment 一、少尿或无尿期1 控制入水量：原则，量出而入，宁少勿多。 (1)Oliguria or anuria phaseA: Restriction of fluid intake Fluid intake should be the sum of the insensible or evaporative fluid loss, urine output and any ongoing losses, such as nosogastric or chest tube drainage, except the water volume produced by the body itself every day.治疗2.营养：低蛋白、高热量、高维生素饮食。3. 抗感染B: Nutrition: low protein, high energy and vitamin dietsC: Anti-infection 治疗4. 电解质失