肾病——急性肾衰竭英文.pptx

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.第1页/共31页CLASSIFICATION Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia 第2页/共31页ETIOLOGY OF ARF Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)第3页/共31页ETIOLOGY OF ARF Postrenal Azotemiaq Ureteric Obstructionq Bladder Neck Obstructionq Urethral Obstruction第4页/共31页ETIOLOGY OF ARF Intrinsic Renal Azotemia v Diseases Involving Large Renal Vesselsv Diseases of Glomeruli And Microvasculaturev Acute Tubule Necrosisv Diseases of the Tubulointerstitium 第5页/共31页急性肾小管坏死 Acute Tubule Necrosis （ATN）第6页/共31页ETIOLOGY OF ATN Renal Ischemia（50%）Nrphrotoxins （35%）Exogenous Endogenous 第7页/共31页PATHOPHYSIOLOGY OF ATN Intrarenal Vasoconstriction Tubular Dysfunction第8页/共31页Role 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第9页/共31页 Role of Tubule Dysfunction in ATN Two Major TubularAbnormalities:Obstrction Backleak第10页/共31页Metabolic Responses of Tubule cells to Injuryq ATP Depletionq Cell Swellingq Intyacellular Free Calciumq IntyacellularAcidosisq Phospholipase Activationq Protease Activationq Oxidant Injuryq Inflammatory Respose第11页/共31页Pathology第12页/共31页Clinical Presentation of ATN The Clinical Course of ATN：The Initiation Phase The Maintenance Phase The Recovery Phase第13页/共31页The Initiation PhaseGFRLasting Hours or DaysEvidence of true Volume DepletionDecreeced Effective Circulatory VolumeTreatment with NSAIDs or ACEI第14页/共31页The Maintenance PhaseGRR 5 10 ml/minLasting 1 2 WeeksOliguric ARF high catabolismNonoliguric ARFUremic Syndrome第15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16页/共31页The Uremic Syndrome General Complications of ARF：Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectious第17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18页/共31页The 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 function第19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20页/共31页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 第21页/共31页Lab Examinationv Radiologic Evaluation:Plain Abdominal film Renal Ultrasonography IVP Renal angiographyv Renal Biopsy 第22页/共31页 Diagnosis Differentiation：prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosis第23页/共31页Management of ARF (一)q Correction of Reversible causes q Prevention of additional Injuryq Maintaining Fluid balance第24页/共31页Management of ARF(二)Maintaining Fluid balance Fluid Intake：500ml+The Amount of Urine in The Preceding 24 Hours第25页/共31页 Management of ARF(三）Nutritionq Enegy Intake:147kj/dq Dietary Protein:0.8g/kg.dq CRRT(fluid 5L/d)第26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27页/共31页 Management of ARF(五）Metabolic Acidosis HCO3 15mmol/L:5%Sodium Bicarbonate 100-250ml Dialysis第28页/共31页Management of ARF Other Electrolyte Disorder Infection Hart failure Dialysis第29页/共31页第30页/共31页感谢您的观看！第31页/共31页