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1、急性肾衰竭,Acute Renal Failure （ARF）,急性肾衰竭 Acute Renal Fail,DEFINITIONS AND INCIDENCE,Acute 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 app
2、roximately 5% of hospital admissions and up to 30% of admissions to intensive care units.,DEFINITIONS AND INCIDENCEAcu,CLASSIFICATION,Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia,CLASSIFICATION Prerenal azot,ETIOLOGY OF ARF,Prerenal Azotemia,Intravascular Volume Depletion Decreased
3、Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs),ETIOLOGY OF ARF Preren,ETIOLOGY OF ARF,Postrenal Azotemia Ureteric Obstruction Bladder Neck Obstruction Urethral Obstruction,ETIOLOGY OF ARF,ETIOLOGY OF ARF,Intrinsic Renal Azotemia Diseases Involving
4、 Large Renal Vessels Diseases of Glomeruli And Microvasculature Acute Tubule Necrosis Diseases of the Tubulointerstitium,ETIOLOGY OF ARF Intrin,急性肾小管坏死,Acute Tubule Necrosis （ATN）,急性肾小管坏死 Acute Tubule,ETIOLOGY OF ATN,Renal Ischemia（50%） Nrphrotoxins （35%） Exogenous Endogenous,ETIOLOGY OF ATN Renal I
5、schem,PATHOPHYSIOLOGY OF ATN,Intrarenal Vasoconstriction Tubular Dysfunction,PATHOPHYSIOLOGY OF ATN Intrar,Role of Hemodynamic alterations in ATN,Reduction in Total Renal Blood Flow Regional Disturbance in Renal Blood Flow and Oxygen Supply Edothelin (ET) / NO (EDNO) Other Endothelial Vasoconstrctor
6、s The Tubulo-glomerular Feed Back,Role of Hemodynamic alteration,Role of Tubule Dysfunction in ATN,Two Major TubularAbnormalities: Obstrction Backleak,Role of Tubule Dysfunction i,Metabolic Responses of Tubule cells to Injury,ATP Depletion Cell Swelling Intyacellular Free Calcium IntyacellularAcidos
7、is Phospholipase Activation Protease Activation Oxidant Injury Inflammatory Respose,Metabolic Responses of Tubule,Pathology,Pathology,Clinical Presentation of ATN,The Clinical Course of ATN： The Initiation Phase The Maintenance Phase The Recovery Phase,Clinical Presentation of ATN,The Initiation Pha
8、se,GFRLasting Hours or DaysEvidence of true Volume DepletionDecreeced Effective Circulatory VolumeTreatment with NSAIDs or ACEI,The Initiation PhaseGFR,The Maintenance Phase,GRR 5 10 ml/minLasting 1 2 WeeksOliguric ARF high catabolismNonoliguric ARFUremic Syndrome,The Maintenance PhaseGRR 5 1,High C
9、atabolic State,Daily 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,High Catabolic StateDaily Incr,The Uremic Syndrome,General Complications of ARF： Gastrointestinal Cardiovascular Respirat
10、ory Neurologic Hematologic Infectious,The Uremic Syndrome Gen,The Uremic Syndrome,Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance： Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatemia,The Uremic Syndrome Homeosta,The Recovery Phase,The Period
11、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,The Recovery Phase The Peri,Lab Examination,Blood Routine Test and Chemistry Assays: Animia, RBC , Hb BUN and Scr Na ，K,Ca2，P3+ pH ，AG ，HCO3 ,Lab Exam
12、ination Blood Routine,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 1 Fractional Excretion of Na+ 1 Urine Sediment Hyaline Brown ranular,Lab Examination Diagnostic I,Lab Examination,Radiologic Eval
13、uation: Plain Abdominal film Renal Ultrasonography IVP Renal angiography Renal Biopsy,Lab Examination Radiologic,Diagnosis Differentiation：,prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosis,Diagnosis Differ
14、entiatio,Management of ARF (一),Correction of Reversible causes Prevention of additional Injury Maintaining Fluid balance,Management of ARF (一) Correc,Management of ARF (二),Maintaining Fluid balance Fluid Intake ： 500ml + The Amount of Urine in The Preceding 24 Hours,Management of ARF (二) M,Managemen
15、t of ARF (三）,Nutrition Enegy Intake:147kj/d Dietary Protein: 0.8g/kg.d CRRT ( fluid 5L/d),Management of ARF (三） Nutr,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,Management of ARF (四）,Management of ARF (五）,Metabolic Acidosis HCO3 15mmol/L : 5% Sodium Bicarbonate 100-250ml Dialysis,Management of ARF (五）,Management of ARF,Other Electrolyte Disorder Infection Hart failure Dialysis,Management of ARF Other Elect,急性肾衰竭内科学,
