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,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,代理报关委托书委托报关协议关于审理城镇房屋租赁合同纠纷案件司法解释有关劳务派遣制度设计及对劳务派遣行业的影响分析糖皮质激素在呼吸系统疾病中的合理应用严重脓毒症导致急性肺损伤病人自发利尿现象的观察分析,Acute Renal Failure,.,.,.,Definition and Classification,Epidemiology,Pathophysiology,and Etiology,Prerenal,ARF,Intrinisic,ARF,Postrenal,ARF,Pharmacologic Management of ARF,RRT in ARF,.,.,.,Definition,.,.,.,.,.,.,MDRD,eGFR= 186 x Screat X Age ,X 1.21 if black X o.74 if female,Undersetimates GFR in healthy people (when GFR 60 ml/min),Cockcroft-Gault formula,(140-Age) X Mass (In KG) X o.85 if female/72 X Serum Creat,The non-steady-state conditions that prevail in ARF preclude estimation of GFR using standard formulae derived from patients with chronic kidney disease.,.,.,.,RR= 2.4,RR= 4.15,RR=6.37,.,.,.,Shortcomings,The assignement of corresponding changes in serum creat and changes in urine output to the same strata is not based on evidence. The criteria that results in the least favorable rifle strata to be used.,The patient would progress from risk on day one to injury on day two and failure on day three, even though the actual GFR has been 20 (15 in ATN),FeNa 1% in ATN),UNa/K 20,.,.,.,BUN/CREAT of 20 is typical, BUT is not specific to prerenal ARF and may also be seen:,Obstructive uropathy,Gastrointestinal bleeding,Other states associated with increased urea production.,.,.,.,FE Urea,Patients on diuretics,Prerenal azotemia due to vomiting on NG suctioning.,FE Na may be low is sepsis, RCN, myoglobinuria, nonoliguric ATN, acute GN, urinary tract obstruction and renal allograft rejection,.,.,.,Significance of the fractional excretion of urea in thedifferential diagnosis of acute renal failure,102 patients were divided into three groups:,Prerenal azotemia (N 50),Prerenal azotemia treated with diuretics (N 27),ATN (N 25),Kidney International, Vol. 62 (2002), pp. 22232229,.,.,.,FENa was low only in the patients with untreated plain prerenal azotemia while it was high in both the prerenal with diuretics and the ATN groups.,FEUN was essentially identical in the two pre-renal groups (27.9 2.4% vs. 24.5 2.3%), and very different from the FEUN found in ATN (58.6 3.6%,P ,0.0001).,92% of the patients with prerenal azotemia had FENa 1%.,48% of those patients with prerenal and diuretic therapy had FENa 1%,89% of patients with prerenal azotemia and on diuretics had a FEUN 35%.,.,.,.,FE UREA,Low FE urea 0.5 mg/dl if the initial serum creatinine is 1.0 mg/dl if the baseline serum creatinine is 2.0 mg/dl, has been suggested as a threshold for discontinuation of therapy,.,.,.,The development of ARF should prompt an evaluation for cardiac failure, hypotension, volume depletion, use of a concomitant vasoconstrictive agent, or renovascular disease.,.,.,.,Acute Renal Failure Associated with NSAIDS,.,.,.,Nonsteroidal anti-inflammatory drugs (NSAID) agents inhibit the synthesis of vasodilatory prostaglandins in the kidney.,.,.,.,.,.,.,Risk factors:,Severe CHF,Advanced liver disease,Severe atherosclerotic vascular disease,CKD,.,.,.,Elderly patients are at increased risk due to the increased prevalence of cardiac dysfunction, occult renal vascular disease, and subclinical chronic kidney disease.,.,.,.,Abdominal Compartment Syndrome,.,.,.,Unusual cause of decreased renal perfusion associated with increased intra-abdominal pressure,Trauma patients who require massive volume resuscitation,Mechanical limitations of the abdominal wall (tight surgical closures or scarring after burn injuries),Medical etiologies that are characterized by intraabdominal inflammation with fluid sequestration, such as bowel obstruction, pancreatitis, and peritonitis.,.,.,.,Clinical manifestations,Respiratory compromise,Decreased cardiac output,Intestinal ischemia,Hepatic dysfunction,Oliguric renal failure,.,.,.,The renal insufficiency results from decreased renal perfusion and correlates with the severity of the increased intraabdominal pressure.,Oliguria develops when the intraabdominal pressure exceeds 15 mmHg, with anuria developing at pressures 30 mmHg,.,.,.,.,Diagnosis,The diagnosis should be suspected in patients with a tensely distended abdomen and progressive oliguria.,Measurement of intraabdominal bladder pressure.,Abdominal compartment syndrome can be excluded when the bladder pressure is 25 mmHg.,.,.,.,Treatment,Abdominal decompression:,Paracentesis if massive ascites.,Surgical decompression is required in the majority of patients.,Renal failure usually recovers promptly after relief of the increased intraabdominal pressure,.,.,.,Postrenal Acute Renal Failure,.,.,.,.,.,.,Intrinsic,Extrinsic,Lower tract obstruction,.,.,.,Urine output?,The obstruction:,Complete Anuria,InComplete,.,.,.,Pathophysiology,After the acute onset of obstruction, GFR declines progressively, but it does not fall to zero.,Factors that maintain GFR include continued salt and water reabsorption along the nephron, dilatation of the collecting system, and alterations in renal hemodynamics.,Intratubular pressure rises acutely, but it begins to decline within the first 4 to 8 h, returning to nearly normal by 24 h.,.,.,.,Ureteral Pr,RBF,GFR,1- 2 H,2-5 H,Late phase,.,.,.,Complete obstruction,Recovery after relief of obstruction depends on:,Severity,Duration,Less than 1 wk duration, recovery complete.,Little or no recovery after 12 wk.,.,.,.,Partial obstruction,The course after relief of partial obstruction is less predictable,Depends on,Severity,Duration,Presence of infection or preexisting renal disease.,.,.,.,Relief of obstruction may be accompanied by a post-obstructive diuresis;,Excretion of salt and water retained during the obstruction.,Persistent salt-wasting and impaired urinary concentrating ability .,.,.,.,Diagnosis,Elderly male patients,Measurement of a post-voiding residual bladder volume, either by an bedside ultrasound bladder scan or by placement of an indwelling bladder catheter.,.,.,.,Diagnosis,Ultrasonography,Sensitivity and specificity are high,Non diagnostic,Early in the course of postrenal ARF.,Severe volume depletion.,Obstruction is due to retroperitoneal disease (,e.g., retroperitoneal fibrosis, tumors, adenopathy) encasing the ureter and preventing dilatation,.,.,.,Diagnosis,Computed tomography,Non-contrasted CT scanning may be particularly useful for the identification of obstructing kidney stones,.,.,.,Intrinsic ARF,.,.,.,Etiology of Intrinsic ARF,.,.,.,.,.,.,Acute tubular necrosis,Ischemic,hypotension,hypovolemic shock,sepsis,cardiopulmonary arrest,cardiopulmonary bypass,Nephrotoxic,drug-induced,aminoglycosides,radiocontrast agents,amphotericin,cisplatinum,acetaminophen,pigment nephropathy,intravascular hemolysis,rhabdomyolysis,Acute interstitial nephritis,Dug-induced,penicillins,cephalosporins,sulfonamides,rifampin,dilantin,furosemide,non-steroidal antiinflammatory drugs,Infection-related,bacterial infection,viral infections,rickettsial disease,tuberculosis,.,.,.,Systemic diseases,systemic lupus erythematosus,sarcoidosis,Sjgren syndrome,tubulointerstitial nephritis and uveitis (TINU) syndrome,Malignancy,malignant infiltration of interstitium,multiple myeloma,Idiopathic,Acute glomerulonephritis,poststreptococcal glomerulonephritis,postinfectious glomerulonephritis,endocarditis-associated glomerulonephritis,systemic vasculitis,hemolytic uremic syndrome/thrombotic thrombocytopenic purpura,rapidly progressive glomerulonephritis (RPGN),Acute vascular syndromes,renal artery thromboembolism,renal artery dissection,renal vein thrombosis,atheroembolic disease,.,.,.,ATN,.,.,.,Acute tubular necrosis is the most common form of intrinsic ARF (85 %),Tubular injury,Nephrotoxic (35%),Ischemic (50%),Multifactorial.,Profound ischemic injury may result in bilateral cortical necrosis.,.,.,.,.,.,.,.,.,.,Nephrotoxic ATN,.,.,.,Clinical course,.,.,.,Pathogenesis of ATN,.,.,.,.,.,.,.,.,.,Recovery from Ischemic Injury,In contrast to the heart and brain, where ischemic injury results in permanent cell loss, the kidney is able to completely restore its structure and function after acute ischemic or toxic injury.,The recovery from tubular necrosis involves the dedifferentiation and proliferation of remaining viable tubular epithelial cells followed by reestablishment of cellular polarity, normal histologic appearance, and physiologic function,.,.,.,.,Under normal circumstances, renal tubular cells,in vivo,are quiescent and do not divide in response to growth factors.,After ischemic or toxic injury, alterations in gene expression are observed that are similar to those induced,in vitro,by growth factors.,Multiple growth factors, including (IGF-1), (EGF), and (HGF), and their receptors are upregulated during the regenerative process after renal injury,Administration of exogenous IGF-1, EGF, or HGF to experimental animals after ischemic or toxic renal injury accelerates renal regeneration.,Concern has been raised, that growth factors may also have a deleterious effect, augmenting tubulointerstitial injury and fibrosis.,.,.,.,Short-term,Outcomes,The outcome of ATN is highly dependent on the severity of comorbid conditions.,Uncomplicated ATN is associated with mortality rates of 7 to 23%,Mortality of ATN in postoperative or critically ill patients with multisystem organ failure is high as 50 to 80%.,Mortality rates increases with the number of failed organ systems,.,.,.,Long-term,Outcomes,Long term outcomes in ARF in patients treated with continuous RRT. Am J Kidney Dis, 2002,Long-term outcomes of patients who survive are good.,Of a population of 979 critically ill patients with ARF who required RRT (predominately patients with ATN), in-hospital mortality was 69%.,Patients who survived to hospital discharge, 6-mo survival was 77%, 1-yr survival was 69%, and 5-yr survival was 50%,59% of surviving patients had no residual renal insufficiency, and only 10% required chronic dialysis therapy.,.,.,.,Radiocontratst Nephropathy,.,.,.,Contrast media induced nephropathy (CMIN) is the third highest cause of hospital-acquired acute renal failure.,In nearly half of these patients, CMIN occurred during cardiac diagnostic or interventional procedures such as percutaneous coronary intervention.,.,.,.,.,.,.,.,.,.,ARF:increase in serum creat of50 % above baseline or 1 mg/dl if baseline2 mg/dl,Normal baseline creat negilgible risk,Mild to moderate CKD 5-10 % risk,Mild to moderate CKD + DM 10- 40 %,Advanced renal insufficiency 50 % risk,.,.,.,Pathogenesis,Haemodynamic alterations and tubuloglomerular feedback,The injection of CM induces early, rapid renal vasodilatation followed by prolonged vasoconstriction, with an increase in intrarenal vascular resistances, a reduction of total renal blood flow (RBF) and a decrease in glomerular filtration rate (GFR).,Conversely, the effect on the extrarenal vasculature is transient vasoconstriction that precedes a stable decrease in vascular peripheral resistances.,The resulting renal ischaemia due to these haemodynamic effects is, in part, responsible for nephropathy,.,.,.,.,.,.,Endothelial dysfunction,Vasoactive mediators,Free radicals and reperfusion damage,Haemorheological factors,Tubular toxicity and immunological mechanisms,.,.,.,Treatment,The best treatment of contrast-induced renal failure is prevention.,The use, if clinically possible, of ultrasonography, magnetic resonance imaging or CT scanning without radiocontrast agents, particularly in high-risk patients.,The use of lower doses of contrast and avoidance of repetitive studies that are closely spaced (within 48 to 72 hours).,Avoidance of volume depletion or nonsteroidal antiinflammatory drugs, both of which can increase renal vasoconstriction.,The use of low or iso-osmolal nonionic contrast agents.,.,.,.,Treatment,The administration of Intravenous Saline.,Isotonic saline at a rate of 1 mL/kg per hour, begun at least two and preferably 6 to 12 hours prior to the procedure, and continuing for 6 to 12 hours after contrast administration.,The administration of the antioxidant Acetylcysteine.,Dose of 600 to 1200 mg orally twice daily, administered the day before and the day of the procedure, based upon its potential for benefit and low toxicity and cost.,.,.,.,Treatment,Routine hemofiltration or hemodialysis for the prevention of contrast nephropathy in patients with stage 3 and 4 CKD is not recommended.,More data are needed in stage 5 CKD (Prophylactic use of hemodialysis in patients with stage 5 CKD, can be considered,provided that a functioning access is already available),Extracorporeal blood purification therapies for prevention of radiocontrast-induced nephropathy: a systematic review. Am J Kidney Dis 2006; 48:361.,Renal protection for coronary angiography in advanced renal failure patients by prophylactic hemodialysis. A randomized controlled trial. J Am Coll Cardiol 2007; 50:1015.,.,.,.,Treatment,There is no
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