肾病课件——急性肾衰竭(英文）.ppt

急性肾衰竭 AcuteRenalFailure ARF DEFINITIONSANDINCIDENCE Acuterenalfailure ARF isasyndromecharacterizedbyrapiddeclineinglomerularfiltrationrate GFR andretentionofnitrogenouswasteproductssuchasbloodureanitrogen BUN andcreatinine ARFcomplicatesapproximately5 ofhospitaladmissionsandupto30 ofadmissionstointensivecareunits CLASSIFICATION PrerenalazotemiaIntrinsicrenalazotemiaPostrenalazotemia ETIOLOGYOFARF PrerenalAzotemia IntravascularVolumeDepletionDecreasedCardiacOutputSystemicVasodilatationRenalVasoconstrictionPharmacologicAgents ACEIorNSAIDs ETIOLOGYOFARF PostrenalAzotemiaUretericObstructionBladderNeckObstructionUrethralObstruction ETIOLOGYOFARF IntrinsicRenalAzotemiaDiseasesInvolvingLargeRenalVesselsDiseasesofGlomeruliAndMicrovasculatureAcuteTubuleNecrosisDiseasesoftheTubulointerstitium 急性肾小管坏死 AcuteTubuleNecrosis ATN ETIOLOGYOFATN RenalIschemia 50 Nrphrotoxins 35 ExogenousEndogenous PATHOPHYSIOLOGYOFATN IntrarenalVasoconstrictionTubularDysfunction RoleofHemodynamicalterationsinATN ReductioninTotalRenalBloodFlowRegionalDisturbanceinRenalBloodFlowandOxygenSupplyEdothelin ET NO EDNO OtherEndothelialVasoconstrctorsTheTubulo glomerularFeedBack RoleofTubuleDysfunctioninATN TwoMajorTubularAbnormalities ObstrctionBackleak MetabolicResponsesofTubulecellstoInjury ATPDepletionCellSwellingIntyacellularFreeCalcium IntyacellularAcidosisPhospholipaseActivationProteaseActivationOxidantInjuryInflammatoryRespose Pathology ClinicalPresentationofATN TheClinicalCourseofATN TheInitiationPhaseTheMaintenancePhaseTheRecoveryPhase TheInitiationPhase GFR LastingHoursorDaysEvidenceoftrueVolumeDepletionDecreecedEffectiveCirculatoryVolumeTreatmentwithNSAIDsorACEI TheMaintenancePhase GRR5 10ml minLasting1 2WeeksOliguricARFhighcatabolismNonoliguricARFUremicSyndrome HighCatabolicState DailyIncreaseinBUN 10 1 17 9mmol LDailyIncreaseinSerumCreatinine 176 8 mol LDailyIncreaseinSerumPotassium 1 2mmol LDailyDecreaseinSerumHCO3 2mmol L TheUremicSyndrome GeneralComplicationsofARF GastrointestinalCardiovascularRespiratoryNeurologicHematologicInfectious TheUremicSyndrome HomeostaticDisorderofwater ElectrolyteandAcid alkaliBalance VolumeOverloadMetabolicAcidosisHyperkalemiaHyponatremiaHypocalcemiaHyperphosphatemia TheRecoveryPhase ThePeriodofRepairandRegenerationofRenalTissue GradualIncreaseinUrineOutput Post ATN DiuresisFallinBUNandScrRecoveryofGFR Tubulefunction LabExamination BloodRoutineTestandChemistryAssays Animia RBC Hb BUNandScr Na K Ca2 P3 pH AG HCO3 LabExamination DiagnosticIndexPrerenalRenalSpecificGravity 1 020 1 010Osmolality mOsm KgH2O 500 300UrinaryNa mmol L 20Ucr Scr 408201FractionalExcretionofNa 1UrineSedimentHyalineBrownranular LabExamination RadiologicEvaluation PlainAbdominalfilmRenalUltrasonographyIVPRenalangiographyRenalBiopsy DiagnosisDifferentiation prerenalazotemiapostrenalazotemiaGlomerulonephritis VasculitisHUS TTPInterstitialNephritisRenalArteryThrombosisRenalveinthrombosis ManagementofARF 一 CorrectionofReversiblecausesPreventionofadditionalInjuryMaintainingFluidbalance ManagementofARF 二 MaintainingFluidbalanceFluidIntake 500ml TheAmountofUrineinThePreceding24Hours ManagementofARF 三 NutritionEnegyIntake 147kj dDietaryProtein 0 8g kg dCRRT fluid 5L d ManagementofARF 四 HyperkalemiaK 6mmol L10 CalciumGluconate10 20ml5 SodiumBicarbonate100 200ml20 Glucose3ml kg h Insulin0 5U kg hDialysis ManagementofARF 五 MetabolicAcidosisHCO3 15mmol L 5 SodiumBicarbonate100 250mlDialysis ManagementofARF OtherElectrolyteDisorderInfectionHartfailureDialysis