急性肾衰竭,Acute Renal Failure （ARF）,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 approximately 5% of hospital admissions and up to 30% of admissions to intensive care units.,CLASSIFICATION,Prerenal azotemia Intrinsic renal azotemia Postrenal azotemia,ETIOLOGY OF ARF,Prerenal Azotemia,Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs),ETIOLOGY OF ARF,Postrenal Azotemia Ureteric Obstruction Bladder Neck Obstruction Urethral Obstruction,ETIOLOGY OF ARF,Intrinsic Renal Azotemia Diseases Involving Large Renal Vessels Diseases of Glomeruli And Microvasculature Acute Tubule Necrosis Diseases of the Tubulointerstitium,急性肾小管坏死,Acute Tubule Necrosis （ATN）,ETIOLOGY OF ATN,Renal Ischemia（50%） Nrphrotoxins （35%） Exogenous Endogenous,PATHOPHYSIOLOGY OF ATN,Intrarenal Vasoconstriction Tubular Dysfunction,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 Vasoconstrctors The Tubulo-glomerular Feed Back,Role of Tubule Dysfunction in ATN,Two Major TubularAbnormalities: Obstrction Backleak,Metabolic Responses of Tubule cells to Injury,ATP Depletion Cell Swelling Intyacellular Free Calcium Intyacellular Acidosis Phospholipase Activation Protease Activation Oxidant Injury Inflammatory Respose,Pathology,Clinical Presentation of ATN,The Clinical Course of ATN： The Initiation Phase The Maintenance Phase The Recovery Phase,The Initiation Phase,GFR Lasting Hours or Days Evidence of true Volume Depletion Decreeced Effective Circulatory Volume Treatment with NSAIDs or ACEI,The Maintenance Phase,GRR 5 10 ml/min Lasting 1 2 Weeks Oliguric ARF high catabolism Nonoliguric ARF Uremic Syndrome,High Catabolic State,Daily Increase in BUN 10.117.9 mmol/L Daily Increase in Serum Creatinine 176.8mol/L Daily Increase in Serum Potassium 12 mmol/L Daily Decrease in Serum HCO 3 2 mmol/L,The Uremic Syndrome,General Complications of ARF： Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectious,The Uremic Syndrome,Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance： Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatemia,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,Lab Examination,Blood Routine Test and Chemistry Assays: Animia, RBC , Hb BUN and Scr Na ，K,Ca2，P3+ pH ，AG ，HCO3 ,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,Radiologic Evaluation: Plain Abdominal film Renal Ultrasonography IVP Renal angiography Renal Biopsy,Diagnosis Differentiation：,prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosis,Management of ARF (一),Correction of Reversible causes Prevention of additional Injury Maintaining Fluid balance,Management of ARF (二),Maintaining Fluid balance Fluid Intake ： 500ml + The Amount of Urine in The Preceding 24 Hours,Management of ARF (三）,Nutrition Enegy Intake:147kj/d Dietary Protein: 0.8g/kg.d CRRT ( fluid 5L/d),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 (五）,Metabolic Acidosis HCO3 15mmol/L : 5% Sodium Bicarbonate 100-250ml Dialysis,Management of ARF,Other Electrolyte Disorder Infection Hart failure Dialysis,