急性肾衰竭急性肾衰竭急性肾衰竭急性肾衰竭 Acute Renal Failure （ARF）1DEFINITIONS AND INCIDENCEDEFINITIONS 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.2CLASSIFICATIONCLASSIFICATIONl Prerenal azotemia l Intrinsic renal azotemial Postrenal azotemia 3ETIOLOGY OF ARFETIOLOGY OF ARF Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)4ETIOLOGY OF ARFETIOLOGY OF ARF Postrenal Azotemiaq Ureteric Obstructionq Bladder Neck Obstructionq Urethral Obstruction5ETIOLOGY OF ARFETIOLOGY OF ARF Intrinsic Renal Azotemia v Diseases Involving Large Renal Vesselsv Diseases of Glomeruli And Microvasculaturev Acute Tubule Necrosisv Diseases of the Tubulointerstitium 6急性肾小管坏死急性肾小管坏死急性肾小管坏死急性肾小管坏死 Acute Tubule Necrosis （ATN）7ETIOLOGY OF ATNETIOLOGY OF ATNl Renal Ischemia（50%）l Nrphrotoxins （35%） Exogenous Endogenous 8PATHOPHYSIOLOGY OF ATNPATHOPHYSIOLOGY OF ATNl Intrarenal Vasoconstrictionl Tubular Dysfunction9Role of Hemodynamic alterations Role of Hemodynamic alterations in ATNin 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 Back10 Role of Tubule Dysfunction Role of Tubule Dysfunction in ATN in ATN Two Major TubularAbnormalities: Obstrction Backleak11Metabolic Responses of Metabolic Responses of Tubule cells to InjuryTubule cells to Injuryq ATP Depletionq Cell Swellingq Intyacellular Free Calciumq IntyacellularAcidosisq Phospholipase Activationq Protease Activationq Oxidant Injuryq Inflammatory Respose12PathologyPathology13Clinical Presentation of ATNClinical Presentation of ATN The Clinical Course of ATN： The Initiation Phase The Maintenance Phase The Recovery Phase14The Initiation PhaseThe Initiation PhaselGFRlLasting Hours or DayslEvidence of true Volume DepletionlDecreeced Effective Circulatory VolumelTreatment with NSAIDs or ACEI15The Maintenance PhaseThe Maintenance PhaselGRR 5 10 ml/minlLasting 1 2 WeekslOliguric ARF lhigh catabolismlNonoliguric ARFlUremic Syndrome16High Catabolic StateHigh Catabolic StatelDaily Increase in BUN 10.117.9 mmol/LlDaily Increase in Serum Creatinine 176.8mol/LlDaily Increase in Serum Potassium 12 mmol/LlDaily Decrease in Serum HCO 3 2 mmol/L17The Uremic SyndromeThe Uremic Syndrome General Complications of ARF： Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectious18The Uremic SyndromeThe Uremic Syndrome Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance： Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatemia19The Recovery PhaseThe 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 function20Lab ExaminationLab Examination Blood Routine Test and Chemistry Assays: Animia, RBC , Hb BUN and Scr Na ，K,Ca2，P3+ pH ，AG ，HCO3 21Lab ExaminationLab 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 22Lab ExaminationLab Examinationv Radiologic Evaluation: Plain Abdominal film Renal Ultrasonography IVP Renal angiographyv Renal Biopsy 23 Diagnosis Differentiation Diagnosis Differentiation： prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosis24Management of ARF (Management of ARF (一一一一) )q Correction of Reversible causes q Prevention of additional Injuryq Maintaining Fluid balance25Management of ARF (Management of ARF (二二二二) ) Maintaining Fluid balance Fluid Intake ： 500ml + The Amount of Urine in The Preceding 24 Hours26 Management of ARF ( Management of ARF (三）三）三）三） Nutritionq Enegy Intake:147kj/dq Dietary Protein: 0.8g/kg.dq CRRT ( fluid 5L/d)27Management of ARF (Management of ARF (四）四）四）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 Dialysis28 Management of ARF ( Management of ARF (五）五）五）五） Metabolic Acidosis HCO3 15mmol/L : 5% Sodium Bicarbonate 100-250ml Dialysis29Management of ARFManagement of ARFl Other Electrolyte Disorderl Infectionl Hart failurel Dialysis3031