急性腎衰竭ppt課件

1、 Acute Renal Failure ARFqAcute 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

2、admissions to q intensive care units.l Prerenal azotemia l Intrinsic renal azotemial Postrenal azotemia Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs) Postrenal Azotemia Ureteric Obstructi

3、on Bladder Neck Obstruction Urethral Obstruction Intrinsic Renal Azotemia Diseases Involving Large Renal Vessels Diseases of Glomeruli And Microvasculature Acute Tubule Necrosis Diseases of the Tubulointerstitium Acute Tubule Necrosis ATNl Renal Ischemia50%l Nrphrotoxins 35%l Exogenousl Endogenousl

4、l Intrarenal Vasoconstrictionl Tubular Dysfunctionv Reduction in Total Renal Blood v Flow Regional Disturbance in v Renal Blood Flow and Oxygen v Supplyv Edothelin (ET) / NO (EDNO)v Other Endothelial Vasoconstrctorsv The Tubulo-glomerular Feed Back Two Major TubularAbnormalities: Obstrction Backleak

5、q ATP Depletionq Cell Swellingq Intyacellular Free Calciumq IntyacellularAcidosisq Phospholipase Activationq Protease Activationq Oxidant Injuryq Inflammatory Respose The Clinical Course of ATN： The Initiation Phase The Maintenance Phase The Recovery PhaselGFRlLasting Hours or DayslEvidence of true

6、Volume DepletionlDecreeced Effective Circulatory VolumelTreatment with NSAIDs or ACEIlGRR 5 10 ml/minlLasting 1 2 WeekslOliguric ARF lhigh catabolismlNonoliguric ARFlUremic SyndromelDaily Increase in BUN 10.117.9 mmol/LlDaily Increase in Serum Creatinine 176.8mol/LlDaily Increase in Serum Potassium

7、12 mmol/LlDaily Decrease in Serum HCO 3 2 mmol/L General Complications of ARF： Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectious Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance： Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hy

8、perphosphatemia 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 Blood Routine Test and Chemistry Assays: Animia, RBC , Hb BUN and Scr Na ，K,Ca2，P3+ pH ，AG ，HCO3 Diagnostic Index Prerenal R

9、enal 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 v Radiologic Evaluation:v Plain Abdominal filmv Renal Ultrasonographyv IVPv Renal angiographyv Rena

10、l Biopsy prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Artery Thrombosis Renal vein thrombosisq Correction of Reversible causes q Prevention of additional Injuryq Maintaining Fluid balance Maintaining Fluid balance Fluid Intake ： 500ml + The Amount of Urine in The Preceding 24 Hours Nutrition Enegy Intake:147kj/d Dietary Protein: 0.8g/kg.d CRRT ( fluid 5L/d) Hyperkalemia K+6mmol/L 10%Calcium Gluconate 10-20ml 5% Sodium Bicarbonate 100-200ml 20% Glucose 3ml/k