1、 Acute Renal Failure （ARF）第1页，共31页。qAcute 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%
2、of admissions to intensive care units.第2页，共31页。l Prerenal azotemia l Intrinsic renal azotemial Postrenal azotemia 第3页，共31页。Prerenal Azotemia Intravascular Volume Depletion Decreased Cardiac Output Systemic Vasodilatation Renal Vasoconstriction Pharmacologic Agents (ACEI or NSAIDs)第4页，共31页。Postrenal
3、Azotemial Ureteric Obstructionl Bladder Neck Obstructionl Urethral Obstruction第5页，共31页。Intrinsic Renal Azotemia l Diseases Involving Large Renal Vesselsl Diseases of Glomeruli And Microvasculaturel Acute Tubule Necrosisl Diseases of the Tubulointerstitium 第6页，共31页。Acute Tubule Necrosis （ATN）第7页，共31页
4、。l Renal Ischemia（50%）l Nrphrotoxins （35%）Exogenous Endogenous 第8页，共31页。l Intrarenal Vasoconstrictionl Tubular Dysfunction第9页，共31页。v 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-g
5、lomerular Feed Back第10页，共31页。Two Major TubularAbnormalities:Obstrction Backleak第11页，共31页。q ATP Depletionq Cell Swellingq Intyacellular Free Calciumq IntyacellularAcidosisq Phospholipase Activationq Protease Activationq Oxidant Injuryq Inflammatory Respose第12页，共31页。第13页，共31页。The Clinical Course of AT
6、N：The Initiation Phase The Maintenance Phase The Recovery Phase第14页，共31页。lGFRlLasting Hours or DayslEvidence of true Volume DepletionlDecreeced Effective Circulatory VolumelTreatment with NSAIDs or ACEI第15页，共31页。lGRR 5 10 ml/minlLasting 1 2 WeekslOliguric ARF lhigh catabolismlNonoliguric ARFlUremic
7、Syndrome第16页，共31页。lDaily 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/L第17页，共31页。General Complications of ARF：Gastrointestinal Cardiovascular Respiratory Neurologic Hematologic Infectiou
8、s第18页，共31页。Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance：Volume Overload Metabolic Acidosis Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatemia第19页，共31页。The Period of Repair and Regeneration of Renal Tissue:Gradual Increase in Urine Output “Post-ATN”Diuresis Fall in BUN and
9、Scr Recovery of GFR/Tubule function第20页，共31页。Blood Routine Test and Chemistry Assays:Animia,RBC,Hb BUN and Scr Na ，K,Ca2，P3+pH，AG，HCO3 第21页，共31页。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
10、 1 Fractional Excretion of Na+1 Urine Sediment Hyaline Brown ranular 第22页，共31页。v Radiologic Evaluation:Plain Abdominal film Renal Ultrasonography IVP Renal angiographyv Renal Biopsy 第23页，共31页。prerenal azotemia postrenal azotemia Glomerulonephritis/Vasculitis HUS/TTP Interstitial Nephritis Renal Arte
11、ry Thrombosis Renal vein thrombosis第24页，共31页。q Correction of Reversible causes q Prevention of additional Injuryq Maintaining Fluid balance第25页，共31页。Maintaining Fluid balance Fluid Intake：500ml+The Amount of Urine in The Preceding 24 Hours第26页，共31页。Nutritionl Enegy Intake:147kj/dl Dietary Protein:0.
12、8g/kg.dl CRRT(fluid 5L/d)第27页，共31页。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第28页，共31页。Metabolic Acidosis HCO3 15mmol/L:5%Sodium Bicarbonate 100-250ml Dialysis第29页，共31页。l Other Electrolyte Disorderl Infectionl Hart failurel Dialysis第30页，共31页。第31页，共31页。
