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1、1,Renal failure,2,患儿女，11月。因呕吐、腹泻伴发热9天，无尿5天入院。 9天前无诱因出现腹泻，每天34次，伴频繁呕吐，非喷射状，量较多；同时发热，体温最高41。给予口服抗生素治疗，三天后腹泻、呕吐次数减少，但体温仍在3839之间。近5天一直无尿。 体检： 呼吸60次/分，脉搏120次/分，血压85/54mmHg。 昏睡状态。双眼睑及球结膜水肿，睑结膜稍苍白，口唇干裂，咽充血，颈无抵抗；呼吸深大。 实验室检查： 便常规正常；血钾8.6mmol/L，血钠128mmol/L,氯化物100mmol/L, 血钙1.98mmol/L，血磷2.33mmol/L, 尿素氮37.12mmol
2、/L,血肌酐804.44mol/L；血气分析：pH7.17, PCO224.5mmHg, HCO3-8.6mmol/L, SBE -18.3mmol/L；心电图：室内传导阻滞，T波高尖。,3,1 Introduction,Normal function of the kidney Renal insufficiency Causes Basic manifestation of renal insufficiency,4,Normal function of the kidney,Remove waste product from the body； Regulate electrolyte
3、and acid-base balance.,1.Excretion,Produce renin、EPO、1,25(OH)2D3 and prostaglandins； Inactivate gastrin、PTH.,2. Endocrine,5,Renal insufficiency,Diseases,Dysfunction of excretion and endocrine,Symptoms and signs,Edema, hypertension, oliguric, polyuria, hematuria, proteinuria, anemia, osteodystrophy.,
4、6,Causes:,1 Primary renal diseases Primary glomerular diseases, Primary tubular diseases, Interstitial nephritis, et al. 2 Secondary renal lesion Circulatory system diseases, immunity siseases, metabolic diseases, hematopathy, et al.,7,1 Glomerular dysfunction 2 Tubular dysfunction 3 Endocrine dysfu
5、nction,Basic manifestation of renal insufficiency,8,1 Glomerular dysfunction,GFR blood flow net filtration pressure Kf Glomerular permselectivity,9,10,2 Tubular dysfunction,proximal tubule Renal glycosuria, aminoaciduria, renal tubular acidosis, hypophosphatemia loop of Henle Hypotonic or isotonic u
6、rine, polyuria distal tubule Acid-base and electrolyte disorders, polyuria,11,3 Endocrine dysfunction, Renin Endothelins KKS disorders AA Disequilibrium EPO 1,25(OH)2D3,12,Diseases,Conception,2 Acute renal failure,water intoxication,azotemia, hyperkalemia, metabolic acidosis,13,1 causes Prerenal Int
7、rarenal Postrenal ,2renallesion functional organic obstructive ,3urine volume Oliguric Nonoliguric ,* Classification,Section 1 Cause and Classification,14,Causes,1 Prerenal factor renal blood flow,Characteristic early stage: functional late stage: organic (2) oliguria,15,Mechanism,ECF,RBF ,GFR Reabs
8、orption,oliguria Impaired homeostasis,16,Causes (1) acute tubular necrosis,ATN 2/3acute renal ischemia acute renal poisoning hemoglobinuria, myoglobinuria(2) renal disease,Characteristic (1) parenchymal (2) oliguric nonoliguric ,2 intrarenal factor,17,Differentiation between the two RF urine functio
9、nalRF organic RF specific gravity 1.020 700 40 UrCr/SrCr 40 20 Sediment normalManicol test urine volume urine volume,Necrosis epithelial cells,RBC,casts, albuminuria,18,Causes Kidney stone, tumor, obstruction of necrosis tissue,Characteristic early stage: obstructive late stage: organic ,3 Postrenal
10、 factor,19,Mechanism,Obstruction of the urinary tract,Bowmans capsule pressure,Net filtration pressure,GRF,Oliguria, anuria,20,Section 2 Pathogenesis, RBF （1） Net filtration pressureBP 60mmHgCO RBFBP (50-70mmHg) GFR (1/2 2/3)BP(40mmHg) GFR = 0 Urinary obstruction intracapsular pressure,1 Glomerular
11、factor,21,（2）renal vessels constrictionRBF sympathetic nerveShock RASprostaglandin kallikrein - kinin syetem ANPNO,22,（3） swelling endothelial cellischemia Na+ - K+ - ATPase free radical endothelial cellular injury （4）alteration of renal hemorheology fibrinogen Blood viscosityRBC聚集和变形能力PLT聚集WBC粘附、嵌顿
12、微血管改变,renal DIC,23, Glomerular lesionfiltration surface areaGlomerular permselectivityGFR,24,2 Tubular factor,tuble obstruction 管型 阻塞管腔 原尿不易通过 尿量管腔内压 GFR passive backflow 肾小管上皮细胞变性、坏死 原尿漏出 肾间质水肿 囊内压 GFR 尿量,25,26,1、受损细胞的种类及特征（1） 肾小管细胞1）坏死性损伤小管破裂性损伤：可发生于各段肾小管上皮坏死+基底膜破坏。 肾持续缺血和肾中毒均可见肾毒性损伤：主要发生于近球小管仅上皮坏
13、死，基底膜完整。主要见于肾中毒,(三)肾细胞损伤及其机制,27,(2)内皮细胞 内皮细胞肿胀 血流阻力内皮细胞受损 PLT聚集，微血栓形成 肾小球内皮窗 GFR 内皮细胞释放舒血管因子,2）凋亡性损伤远端肾小管,28,（3）系膜细胞 Ang、ADH 系膜细胞收缩 庆大霉素、腺苷肾小球血管阻力滤过面积GFR,29,2、细胞损伤机制（1） ATP合成减少和离子泵失灵缺氧缺血 线粒体损伤 ATP中毒 Na+ - K+ - ATPase Ca2+ - ATPase细胞内 Na+，H2O 细胞内 Ca2+,30,（2）自由基(FR)肾缺血 还原型谷胱甘肽(GSH)FR清除 细胞损伤再灌注 FR产生 （3
14、）GSH 细胞抗氧化能力 ，膜稳定性 （4）磷酯酶活性细胞内 Ca2+ 磷酯酶 A2 细胞膜损伤,31,（5）细胞骨架结构改变肾缺血 ATP 细胞骨架结构改变肾中毒（6）细胞凋亡的激活,32,Section 3 Clinical Course and manifestation,1 oliguria phase（daysweeks）(1)features of urineurine volume：oliguria（400ml/d）or anuria（100ml/d）S.G.：1.0101.020Na+ ：tubular reabsorption dysfunctionurine sedimen
15、t:erythrocytes, casts, proteinuria,oliguric ARF,33,(2) water toxication,oliguria Catabolism ，内生水 Transfuse fluid,Fluid retention,Hypervolemic hyponatremia,Cell edema,34,(3) Hyperkalemia most serious,Urinary excretion of K+ Tissue destruction Metabolic acidosis Transfuse non-fresh blood, high K+ diet hyponatremia，exchange of K+and Na+,
