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1、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 hospita
2、l admissions and up to 30% of admissions to intensive care units.,CLASSIFICATION,Prerenal azotemia Intrinsic renal azotemiaPostrenal azotemia,ETIOLOGY OF ARF,Prerenal Azotemia,Intravascular Volume DepletionDecreased Cardiac OutputSystemic VasodilatationRenal VasoconstrictionPharmacologic Agents (ACE
3、I or NSAIDs),ETIOLOGY OF ARF,Postrenal AzotemiaUreteric ObstructionBladder Neck ObstructionUrethral Obstruction,ETIOLOGY OF ARF,Intrinsic Renal Azotemia Diseases Involving Large Renal VesselsDiseases of Glomeruli And MicrovasculatureAcute Tubule NecrosisDiseases of the Tubulointerstitium,急性肾小管坏死,Acu
4、te Tubule Necrosis（ATN）,ETIOLOGY OF ATN,Renal Ischemia（50%）Nrphrotoxins （35%）ExogenousEndogenous,PATHOPHYSIOLOGY OF ATN,Intrarenal VasoconstrictionTubular Dysfunction,Role of Hemodynamic alterations in ATN,Reduction in Total Renal Blood Flow Regional Disturbance in Renal Blood Flow and Oxygen Supply
5、Edothelin (ET) / NO (EDNO)Other Endothelial VasoconstrctorsThe Tubulo-glomerular Feed Back,Role of Tubule Dysfunction in ATN,Two Major TubularAbnormalities:ObstrctionBackleak,Metabolic Responses of Tubule cells to Injury,ATP DepletionCell SwellingIntyacellular Free CalciumIntyacellular AcidosisPhosp
6、holipase ActivationProtease ActivationOxidant InjuryInflammatory Respose,Pathology,Clinical Presentation of ATN,The Clinical Course of ATN：The Initiation PhaseThe Maintenance PhaseThe Recovery Phase,The Initiation Phase,GFR Lasting Hours or Days Evidence of true Volume Depletion Decreeced Effective
7、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 Potas
8、sium 12 mmol/L Daily Decrease in Serum HCO 3 2 mmol/L,The Uremic Syndrome,General Complications of ARF：GastrointestinalCardiovascularRespiratoryNeurologicHematologicInfectious,The Uremic Syndrome,Homeostatic Disorder of water，Electrolyte and Acid-alkali Balance：Volume OverloadMetabolic AcidosisHyper
9、kalemiaHyponatremiaHypocalcemiaHyperphosphatemia,The Recovery Phase,The Period of Repair and Regeneration of Renal Tissue:Gradual Increase in Urine Output“Post-ATN” DiuresisFall in BUN and ScrRecovery of GFR/ Tubule function,Lab Examination,Blood Routine Test and Chemistry Assays:Animia, RBC , Hb BU
10、N and ScrNa ，K,Ca2，P3+ pH ，AG ，HCO3 ,Lab Examination,Diagnostic Index Prerenal RenalSpecific Gravity 1.020 1.010Osmolality(mOsm/Kg H2O) 500 300Urinary Na+ (mmol/L) 20Ucr/Scr 40 8 20 1Fractional Excretion of Na+ 1Urine Sediment Hyaline Brown ranular,Lab Examination,Radiologic Evaluation:Plain Abdomin
11、al filmRenal UltrasonographyIVPRenal angiographyRenal Biopsy,Diagnosis Differentiation：,prerenal azotemiapostrenal azotemiaGlomerulonephritis/VasculitisHUS/TTPInterstitial NephritisRenal Artery ThrombosisRenal vein thrombosis,Management of ARF (一),Correction of Reversible causes Prevention of additi
12、onal InjuryMaintaining Fluid balance,Management of ARF (二),Maintaining Fluid balanceFluid Intake ：500ml + The Amount of Urinein The Preceding 24 Hours,Management of ARF (三）,NutritionEnegy Intake:147kj/dDietary Protein: 0.8g/kg.dCRRT ( fluid 5L/d),Management of ARF (四）,HyperkalemiaK+6mmol/L 10%Calcium Gluconate 10-20ml5% Sodium Bicarbonate 100-200ml20% Glucose 3ml/kg.h+Insulin 0.5U/kg.hDialysis,Management of ARF (五）,Metabolic AcidosisHCO3 15mmol/L :5% Sodium Bicarbonate 100-250mlDialysis,Management of ARF,Other Electrolyte DisorderInfectionHart failureDialysis,
