Du Juan Department of Nephrology Renmin Hospital of Wuhan University
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Transcript of Du Juan Department of Nephrology Renmin Hospital of Wuhan University
Acute Renal FailureAcute Renal Failure
Du Juan Du Juan Department of NephrologyDepartment of NephrologyRenmin Hospital of Wuhan Renmin Hospital of Wuhan
UniversityUniversity
DefinitionsDefinitions
Acute Renal Failure (ARF) Acute Renal Failure (ARF) is a syndrome is a syndrome
characterized by rapid (hours to weeks) characterized by rapid (hours to weeks)
decline in glomerular filtration rate (GFR) decline in glomerular filtration rate (GFR)
and retention of nitrogenous waste products and retention of nitrogenous waste products
such as creatininesuch as creatinine
Clinical SyndromeClinical Syndrome
AbruptAbrupt SustainedSustained Decline in GFR Decline in GFR
Occurs over Hours or DaysOccurs over Hours or Days
Rising Serum Creatinine(≥44.2Rising Serum Creatinine(≥44.2µµmol/L /day)mol/L /day)
Clinical Results Clinical Results
DefinitionsDefinitions
Definition of AKIDefinition of AKI
Functional or structural abnormalities or Functional or structural abnormalities or
markers of kidney damage including markers of kidney damage including
abnormalities in blood , urine or tissue testsabnormalities in blood , urine or tissue tests
or imaging studies present foror imaging studies present for << 3 months 3 months
急性肾损伤定义急性肾损伤定义 急性肾损伤是指不超过急性肾损伤是指不超过 33 个月的肾脏结个月的肾脏结
构或功能异常,包括血、尿、组织学或构或功能异常,包括血、尿、组织学或影像学方面的肾损伤标志的异常影像学方面的肾损伤标志的异常
Criteria for AKICriteria for AKI
4848 小时内小时内 ScrScr 上升≥上升≥ 26.526.5µµmol/Lmol/L (( 0.3mg/dl0.3mg/dl ) ) 或较前升高≥或较前升高≥ 5050 %%
尿量减少,<尿量减少,< 0.5ml/kg/h0.5ml/kg/h ,持续,持续 66 小时以上小时以上(排除尿路梗阻或脱水状态等)(排除尿路梗阻或脱水状态等)
Staging of AKIStaging of AKIPhase Scr Criteria Urine Output Criteria 1 ↑≥0.3mg/dl or↑≥50 % < 0.5ml/kg/h×6hr 2 ↑≥200%-300% < 0.5ml/kg/h×12hr 3 ↑≥300% Oliguria ≥4.0mg/dl ( < 0.3ml/kg/h×24hr ) (Acute rise≥0.5mg/dl ) or Anuria×12hr
Prerenal 55% ~60%
Intrarenal 35% ~40%
Postrenal < 5 %
ClassificationClassification
Intravascular Volume Intravascular Volume DepletionDepletion
Hemorrage
Renal Losses
Skin and Mucous LossesDiuretic
Gastrointestinal Losses
Vomiting
Diarrhea
Prerenal ARF (1)Prerenal ARF (1)
DecreasedEffective
Circulatory Volume
Decreased Cardiac Output
Prerenal ARF (2)Prerenal ARF (2)
Bilateral Ureteric Obstruction
Bladder Neck Obstruction
Urethral Obstruction
Postrenal ARFPostrenal ARF
Acute Glomerulonephritis Rapidly Progressive Glomerulonephritis
Diseases of GlomeruliIntrarenal ARF Intrarenal ARF (1)(1)
Tubulointerstitial Tubulointerstitial NephritisNephritis
Rash
Hematuria
Fever
Renal Renal
BiopsBiopsyy
Intrarenal ARF (2)Intrarenal ARF (2)
Diseases of Large Renal Diseases of Large Renal VesselsVessels
AtheroembolismAtheroembolism
ThrombosisThrombosis
Intrarenal ARF (3)Intrarenal ARF (3)
AAcute cute TTubular ubular NNecrosisecrosis((ATN)ATN)
Intrarenal ARF (4)Intrarenal ARF (4)
Acute TubularNecrosis
Acute Tubular NecrosisAcute Tubular Necrosis
ATNATN Etiology Etiology PathogenisisPathogenisis Pathology Pathology Clinical PresentationsClinical Presentations Laboratory ExaminationsLaboratory Examinations Diagnosis & Diagnosis &
DifferentiationDifferentiation ManagementManagement
Ischemic ATN Severe or prolonged renal hypoperfusion
Nephrotoxic ATN
Many medications and poisons
EtiologyEtiology
PathogenesisPathogenesis
发病机制发病机制 肾血流动力学异常肾血流动力学异常 肾小管上皮脱落,管腔内管型形成肾小管上皮脱落,管腔内管型形成
肾小管阻塞(肾小管阻塞( Intratubular Obstruction)Intratubular Obstruction) 肾小管反漏(肾小管反漏( Tubular Fluid Backleak)Tubular Fluid Backleak)
肾小管上皮细胞代谢障碍肾小管上皮细胞代谢障碍
Ischemic / Toxic Renal Injury
Tubular DamageHemodynamic Abnormalities
Endothelial SwellingReduced EDRF
Vasoconstrictor ReleaseEndothelinAngiotensin
ThromboxaneNorepinephrine
Afferent Arteriolar Constriction
Kf Glomerular
Capillary Pressure RBFTubular
Obstruction Backleak
Reduced Glomerular Filtration Rate
Tubuloglomerular Feedback
Events Following the Initiation of Renal Events Following the Initiation of Renal IschemiaIschemia
Renal Ischemia
Supply of O2
Nutrients to Kidney
ATP
Nephrotoxins Lipid Peroxidation
Oxygen-Derived Free Radicals
Scavenging Systems
Abnormal Metabolic Levels
Adenosine Hypoxanthine
Tubular Sodium PumpIinhibition Na+, Cl- pH ↓Cell Volume
Cell structure changesMembrane Integrity
Cytoskeleton DamagedMitochondria Swell
Pathologic ChangesTubular Dysfunction: Leakage, Obstruction,
Loss of Filtration, NecrosisIntrarenal Vessel Constriction: Increased Ischemia
Cell death
PathologyPathology
NormalNormal
Tubule vacuolization (green arrow) Tubule vacuolization (green arrow)
Tubule dilation and brush border losses (black arrows) Tubule dilation and brush border losses (black arrows)
Mild ATN
Denuded basement membrane and
the presence of intraluminal casts
Degenerated and sloughed,Degenerated and sloughed,
frank necrosis tubular cellsfrank necrosis tubular cells
Severe ATN
Clinical Course of Clinical Course of ATNATN
Initiation Phase Initiation Phase
Maintenance PhaseMaintenance Phase
Recovery PhaseRecovery Phase
临床病程临床病程 起始期起始期 维持期维持期 恢复期恢复期
Initiation PhaseInitiation Phase
Reversible Fall in GFR Reversible Fall in GFR PreventivePreventive HypotensionHypotension SepsisSepsis Renal ToxinsRenal Toxins
Maintenance PhaseMaintenance Phase Oliguria PhaseOliguria Phase
7~14d or Even 4~6w of Duration7~14d or Even 4~6w of Duration OliguriaOliguria :: Urine OutputUrine Output <<
400ml/d400ml/d AnuriaAnuria :: Urine OutputUrine Output <<
100ml/d100ml/d NonoliguriaNonoliguria
Clinical Presentations Clinical Presentations (( 11 ))
Disturbance of Disturbance of WaterWater 、、 Electrolyte & Base- Acid Electrolyte & Base- Acid HomeostasisHomeostasis HyponatremiaHyponatremia (低钠血症)(低钠血症) HyperkalemiaHyperkalemia (高钾血症)(高钾血症) Hypocalcemia Hypocalcemia (低钙血症)(低钙血症) HyperphosphatemiaHyperphosphatemia (高磷血症)(高磷血症) Metabolic AcidosisMetabolic Acidosis (代谢性酸中毒)(代谢性酸中毒)
Clinical Presentations Clinical Presentations (( 22 ))
Systemic Complications Systemic Complications ::InfectionInfection The most common and serious The most common and serious complications of ARFcomplications of ARF Occurring in 50% to 90% of casesOccurring in 50% to 90% of cases Aaccouting for up to 75% of deathsAaccouting for up to 75% of deaths
Clinical Presentations Clinical Presentations (( 33 ))
Systemic ComplicationsSystemic Complications Gastrointestinal Symptoms:Gastrointestinal Symptoms: Anorexia, Anorexia,
Nausea, Vomiting, HemorrhageNausea, Vomiting, Hemorrhage Cardiac Complications:Cardiac Complications: Hypertension, Hypertension,
Congestive Heart Failure, ArrhythmiasCongestive Heart Failure, Arrhythmias
Clinical Presentations Clinical Presentations (( 44 ))
Pulmanary Complications:Pulmanary Complications: Infection, Adult Respiratory Infection, Adult Respiratory Distress SyndromeDistress Syndrome
呼吸系统:并发感染、呼吸系统:并发感染、 ARDSARDS Neruopsychiatric Disturbance:Neruopsychiatric Disturbance:
Confusion, Delirium or Coma, Confusion, Delirium or Coma, Seizure Seizure
神经系统:意识模糊、谵妄、昏迷、 抽搐神经系统:意识模糊、谵妄、昏迷、 抽搐
Volume of Urine Volume of Urine 3000-5000ml/d Duration 1-3w3000-5000ml/d Duration 1-3w ComplicationsComplications
HyponatremiaHyponatremia 、、 HypokalemiaHypokalemia InfectionInfection Redecreased Volume of UrineRedecreased Volume of Urine
Renal Biopsy Show Everlasting Renal Renal Biopsy Show Everlasting Renal Pathological Changes in Minority of Pathological Changes in Minority of PatientsPatients
Recovery Phase
Laboratory Laboratory ExaminationsExaminations
Blood Analysis Blood Analysis UrinalysisUrinalysis Imaging Evaluation Imaging Evaluation Renal BiopsyRenal Biopsy
Blood-Rt and BCABlood-Rt and BCA Serum Creatinine & BUN↑Serum Creatinine & BUN↑ Serum Potassium ↑Serum Potassium ↑ Serum Sodium ↓Serum Sodium ↓ Serum Calcium ↓Serum Calcium ↓ Serum HCOSerum HCO33
- - ↓↓ Mild-Moderate AnemiaMild-Moderate Anemia Serum BUN/ScrSerum BUN/Scr
UrinalysisUrinalysis Urine Output Urine Output 尿量改变:少尿型、非少尿型尿量改变:少尿型、非少尿型 Urine Sediment Urine Sediment :肾小管上皮细胞:肾小管上皮细胞 Urine Specific Gravity Urine Specific Gravity 尿比重尿比重 <1.015<1.015 Urine Osmotality Urine Osmotality 尿渗透浓度尿渗透浓度 <350mOsmol/L<350mOsmol/L Urinary NaUrinary Na+ + Concentration Concentration 尿钠尿钠 20~60mmol/L20~60mmol/L Urinary Creatinine/Plasma Creatinine RatioUrinary Creatinine/Plasma Creatinine Ratio 尿肌酐尿肌酐 // 血肌酐血肌酐 <20<20
Renal Tubular Epithelial Cell Casts
Imaging InvestigationsImaging Investigations Ultrasound Ultrasound BB 超超 Plain Abdomen Plain Abdomen 腹部平片腹部平片 Excretory Excretory
Urography/CystourethrographyUrography/Cystourethrography 排泄性尿路造影排泄性尿路造影 // 逆行尿路造影逆行尿路造影 CT ScanningCT Scanning Isotope Renography or Renal Isotope Renography or Renal
Angiography Angiography 核素扫描或血管造影核素扫描或血管造影
Renal Biopsy Renal Biopsy
DiagnosisDiagnosis History History Abrupt Sustained Decline in Renal Abrupt Sustained Decline in Renal
FunctionFunction Increased Absolute Scr ≥44.2umol/L/dIncreased Absolute Scr ≥44.2umol/L/d Increased Relative Scr 25% Over Increased Relative Scr 25% Over
Baseline/dBaseline/d Clinical ManifestationsClinical Manifestations Laboratory ExaminationsLaboratory Examinations
Differential DiagnosisDifferential Diagnosis
ARF Secondary to ARF Secondary to CKD CKD
Prerenal ARFPrerenal ARF Postrenal ARFPostrenal ARF
Intrinsic ARFIntrinsic ARF
Postrenal ARFPostrenal ARF Primary Disease of Urinary Primary Disease of Urinary
ObstructionObstruction Abrupt Oliguria or Even AnuriaAbrupt Oliguria or Even Anuria Renal AnginaRenal Angina Tenderness or PercussionTenderness or Percussion Signs of Urine RetentionSigns of Urine Retention Renal ImagingRenal Imaging
Prerenal ARFPrerenal ARF Transfusion TestTransfusion Test
History of Body Fluids LossesHistory of Body Fluids Losses Signs of HypovolemiaSigns of Hypovolemia IV.drop 5% Glucose 200IV.drop 5% Glucose 200 ~~ 250ml 250ml ++
IV. Frusemide 40IV. Frusemide 40 ~~ 100mg100mg
Differential Diagnosis Between Pre-renal ARF and Differential Diagnosis Between Pre-renal ARF and ATNATN
Diagnosis Index Diagnosis Index Prerenal Prerenal ARFARF ATNATN
Urine GravityUrine Gravity >> 1.0181.018 << 1.0151.015
Urine Urine Osmotality(mmol/L)Osmotality(mmol/L) >> 500 500 << 350350
Urine Natrium Urine Natrium Concentration (mmol/L)Concentration (mmol/L) << 2020 >> 2020
Serum BUN/ScrSerum BUN/Scr >> 2020 << 1515
ARF IndexARF Index << 11 >> 11
Natrium Filtration Natrium Filtration FractionFraction << 11 >> 11
Urine SedimentUrine Sediment Clarity CastClarity CastBrown Brown
Granular Granular CastsCasts
Transfusion TestTransfusion Test ++ --
Treatment Treatment (( 11 ))PreventionPrevention ((纠正可逆因素,预防额外损伤)纠正可逆因素,预防额外损伤) Identify at Risk PatientsIdentify at Risk Patients ((治疗基础疾病)治疗基础疾病)
Pre-existing CKD, Diabetes, ElderlyPre-existing CKD, Diabetes, Elderly Optimise Renal PerfusionOptimise Renal Perfusion
IV Fluids, Blood TransfusionIV Fluids, Blood Transfusion Avoid Nephrotoxic AgentsAvoid Nephrotoxic Agents
NSAIDS, Radiocontrast, NSAIDS, Radiocontrast, AminoglycosidesAminoglycosides ,, ACEIACEI
Maintain Adequate DiuresisMaintain Adequate Diuresis ?? FrusemideFrusemide
Treatment Treatment ( ( 2 2 ))Management of Volume Management of Volume
HomeostasisHomeostasis Record I/O Record I/O Fluid = Urine Output + 500mlFluid = Urine Output + 500ml DiureticsDiuretics Dialysis Dialysis
Treatment Treatment (( 33 ))Management of Electrolyte Management of Electrolyte
HomeostaisHomeostais HyponatremiaHyponatremia HyperkalemiaHyperkalemia Hypocalcemia Hypocalcemia Hyperphosphatemia Hyperphosphatemia
Methods of TreatmentMethods of TreatmentDRUG
Calcium Glucose
Glucose + Insulin
Natrium Bicarbonate
Na polysterne sulfonate
Dialysis
DOSE
10 ml of 10%
50 ml of 50% + 10U
100ml~200ml of 5%
DURATION
30 minutes
1 - 4 hours
1 - 8 hours
There is always dialysis!
Treatment Treatment (( 44 )) Nutritional SupportNutritional Support Calorie 35Kcal/kg/dCalorie 35Kcal/kg/d
Maximal Carbohydrate and Maximal Carbohydrate and LipidLipid
Minimal Recommand Minimal Recommand Protein Intake 0.8g/kg/dayProtein Intake 0.8g/kg/day
Limit NaLimit Na 、、 KK 、、 Cl Intake Cl Intake IV. Essence Amino AcidIV. Essence Amino Acid
Treatment Treatment (( 55 )) Heart FailureHeart Failure
DigoxineDigoxine DiureticsDiuretics Vessel Dilative AgentsVessel Dilative Agents Dialysis Most EffectiveDialysis Most Effective
InfectionInfection
Absolute IndicationsAbsolute Indications Volume OverloadVolume Overload
HyperkalemiaHyperkalemia
Metabolic AcidosisMetabolic Acidosis
OvertOvert Uremic SymptomsUremic Symptoms
Treatment Treatment (( 66 ))
Prophylaxis Dialysis Prophylaxis Dialysis Relieve Retention of Excess Water and Relieve Retention of Excess Water and
ToxinsToxins Maintain Electrolyte and Acid-Base Maintain Electrolyte and Acid-Base
HomeostaisHomeostais For Nutritional Therapy For Nutritional Therapy Avoid MOSDAvoid MOSD
Dialysis PatternDialysis Pattern
Intermittent Intermittent HemodialysisHemodialysis (( IHDIHD ))
CContinuous ontinuous RRenal enal RReplacement eplacement TTherapyherapy
Peritoneal DialysisPeritoneal Dialysis (( PDPD ))
透析适应症透析适应症 急性肺水肿急性肺水肿 高钾血症高钾血症 6.5mmol/L6.5mmol/L 以上以上 BUN≥21.4mmol/LBUN≥21.4mmol/L 或或
Scr≥442umol/LScr≥442umol/L 高分解代谢状态高分解代谢状态 每日每日 BUNBUN 上升≥上升≥ 8.9mmol/L8.9mmol/L 或或
ScrScr 上升≥上升≥ 176.8umol/L176.8umol/L ,血钾,血钾上升≥上升≥ 1mmol/L1mmol/L
无尿无尿 22 天或少尿天或少尿 44 天以上天以上 酸中毒 酸中毒 COCO22CPCP << 13mmol/L13mmol/L , , pHpH <<
7.257.25 少尿少尿 22 天以上并伴有下列情况之一者天以上并伴有下列情况之一者 体液潴留体液潴留
尿毒症症状 尿毒症症状 血钾> 血钾> 6.0mmol/L6.0mmol/L ,心电图有高钾表现,心电图有高钾表现
恢复期的治疗 多尿的治疗多尿的治疗
维持水、电解质和酸碱平衡维持水、电解质和酸碱平衡 控制氮质血症控制氮质血症 防止发生并发症防止发生并发症
定期随访肾功能定期随访肾功能 避免使用肾毒性药物避免使用肾毒性药物
PrognosisPrognosis
ATN Without Complications ATN Without Complications 7%-23%7%-23%
ATN With MOSD ATN With MOSD 50%-80%50%-80%
QuestionsQuestions WhatWhat’’s the Difference between s the Difference between
Acute Renal Failure and ATN?Acute Renal Failure and ATN? How to Deal with How to Deal with
Hyperkalemia in ARF Hyperkalemia in ARF Patients?Patients?
What is the Indication of What is the Indication of Hemodialysis in ARF Patients?Hemodialysis in ARF Patients?
THANK YOU