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 hospital
admissions and up to 30% of admissions to
intensive care units.
CLASSIFICATION
? Prerenal azotemia
? Intrinsic renal azotemia
? Postrenal azotemia
ETIOLOGY OF ARF
Prerenal Azotemia
? Intravascular Volume Depletion
? Decreased Cardiac Output
? Systemic Vasodilatation
? Renal Vasoconstriction
? Pharmacologic Agents (ACEI or NSAIDs)
ETIOLOGY OF ARF
Postrenal Azotemia
? Ureteric Obstruction
? Bladder Neck Obstruction
? Urethral Obstruction
ETIOLOGY OF ARF
Intrinsic Renal Azotemia
? Diseases Involving Large Renal Vessels
? Diseases of Glomeruli And Microvasculature
? Acute Tubule Necrosis
? Diseases of the Tubulointerstitium
急性 肾小管坏死
Acute Tubule Necrosis
（ ATN）
ETIOLOGY OF ATN
? Renal Ischemia（ 50%）
? Nrphrotoxins （ 35%）
Exogenous
Endogenous
PATHOPHYSIOLOGY OF ATN
? Intrarenal Vasoconstriction
? Tubular Dysfunction
Role of Hemodynamic alterations
in ATN
?Reduction in Total Renal Blood
Flow Regional Disturbance in
Renal Blood Flow and Oxygen
Supply
? Edothelin (ET) / NO (EDNO)
? Other Endothelial Vasoconstrctors
? The Tubulo-glomerular Feed Back
Role of Tubule Dysfunction
in ATN
Two Major TubularAbnormalities:
Obstrction
Backleak
Metabolic Responses of
Tubule cells to Injury
? ATP Depletion
? Cell Swelling
? Intyacellular Free Calcium↑
? Intyacellular Acidosis
? Phospholipase Activation
? Protease Activation
? Oxidant Injury
? Inflammatory Respose
Pathology
Clinical Presentation of ATN
The Clinical Course of ATN：
The Initiation Phase
The Maintenance Phase
The Recovery Phase
The Initiation Phase
? GFR↓
? Lasting Hours or Days
? Evidence of true Volume Depletion
? Decreeced Effective 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 >10.1~17.9 mmol/L
?Daily Increase in Serum Creatinine >176.8μmol/L
?Daily Increase in Serum Potassium >1~2 mmol/L
?Daily Decrease in Serum HCO 3 － >2 mmol/L
The Uremic Syndrome
General Complications of ARF：
Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
The Uremic Syndrome
Homeostatic Disorder of water，
Electrolyte and Acid-alkali Balance：
Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
Hyperphosphatemia
The Recovery Phase
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
Lab Examination
Blood Routine Test and Chemistry Assays:
Animia,RBC ↓,Hb ↓
BUN and Scr↑
Na ＋ ↓,K＋ ↑,Ca2＋ ↓,P3+ ↑
pH ↓,AG ↑,HCO3－ ↓
Lab Examination
Diagnostic Index Prerenal Renal
Specific Gravity > 1.020 ~ 1.010
Osmolality(mOsm/Kg H2O) > 500 ~ 300
Urinary Na+ (mmol/L) < 10 > 20
Ucr/Scr > 40 < 20
UUN/BUN > 8 < 3
BUN/Scr > 20 < 10-15
Renal Failure Index < 1 > 1
Fractional Excretion of Na+ < 1 > 1
Urine Sediment Hyaline Brown ranular
Lab Examination
? Radiologic Evaluation:
Plain Abdominal film
Renal Ultrasonography
IVP
Renal angiography
? Renal Biopsy
Diagnosis Differentiation：
prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosis
Management of ARF (一 )
? Correction of Reversible causes
? Prevention of additional Injury
? Maintaining Fluid balance
Management of ARF (二 )
Maintaining Fluid balance
Fluid Intake,
500ml + The Amount of Urine
in The Preceding 24 Hours
Management of ARF (三）
Nutrition
? Enegy Intake:147kj/d
? Dietary Protein,0.8g/kg.d
? CRRT ( fluid > 5L/d)
Management of ARF (四）
Hyperkalemia
K+<6mmol/L
Restriction of Dietary Potassium Intake
K+-Binding Ion Exchange Resins
K+>6mmol/L
10%Calcium Gluconate 10-20ml
5% Sodium Bicarbonate 100-200ml
20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h
Dialysis
Management of ARF (五）
Metabolic Acidosis
HCO3－ < 15mmol/L,
5% Sodium Bicarbonate 100-250ml
Dialysis
Management of ARF
? Other Electrolyte Disorder
? Infection
? Hart failure
? Dialysis
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 hospital
admissions and up to 30% of admissions to
intensive care units.
CLASSIFICATION
? Prerenal azotemia
? Intrinsic renal azotemia
? Postrenal azotemia
ETIOLOGY OF ARF
Prerenal Azotemia
? Intravascular Volume Depletion
? Decreased Cardiac Output
? Systemic Vasodilatation
? Renal Vasoconstriction
? Pharmacologic Agents (ACEI or NSAIDs)
ETIOLOGY OF ARF
Postrenal Azotemia
? Ureteric Obstruction
? Bladder Neck Obstruction
? Urethral Obstruction
ETIOLOGY OF ARF
Intrinsic Renal Azotemia
? Diseases Involving Large Renal Vessels
? Diseases of Glomeruli And Microvasculature
? Acute Tubule Necrosis
? Diseases of the Tubulointerstitium
急性 肾小管坏死
Acute Tubule Necrosis
（ ATN）
ETIOLOGY OF ATN
? Renal Ischemia（ 50%）
? Nrphrotoxins （ 35%）
Exogenous
Endogenous
PATHOPHYSIOLOGY OF ATN
? Intrarenal Vasoconstriction
? Tubular Dysfunction
Role of Hemodynamic alterations
in ATN
?Reduction in Total Renal Blood
Flow Regional Disturbance in
Renal Blood Flow and Oxygen
Supply
? Edothelin (ET) / NO (EDNO)
? Other Endothelial Vasoconstrctors
? The Tubulo-glomerular Feed Back
Role of Tubule Dysfunction
in ATN
Two Major TubularAbnormalities:
Obstrction
Backleak
Metabolic Responses of
Tubule cells to Injury
? ATP Depletion
? Cell Swelling
? Intyacellular Free Calcium↑
? Intyacellular Acidosis
? Phospholipase Activation
? Protease Activation
? Oxidant Injury
? Inflammatory Respose
Pathology
Clinical Presentation of ATN
The Clinical Course of ATN：
The Initiation Phase
The Maintenance Phase
The Recovery Phase
The Initiation Phase
? GFR↓
? Lasting Hours or Days
? Evidence of true Volume Depletion
? Decreeced Effective 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 >10.1~17.9 mmol/L
?Daily Increase in Serum Creatinine >176.8μmol/L
?Daily Increase in Serum Potassium >1~2 mmol/L
?Daily Decrease in Serum HCO 3 － >2 mmol/L
The Uremic Syndrome
General Complications of ARF：
Gastrointestinal
Cardiovascular
Respiratory
Neurologic
Hematologic
Infectious
The Uremic Syndrome
Homeostatic Disorder of water，
Electrolyte and Acid-alkali Balance：
Volume Overload
Metabolic Acidosis
Hyperkalemia
Hyponatremia
Hypocalcemia
Hyperphosphatemia
The Recovery Phase
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
Lab Examination
Blood Routine Test and Chemistry Assays:
Animia,RBC ↓,Hb ↓
BUN and Scr↑
Na ＋ ↓,K＋ ↑,Ca2＋ ↓,P3+ ↑
pH ↓,AG ↑,HCO3－ ↓
Lab Examination
Diagnostic Index Prerenal Renal
Specific Gravity > 1.020 ~ 1.010
Osmolality(mOsm/Kg H2O) > 500 ~ 300
Urinary Na+ (mmol/L) < 10 > 20
Ucr/Scr > 40 < 20
UUN/BUN > 8 < 3
BUN/Scr > 20 < 10-15
Renal Failure Index < 1 > 1
Fractional Excretion of Na+ < 1 > 1
Urine Sediment Hyaline Brown ranular
Lab Examination
? Radiologic Evaluation:
Plain Abdominal film
Renal Ultrasonography
IVP
Renal angiography
? Renal Biopsy
Diagnosis Differentiation：
prerenal azotemia
postrenal azotemia
Glomerulonephritis/Vasculitis
HUS/TTP
Interstitial Nephritis
Renal Artery Thrombosis
Renal vein thrombosis
Management of ARF (一 )
? Correction of Reversible causes
? Prevention of additional Injury
? Maintaining Fluid balance
Management of ARF (二 )
Maintaining Fluid balance
Fluid Intake,
500ml + The Amount of Urine
in The Preceding 24 Hours
Management of ARF (三）
Nutrition
? Enegy Intake:147kj/d
? Dietary Protein,0.8g/kg.d
? CRRT ( fluid > 5L/d)
Management of ARF (四）
Hyperkalemia
K+<6mmol/L
Restriction of Dietary Potassium Intake
K+-Binding Ion Exchange Resins
K+>6mmol/L
10%Calcium Gluconate 10-20ml
5% Sodium Bicarbonate 100-200ml
20% Glucose 3ml/kg.h+Insulin 0.5U/kg.h
Dialysis
Management of ARF (五）
Metabolic Acidosis
HCO3－ < 15mmol/L,
5% Sodium Bicarbonate 100-250ml
Dialysis
Management of ARF
? Other Electrolyte Disorder
? Infection
? Hart failure
? Dialysis
