Renal failure

11959344138395 60/120/85/54mmHg 8.6mmol/L128mmol/L,100mmol/L, 1.98mmol/L2.33mmol/L, 37.12mmol/L,804.44mol/LpH7.17, PCO224.5mmHg, HCO3-8.6mmol/L, SBE -18.3mmol/LT

1 IntroductionNormal function of the kidneyRenal insufficiencyCausesBasic manifestation of renal insufficiency

Normal function of the kidneyRemove waste product from the bodyRegulate electrolyte and acid-base balance.1.ExcretionProduce reninEPO1,25(OH)2D3 and prostaglandinsInactivate gastrinPTH.2. Endocrine

Renal insufficiencyDiseases Dysfunction of excretion and endocrine Symptomsand signs Edema, hypertension, oliguric, polyuria, hematuria, proteinuria, anemia, osteodystrophy.

Causes:1 Primary renal diseasesPrimary glomerular diseases, Primary tubular diseases, Interstitial nephritis, et al.2 Secondary renal lesionCirculatory system diseases, immunity siseases, metabolic diseases, hematopathy, et al.

Basic manifestation of renal insufficiency 1 Glomerular dysfunction2 Tubular dysfunction3 Endocrine dysfunction

1 Glomerular dysfunctionGFRblood flownet filtration pressure Kf Glomerular permselectivity

2 Tubular dysfunctionproximal tubuleRenal glycosuria, aminoaciduria, renal tubular acidosis, hypophosphatemialoop of HenleHypotonic or isotonic urine, polyuriadistal tubuleAcid-base and electrolyte disorders, polyuria

3 Endocrine dysfunction ReninEndothelinsKKS disordersAA DisequilibriumEPO 1,25(OH)2D3

2 Acute renal failure

DiseasesConceptionwater intoxication,azotemia, hyperkalemia, metabolic acidosis

Section 1 Cause and Classification 1 causes Prerenal ~ Intrarenal ~ Postrenal ~2renallesion functional~ organic ~obstructive ~3urine volumeOliguric ~Nonoliguric ~*** Classification

Causes 1 Prerenal factor renal blood flow Characteristicearly stage: functional~ late stage: organic ~(2) oliguria

MechanismECFRBF GFRReabsorptionoliguriaImpaired homeostasis

Causes (1) acute tubular necrosis,ATN 2/3 acute renal ischemiaacute renal poisoning hemoglobinuria, myoglobinuria (2) renal disease

Characteristic (1) parenchymal(2) oliguric ~nonoliguric ~2 intrarenal factor

Differentiation between the two RFurine functionalRF organic RFspecific gravity> 1.020 < 1.015OP(mmol/L) > 700 < 250Na(mmol/L) < 20 > 40UrCr/SrCr > 40 < 20Sediment normalManicol test urine volume urine volume Necrosis epithelial cells,RBC,casts,albuminuria

Causes Kidney stone, tumor, obstruction of necrosis tissueCharacteristic early stage: obstructive ~ late stage: organic ~ 3 Postrenal factor

MechanismObstruction of the urinary tractBowmans capsule pressureNet filtration pressureGRFOliguria, anuria

Section 2 Pathogenesis RBF1 Net filtration pressure BP < 60mmHg CO RBF BP (50-70mmHg) GFR (1/2 2/3) BP(40mmHg) GFR = 0Urinary obstruction intracapsular pressure

1 Glomerular factor

2renal vessels constriction RBF sympathetic nerve Shock RAS prostaglandinkallikrein - kinin syetem ANP NO

3 swelling endothelial cell ischemia Na+ - K+ - ATPase free radical endothelial cellular injury 4alteration of renal hemorheology fibrinogen Blood viscosity RBC PLT WBC

renal DIC

Glomerular lesion filtration surface area Glomerular permselectivity GFR

2 Tubular factortuble obstruction GFRpassive backflow GFR

1 1 1 + ()

(2) PLT GFR

2

3AngADH GFR

2 1 ATP ATP Na+ - K+ - ATPase Ca2+ - ATPase

Na+H2O Ca2+

2(FR) (GSH) FR FR3GSH 4 Ca2+ A2

5 ATP 6

Section 3 Clinical Course and manifestation1 oliguria phasedaysweeks (1)features of urine urine volumeoliguria400ml/dor anuria100ml/d S.G.1.0101.020 Na+ tubular reabsorption dysfunction urine sediment:erythrocytes, casts, proteinuriaoliguric ARF

(2) water toxication oliguriaCatabolism Transfuse fluidFluid retentionHypervolemic hyponatremiaCell edema

(3) Hyperkalemia most serious Urinary excretion of K+Tissue destructionMetabolic acidosisTransfuse non-fresh blood, high K+ diethyponatremiaexchange of K+and Na+HyperkalemiaMovement of K+ from cells into ECF

(4) Metabolic acidosis grogressive,difficult to correctGFR excretion of acid productionSecretion of HNH3 , reabsorption of HCO3Catabolism acid productionMetabolic acidosisHyperkalemia

(5) Azotemia (NPN>40 mg/dl)Excretion of protein metaboliteProtein catabolism

2 diuresis phase12W Mechanism

manifestation polyuria>400 ml/dEarly stage Hyperkalemia, Azotemia , Metabolic acidosis Late stagedehydration, hypokalemia, hyponatremia, infection.3 recovery phase

Nonoliguric ARFFeaures

Section 4 Treatment Principle of ARF1. Treat the cause; 2. Rescue actively. .

11959344138395 60/120/85/54mmHg 8.6mmol/L128mmol/L,100mmol/L, 1.98mmol/L2.33mmol/L, 37.12mmol/L,804.44mol/LpH7.17, PCO224.5mmHg, HCO3-8.6mmol/L, SBE -18.3mmol/LT

Chronic Renal Failureetiological factors destruct nephronDysfunction of excretion and endocrine waste product , acid-base and electrolyte disorders dysfunction of endocrine Section 1 Conception

Section 2 Causes of CRFRenal diseases chronic glomerulonephritis et alVascular disordersdiabetes mellitushypertensive diseasePeriarteritis nodosa, et alUrinary tract obstructionurinary calculusprostatic hyperplasia et al

Section 3 Clinical Course of CRFcompensatory stage Renal insufficiency stage Renal failure stage Uremia stage

GFRml/minBUN(mmol/L)Cr(umol/L)>50

Section 4 PathogenesisIntact nephron hypothesisGlomerular hyperfiltration hypothesisTrade-off hypothesisTubulointerstitial injury

Intact nephron hypothesis

causesProgressive reduction in the number of nephronsDestroy nephron persistentlyRenal compensation insufficiencyRenal failure

Glomerular hyperfiltration hypothesisCompensatory glomerular hyperfiltration GlomerulosclerosisRenal failure

Trade-off hypothesisGFR(P)()(PTH)()()

() GFR PTH

renal tubule -interstitial fibrosis

Section 5 Changes of Function and Metabolism1 characteristics of urine volumenocturiapolyuria>2000ml/dor oliguria(

1.035

1.020

1.012

1.008

1.002

2 acid-base and electrolyte disorders (1)fluidpulmonary and cerebral edemaheart failuredehydration(2)NahyponatremiaHypernatremia(3) Khypokalemia or hyperkalemiaK+ diet emesisdiuretic(excrete K +)K+ oliguriaPotassium-sparing diureticacidosiscatabolism , hemolysisintake K +

(4) Ca P P early stage : compensationPTH late stage: nephron bone dissolveCa P Vit D calcium phosphateToxic substance damage intestinal tract intake(5) Acidosis carbonic anhydrase NH3 H+ Absorption of intestine Ca

3 azotemia (NPN>28.6mmol/L)BUN is not parallel to renal functionPlasma creatinine endogenous creatinine clearance rate ----CCR=Ucr VuPcr

4 renal hypertension(1) Fluid and sodium retention(2) renin(3) kininPGE2

5 hemorrhagic tendencyToxic substance inhibite the function of plateletPF3

(1) EPO(2) bone marrow(3)bleeding(4) Erythrocyte life span(5)Fe and Folic acid deficiency6Al7 Renal anemia

5 renal osteodystrophyD3

(2)Vit D3 (4)Al (1)P Ca and secondary hyperparathyroidism(3) acidosisbone mineral lysisdecalcification, VitD3 absorption of intestine Ca

GFR1,25(OH)2D3 PTH

End-stage renal failureuremiaARFCRFToxinIntoxicationsymptom

source 1. Metabolite 2. Ectogenesis toxin 3. Ectogenesis toxin metabolite 4. Normal activity materialUremia toxin

common urea, guanidine, amines and phenolmiddle moleculesPTHAlUremia toxin

change of function and metabolism

-

Treatment principle

1treatment of the primary disease 2 dialysis therapy 3 renal transplantation

35201 6104-52000ml/BP146/100mmHgHb40-70g/LRBC1.3-1.761012/L+RBCWBC5-7/HP32500-3500ml/1.01010 T37R20/P120/BP150/100mmHgRBC1.49 1012/LHb47g/LWBC9.6 109/L1.9mmol/L1.3mmol/L+RBC10-15/HpWBC0-2/Hp0-2/Hp2-3/LPX

parenchymal