病理生理學英文課件acute-renal-failure-foreign-student

AcuteRenalFailure

(ARF)ChengwuLiu2015AcuteRenalFailure

(ARF)Chen1.Reviewofrenalstructureandphysiology2.DefinitionofARF3.Causesandclassification4.Pathogenesis(acutetubularnecrosis，ATN)5.Alterationsofmetabolismandfunction6.Preventionandtreatmentoutline21.ReviewofrenalstructureaToexcreteurineandwasteproductsToregulatethebalanceofwaterandelectrolytesToregulatetheBPToinvolveinendocrineregulation:

-Renin-Erythropoietin(EPO)-VitaminD3-Prostaglandin(PG)

reviewThemainfunctionsofkidney1.review3ToexcreteurineandwasteproAbdominalaortaAdrenalglandUreterInferiorvenacavareviewTherenalstructure4AbdominalaortaAdrenalglandUrreview5review5review6review6review

CortexMedula7reviewCortexMedula7reviewNephroticsyndrome:EdemaProteinuria

HyperlipidemiaHypoproteinemiaTheStructureoftheGlomerulus8reviewNephroticTheStructureoSympatheticnervefiberJuxtaglomerularcellsAfferentarterioleMacula

densaSmoothmusclecellsDistaltubuleMesangialcellsEfferentarteriolePodocytesTheJuxtaglomerularApparatusreview9SympatheticnervefiberJuxtaglreview10review10NetFiltrationPressureBloodhydrostaticpressure(BHP)60mmHgoutColloidosmoticpressure(COP)-25mmHginCapsularpressure(CP)-10mmHginNetfiltrationpressure(NFP)25mmHgoutNFPBHP60outCOP25inCP25out10inreview11NetFiltrationPressureBloodhreview12review12adrenalglandcortexJuxtaglomerularapparatus,βcellreninangiotensinogenangiotensinⅠangiotensinⅡliverlungACEVesselconstrictionaldosteroneH2O,Na+reabsorptionBPEndocrinefunctionofkidney:ActivationofRAASBP↓,Na+↓,sympatheticN(+)review13adrenalglandcortexJuxtaglomeSo,

everypartoftherenalsystemshouldbeintactinstructure,otherwise,itishardtoensureitsfunction,includingoriginalurineproducing,dilutingandconcentrating,endocrineregulatoryfunctionetc.review14So,review14

2.definitionAcuteRenalFailure(ARF)：

anacuteandseveresyndromewhichshowsaabruptandsustaineddeclineinkidney’sabilitytocleartoxicsubstancesinblood,leadingtoanaccumulationofmetabolicwaste,manifesting

azotemia,hyperkalemia,

metabolicacidosis,andoftenaccompaniedbyoliguriaor

anuria.definition152.definitiondefinition15●Characteristics：

(1)AbruptsustaineddeclineinGFR

(2)Risingserumureaandcreatinine(3)Lossofwaterandsalthomeostasis

(4)Lifethreateningmetabolicchange(5)Occursoverhoursordays(6)Incidenceabout140ppmperyear(7)Highmortalitycharacters16●Characteristics：characters16classification:prerenalARFintrarenalARFpostrenalARFbladderureterkidney3.causeandclassification17classification:prerenalARFblPre-renalARF(1)CausesofprerenalARFhypovolemiahaemorrhage,burns,fluidloss，hypotension,cardiogenicshock,sepsisrenalhypoperfusionrenalvasoconstriction,drugs,liverdiseases,renalvasculardiseases(thrombosis,DIC)feature:reversibility

causesandclassification18Pre-renalARF(1)Causesofprerenalangiographystraitnesscausesandclassification19renalangiographystraitnesscau(2)CausesofintrarenalARFDiseasesoftherenalparenchyma①ATN（acutetubularnecrosis）prolongedischaemia(50%),directtoxicity(35%):fishgall,aminoglycoside(Gentamycin),mercury,arsenic(As),myoglobin,sepsis②vasculardiseasevasculitis,infarctioncausesandclassification20(2)CausesofintrarenalARFDi③diseasesofglomerulusorarteriolesRPGN(rapidlyprogressiveglomerulonephritis)HUS(haemolyticuraemicsyndrome)SLE(systemiclupuserythematosus)vasculitis④tubule-interstitialnephritisDrugrelatedparaneoplasticcausesandclassification21③diseasesofglomerulusorarImmunecomplexglomerulonephritiscausesandclassification22ImmunecomplexglomerulonephriImmunecomplexdepositionintheglomerulus(B).B,immunofluorescencemicrographstainedwithfluorescentanti-IgGfromapatientwithdiffuseproliferativelupusnephritis.causesandclassification23Immunecomplexdepositionint(3)CausesofpostrenalARFuretercalculi,carcinoma,fibrosis,straitnessbladderprostatichypertrophyormalignancy,carcinoma,calculicausesandclassification24(3)CausesofpostrenalARFuretype

causesclinicalfeaturesprerenalintrarenalpostrenal

renalhypoperfusion:earlystageofshockoliguriaoranuria,azotemia,urine[Na+]↓kidney’sorganic

changes:prolongedrenalischemianephrotoxinoliguric:nonoliguric:obstructionofureterandurethrabycalculusorcarcinomaabruptanuria,aggravationofazotemiacausesandclassificationsummary25typecauses(1)Changeofrenalhemodynamics：

Renalhypoperfusion:

theprogressivestageofshock4.PathogenesisofARF:(ATN)26(1)Changeofrenalhemodynami◆Renalvasoconstriction：

①TheactivationofRenin-AngiotensinSystem(RAS)②Catecholamine:adrenaline,noradrenaline③Unbalanceofprostaglandin/TXA2

④Endothelin(ET)⑤Others:NO,TNF,ADH,PAF(plateletactivatingfactor)27◆Renalvasoconstriction：27SwellingofepithelialcellsNecrosisofepithelialcellsIschemia,hypoxiaPoisonousagents:Mercury,Plumbum,GentamycinOliguria,anuria,wasteaccumulation(+)Hypoperfusion(2)Injuryofrenaltubules:ConstrictionofafferentarterioleEffectivefiltratingpressure

↓GFR↓↓Na+reabsorption↑Na+loadin

maculadensaRAS(+)BackflowofultrafiltrateObstructionoftubulespathogenesis28SwellingofNecrosisofIschemefferentarterioletubularepithelialcellsultrafiltrateoliguria,anuriaThemechanismofbackflowofultrafiltrateinterstitialedemadebris,necroticcellsoppresseffectlessfiltration29efferenttubularultrafiltrateurineflowdenudedtubularmembraneinjuredtubularcellsobstructionfromdebrisandnecroticcellspathogenesis30urineflowdenudedtubularmembraATNandinterstitialedemapathogenesis31ATNandinterstitialedemapathpathogenesis32pathogenesis32Acutetubularnecrosisintheallograftpathogenesis33Acutetubularnecrosisinthe(3)renalcellinjury:endothelialcell,mesangialcellATP↓,ionpumpimpaired:ischemia,shockOFR↑:ischemia/reperfusionGlutathione↓cleanFR↓pathogenesis34(3)renalcellinjury:endothephospholipases↑

hydrolyzephospholipid↑activateneutrophilsandinflammatoryresponsecellapoptosispathogenesis35pathogenesis35oliguricARFnonoliguricARFoliguricphasediureticphaserecoveryphaseAFR5.Alterationsofmetabolismandfunction36oliguricARFnonoliguricARFoli(1)OliguricARF1)

oliguricphaseThemostdangerousphase7-14days,If>1month→badprognosisoliguricphase37(1)OliguricARF1)oliguricphurinevolume:oliguria(<400ml/24h)or

anuria(<100ml/24h);urineNa+:↑(>40mmol/L)urinespecificgravity:↓(1.010-1.020)or

isosthenuria

①alterationofurineoliguricphase38①alterationofurineoliguricbloodureanitrogen(BUN):↑normalvalue：3.57~7.14mmol/L

30%nephronscanmaintainBUNinnormalvalue.serumcreatinine(Scr):↑

normalvalue：53~106μmol/L;②azotemiaoliguricphase39②azotemiaoliguricphase39

③disturbanceofbodyfluidH2Oretention→hyponatruria,intracellularedema

④hyperkalemiathemostdangerouschangeandcommoncauseofdeatholiguricphase40③disturbanceof⑤metabolicacidosisacidproduce↑acidexclude↓⑥dysfunctionofothersystemoliguricphase41⑤metabolicacidosisoliguricphThecomparisonoforganicandfunctionalARFFunctional(hypovolaemia)organic(ATN)urinemicroscopical

testalmostnormalmorecast(protein,RBC,WBC,EC)urineprotein(-)ortraceurineNa+(mmol/L)<20osmolarity(mOsm/L)>400(700mmol/L)<350(250mmol/L)urinespecificgravity>1.020<1.015urineCr/serumCr>40/1<10/1diureticeffectofmannitolgoodNoresponse>30(40)+～+++oliguricphase42Thecomparisonoforganicand2)

Diureticphaseurine>400ml/24h,indicatingtheregenerationoftubules14daysDiureticphase432)DiureticphaseDiureticphas

Themechanismsofdiuresis①GFRrestoregradually；②Obstructionarereleasedgradually；③Tubularepithelialcellsbegintoregenerate,butitsconcentratedfunctionsarestillveryweak；④Ureablockedinoliguricphasebegintobeexclude，causingosmoticdiuresis；Diureticphase44Themechanismsofdiuresis①Gstillindangeroussituation:

filtrationfailurestillexists；

mighthavedehydration,hyponatremia,hypokalemia,etc；

thefunctionsofepitheliumarenotcompletelyrecovery.Diureticphase45stillindangeroussituation:(3)recoveryphaseSeveralweeksto1year.UrinevolumeandNPNreturntonormalDisturbanceofwater,electrolyteandbase-acidbalanceandtheirsymptomsdisappear.rescoveryphase46(3)recoveryphaseSeveralweekUrinevolume:400-1000ml/24hmildersymptom,shortercourse,lesscomplication,lightpathologicalinjury.(2)NonoliguricARFNonoliguricARF47Urinevolume:400-1000ml/24h(2Mainlycausedbythedysfunctionoftubularconcentration,sourinevolumeiswithinnormalrangealthoughserumNPNishigh.Urinespecialgravity↓(<1.020),lesshyperkalemiaNonoliguricARF48MainlycausedbythedysfunctiThenatureofnonoliguricAFRisthesameasoliguricAFR,theonlydifferenceisthattheirdegreeandcourseofillness.49ThenatureofnonoliguricrelationbetweenGFRandurinevolumeNormalGFRTFVUVUV/TFVOliguricphaseDirueticphaseNonoliguricAFR1208141801.51261500150-3001200-2400600-1200<110-2010-2010-20TFV:totalfiltratingvolume;UV:urinevolume50relationbetweenGFRandurine(1)PreventionIdentifyatriskpatientspre-existingCRF,diabetes,jaundice,myelomaOpti