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郑州大学一附院泌尿外科
Center of Hemodialysis, The First Affiliated
Hospital of Zhengzhou University
丰贵文
Feng Guiwen
一、 定义:肾 1. Concept:
排泄功能在数小时至 Acute renal failure is cha
数周内迅速减退,血 racterized by a sudden de
cline in renal function and
尿素氮及血肌酐持续 associated with the increa
升高,肌酐清除率下 sing of blood urea nitroge
降低于正常的一半时 n(BUN) and serum creatin
ine(Cr), when the Cr clear
,引起水电解质及酸 ance(Ccr) decreased belo
碱平衡失调及氮质血 w a half of normal value, d
症,称之为 ARF 。 isorders of water and elect
rolyte metabolism, acid-ba
se disturbances and azote
mia were caused.
少尿: <400ml/hr Oliguria: Urine volume
<400ml per day in adult
s.
无尿: <100ml/24hr
Anuria: Urine volume <
100ml per day in adults.
两者共同作用:广泛烧伤、
These two causes usually act
挤压伤、感染性休克、肝肾
together.
综合症。
发病机理 Pathogene
sis
肾血管收缩缺血和肾小 Renal ischemia due to
管上皮细胞变性和坏死。 vasoconstriction
ATN(Acute Tubular
Necrosis
发病机理
(一)少尿或无尿期 (1) Oliguria or anuria ph
ase
1. 肾缺血、肾小球滤过率 A: Renal ischemia with
降低 GRF decreasing
2 .肾小管上皮细胞变性坏 B:Necrosis of renal tubular e
死 pithelial cell
3 .缺血 - 再灌注损伤 C: Ischemia and reperfusion
damage
4 .肾小管机械性梗阻
D: Tubule obstruction
发病机理
(二)多尿期 (2) Diuresis phase
A:The inability of regene
1. 再生肾小管上皮再吸收 rating tubules to reabsor
的浓缩功能不健全 b sodium and water.
2. 少尿或无尿期积聚体内 B:The diuresis effect of u
的大量尿素,起渗透利尿作 rea, water, electrolyte co
用 ncentrated in the oliguria
电解质和水潴留过多加重利 or anuria phase.
尿
临床表现
Clinical findings
(一)少尿或无尿期 (1)Oliguria or anuria
三高三低三中毒一倾向 phase
Usually lasting for a pe
riod from one to two w
eeks, the average dura
tion is between 5 and 6
days
临床表现
1.Water, electrolyte an
一、水、电解质和酸碱平衡 d acid-base disturban
ces A:Hypervolemia: wit
紊乱
hout restriction of fluid t
1. 水中毒: aking. Its manifestations
①Na 、水摄入过多 are circulatory overload,
②内生水 450-500ml/24hr 。 such as pulmonary ede
ma, brain edema, high b
高血压、脑水肿、肺水肿、 lood pressure, heart fail
心力衰竭。 ure. The patient can feel
恶心、呕吐、头晕、嗜睡的 nausea, vomiting, dizzy,
昏迷。 even coma.
临床表现
2. 高血钾: B:Hyperkalemia: Normall
y, 90% K+ are excreted by
90%K+ 由肾排泄→主 the kidney. When blood po
要死亡原因。 tassium reached to 6-6.5m
心律失常、心脏骤停 mol/L, cardiac arrhythmias,
cardiac arrest can be caus
Q-T 间期缩短、 T 波高 ed, ECG changes include
峰; QRS 间期延长, P peaked T wave ,prolonged
R 间期增宽, P 波降低。 P-R interval, widening of Q
RS complex, etc.
临床表现
3. 高镁血症: C: Hypermagnesemia: H
ypermagnesemia is cause
血镁 - 与血钾呈 d by reduction of GRF.
平行改变。 Hypermagnsemia decreas
神经肌肉传导障碍 : 低 es neuromuscular irritabilit
血压、呼吸抑制、肌力 y, it caused muscle weakn
ess, drowsiness and coma
减弱、昏迷、心跳骤停 . ECG changes include pro
ECG : P-R 间期延长、 longed P-R interval etc.
QRS 增宽、 T 波增高。
临床表现
D: Hyperphosphatemia
4. 高磷血症和低钙血症: and Hypocalcemia: 60
%-80% phosphate are ex
60%-80% 的磷转向肠道 created from intestine and
排泄,形成不溶性磷酸钙 combined with calcium to
,影响钙的吸收,出现低 form nonabsorbable comp
ounds. Therefore absorpti
钙血症 on of calcium is diminishe
低钙抽搐 d and hypocalcemia is ca
used. The effects of hypo
加重低钾对心肌的毒性作 calcemia are muscle tetan
用 y etc.
临床表现
5. 低 Na 血症: E: Hyponatremia:
a: Excessive amounts of s
① 呕吐、腹泻、出汗 odium lost by vomiting, dia
等使 Na 流失。 rrhea and sweating.
②输入无钠或少钠液③代 b: Excessive fluid intake wi
谢障碍→“钠泵”效应下 th water only.
降↓→细胞内 c: Abnormal Na+ distributio
Na 不能泵出→细胞外液 n.
d: Decreased Na+ reabsor
Na 下降。 ption by the renal tubule.
④肾小管功能障碍, Na
再吸收下降。
临床表现
6. 低氯血症: F: Hypochloremia
The causes resulting i
Cl- 、 Na+ 具有相同比 n hyponatremia also c
例下丢失。 ause hyochloremia.
临床表现
7. 酸中毒: G: Metabolic acidosis
a: Retention of sulfates
( 1 )乏氧代谢增加 and phosphates as the
,酸性代谢产物↑。 consequence of reduced
GRF.
( 2 )肾小管功能损害 b: Renal tubule failed to
、丢失硷基 reabsorb or regenerate
bicarbonate.
胸闷、气急、恶心 Clinical manifestation:
、呕吐、软弱、嗜睡及 Nausea, vomiting,
昏迷,并有血压下降,心 weakness, even coma, low
律失常,甚至心跳搏。 blood pressure, cardiac
arrhythmias, cardiac arrest.
临床表现
二、 . 尿毒症: ② Azotemia and urem
蛋白质代谢产物不 ia
能经肾排出,含氮物质
积 聚于血中,氮质血症。
血酚、胍等毒性物质增
加,形成尿毒症。
恶心、呕吐、头痛
、烦燥、倦怠无力、意
识模糊,昏迷。
临床表现
三、 出血倾向: ③ Hemorrhage tendency
1. 血小板质量下降。 A: Abnormal platelet f
2. 毛细血管脆性增加。 unction or quantity.
3. 多种凝血因子减少 B: Increased blood capil
laries fragility.
C: Prolonged prothromb
in time(PT).
临床表现
(二)多尿期: (2)Diuresis phase
After oliguria lasting for 7-1
少尿或无尿 7-14 日 4 days, the production of
,如 24 小时尿量增加至 more than 400ml of urine p
er day indicate the beginni
400ml 以上,即为多尿 ng of diuresis phase, Norm
期的开始,历时 14 天。 ally the urine volume can r
早期多尿 each to 3000ml per day an
d lasting for 14 days.
后期多尿
临床表现
1 .三种形式: A.There are three caterg
突然增加: 5-7 天 ories of the urine volume
1500ml 预后好 increasing in this phase:
逐步增加: 7-14 A: Increasing suddenly,
1500ml
200-500ml/ 日 B: Increasing gradually,
缓慢增加: 500- 200-500ml per day
700ml→ 停滞,预 C: Increasing slowly, 50
后差 0ml-700ml
临床表现
2 . 低 K+ 、低 Na+ 、 Because azotemia and wat
er, electrolyte disturbance
低 Ca++ 、低 also exist in this phase, it h
Mg++ as been pointed out that a
pproximately 25% of the d
3. 脱水 eaths in ARF occurred foll
4 . 感染 owing the onset of the diur
esis. The main complicatio
ns are hypokalemia and inf
ection.
诊断 Di
agnosis
(一) 病史及体格检查 (1). History and physi
1 . 有无急性肾小 cal examination
管坏死的病因。 A: prerenal causes
2 . 有无肾前性因素。 B: postrenal causes
C: Intrarenal cause
3 . 有无肾后性因素。 s
诊断
(二) 尿量及尿液检查 (2)Urine detection
1 . 尿量:留置尿管,记录每 A: Urine volume
小时尿量 B: Urine specific
2 . 尿比重及渗透压:低而
固定 1.010-1.014 ,酸性、等渗 gravity
尿。
3 . 镜检:肾前、后性:早期 C:Urine RT and
一般无管型。
肾性:肾衰管型。
microcopic
4. 物理性状 findings
诊断
(三) 血液检查 (3)Renal function
1. 血常规 A: blood urea nitrogen(BU
2. 肾功能指标 N) and serum creatinine(C
r)
3. 测定电解质、血浆 [H
B: Urine sodium
CO3-] 或 PH 值
C: Urine osmolality
D: Urine urea concentratio
n
(4)Electrolyte, Co2cp, PH
(四)鉴别诊断
Differential Diagnosis
or anuria phase?
(4) The differential diagnosis of prerenal