Chapter 16. Renal failure. p207

Transcription

1 Chapter 16 Renal failure p207

2 objective Master: The concept of acute renal failure (ARF), chronic renal failure (CRF) and uremia. Etiology and classification of ARF. Alterations of metabolism and function of ARF and CRF. Understand: Alterations of metabolism and function of uremia; Etiology and clinical course of CRF.

3 Renal function Excretion: Excreting metabolic waste, medicine and Toxic substance Regulation: Maintaining water, electrolyte and acid base balance. Endocrine: Releasing renin, erythropoietin, 1,25(OH) 2 VD 3

4 Concept: Renal deficiency can be caused by inadequate blood flow to the kidney, renal and systemic diseases and disorders related to the urinary tract obstruction. The major manifestations of altered kidney function are the effects on excretion of metabolic wastes and on manifestation of Na +, K +, water, and acid base balance, failure to excrete urea and other metabolic wastes adequately, manifested as progressive elevation of blood urea nitrogen (BUN) and serum creatinine.

5 Clssification: Acute renal failure Uremia Chronic renal failure

6 ACUTE RENAL FAILURE ARF* ARF is characterized by a sudden (within hours to days) deterioration of renal function and usually associated with oliguria (<400ml per day) or anuria (<100ml per day), resulting in water intoxication, azotemia, hyperkalemia and metabolic acidosis.

7 Etiology and classification* Prerenal: Inadequate blood flow Intrarenal: Damage to the nephrons Postrenal: Urinary tract obstruction Refer to the form on the page of 207

8 Pathogenesis Renal ischemia and poisons (Glomerular Filtration Rate) GFR Acute Tubular Necrosis(ATN) Refer to the diagram on the page of 209

9

10 Renal ischemia renal hypoperfusion renal vasoconstriction

11 renal poisons Necrosis Urine flow obstruction 囊内压 Denuded tubular membrane Urine backflow Injured tubular cells Obstruction from debris and necrotic cells

12 Alterations of metabolism and function*

13 Urinary Abnormalities Volume (ATN) Oliguria(<400ml/d) or anuria(<100ml/d) Osmotic pressure or (see the form below) Granular and cellular casts in urine protein, RBC, WBC, epithelial cells

14 According to whether there is an intrinsic damage, ARF can be divided into functional acute renal failure and organic acute renal failure.

15 Azotemia Blood Urea Nitrogen (BUN), creatinine Water intoxic,ation Hyperkalemia Metabolic acidosis

16 According to the urine volume, the progress of course of oliguric type of ARF may be divided into three stages: oliguric stage, polyuric stage and recovery stage. Oliguric stage is often persists several days to several weeks, which is the most dangerous stage. The longner the stage lasts, the worse the prognosis is. But some patient also present non oliguric.

17 Pathophysiological basis of prevention and treatment treat the primary diseases Supportive care dialysis

18

19 CHRONIC RENAL FAILURE CRF* CRF is a syndrome of impaired homeostasis owing to structural damage (reduced functional nephrons) of the kidneys. The disturbances are characterized by metabolic acidosis, hypocalcemia, hyperphosphatemia, alteration in vitamin D metabolism and the presence of certain toxic materials in body fluid.

20 Etiology Primary kidney disease : chronic glomerulonephritis, interstitial nephritis Secondary kidney disease: diabetic renal disease and hypertensive renal disease Others: chronic pyelonephritis, renal tuberculosis, systemic lupus erythematosus (SLE), and urinary tract obstruction

21 Clinical courses of CRF Stage of decreased renal reserve Stage of renal insufficiency Stage of renal failure Stage of uremia Refer to the content on the page of 211, Link the following address to understand the test of renal function more

22 Pathogenesis Intact Nephron Hypothesis GFR Number of Intact Nephrons

23 Trade off Hypothesis Compensation secondary disorder see a example in the following part of alterations of metabolism and function calcium, phosphate and bone metabolism Glomerular Hyperfiltration Hypothesis

24 Alterations of metabolism and function Disorder of urine nocturia polyuria >2500 ml/d Oliguria,anuria Hyposthenuria Isosthenuria Granular and cellular casts in urine

25 Disorders of water and sodium balance Disorders of potassium balance Metabolic acidosis Renal hypertension Renal azotemia Renal anemia and bleeding tendency

26 Disorders of Calcium, phosphate and bone metabolism* Hyperphosphatemia Hypocalcemia Renal osteodystrophy rickets, osteomalacia, osteoporosis etc. Refer to Endocrine Control of Calcium and Phosphate Homeostasis, link to the following address: html

27 The regulation of Calcitonin and PTH on Calcium

28 1,25 (OH) 2 D 3 CRF GFR Metabolic acidosis Dysfunctio n of bone calcificatio n Absorb calcium from gut Hypocalcemia excrete phosphate Hyperphosphatemia PTH calcium release from bone bone demineralization Renal osteodystrophy

29 X ray of renal osteopathy

30 Uremia Uremia is a clinical and biochemical syndrome that occurs either abruptly or gradually as renal function decreases acutely or chronically. Uremia is the endstage of renal failure, with which the patients have to receive treatment in the form of dialysis or renal transplantation.

31 Etiology and pathogenesis uremia toxin retention, morn than 200 metabolic wastes and toxins has been found in uremic patient, but the mechanism remains unknown.

32 Alterations of metabolism and function Neuromuscular abnormalities Cardiovascular and pulmonary abnormalities Hematological abnormalities Gastrointestinal abnormalities Endocrine and metabolic abnormalities Dermotologic abnormalities Immunologic abnormalities

33 Clinical case Refer to the case of 1 and 2 on the page of 218, think about the questions

34