Renal failure

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Renal failure
2

• ???,11???????????9?,??5????
• 9?????????,??34?,?????,????,???????,????41??????
  ?????,????????????,?????3839?????5??????????60
  ?/?,??120?/?,??85/54mmHg???????????????,??????,??
  ??,???,?????????
• ????????????8.6mmol/L,??128mmol/L,???100mmol/L,
  ??1.98mmol/L,??2.33mmol/L, ???37.12mmol/L,???804.
  44µmol/L????pH7.17, PCO224.5mmHg,
  HCO3-8.6mmol/L,
• SBE -18.3mmol/L?????????,T????

3
1 Introduction

• Normal function of the kidney
• Renal insufficiency
• Causes
• Basic manifestation of renal insufficiency

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Normal function of the kidney
1.Excretion

• Remove waste product from the body
• Regulate electrolyte and acid-base balance.

2. Endocrine
Produce renin?EPO?1,25(OH)2D3 and
prostaglandins Inactivate gastrin?PTH.
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Renal insufficiency
Dysfunction of excretion and endocrine
Diseases
Symptoms and signs
Edema, hypertension, oliguric, polyuria,
hematuria, proteinuria, anemia, osteodystrophy.
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Causes

• 1 Primary renal diseases
• Primary glomerular diseases, Primary tubular
  diseases, Interstitial nephritis, et al.
• 2 Secondary renal lesion
• Circulatory system diseases, immunity siseases,
  metabolic diseases, hematopathy, et al.

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Basic manifestation of renal insufficiency

• 1 Glomerular dysfunction
• 2 Tubular dysfunction
• 3 Endocrine dysfunction

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1 Glomerular dysfunction

• ?GFR
• ?blood flow
• ?net filtration pressure
• ? Kf
• ? Glomerular permselectivity

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(No Transcript)
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2 Tubular dysfunction

• ?proximal tubule
• Renal glycosuria, aminoaciduria, renal tubular
  acidosis, hypophosphatemia
• ?loop of Henle
• Hypotonic or isotonic urine, polyuria
• ?distal tubule
• Acid-base and electrolyte disorders, polyuria

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3 Endocrine dysfunction

• ? Renin
• ?Endothelins
• ?KKS disorders
• ?AA Disequilibrium
• ?EPO
• ? 1,25(OH)2D3

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2 Acute renal failure
Conception
Diseases

water intoxication,azotemia, hyperkalemia,
metabolic acidosis
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Section 1 Cause and Classification
Classification
1 causes Prerenal Intrarenal Postrenal
2renallesion functional organic obstructive
3urine volume Oliguric Nonoliguric
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Causes

• 1 Prerenal factor
• renal blood flow

• Characteristic
• early stage functional late stage organic
• (2) oliguria

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Mechanism
ECF?
RBF ?
GFR? Reabsorption?
oliguria Impaired homeostasis
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2 intrarenal factor

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

• Characteristic
• (1) parenchymal
• (2) oliguric
• nonoliguric

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• Differentiation between the two RF
• urine functionalRF organic RF
• specific gravity gt 1.020 lt 1.015
• OP(mmol/L) gt 700 lt 250
• Na(mmol/L) lt 20 gt 40
• UrCr/SrCr gt 40 lt 20
• Sediment normal
• Manicol test urine volume urine volume

Necrosis epithelial cells,RBC,casts, albuminuria
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3 Postrenal factor

• Causes
• Kidney stone, tumor, obstruction of necrosis
  tissue

• Characteristic
• early stage obstructive
• late stage organic

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Mechanism
Bowmans capsule pressure?
Obstruction of the urinary tract
Net filtration pressure?
GRF?
Oliguria, anuria
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Section 2 Pathogenesis
1 Glomerular factor

• ? RBF
• (1) Net filtration pressure
• BP lt 60mmHg
• CO RBF
• BP (50-70mmHg) GFR (1/2 2/3)
• BP(40mmHg) GFR 0
• Urinary obstruction intracapsular pressure

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(2)renal vessels constriction RBF
sympathetic nerve Shock RAS
prostaglandin kallikr
ein - kinin syetem ANP
NO
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(3) swelling endothelial cell ischemia
Na - K - ATPase free radical
endothelial cellular injury
(4)alteration of renal hemorheology
fibrinogen Blood viscosity
RBC??????? PLT?? WBC????? ?????
renal DIC
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? Glomerular lesion
filtration surface area
Glomerular permselectivity
GFR
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2 Tubular factor
?tuble obstruction ?? ???? ?????? ??
???? GFR ?passive
backflow ???????????? ???? ????? ???
GFR ??
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(No Transcript)
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(?)?????????

• 1???????????
• (1) ?????
• 1)?????
• ????????????????
• ??????????
• ????????????
• ??????????????
• ?????,??????
• ???????

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2)????? ?????
(2)???? ?????? ???? ??????
PLT??,?????
?????? GFR
???????????
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(3)???? Ang??ADH ?????? ???????
???????
????   GFR
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2??????? (1) ATP?????????? ?? ??
????? ATP ??   Na - K
- ATPase Ca2 - ATPase ???
Na,H2O ??? Ca2
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(2)???(FR) ??? ???????(GSH)
FR?? ???? ???
FR?? (3)GSH ??????? ,???? (4)?????
??? Ca2 ??? A2  
?????
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(5)???????? ??? ATP ????????
??? (6)???????
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Section 3 Clinical Course and manifestation
oliguric ARF

• 1 oliguria phase(daysweeks)
• (1)features of urine
• urine volumeoliguria(?400ml/d)or
  anuria(?100ml/d)
• S.G.1.0101.020
• Na tubular reabsorption dysfunction
• urine sedimenterythrocytes, casts,
  proteinuria

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(2) water toxication

• oliguria
• Catabolism ,???
• Transfuse fluid

Hypervolemic hyponatremia
Fluid retention
Cell edema
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(3) Hyperkalemia most serious

• Urinary excretion of K
• Tissue destruction
• Metabolic acidosis
• Transfuse non-fresh blood, high K diet
• hyponatremia,exchange of Kand Na

Movement of K from cells into ECF
Hyperkalemia
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(4) Metabolic acidosis
grogressive,difficult to correct

• GFR excretion of acid production
• Secretion of H??NH3? , reabsorption of HCO3
• Catabolism , acid production

Metabolic acidosis
Hyperkalemia
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(5) Azotemia (NPNgt40 mg/dl)

• Excretion of protein metabolite
• Protein catabolism

??????????????? ??????
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2 diuresis phase(12W)

• Mechanism
• ???????????????
• ???????????????
• ?????????,?????
• ???????,?????

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manifestation

• polyuria,gt400 ml/d
• Early stage Hyperkalemia, Azotemia ,
• Metabolic acidosis
• Late stagedehydration, hypokalemia,
  hyponatremia, infection.

3 recovery phase
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Nonoliguric ARF

• Feaures
• ???????????
  ????
• ???????????
  ???
• ???,???,???????

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Section 4 Treatment Principle of ARF

• 1. Treat the cause
• ?????????????
• ???????????
• 2. Rescue actively.
• ?????? ????
• ??????????
• ????.

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• ???,11???????????9?,??5????
• 9?????????,??34?,?????,????,???????,????41??????
  ?????,????????????,?????3839?????5??????????60
  ?/?,??120?/?,??85/54mmHg???????????????,??????,??
  ??,???,?????????
• ????????????8.6mmol/L,??128mmol/L,???100mmol/L,
  ??1.98mmol/L,??2.33mmol/L, ???37.12mmol/L,???804.
  44µmol/L????pH7.17, PCO224.5mmHg,
  HCO3-8.6mmol/L,
• SBE -18.3mmol/L?????????,T????

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Chronic Renal Failure
Section 1 Conception

• etiological factors destruct nephron

Dysfunction of excretion and endocrine
waste product , acid-base and electrolyte
disorders , dysfunction of endocrine
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Section 2 Causes of CRF

• Renal diseases chronic glomerulonephritis et al
• Vascular disordersdiabetes mellitus?hypertensive
  disease?Periarteritis nodosa, et al
• Urinary tract obstructionurinary
  calculus?prostatic hyperplasia et al

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Section 3 Clinical Course of CRF

• compensatory stage
• Renal insufficiency stage
• Renal failure stage
• Uremia stage

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?? GFR (ml/min) BUN (mmol/L) Cr (umol/L) ????
??? gt50 lt9 lt178 ????,?????
?????? 2550 920 178445 ??,????,?????
?????? lt25 2028 451707 ??,??????,?????????????
???? lt10 gt28.6 gt707 ?????????
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Section 4 Pathogenesis

• Intact nephron hypothesis
• Glomerular hyperfiltration hypothesis
• Trade-off hypothesis
• Tubulointerstitial injury

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• Intact nephron hypothesis

causes
Destroy nephron persistently
Progressive reduction in the number of nephrons
Renal compensation insufficiency
Renal failure
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• Glomerular hyperfiltration hypothesis

Compensatory glomerular hyperfiltration
Glomerulosclerosis
Renal failure
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• Trade-off hypothesis

(??) ????
GFR?
?????(P)?
(????)
???? (??)
???(PTH)?
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????
???
????? (?????)
??
???? GFR?
????
???
PTH?
???
??
??
????
???? ???????
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renal tubule -interstitial fibrosis

• ??????????
• ?????????
• ????
• ?????

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Section 5 Changes of Function and Metabolism
?????? ????? ???????

• 1 characteristics of urine
• volumenocturia?polyuria(gt2000ml/d)or
  oliguria(lt400ml/d)

specific gravityhypotonic urine (early stage)?
isotonic urine(late stage) sedimentProteinuria?he
maturia?casts
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???????
??
???
???

• ?????

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2 acid-base and electrolyte disorders

• (1)fluidpulmonary and cerebral edema,heart
  failure,dehydration
• (2)Nahyponatremia?Hypernatremia
• (3) Khypokalemia or hyperkalemia
• K diet emesis?diuretic(excrete K )
• K oliguria?Potassium-sparing
  diuretic?acidosis?catabolism ,
  hemolysis?intake K

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(4) Ca P

• P early stage compensation(PTH )
• late stage nephron
  bone dissolve
• Ca P
• Vit D
• calcium phosphate
• Toxic substance damage intestinal tract
• intake
• (5) Acidosis ?????? ?carbonic anhydrase
  ??NH3 ??H

Absorption of intestine Ca
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3 azotemia (NPNgt28.6mmol/L)

• BUN is not parallel to renal function
• Plasma creatinine
• endogenous creatinine clearance rate
• ----?????

Ucr Vu
CCR
Pcr
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4 renal hypertension

• (1) Fluid and sodium retention
• (2) renin
• (3) kinin?PGE2

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5 hemorrhagic tendency

• Toxic substance inhibite the function of platelet
• PF3 ????????????

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(1) EPO(2) bone marrow(3)bleeding(4)
Erythrocyte life span(5)Fe and Folic acid
deficiency(6)Al
7 Renal anemia
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5 renal osteodystrophy

• ?????,???????????????????D3???????????????

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(2)Vit D3 ???? ,????
(1)P Ca and secondary hyperparathyroidism
(3) acidosisbone mineral lysis,decalcification,
VitD3 ,absorption of intestine Ca

• (4)Al ????????????????????

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• ???????

GFR?
1,25(OH)2D3???
??
????
??????
?????
???
????
???
PTH???
????? ???
???? ???
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End-stage renal failure
uremia
ARF CRF
Intoxication symptom
Toxin
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source 1. Metabolite 2. Ectogenesis
toxin 3. Ectogenesis toxin metabolite
4. Normal activity material
Uremia toxin
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common urea, guanidine, amines and
phenol,middle molecules?PTH?Al
Uremia toxin
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change of function and metabolism
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Treatment principle 1?treatment of the
primary disease 2? dialysis therapy 3?
renal transplantation
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????
??,?,35?????????????20?,??1??????
???????????6????????,??10??,??4-5?,2000ml/????,BP1
46/100mmHg,Hb40-70g/L,RBC1.3-1.76?1012/L????,RBC?
WBC?????5-7/HP?3???????,???2500-3500ml/?,?????1.01
0????????????,???????????10?????????,???????????
?????????????????????,?????????
T37??R20?/??P120?/??BP150/100mmHg?RBC1.49
?1012/L?Hb47g/L,WBC9.6 ?109/L,??1.9mmol/L,??1.3mmo
l/L????,RBC10-15/Hp,WBC0-2/Hp,??0-2/Hp,????2-3/LP
?X???????,?????,?????????????,?????

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Thanks