Acte Renal Failure

Acute Renal Failure Introduction Glomerular Filtration Rate (GFR) Decrease Rapidly (all kinds of causes) Broad Sense: Pre-renal; Intrinsic Renal Disease; Post-renal Narrow Sense: Acute Tubular Necrosis Involve All Specialized Subject

Acute Renal Failure Causes Ischemia: Shock 、 Hypovolemia Renal Toxicant :Medicine （ Aminoglycoside Antibiotic, Mannitol etc ） Contrast Medium Chemical Poison — Arsenism Biological Poison

Acute Renal Failure Cause—Medicine

There is no medicine without effect. There is effect we can’t see. There is no medicine without sideeffect. There is side-effect we can’t see.

Drug-induced ARF Others 37%

NSAIDs 16%

Antibiotic 34% R.C.M 13%

Acute Renal Failure Mechanism （ 1 ） Hemodynamic Changes ： Sympathetic N、 RAS 、 PG-K 、 NO-ET （ 2 ） Tubular Epithelium Cell Dysfunction （ 3 ） Tubular Epithelium Cell Exfoliate 、 Cast Form

Acute Renal Failure Pathology • Ischemia: Parts of Tubule unequally Degenerate and Necrosis 、 GBM Break • Toxication: Proximal tubule equally Degenerate and Necrosis 、 GBM is Intact.

Acute Renal Failure Clinical Manifestation Oliguric stage

5-14d ; 3-4w(few)

Oliguria,Edema:<400ml/d ; without Oliguria (minority) Multi-systematic Symptom ： Nausea and Vomiting 、

Heart Failure 、 Pulmonary Edema 、 Hemorrhagic Tendency 、 Nervousmental symptom Urine ： Specific Gravity 、 Proteinuria 、 Hematuria 、 Cast Urine Cr 、 BUN 、 Acidosis 、 Hyperpotassaemia

Polyuric Stage

1-3 W

Urine Volume Increase >500ml/d approach 3000-5000ml Body Weight 、 even Dehydration Urine Recover Cr 、 BUN probably Electrolyte Disturbance Convalescent Stage

3-6M

All Indexes Recover

Specific Gravity is normal

completely Recover

Acute Renal Failure Diagnosis

（ 1 ） History:Hypovolemia+Renal Toxic Drugs

（ 2 ） usually without Anemia and Hypoproteinemia

（ 3 ） Nephrauxe

（ 4 ） Test of Nail Cr

（ 5 ） Renal Biopsy

Acute Renal Failure Differential Diagnosis Differential Diagnosis of Oliguria ——Oliguria is not only the first symptom of ARF,but also the definite sign of prerenal hypoperfusion ， the treatment is different. Putting Zhang’s hat on Li’s hat may break out at any moment, putting Li’s hat on Zhang’s hat may snow plus frost.

Acute Renal Failure Differential Diagnosis Pre-renal Oliguria Specific gravity Urinary Precipitate Urinary 0smotic pressure Urine/Blood 0smotic pressure Urinary sodium concentration UCr/SCr BUN/SCr NaKF RFI Experimental treat

>1.020 Normal >550mOsm/L >2:1 <20 >40:1 >20:1 <1 <1 Good reaction

ATN <1.015 Protein 、 Cast <350mOsm/L <1.1:1 >40 <10:1 <10:1 >1 >2 No reaction

Oliguria 、 Anuria 5-10%GS 500ml or + Dopamine 40mg Urine Volume↑

Urine Volume(-) 20% Mannitol 100-200 ml iv

Urine volume ↑

Urine volume(-) Lasix

Good Reaction ↑ Hypovolemia

60-100mg

iv

No Reaction ARF

Method and Approach of experimental fluid infusion and diuresis provocative test

Acute Renal Failure Treatment “Waiting”is the best way ——“go to bed” “Waiting”the coming of polyuria —— the light of life. Attitude should be active —— but Action should be slow.

Acute Renal Failure Treatment 

Limit water: 

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It’s TOTAL FLUID INTAKE that counts, not water the patient drinks

Limit salt: 

It’s TOTAL SODIUM INTAKE that counts, not salt the patient takes in

Acute Renal Failure Treatment Emergency Treatment of Hyperpotassemia Dialysis （ HD+PD ） 5% NaHCO3 100ml iv 5%GS 50ml+RI 10u

iv

10% Calcium Gluconate 10ml iv Ion-exchange Resin Po

Acute Renal Failure

Treatment

Index of Acidosis

Index: Deep Breath 、 Central Inhibition 、 Blood Gas Analysis Begin from 5%NaHCO3 100ml Dialysis Acute Left Heart Failure 、 Pulmonary Edema Hyperpotassemia >6.5ml/L Acidosis PH<7.25 CO2CP <13mmol/L High Catabolism Cr>176.8μmol/L/d BUN>8.9mmol/L/d

Acute Renal Failure Severe ARF Effective Treatment

CRRT

Continuous Renal Replacement Therapy

Advantage ： Mild Effect on Hemodynamics. Liquid Balance ， no Disturbance Syndrome. Internal Environment is more stable.

Acute Renal Failure Famous Saying 





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NO drug make the tubular cells to regenerate MANY drugs may be hazardous to kidney STOP unnecessary drugs is crucial NECESSARY drug using should be monitored

Acute Renal Failure Famous Saying  All

substances are poisons;  There is none which is not a poison.  The right dose differentiates a poison and a remedy 

---- Paracetsus 1493- 1541