Acute Renal Failure ,arf

急性肾功能衰竭 （ Acute Renal Failure ,ARF ） 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 排泄功能在数小时至 数周内迅速减退，血 尿素氮及血肌酐持续 升高，肌酐清除率下 降低于正常的一半时 ，引起水电解质及酸 碱平衡失调及氮质血 症，称之为 ARF 。

 1.       Concept:   Acute renal failure is characterized by a sudden decline in renal function and associated with the increasing of blood urea nitrogen(BUN) and serum creatinine(Cr), when the Cr clearance(Ccr) decreased below a half of normal value, disorders of water and electrolyte metabolism, acid-base disturbances and azotemia were caused.



少尿： <400ml/hr

 无尿： <100ml/24hr

 非少尿型 ARF ： >800ml/24hr ，而血 BUN 、 Cr 进行性增 高  

 Oliguria: Urine volume <400ml per day in adults.  Anuria: Urine volume <100ml per day in adults.  Non-oliguria ARF: patients has high level BUN but urine volume does not change, usually>800ml per day.

病因

Etiology

 1 Prerenal Causes: Any disorders such as severe hemorrhage, shock, hypovolemia etc.decrease the blood supply to the nephron. Ultimately, 有效血容量↓→肾灌注↓→功能性 functional disorders(ATN, 肾功能不全、急性肾小管坏死。Acute Tubular Necrosis) develop secondary to renal ischemia or depression of glomerular filtration or both.

 1. 肾前性： 大出血、休克、脱水  全身疾病  心脏疾病

病因  2. 肾后性：   双侧输尿管结石 盆腔晚期肿瘤 手术、损伤 早期解除梗阻，可恢复肾 功能

 (2)Postrenal causes:  A: bilateral obstruction of the ureters caused by stone  B: pelvic neoplasms  C:ureter obstruction secondary to operation or trauma  With this type of renal failure, normal kidney function can be restored if the basic cause of the problem is corrected with a few hours.

病因  3. 肾性：

 (3)Intrarenal causes:

 缺血

 Severe renal ischemia

 中毒：氨基糖甙类抗生素、  Renal poisoning Carbon tetrachloride, heavy metals such 四氯化碳、重金属（汞、铅 as mercury etc, X-ray contrast media, 、砷） X 线造影剂过敏，蛇 mushroom poisoning, various medications 毒和蕈毒等。 which are used as antibiotics  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 Pathogenesis  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. 肾缺血、肾小球滤过率 降低 2 ．肾小管上皮细胞变性 坏死 3 ．缺血 - 再灌注损伤 4 ．肾小管机械性梗阻

(1)  Oliguria or anuria  phase A: Renal ischemia with GRF decreasing B:Necrosis of renal tubular epithelial cell C: Ischemia and reperfusion damage D: Tubule obstruction

发病机理  （二）多尿期 1. 再生肾小管上皮再吸收 的浓缩功能不健全 2. 少尿或无尿期积聚体内 的大量尿素，起渗透利尿作 用 电解质和水潴留过多加重利 尿

 (2) Diuresis phase A:The inability of regenerating tubules to reabsorb sodium and water. B:The diuresis effect of urea, water, electrolyte concentrated in the oliguria or anuria phase.

临床表现 Clinical findings  （一）少尿或无尿期 三高三低三中毒一倾向

  (1)Oliguria or anuria  phase Usually lasting for a period from one to two weeks, the average duration is between 5 and 6 days

临床表现  一、水、电解质和酸碱平 衡紊乱  1. 水中毒： ①Na 、水摄入过多 ②内生水 450500ml/24hr 。 高血压、脑水肿、肺水肿、 心力衰竭。 恶心、呕吐、头晕、嗜睡的 昏迷。

 1.Water, electrolyte  and acid-base  disturbances A:Hypervolemia: without restriction of fluid taking. Its manifestations are circulatory overload, such as pulmonary edema, brain edema, high blood pressure, heart failure. The patient can feel nausea, vomiting, dizzy, even coma.

临床表现  2. 高血钾： 90%K+ 由肾排泄→主 要死亡原因。 心律失常、心脏骤停 Q-T 间期缩短、 T 波高 峰； QRS 间期延长， PR 间期增宽， P 波降 低。

 B:Hyperkalemia: Normally, 90% K+ are excreted by the kidney. When blood potassium reached to 6-6.5mmol/L, cardiac arrhythmias, cardiac arrest can be caused, ECG changes include peaked T wave ,prolonged P-R interval, widening of QRS complex, etc.

临床表现  3. 高镁血症： 血镁 - 与血钾呈 平行改变。 神经肌肉传导障碍 : 低 血压、呼吸抑制、肌力减 弱、昏迷、心跳骤停 ECG ： P-R 间期延长、 QRS 增宽、 T 波增高。

 C: Hypermagnesemia: Hypermagnesemia is caused by reduction of GRF.  Hypermagnsemia decreases neuromuscular irritability, it caused muscle weakness, drowsiness and coma. ECG changes include prolonged P-R interval etc.

临床表现  4. 高磷血症和低钙血症 ： 60%-80% 的磷转向肠 道排泄，形成不溶性磷酸 钙，影响钙的吸收，出现 低钙血症  低钙抽搐 加重低钾对心肌的毒性作 用

 D: Hyperphosphatemia and Hypocalcemia: 60%-80% phosphate are excreated from intestine and combined with calcium to form nonabsorbable compounds. Therefore absorption of calcium is diminished and hypocalcemia is caused. The effects of hypocalcemia are muscle tetany etc.

临床表现  5. 低 Na 血症： ① 呕吐、腹泻、出 汗等使 Na 流失。 ②输入无钠或少钠液③ 代谢障碍→“钠泵”效应 下降↓→细胞内 Na 不能泵出→细胞外液 Na 下降。 ④肾小管功能障 碍， Na 再吸收下降。

 E: Hyponatremia: a: Excessive amounts of sodium lost by vomiting, diarrhea and sweating. b: Excessive fluid intake with water only. c: Abnormal Na+ distribution. d: Decreased Na+ reabsorption by the renal tubule.

临床表现  6. 低氯血症： Cl- 、 Na+ 具有相同比 例下丢失。

 F: Hypochloremia The causes resulting in hyponatremia also cause hyochloremia.

临床表现  7. 酸中毒： （ 1 ）乏氧代谢增 加，酸性代谢产物↑。 （ 2 ）肾小管功能损 害、丢失硷基 胸闷、气急、恶心 、呕吐、软弱、嗜睡及 昏迷，并有血压下降， 心律失常，甚至心跳搏 。

 G: Metabolic acidosis a: Retention of sulfates and phosphates as the consequence of reduced GRF. b: Renal tubule failed to reabsorb or regenerate bicarbonate. Clinical manifestation: Nausea, vomiting, weakness, even coma, low blood pressure, cardiac arrhythmias, cardiac arrest.

临床表现  二、 . 尿毒症： 蛋白质代谢产物不 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。

 ② Azotemia and  uremia

临床表现  三、 出血倾向：  ③ Hemorrhage tendency 1. 血小板质量下降。 A: Abnormal platelet 2. 毛细血管脆性增加。 function or quantity. 3. 多种凝血因子减少 B: Increased blood capillaries fragility. C: Prolonged prothrombin time(PT).

临床表现  （二）多尿期： 少尿或无尿 7-14 日 ，如 24 小时尿量增加至 400ml 以上，即为多尿 期的开始，历时 14 天。 早期多尿 后期多尿

 (2)Diuresis phase After oliguria lasting for 714 days, the production of more than 400ml of urine per day indicate the beginning of diuresis phase, Normally the urine volume can reach to 3000ml per day and lasting for 14 days.

临床表现  1 ．三种形式： 突然增加： 5-7 天 1500ml 预后好 逐步增加： 7-14 200-500ml/ 日 缓慢增加： 500700ml→ 停滞，预 后差

 A.There are three catergories of the urine volume increasing in this phase: A: Increasing suddenly, 1500ml B: Increasing gradually, 200-500ml per day C: Increasing slowly, 500ml-700ml

临床表现   2 ．    低 K+ 、低 Na+ 、  低 Ca++ 、低 Mg++  3． 脱水 4 ．    感染

Because azotemia and water, electrolyte disturbance also exist in this phase, it has been pointed out that approximately 25% of the deaths in ARF occurred following the onset of the diuresis. The main complications are hypokalemia and infection.

    诊断 Diagnosis  （一）  病史及体格 检查 1 ．   有无急性肾小 管坏死的病因。 2 ．   有无肾前性因 素。 3 ．   有无肾后性因 素。

   (1). History and physical examination A: prerenal causes B: postrenal causes C: Intrarenal causes

诊断  （二）    尿量及尿液检查 1 ．   尿量：留置尿管，记录每 小时尿量 2 ．   尿比重及渗透压：低而固 定 1.010-1.014 ，酸性、等渗尿。 3 ．   镜检：肾前、后性：早期 一般无管型。 肾性：肾衰管型。 4. 物理性状

 (2)Urine detection A: Urine volume B: Urine specific gravity C:Urine RT and microcopic findings

诊断  （三）   血液检查      1. 血常规      2. 肾功能指标   3. 测定电解质、血浆 [HCO3-] 或 PH 值

 (3)Renal function A: blood urea nitrogen(BUN) and serum creatinine(Cr) B: Urine sodium C: Urine osmolality D: Urine urea concentration (4)Electrolyte, Co2cp, PH

（四）鉴别诊断 Differential Diagnosis

 1. 肾前性与肾性 ARF 的鉴别 :  补液试验  2. 肾性与肾后性 ARF 的鉴别

The differential diagnosis of ARF and hypovolemia 

Oliguria phase of ARF Urine volume after infusion Urine specific gravity Urine sediment Urine sodium concentration (mmol/L)

Hypovolemia

<400ml 1.010

Increased >1.020

tubular epithelial cells and casts >40

Urine urea and blood plasma urea ratio <10:1 Urine creatinine and blood plasma creatinine ratio <20:1 Serum potassium Increased markedly Hematocrit(Hct),Blood plasma protein decreased

(--) <20 >10:1

>30:1 Increased slowly Increased

   治疗  一、少尿或无尿期 1 ．      控制入 水量： ( 原则 ) 量出 而入，宁少勿多。

Treatment   (1)Oliguria or anuria  phase A: Restriction of fluid intake Fluid intake should be the sum of the insensible or evaporative fluid loss, urine output and any ongoing losses, such as nosogastric or chest tube drainage, except the water volume produced by the body itself every day.

治疗  2. 营养：低蛋白、高热 量、高维生素饮食。

 B: Nutrition: low protein, high energy and vitamin diets

 3. 抗感染  C: Anti-infection

治疗  E: Treatment of electrolyte  4. 电解质失调的处理 disorders ⑴高钾血症： a:Hyperkalemia: Hyperkalemia represents a life 禁摄含 K+ 食物、药物。 threatening complication of  彻底清创，防止感染；不输 ARF and must be treated 库存血。补足热量，减少蛋 properly, largely because of its 白的分解。 cardiac toxicity. Serum K+>5.5mmol/L. i: 10% gluconate 20ml iv ii: 5%NaHCO3 100ml ivgtt iii: 25%glucosi +insulin(35g:1U) 200ml ivgtt iv: ion exchange compounds

治疗  ⑵ 低 Na 血症： 稀释性低 Na 血症 纠正酸中毒成高血 钾时补充 NaHCO3 。

 b:Hyponatremia

治疗  c: Acidosis  ⑶ 酸中毒： Co2cp<13.5mmol/L, 5% CO2CP<13.5mmol/L 时 NaHCO3 100ml-200ml 纠酸，以免盐酸过多。 ivgtt  ⑷ 低血钙： 10% 葡萄  d: Hypocalcemia 10% 糖酸钙 10-20ml ， 2-3 gluconate 10-20ml bid 次 / 日。 iv

治 疗  F: Hemodialysis a:BUN >25mmol/L,  5 ．透析指征： Cr >442umol/L (1) 血 b:Hyperkalemia, serum BUN>25mmol/L ， Cr>4 K+>6.5mmol/L 42umol/L 。 c: An increased (2) 血 K+>6.5mmol/L ， intravascular volume resulting in congestive (3) 出现水中毒现象，一 heart failure, pulmonary 般措施不能改善， (4) 酸

中毒不能用补碱纠正者 。

edema, brain edema, intractable hypertension d: Developing acidosis, Co2cp<15mmol/L

Peritoneal dialysis

治疗  (2)Diuresis phase  （二）多尿期： A: Infusion: 1/3-1/2 1. 适量补液： volume of the water 2/3-1/2 excreated by the body 2. 纠正电解质紊乱特别 per day. 是低 K+ B: Correct electrolyte 3. 预防感染 disorders, especially hypokalemia. 4. 加强营养。 C: Anti-infection D: Increase nutrition

Answer the following questions (1)

The concept of acute renal failure? (2) The causes of acute renal failure? (3) The clinical findings of AFR in oliguria or anuria phase? (4) The differential diagnosis of prerenal ARF and renal ARF? (5) The treatment of hyperkalemia in oliguria or anuria phase of ARF?