内科学急性肾损伤(八年制).pptx

急性肾损伤Acute Kidney Injury (AKI)Acute Renal Failure (ARF) Case-1XXX，男性，78岁。因尿少2天、无尿1天入院。病前5天起腹泻史5天，在急诊室用过一次丁卡0.4静脉滴注。体检。神志清、皮肤较干燥、血压100/60mmHg, 心率88次/分，律齐，两肺清。双下肢无浮肿。Scr198umol/L, BUN12.5mol/L, UA456mol/L。 问题： 诊断？需进一步做什么检查予以确诊 治疗措施？Case-2XXX, 女性，69岁。7天前行两尖瓣换瓣术，术中出血较多，术后出现少尿3天，无尿两天。术前Scr149umol/L。目前Scr 686umol/L, 全身浮肿、球结膜水肿、血压125/50mmHg.,心率126次/分，房颤，两肺底湿罗音。血K5.9mmol/L, 血PH7.26, HCO3 12.5mmol/L. 问题： 诊断？紧急处理原则 Case-3XXX，男性，65岁。因浮肿1周伴全身皮疹就诊。体检：双下肢轻度浮肿，全身散在皮疹。BP165/95mmHg.。化验：尿常规：蛋白3+, RBC3+, WBC2+, 尿蛋白定量1.8克/天， Scr345umol/L, BUN10.6mol/L, UA453mol/L, Hb 9.8g/dL, WBC10.5 x109。病前2周有感冒发热史，用过菌必治。 问题： 诊断？治疗？AKI/ARF由各种原因引起的肾功能突然衰退(几小时至几天)而出现的临床综合征 血肌酐和尿素氮迅速升高, 水、电解质和酸碱平衡紊乱，及全身各系统并发症。常伴有少尿(400ml/d)或无尿(100ml/d),但在非少尿型者,则可无少尿表现 AKI Definition---KDIGOIncrease in SCr by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or Increase in SCr to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or Urine volume 0.5 ml/kg/h for 6 hours发病率（incidence)所有病人中占1-5%ICU中占7-23%老年住院患者中AKI发生率为20%--35% 60岁以上的AKI患者占同期AKI患者的57%-64% EtiologyTraditional difinition：Acute tubular necrosis（ATN） Broad definition：Prerenal AKIRenal AKIPostrenal AKI ETIOLOGY- Prerenal Prerenal azotemia results from either (ischimia)Volume depletion due to Bleeding (surgery, trauma, gastrointestinal bleeding)Gastrointestinal (vomiting, diarrhea), urinary (diuretics, diabetes insipidus)Cutaneous losses (burns). Decreased effective arterial pressure and/or effective circulating volume seen inHeart failure ShockCirrhosis ETIOLOGY-renalIntrinsic renal disorders includes disorders that involve Renal vascularGlomerular: Glonephritis, IgAN, LN,RPGN （crescents nephritis）Tubular/interstitial pathology ETIOLOGY-renal (Vascular )Vascular causes of AKI include Thrombosis (arterial and venous)Hemolytic-uremic syndromeMalignant hypertensionVasculitis The principal glomerular cause of AKIAKI can be observed with most of the glomerulonephritis.RPGN (crescent nephritis)IgANMN MPGN LNTubular and interstitial di