Acute Renal FailureAcute Renal Failure

Du Juan Du Juan Department of NephrologyDepartment of NephrologyRenmin Hospital of Wuhan Renmin Hospital of Wuhan

UniversityUniversity

DefinitionsDefinitions

Acute Renal Failure (ARF) Acute Renal Failure (ARF) is a syndrome is a syndrome

characterized by rapid (hours to weeks) characterized by rapid (hours to weeks)

decline in glomerular filtration rate (GFR) decline in glomerular filtration rate (GFR)

and retention of nitrogenous waste products and retention of nitrogenous waste products

such as creatininesuch as creatinine

Clinical SyndromeClinical Syndrome

AbruptAbrupt SustainedSustained Decline in GFR Decline in GFR

Occurs over Hours or DaysOccurs over Hours or Days

Rising Serum Creatinine(≥44.2Rising Serum Creatinine(≥44.2µµmol/L /day)mol/L /day)

Clinical Results Clinical Results

DefinitionsDefinitions

Definition of AKIDefinition of AKI

Functional or structural abnormalities or Functional or structural abnormalities or

markers of kidney damage including markers of kidney damage including

abnormalities in blood , urine or tissue testsabnormalities in blood , urine or tissue tests

or imaging studies present foror imaging studies present for ＜＜ 3 months 3 months

急性肾损伤定义急性肾损伤定义 急性肾损伤是指不超过急性肾损伤是指不超过 33 个月的肾脏结个月的肾脏结

构或功能异常，包括血、尿、组织学或构或功能异常，包括血、尿、组织学或影像学方面的肾损伤标志的异常影像学方面的肾损伤标志的异常

Criteria for AKICriteria for AKI

4848 小时内小时内 ScrScr 上升≥上升≥ 26.526.5µµmol/Lmol/L （（ 0.3mg/dl0.3mg/dl ） ） 或较前升高≥或较前升高≥ 5050 ％％

尿量减少，＜尿量减少，＜ 0.5ml/kg/h0.5ml/kg/h ，持续，持续 66 小时以上小时以上（排除尿路梗阻或脱水状态等）（排除尿路梗阻或脱水状态等）

Staging of AKIStaging of AKIPhase Scr Criteria Urine Output Criteria 1 ↑≥0.3mg/dl or↑≥50 ％ ＜ 0.5ml/kg/h×6hr 2 ↑≥200%-300% ＜ 0.5ml/kg/h×12hr 3 ↑≥300% Oliguria ≥4.0mg/dl ( ＜ 0.3ml/kg/h×24hr ) (Acute rise≥0.5mg/dl ) or Anuria×12hr

Prerenal 55% ～60%

Intrarenal 35% ～40%

Postrenal < 5 %

ClassificationClassification

Intravascular Volume Intravascular Volume DepletionDepletion

Hemorrage

Renal Losses

Skin and Mucous LossesDiuretic

Gastrointestinal Losses

Vomiting

Diarrhea

Prerenal ARF (1)Prerenal ARF (1)

DecreasedEffective

Circulatory Volume

Decreased Cardiac Output

Prerenal ARF (2)Prerenal ARF (2)

Bilateral Ureteric Obstruction

Bladder Neck Obstruction

Urethral Obstruction

Postrenal ARFPostrenal ARF

Acute Glomerulonephritis Rapidly Progressive Glomerulonephritis

Diseases of GlomeruliIntrarenal ARF Intrarenal ARF (1)(1)

Tubulointerstitial Tubulointerstitial NephritisNephritis

Rash

Hematuria

Fever

Renal Renal

BiopsBiopsyy

Intrarenal ARF (2)Intrarenal ARF (2)

Diseases of Large Renal Diseases of Large Renal VesselsVessels

AtheroembolismAtheroembolism

ThrombosisThrombosis

Intrarenal ARF (3)Intrarenal ARF (3)

AAcute cute TTubular ubular NNecrosisecrosis((ATN)ATN)

Intrarenal ARF (4)Intrarenal ARF (4)

Acute TubularNecrosis

Acute Tubular NecrosisAcute Tubular Necrosis

ATNATN Etiology Etiology PathogenisisPathogenisis Pathology Pathology Clinical PresentationsClinical Presentations Laboratory ExaminationsLaboratory Examinations Diagnosis & Diagnosis &

DifferentiationDifferentiation ManagementManagement

Ischemic ATN Severe or prolonged renal hypoperfusion

Nephrotoxic ATN

Many medications and poisons

EtiologyEtiology

PathogenesisPathogenesis

发病机制发病机制 肾血流动力学异常肾血流动力学异常 肾小管上皮脱落，管腔内管型形成肾小管上皮脱落，管腔内管型形成

肾小管阻塞（肾小管阻塞（ Intratubular Obstruction)Intratubular Obstruction) 肾小管反漏（肾小管反漏（ Tubular Fluid Backleak)Tubular Fluid Backleak)

肾小管上皮细胞代谢障碍肾小管上皮细胞代谢障碍

Ischemic / Toxic Renal Injury

Tubular DamageHemodynamic Abnormalities

Endothelial SwellingReduced EDRF

Vasoconstrictor ReleaseEndothelinAngiotensin

ThromboxaneNorepinephrine

Afferent Arteriolar Constriction

Kf Glomerular

Capillary Pressure RBFTubular

Obstruction Backleak

Reduced Glomerular Filtration Rate

Tubuloglomerular Feedback

Events Following the Initiation of Renal Events Following the Initiation of Renal IschemiaIschemia

Renal Ischemia

Supply of O2

Nutrients to Kidney

ATP

Nephrotoxins Lipid Peroxidation

Oxygen-Derived Free Radicals

Scavenging Systems

Abnormal Metabolic Levels

Adenosine Hypoxanthine

Tubular Sodium PumpIinhibition Na+, Cl- pH ↓Cell Volume

Cell structure changesMembrane Integrity

Cytoskeleton DamagedMitochondria Swell

Pathologic ChangesTubular Dysfunction: Leakage, Obstruction,

Loss of Filtration, NecrosisIntrarenal Vessel Constriction: Increased Ischemia

Cell death

PathologyPathology

NormalNormal

Tubule vacuolization (green arrow) Tubule vacuolization (green arrow)

Tubule dilation and brush border losses (black arrows) Tubule dilation and brush border losses (black arrows)

Mild ATN

Denuded basement membrane and

the presence of intraluminal casts

Degenerated and sloughed,Degenerated and sloughed,

frank necrosis tubular cellsfrank necrosis tubular cells

Severe ATN

Clinical Course of Clinical Course of ATNATN

Initiation Phase Initiation Phase

Maintenance PhaseMaintenance Phase

Recovery PhaseRecovery Phase

临床病程临床病程 起始期起始期 维持期维持期 恢复期恢复期

Initiation PhaseInitiation Phase

Reversible Fall in GFR Reversible Fall in GFR PreventivePreventive HypotensionHypotension SepsisSepsis Renal ToxinsRenal Toxins

Maintenance PhaseMaintenance Phase Oliguria PhaseOliguria Phase

7~14d or Even 4~6w of Duration7~14d or Even 4~6w of Duration OliguriaOliguria ：： Urine OutputUrine Output ＜＜

400ml/d400ml/d AnuriaAnuria ：： Urine OutputUrine Output ＜＜

100ml/d100ml/d NonoliguriaNonoliguria

Clinical Presentations Clinical Presentations （（ 11 ））

Disturbance of Disturbance of WaterWater 、、 Electrolyte & Base- Acid Electrolyte & Base- Acid HomeostasisHomeostasis HyponatremiaHyponatremia （低钠血症）（低钠血症） HyperkalemiaHyperkalemia （高钾血症）（高钾血症） Hypocalcemia Hypocalcemia （低钙血症）（低钙血症） HyperphosphatemiaHyperphosphatemia （高磷血症）（高磷血症） Metabolic AcidosisMetabolic Acidosis （代谢性酸中毒）（代谢性酸中毒）

Clinical Presentations Clinical Presentations （（ 22 ））

Systemic Complications Systemic Complications ：：InfectionInfection The most common and serious The most common and serious complications of ARFcomplications of ARF Occurring in 50% to 90% of casesOccurring in 50% to 90% of cases Aaccouting for up to 75% of deathsAaccouting for up to 75% of deaths

Clinical Presentations Clinical Presentations （（ 33 ））

Systemic ComplicationsSystemic Complications Gastrointestinal Symptoms:Gastrointestinal Symptoms: Anorexia, Anorexia,

Nausea, Vomiting, HemorrhageNausea, Vomiting, Hemorrhage Cardiac Complications:Cardiac Complications: Hypertension, Hypertension,

Congestive Heart Failure, ArrhythmiasCongestive Heart Failure, Arrhythmias

Clinical Presentations Clinical Presentations （（ 44 ））

Pulmanary Complications:Pulmanary Complications: Infection, Adult Respiratory Infection, Adult Respiratory Distress SyndromeDistress Syndrome

呼吸系统：并发感染、呼吸系统：并发感染、 ARDSARDS Neruopsychiatric Disturbance:Neruopsychiatric Disturbance:

Confusion, Delirium or Coma, Confusion, Delirium or Coma, Seizure Seizure

神经系统：意识模糊、谵妄、昏迷、 抽搐神经系统：意识模糊、谵妄、昏迷、 抽搐

Volume of Urine Volume of Urine 3000-5000ml/d Duration 1-3w3000-5000ml/d Duration 1-3w ComplicationsComplications

HyponatremiaHyponatremia 、、 HypokalemiaHypokalemia InfectionInfection Redecreased Volume of UrineRedecreased Volume of Urine

Renal Biopsy Show Everlasting Renal Renal Biopsy Show Everlasting Renal Pathological Changes in Minority of Pathological Changes in Minority of PatientsPatients

Recovery Phase

Laboratory Laboratory ExaminationsExaminations

Blood Analysis Blood Analysis UrinalysisUrinalysis Imaging Evaluation Imaging Evaluation Renal BiopsyRenal Biopsy

Blood-Rt and BCABlood-Rt and BCA Serum Creatinine & BUN↑Serum Creatinine & BUN↑ Serum Potassium ↑Serum Potassium ↑ Serum Sodium ↓Serum Sodium ↓ Serum Calcium ↓Serum Calcium ↓ Serum HCOSerum HCO33

- - ↓↓ Mild-Moderate AnemiaMild-Moderate Anemia Serum BUN/ScrSerum BUN/Scr

UrinalysisUrinalysis Urine Output Urine Output 尿量改变：少尿型、非少尿型尿量改变：少尿型、非少尿型 Urine Sediment Urine Sediment ：肾小管上皮细胞：肾小管上皮细胞 Urine Specific Gravity Urine Specific Gravity 尿比重尿比重 <1.015<1.015 Urine Osmotality Urine Osmotality 尿渗透浓度尿渗透浓度 <350mOsmol/L<350mOsmol/L Urinary NaUrinary Na+ + Concentration Concentration 尿钠尿钠 20~60mmol/L20~60mmol/L Urinary Creatinine/Plasma Creatinine RatioUrinary Creatinine/Plasma Creatinine Ratio 尿肌酐尿肌酐 // 血肌酐血肌酐 <20<20

Renal Tubular Epithelial Cell Casts

Imaging InvestigationsImaging Investigations Ultrasound Ultrasound BB 超超 Plain Abdomen Plain Abdomen 腹部平片腹部平片 Excretory Excretory

Urography/CystourethrographyUrography/Cystourethrography 排泄性尿路造影排泄性尿路造影 // 逆行尿路造影逆行尿路造影 CT ScanningCT Scanning Isotope Renography or Renal Isotope Renography or Renal

Angiography Angiography 核素扫描或血管造影核素扫描或血管造影

Renal Biopsy Renal Biopsy

DiagnosisDiagnosis History History Abrupt Sustained Decline in Renal Abrupt Sustained Decline in Renal

FunctionFunction Increased Absolute Scr ≥44.2umol/L/dIncreased Absolute Scr ≥44.2umol/L/d Increased Relative Scr 25% Over Increased Relative Scr 25% Over

Baseline/dBaseline/d Clinical ManifestationsClinical Manifestations Laboratory ExaminationsLaboratory Examinations

Differential DiagnosisDifferential Diagnosis

ARF Secondary to ARF Secondary to CKD CKD

Prerenal ARFPrerenal ARF Postrenal ARFPostrenal ARF

Intrinsic ARFIntrinsic ARF

Postrenal ARFPostrenal ARF Primary Disease of Urinary Primary Disease of Urinary

ObstructionObstruction Abrupt Oliguria or Even AnuriaAbrupt Oliguria or Even Anuria Renal AnginaRenal Angina Tenderness or PercussionTenderness or Percussion Signs of Urine RetentionSigns of Urine Retention Renal ImagingRenal Imaging

Prerenal ARFPrerenal ARF Transfusion TestTransfusion Test

History of Body Fluids LossesHistory of Body Fluids Losses Signs of HypovolemiaSigns of Hypovolemia IV.drop 5% Glucose 200IV.drop 5% Glucose 200 ～～ 250ml 250ml ＋＋

IV. Frusemide 40IV. Frusemide 40 ～～ 100mg100mg

Differential Diagnosis Between Pre-renal ARF and Differential Diagnosis Between Pre-renal ARF and ATNATN

Diagnosis Index Diagnosis Index Prerenal Prerenal ARFARF ATNATN

Urine GravityUrine Gravity ＞＞ 1.0181.018 ＜＜ 1.0151.015

Urine Urine Osmotality(mmol/L)Osmotality(mmol/L) ＞＞ 500 500 ＜＜ 350350

Urine Natrium Urine Natrium Concentration (mmol/L)Concentration (mmol/L) ＜＜ 2020 ＞＞ 2020

Serum BUN/ScrSerum BUN/Scr ＞＞ 2020 ＜＜ 1515

ARF IndexARF Index ＜＜ 11 ＞＞ 11

Natrium Filtration Natrium Filtration FractionFraction ＜＜ 11 ＞＞ 11

Urine SedimentUrine Sediment Clarity CastClarity CastBrown Brown

Granular Granular CastsCasts

Transfusion TestTransfusion Test ＋＋ －－

Treatment Treatment （（ 11 ））PreventionPrevention （（纠正可逆因素，预防额外损伤）纠正可逆因素，预防额外损伤） Identify at Risk PatientsIdentify at Risk Patients （（治疗基础疾病）治疗基础疾病）

Pre-existing CKD, Diabetes, ElderlyPre-existing CKD, Diabetes, Elderly Optimise Renal PerfusionOptimise Renal Perfusion

IV Fluids, Blood TransfusionIV Fluids, Blood Transfusion Avoid Nephrotoxic AgentsAvoid Nephrotoxic Agents

NSAIDS, Radiocontrast, NSAIDS, Radiocontrast, AminoglycosidesAminoglycosides ，， ACEIACEI

Maintain Adequate DiuresisMaintain Adequate Diuresis ？？ FrusemideFrusemide

Treatment Treatment （ （ 2 2 ））Management of Volume Management of Volume

HomeostasisHomeostasis Record I/O Record I/O Fluid = Urine Output + 500mlFluid = Urine Output + 500ml DiureticsDiuretics Dialysis Dialysis

Treatment Treatment （（ 33 ））Management of Electrolyte Management of Electrolyte

HomeostaisHomeostais HyponatremiaHyponatremia HyperkalemiaHyperkalemia Hypocalcemia Hypocalcemia Hyperphosphatemia Hyperphosphatemia

Methods of TreatmentMethods of TreatmentDRUG

Calcium Glucose

Glucose + Insulin

Natrium Bicarbonate

Na polysterne sulfonate

Dialysis

DOSE

10 ml of 10%

50 ml of 50% + 10U

100ml~200ml of 5%

DURATION

30 minutes

1 - 4 hours

1 - 8 hours

There is always dialysis!

Treatment Treatment （（ 44 ）） Nutritional SupportNutritional Support Calorie 35Kcal/kg/dCalorie 35Kcal/kg/d

Maximal Carbohydrate and Maximal Carbohydrate and LipidLipid

Minimal Recommand Minimal Recommand Protein Intake 0.8g/kg/dayProtein Intake 0.8g/kg/day

Limit NaLimit Na 、、 KK 、、 Cl Intake Cl Intake IV. Essence Amino AcidIV. Essence Amino Acid

Treatment Treatment （（ 55 ）） Heart FailureHeart Failure

DigoxineDigoxine DiureticsDiuretics Vessel Dilative AgentsVessel Dilative Agents Dialysis Most EffectiveDialysis Most Effective

InfectionInfection

Absolute IndicationsAbsolute Indications Volume OverloadVolume Overload

HyperkalemiaHyperkalemia

Metabolic AcidosisMetabolic Acidosis

OvertOvert Uremic SymptomsUremic Symptoms

Treatment Treatment （（ 66 ））

Prophylaxis Dialysis Prophylaxis Dialysis Relieve Retention of Excess Water and Relieve Retention of Excess Water and

ToxinsToxins Maintain Electrolyte and Acid-Base Maintain Electrolyte and Acid-Base

HomeostaisHomeostais For Nutritional Therapy For Nutritional Therapy Avoid MOSDAvoid MOSD

Dialysis PatternDialysis Pattern

Intermittent Intermittent HemodialysisHemodialysis （（ IHDIHD ））

CContinuous ontinuous RRenal enal RReplacement eplacement TTherapyherapy

Peritoneal DialysisPeritoneal Dialysis （（ PDPD ））

透析适应症透析适应症 急性肺水肿急性肺水肿 高钾血症高钾血症 6.5mmol/L6.5mmol/L 以上以上 BUN≥21.4mmol/LBUN≥21.4mmol/L 或或

Scr≥442umol/LScr≥442umol/L 高分解代谢状态高分解代谢状态 每日每日 BUNBUN 上升≥上升≥ 8.9mmol/L8.9mmol/L 或或

ScrScr 上升≥上升≥ 176.8umol/L176.8umol/L ，血钾，血钾上升≥上升≥ 1mmol/L1mmol/L

无尿无尿 22 天或少尿天或少尿 44 天以上天以上 酸中毒 酸中毒 COCO22CPCP ＜＜ 13mmol/L13mmol/L ， ， pHpH ＜＜

7.257.25 少尿少尿 22 天以上并伴有下列情况之一者天以上并伴有下列情况之一者 体液潴留体液潴留

尿毒症症状 尿毒症症状 血钾＞ 血钾＞ 6.0mmol/L6.0mmol/L ，心电图有高钾表现，心电图有高钾表现

恢复期的治疗 多尿的治疗多尿的治疗

维持水、电解质和酸碱平衡维持水、电解质和酸碱平衡 控制氮质血症控制氮质血症 防止发生并发症防止发生并发症

定期随访肾功能定期随访肾功能 避免使用肾毒性药物避免使用肾毒性药物

PrognosisPrognosis

ATN Without Complications ATN Without Complications 7%-23%7%-23%

ATN With MOSD ATN With MOSD 50%-80%50%-80%

QuestionsQuestions WhatWhat’’s the Difference between s the Difference between

Acute Renal Failure and ATN?Acute Renal Failure and ATN? How to Deal with How to Deal with

Hyperkalemia in ARF Hyperkalemia in ARF Patients?Patients?

What is the Indication of What is the Indication of Hemodialysis in ARF Patients?Hemodialysis in ARF Patients?

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