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急性腎衰竭

急性腎衰竭. 嘉義榮民醫院 腎臟科 姜丁引 醫師 2009.4.23. 課程大綱. 腎臟基本構造與功能 腎功能的評估及處置 Renal blood flow / Glomerular filtration rate assessment Chronic renal failure / Acute renal failure 影響腎臟功能的常見藥物. 腎 筋膜. 腎臟基本構造. Gerota’s fascia. 腎臟的構造. 長度約 10 公分 ﹐ 重量約 120 公克 腎臟位於第 12 胸椎延伸至第 3 腰椎，連同腎上腺一起被腎周圍脂肪包圍

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急性腎衰竭

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  1. 急性腎衰竭 嘉義榮民醫院 腎臟科 姜丁引 醫師 2009.4.23

  2. 課程大綱 • 腎臟基本構造與功能 • 腎功能的評估及處置 • Renal blood flow / Glomerular filtration rate assessment • Chronic renal failure / Acute renal failure • 影響腎臟功能的常見藥物

  3. 腎筋膜 腎臟基本構造 Gerota’s fascia

  4. 腎臟的構造 • 長度約10公分﹐重量約120公克 • 腎臟位於第12胸椎延伸至第3腰椎，連同腎上腺一起被腎周圍脂肪包圍 • 腎元是腎臟基本的基本單元 • 腎皮質位於腎臟外層 ﹐含有所有的腎絲球 • 腎髓質位於腎臟內層﹐由腎椎體構成含有亨利氏環、直靜脈和集尿管的最後段

  5. 腎臟基本構造

  6. 腎臟血流和神經 • 主動脈→腎動脈→大葉間動脈→弓動脈→小葉間動脈→入球小動脈→出球小動脈→入髓質→亨利氏環下降又上升的直靜脈→腎靜脈→下腔靜脈 • 腎臟血流量（RBF）約為1000ml/min，大約占20％的心輸出量，腎絲球過濾率為125ml/min • 控制腎臟的神經﹕T10、T11、T12

  7. 腎臟血流

  8. 腎絲球構造

  9. 腎絲球顯微構造

  10. 尿液的形成 • 腎絲球過濾→近側小管→亨利氏環細上升肢→亨利氏環細上行肢→亨利氏環粗上升肢→緻密斑→遠曲小管→收集管→集尿管 • 腎絲球過濾屏障內含三個結構： • 內皮細胞 (endothelial cell) • 腎絲球基底膜 (glomerular basement membrane) • 鮑氏囊的上皮細胞 (epithelial cell)

  11. 腎臟基本功能

  12. Juxtaglomerular apparatus • Juxtaglomerular cell • 特化的afferent artery • Macular densa

  13. 腎臟功能

  14. 尿毒症之系統嚴重障礙 • 水及電解質失衡：水腫、肺積水、高血鉀 • 代謝性酸中毒：腎無法回收HCO3-及排酸性廢物 • 骨病變：Vit.D3及副甲狀腺機能亢進會有軟骨症及囊狀纖維性骨炎 • 心血管疾病：尿毒症心肌病變致心衰竭、高血壓、心包炎、 肺水腫、肋膜積水。 • 血液系統：貧血、出血傾向。血 小板數目正常但是機能不好

  15. 尿毒症之系統嚴重障礙 • 腸胃系統：噁心、嘔吐、食慾不振、口腔中有尿騷味、病態性打嗝及消化道出血 • 腦神經障礙：尿毒症腦病變、有記憶力減退、注意力不集中、全身性肌肉抖動發抖及雙手有撲異狀震動發生。尿毒症周圍神經病變及運動神經病變 • 皮膚變化：黃黑色變化可能是貧血及尿色素無法排出、搔癢症、指甲易脆

  16. 腎功能的評估及處置 • Renal blood flow measure • Glomerular filtration rate assessment • Chronic renal failure • Acute renal failure

  17. Renal blood flow measure • 腎臟血流量 • 佔C.O 1/5，約1200ml/min • 其中約20%流經腎臟的plasma(約占RBF的50~60%)會被過濾出 • GFR約125 ml/min • 最常用的marker為para-aminohippurate • PAH, 氨基馬尿酸 • ER≒0.7~0.9且會因人而異，及受其他藥物干擾，準確度也就打折扣

  18. GFR assessment • Criteria for a marker of GFR：可自由從glomerulus濾出，濾出後無reabsorption，無secretion，無其他modification • 測量GFR的方法是以clearance的概念為基礎，若符合GFR marker criteria則clearance =GFR • C x Pi = Ui x V • C = Ui x V / Pi

  19. GFR assessment • 外來性物質 • 有Inulin, polyfructosan，又以後者為佳，因其可溶於水 • 其他:51Cr-EDTA, 125mTc-DTPA, 125I-iothalamate也可用來測GFR，但因具輻射線而較少使用 • 內源性creatinine • 分子量113 Da，由肌肉中的creatine, phosphocreatine代謝而來；serum level決定於muscle mass及食物中肉類含量 • creatinine濾出後不會reabsorption，但飽和時會secretion，故當GFR↓時, creatinine clearance會高於inulin clearance • secretion會被一些帶正電的藥物(和Cr競爭)如cimetidine, Trimethoprim, pyrimethamine, dapsone所抑制，但因人差異性大，故難輔以藥物而增加評估clearance的精確性

  20. Creatinine and inulin clearance

  21. GFR assessment

  22. GFR assessment • 20 y/o male, 85 kg, Cr 1.4 • GFR約 100 ml/min • 80 y/o Female, 40 kg, Cr 1.4 • GFR僅 20 ml/min • 單單血中Cr的濃度,難以反映實際的GFR

  23. Chronic renal failure

  24. Acute Renal Failure定義 • Baseline serum Cr<3.0mg/dL • Cr increases >0.5 mg/dL • Baseline serum Cr>3.0mg/dL • Cr increase >1.0 mg/dL

  25. False high value of Pcr • Large meat meal • Ketoacidosis • Acetoacetate can raise Pcr by 0.5~2mg/dl • Cimetidine/Trimethoprim • Raise Pcr 0.4~0.5mg/dl due to inhibit creatinine secretion

  26. False low value of Pcr in ARF • Low muscle mass • Low meat meal • Malnutrition • Cirrhosis (decrease hepatic production of creatine) • Very acute stage of acute renal failure

  27. False high value of BUN • High protein intake • Enhance tissue breakdown: • Trauma • GI bleeding • Steroid • Decrease tissue anabolism • Tetracycline

  28. False low value of BUN in ARF • Severe liver disease • Low protein intake

  29. 輔助證據 1.Check laboratory data: CBC, urine analysis, K, Ca 2.Check sonography of kidney and urinary tract

  30. Classification of ARF • Prerenal ARF (prerenal azotemia)： ~55% • Intrinsic renal ARF (renal azotemia)：~40% • Postrenal ARF (postrenal azotemia)：~5%

  31. How to Approach ARF • Step 1: 先排除最簡單的Post-renal ARF • Step 2: 分辨Pre-renal ARF 及 Intrinsic ARF • Step 3: 若為Intrinsic ARF, 再依損害部位分 • Vascular • Tubular • Interstitial • Glomerular

  32. Therapeutic Trials • Fluid replacement – Pre-renal • ↑cardiac output – Pre-renal • Relief obstruction – Post-renal • DC drugs (NSAIDs, ACE inhibitors) – Drug-related renal failure

  33. Renal Biopsy • No obvious cause • Systemic disease (fever, neurological, pulmonary,skin lesions, joints, diffused LAP) • Heavy proteinuria, persistent hematuria • Anuria (without obstruction) • Prolonged oliguria (>2-3 weeks)

  34. 影響腎臟的常見藥物 • 血管 • Pre-glomerular vasoconstriction • Post-glomerular vasodilation • 腎小管 • Diuretics • 影響ADH的藥物 • 破壞性toxin

  35. Pre-glomerular vasoconstriction • NSAID • Indomethacin • Naproxen • Radiocontrast • Osmotic nephrosis • Endothelin, adenosine may play a role • Norepinephrine • Cyclosporin

  36. Predisposing factor of acute renal failure • Renal perfusion decrease • Combined nephrotoxic drug • UTI • Age • CKD

  37. Post-glomerular vasodilatation • ACEI • ARB • Dipyridamole

  38. 破壞性(toxin) • Radiocontrast • Aminoglycoside • Chemotherapy(cisplastin) • Cyclosporin • Organic solvent(ethylene glycol) • acetaminophen

  39. Thanks for your attention!

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