renal insufficiency
DESCRIPTION
Renal insufficiency. Renal insufficiency is a pathological process in which the functions of kidney are severely damaged, leading to the accumulation of metabolic products, drugs and poisons, and disorders of water, electrolyte, acid-base balance, and renal endocrine function. - PowerPoint PPT PresentationTRANSCRIPT
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Renal insufficiency
Renal insufficiency is a pathological process in which the functions of kidney are severely damaged, leading to the accumulation of metabolic products, drugs and poisons, and disorders of water, electrolyte, acid-base balance, and renal endocrine function.
Renal failure: the terminal stage of renal insufficiency
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Renal insufficiency
Dysfunction of glomerular filtration
Dysfunction of renal tubule
Renal endocrine dysfunction
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Decreased GFR
a decrease in renal blood flow
a decrease in glomerular effective filtration pressure
a decrease in glomerular capillary surface area
a decrease in glomerular filtration coefficient
Increased permeability of glomerular filtration membrane
Dysfunction of glomerular filtration
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Dysfunction of renal tubules
Dysfunction of proximal convoluted tubules
reabsorbing water, glucose, protein, amino acids, phosphate, bicarbonate, sodium, potassium
Dysfunction of Henles’ loop
reabsorbing chloride, sodium
Dysfunction of distal convoluted tubules and collecting ducts
secreting hydrogen, potassium and ammonia
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Renal endocrine dysfunction
Renin-angiotensin-aldosterone system
A decrease in erythropoietin (EPO)
1,25-dihydroxyvitamin D3
Kallikrein-kinin-prostaglandin system
Decreased deactivation of parathyroid hormone (PTH) and gastrin
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Renal failure
Acute renal failure
Chronic renal failure
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Acute renal failure
Acute renal failure represents a rapid decline in renal function leading to increased blood levels of nitrogenous wastes and impaired water and electrolyte balance, and manifesting water intoxication, azotemia, hyperkalemia, and metabolic acidosis.
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Acute renal failure is reversible if the cause can be identified and corrected before permanent kidney damage has occurred.
The most common indicator is azotemia, which is an accumulation of nitrogenous wastes (urea nitrogen, uric acid and creatinine)
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Etiology and classification
Prerenal failure
Intrarenal failure
Postrenal failure
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Prerenal failure- functional failure
Prerenal failure is the most common form of acute renal failure. It is caused by a marked decrease in renal blood flow.
Causes
•Hypovolemia
•Heart failure
•Intrarenal vasoconstriction
•Increased blood vessel bed
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Intrarenal failure- parenchymal renal failure
Intrarenal failure results from conditions that can cause damage to structures within the kidney, glomerular, tubular and interstitial.
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Causes
Acute tubular necrosis (ATN)
Prolonged renal ischemia (ischemic ATN)
or ischemia-reperfusion injury
Toxic insult of tubules by drugs, heavy metals
(nephrotoxic ATN)
Intratubular obstruction
hemoglobin and myoglobin
severe hypokalemia, hypercalcemia
Acute glomerulonephritis and acute pyelonephritis
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Postrenal failure – obstructive renal failure
Obstruction of urine outflow from the kidneys. (ureter, bladder and urethra)
Prostatic hypertrophy (most common)
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Pathogenesis
Decreased renal blood volume
Renal tubular injury
renal tubular obstruction increased intraluminal P
back leak of the glomerular filtrate
decreased urine; interstitial edema
impressing renal tubules and peri-tubular capillaries
Renal cell lesion
renal tubular cells, endothelial cells and mesangial cells
necrotic (tubulorrhexic and nephrotoxic) and apoptotic
ATP↓oxygen free radical↑reduced glutathione(GSH) ↓phospholipase ↑
cytoskeletal structural change activation of cell apoptosis
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Alterations of metabolism and function
The oliguric stage
The diuretic stage
The recovery stage
Oliguric type and nonoliguric type
Oliguric type
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The oliguric stage
Urinous alterations
Water intoxication
Hyperkalemia
Metabolic acidosis
Azotemia
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Urinous alterations
oliguria, anuria
hyposthenuria, isosthenuria
an increase in urine sodium
hematuria, albuminuria, cyclindruria
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Water intoxication
excretion ↓ (due to decreased GFR)
ADH ↑ (due to activation of RAS or decreased ECV)
endogenous water from catabolism ↑
water uptake ↑
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Hyperkalemia
excretion ↓
tissue injury and increased catabolism,
acidosis
hyponatremia
transfusion of storage blood or excessive intake from food or drugs
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Metabolic acidosis
decreased excretion of acidic metabolites
decreased secretion of hydrogen and ammonia
increased production of fixed acids
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The diuretic stage
Restoration of renal perfusion and glomerular filtration
Reduced reabsorption function of neonatal renal tubules
Release of renal obstrction
Osmotic diuretics
The recovery stage
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Treatment of acute renal failure
•Identifying and correcting the causes
•Maintaining water and electrolyte balance
•Supplying adequate calories
•Dialysis
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Chronic renal failure
Chronic renal failure represents progressive and irreversible destruction of kidney structures, leading to the accumulation of metabolic products, drugs and poisons, and disorders of water, electrolyte, acid-base balance, and renal endocrine function.
•Diabetes
•Hypertension
•Glomerulonephritis
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Stages of progression
Chronic renal failure is characterized by a reduction in the number of functional nephrons. The rate of nephron destruction ranges from several months to many years.
•Diminished renal conserve
•Renal insufficiency
•Renal failure
•Uremia
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Pathogenesis
Several hypothesis on chronic failure
Intact nephron hypothesis
Trade-off hypothesis
Glomerular hyperfiltration hypothesis
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Mechanism of nephron dysfunction
Actions of primary disease
Secondary and progressive glomerular sclerosis
protein flux
local inflammation
glomerular DIC
Tubulointerstitial injury
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Alterations of function and metabolism
Alterations of urine
Azotemia
Disorders of water, electrolyte and acid-base balance
Renal hypertension
Renal anemia
Tendency to hemorrhage
Renal osteodystrophy
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Alterations of urine
Early stage polyuria, nocturia, isosthenuria,
protein, RBC, WBC in urine
Late stage oliguria
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Azotemia
Urea and creatinine
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Disorders of water, electrolyte and acid-base balance
Edema or dehydration
Salt-wasting
Hypokalemia (early) or Hyperkalemia (late)
Hyperphosphatemia
Hypocalcemia
Metabolic acidosis
Hyperphosphatemia
Reduced absorption through intestinal tract caused by decreased 1,25-(OH)2 D3, inrestinal injury led by toxins, and calcium consumption through combining with phosphate to form calcium phosphate.
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Osteodystrophy
Increased phosphate levels
Decreased calcium levels
Increased parathyroid hormone
Impaired renal activation of Vitamin D
Metabolic acidosis
Renal rickets, osteomalacia, osteitis fibrosa, osteoporosis, osteosclerosis
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Hematologic disorders
Anemia
decreased EPO production
suppression of red cell production by uremic toxins
decreased life-span of red blood cell
iron deficiency
Coagulopothy---bleeding disorder
platelet function is impaired,
although platelet production is normal.
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Hypertension
Increased blood volume led by water and sodium retention
Decreased levels of renal vasodilator prostaglandins
Increased activity of renin-angiotensin system
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Treatment
Medical management
Dialysis and transplantation
hemodialysis
peritoneal dialysis
transplantation
Dietary management
protein restriction
adequate calorie intake (carbohydrate and fat)
potassium, sodium and fluid restriction