Acute renal failure

Introduction The causes of acute renal failure are complicated, and it is a clinical syndrome caused by various factors. There is no perfect classification method for the etiology classification. According to the habit, it is divided into prerenal, renal and post-renal acute renal failure. Acute renal failure (ARF) is a syndrome caused by a variety of etiologies that cause a sharp decline in renal function in a short period of time, imbalance of water, electrolytes, and acid-base balance, and accumulation of toxic metabolites in the body. When the kidneys are unable to perform their normal functions, they cause toxins, waste and water to accumulate in the body, causing acute kidney failure.

Cause

First, the cause:

(a) prerenal acute renal failure

(1) Digestive tract loss: such as vomiting, diarrhea.

(2) Major bleeding caused by various causes: shock caused by massive bleeding and insufficient blood volume, sometimes coexisting with both, severe renal perfusion, decreased glomerular filtration rate, tubular degeneration and necrosis, common acute renal failure the reason.

(3) a large amount of skin loss: seen in heat stroke and a lot of sweat did not timely replenish blood volume.

(4) third gap loss of fluid: such as large area burns, peritonitis, necrotizing pancreatitis, a large amount of liquid into the third gap caused severe blood volume deficiency, leading to kidney failure.

(5) Excessive diuresis: diuretic can cause loss of water and loss of salt.

2. Cardiovascular disease

Due to severely insufficient blood output from the heart, renal insufficiency is seen in:

(1) Congestive heart failure.

(2) acute myocardial infarction: especially combined with cardiogenic shock or severe arrhythmia is more likely to be associated with acute renal failure.

(3) Pericardial tamponade: At this time, the body circulation is congested, which seriously affects the cardiac output.

(4) Renal artery embolization or thrombosis.

(5) Large area lung infarction.

(6) Severe arrhythmia.

3. Peripheral vasodilation or infection poisoning

At this time, the effective circulation of blood volume is redistributed, which is seen in the blood pressure reduction too fast or excessively toxic shock.

4. Increased renal vascular resistance

Found after major surgery and anesthesia, liver and kidney syndrome, prostaglandin inhibitors caused by decreased secretion of prostaglandins such as aspirin, indomethacin and ibuprofen.

(two) renal acute renal failure

It refers to the primary disease in the kidney itself, divided into five categories: acute tubular necrosis, acute glomerulonephritis and glomerular disease, acute interstitial nephritis, acute renal parenchymal necrosis and renal vascular disease.

Acute tubular necrosis

Found in various shocks, acute hemolysis syndrome, pregnancy-induced hypertension syndrome.

2. Acute nephrotoxic substances

(1) Antibiotics: such as amphotericin B, polymyxin, amino antibiotics, tobramycin, cefotaxime, etc.

(2) Contrast agent: includes various iodine-containing contrast agents.

(3) Heavy metal salts: such as mercury, pot, lead, uranium, riveting, gold, platinum, chromium, hammer, arsenic, phosphorus, etc.

(4) Industrial poisons: such as cyanide, methanol, phenol, benzene, chloroform, carbon tetrachloride, glycerin, insecticides, herbicides, etc.

(5) Biological toxicity: such as snake venom, bee venom, spotted venom, fish gall, poison, etc.

(6) Others: cyclosporine A, large doses of static mannitol, etc.

3. Glomerular disease

Such as glomerulonephritis, nephrotic syndrome, acute nephritis, pulmonary hemorrhagic nephritis syndrome, serum disease and so on.

4. Acute interstitial nephritis

It is a group of diseases that cause renal interstitial damage. The cause is very complicated. Common causes such as kidney infections, kidney toxic substances, long-term exposure to X-rays and various drug poisonings cause renal interstitial damage.

5. Renal vascular disease

Such as renal artery embolism and thrombosis, abdominal aortic aneurysm, renal vein thrombosis and so on.

an examination

Related inspection

Serum 1 microglobulin (1-MG) ceruloplasmin (CP) urinary alkaline phosphatase (UALP) trypsinuria per week protein (BJP)

History

Should include the following:

(1) Understand crush injuries, burns, major bleeding and the situation at the time.

(2) Whether there is a history of serious infection such as sepsis, septic shock, infectious, infective endometritis, suppurative cholangitis, acute pancreatitis, epidemic hemorrhagic fever, toxic bacillary dysentery, shock pneumonia, etc.

(3) Understand the history of severe dehydration, electrolyte imbalance and acid-base balance disorders, with or without a history of shock.

(4) Understand the symptoms of edema, hypertension, and urinary tract irritation. History of glomerulonephritis, pyelonephritis, and urinary tract obstruction, such as dysuria or poor urine flow.

(5) Understand the history of exposure to toxic substances, medication history, fluid replacement, blood transfusion and estimate the amount of fluid.

(6) Understand the history of cardiovascular disease.

In general, the medical history can determine the cause and then diagnose the disease in order to determine prerenal, renal and post-renal acute renal failure.

2. Physical examination

Focus on checking the degree of anemia, venous filling, degree of dehydration, rash, blemishes, and ecchymoses. Examination of cardiopulmonary signs. Abdominal mass and abdominal tenderness, palpation of the kidney and tenderness in the kidney area, pain, and urine retention in the bladder.

3. Laboratory inspection

It is an important diagnostic tool to establish a diagnosis and to infer the cause, and to judge the severity of acute renal failure.

(1) Urine examination: including changes in urine volume and urine relative density. In acute renal failure, the urine volume is less than 400 ml per day or less than 17 ml per hour. Complete anuria indicates renal cortical necrosis or bilateral urinary tract obstruction. Urine sediment examination includes protein qualitative urine cells and various tube types, urine sugar qualitative and so on. The relative density of urine is low and fixed. Under the premise of oliguria, the relative density of urine is 1.018. The basic diagnosis can be made below 1.014, and the diagnosis can be confirmed by 1.010-1.012.

(2) blood routine blood biochemical examination: routine can determine the degree of anemia infection and blood concentration. Biochemical performance of refractory metabolic acidosis, high urea nitrogen, high creatinine, low creatinine clearance. Electrolyte examination is prone to hyperkalemia, hyponatremia (usually dilute hyponatremia, low blood calcium, high blood phosphorus. Hyperkalemia is one of the causes of death.

(3) Determination of urinary sodium: The discharge of raw steel in acute renal failure is greater than 30~40 mih/L, and the functional oliguria discharge is less than 10 min/L, indicating that the renal tubules absorb sodium barrier.

(4) Determination of urine osmotic pressure: normal human urine osmotic pressure>550min/kg.H2o, at this time can show a significant decline.

Differential diagnosis

The diagnosis should be differentiated from the following symptoms:

Renal failure

Pathological condition in which some or all of the kidney function is lost. According to the rapid onset of the attack, it is divided into acute and chronic. Acute renal failure causes the two kidneys to lose excretory function in a short period of time due to various diseases. Referred to as acute renal failure. It is characterized by oliguria (urinary volume without urine (urinary uremia, also non-oliguric type (nitrogen volume >1000mL / d). Timely and appropriate treatment, renal function can be restored. Complex condition, critically ill patients or treatment At that time, it can be converted to chronic renal insufficiency or death. Acute renal failure includes the following three conditions: 1 prerenal azotemia. Insufficient renal blood perfusion due to insufficient blood volume or cardiac insufficiency, glomerular filtration The rate is reduced. 2 Post-renal azotemia. Due to stones, tumors or prostatic fertilizer, the urinary tract is caused by acute obstruction, resulting in oliguria and elevated blood urea nitrogen (Bun). 3 renal acute renal failure. Because of kidney Caused by substantial illness, seen in severe acute glomerular disease, acute interstitial-tubular disease, acute tubular necrosis, acute renal vascular disease and chronic kidney disease, under the influence of certain causes, the two kidneys are rapidly deteriorated, Acute tubular necrosis is most common.

2. Renal failure

Renal failure can be divided into acute and chronic diseases. The condition of acute renal failure progresses rapidly. It is usually caused by insufficient supply of blood in the kidney (such as trauma or burn), damage to the kidney due to some factors, or damage to the poison. The production of acute renal failure. The main cause of chronic renal failure is long-term renal disease. As time and disease progress, the function of the kidney gradually declines, causing renal failure.

3. Chronic renal failure

Chronic renal failure (CRF) is not an independent disease. It is the end-stage manifestation of deterioration of renal damage caused by various causes. When the renal function is close to 10% of normal people, a series of syndromes appear. Generally, there is a relatively long course of disease. According to the degree of renal dysfunction, the renal insufficiency is compensated. The decompensation period of renal insufficiency is also called azotemia, renal failure, and the end stage is also called uremia.

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