acute renal insufficiency
Introduction
Introduction to acute renal insufficiency Acute renal insufficiency (acuterenalinsufficiency, ARI) refers to a syndrome in which the renal urinary function is rapidly reduced in a short period of time, so that the internal environment is not stable, resulting in water, electrolyte and acid-base balance disorders and accumulation of metabolic products. Divided into acute renal insufficiency and chronic renal insufficiency. A serious prognosis is one of the major life-threatening conditions. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: Hypertension Heart failure Pericarditis Metabolic acidosis Electrolyte disorders Hyponatremia Blood in the stool Bloating nausea and vomiting Acute renal failure
Cause
Cause of acute renal insufficiency
Kidney disease (45%)
Such as acute, chronic glomerulonephritis, pyelonephritis, renal tuberculosis, acute tubular degeneration, necrosis caused by chemical poisons and biological poisons, kidney tumors and congenital kidney disease, kidney tuberculosis, renal organic disease caused by trauma, etc. .
Systemic disease (25%)
Although a variety of systemic diseases can have kidney manifestations, relatively few of them cause acute renal insufficiency. More common is that acute renal insufficiency can be secondary to systemic vasculitis, especially in patients with nodular polyarteritis, primary cryoglobulinemia, systemic lupus erythematosus and multiple myeloma. in. Diabetes itself is not a typical cause of acute renal insufficiency, but it is a powerful susceptibility to other causes of acute renal insufficiency, including acute renal insufficiency caused by contrast agents. Acute renal insufficiency may be accompanied by hemolytic uremic or thrombotic thrombocytopenic purpura. In particular, it is suggested that the kidney with acute renal insufficiency in pregnant patients has a poor prognosis, which may be due to the necrosis of the renal cortex.
Drug poisoning (15%)
Drugs that may cause acute tubular necrosis include cisplatin, amphotericin, and acyclovir. Drug poisoning, especially ethylene glycol or acetaminophen, may cause acute tubular necrosis and induce the disease.
Prevention
Acute renal insufficiency prevention
1. Proper use of drugs with nephrotoxicity.
2. Prevent shock and actively rescue shock. Correct treatment of various primary diseases that may cause shock, such as shock and accompanied by functional acute renal insufficiency, should take effective anti-shock measures in time to quickly restore effective circulating blood volume.
Complication
Acute renal insufficiency complications Complications hypertension heart failure pericarditis metabolic acidosis electrolyte disorder hyponatremia blood in the stool nausea and vomiting acute renal failure
1, cardiovascular system complications: including hypertension, heart rhythm disorders, heart failure, pericarditis.
2, metabolic acidosis, electrolyte imbalance, hyponatremia, severe acidosis, hyperkalemia. One of the most dangerous complications of acute renal failure is severe acidosis.
3, digestive system complications: manifested as hematemesis, blood in the stool, anorexia, abdominal distension, nausea, vomiting, etc., most of the bleeding is caused by stress ulcers or gastrointestinal mucosal erosion.
4, blood system complications: because of the sharp decline in renal function, can lead to a decrease in erythropoietin, which can cause anemia, but most of the disease is not serious. However, a small number of patients have a reduced tendency to engrave clotting factors, which may lead to bleeding.
5, infection: is one of the most serious and most common complications, more common in burns, trauma and other high-grade acute renal failure.
6, the complications of the nervous system: can be expressed as coma, epilepsy, headache, lethargy, muscle twitching and so on. There is a great relationship between the complications of the nervous system and the imbalance of acid-base balance, toxin retention in the body, electrolyte imbalance, and water toxicity.
Symptom
Symptoms of acute renal insufficiency Common symptoms Metabolic acidosis No urinary oliguria Polyuria azotemia Hypokalemia
Performance is divided into oliguria and non-oliguric:
Highly degraded ARF: tissue catabolism is fast, blood urea nitrogen and serum creatinine increase at a rate of > 14.3 mmol / L (40 mg / dl) and > 170 umol / L (2 mg / dl), respectively.
1, prerenal azotemia : oliguria, elevated blood urea nitrogen
2, post-renal azotemia : sudden anuria or intermittent no urine
3, the kidney is substantial : can be different due to different parts of the affected.
(1) RPCN has a rapid progressive nephritic syndrome.
(2) oliguric ATN typical oliguria, polyuria and recovery.
(3) The history of AIN caused by drugs is more useful, and a few have a history of allergies. It has the performance of interstitial tubule function damage, such as anemia that is not parallel with the decline of renal function, hypokalemia, normal blood sugar, urine sugar positive and acidosis.
(4) Renal vascular ARF malignant hypertension, one or bilateral large vessel disease.
Examine
Examination of acute renal insufficiency
Urine protein qualitative test:
Generally, three methods of protein test paper method, sulfosalic acid method, and heated acetic acid method are employed. Under normal circumstances, the urine protein qualitative test was negative. However, this method of inspection is susceptible to a number of factors, which can lead to false results. For example, when the urate content is high, the urine is acidic, the protein test paper results are lower than the actual situation, and the sulfosalic acid method is false positive; When penicillin is used in large amounts, the sulfosalic acid method is susceptible to a false positive reaction. When sulfonate contrast agent is used, the sulfosyl acid method and the heated acetic acid method can all have a false positive reaction; when the urine is strongly alkaline, the false result is more, or a false negative reaction of the protein test paper occurs, or a sulfo-relief reaction occurs. A false negative reaction between the acid method and the heated acetic acid method.
When the urine protein is only some special proteins, the protein test paper method and the sulfosalic acid method are not sensitive. Therefore, when performing urinary protein characterization, various factors should be integrated, specific conditions should be analyzed, and appropriate methods should be selected. Although qualitative tests are convenient, it is sometimes difficult to reflect the actual situation of proteinuria. When conditions permit, it is best to perform quantitative tests.
Blood test:
Obvious anemia, normal cell anemia, normal or increased white blood cell count. Decreased platelets and accelerated cell sedimentation rate.
Urine routine examination of renal insufficiency:
There are trapping differences depending on the primary disease. The commonalities are:
1Urine osmotic pressure is reduced, mostly below 450mOsm per kilogram, the weight is low, mostly below 1.018, and when it is severe, it is fixed between 1.010~1.012. When used for urine concentration dilution test, the night urine volume is greater than the daily urine volume, and the urine specific gravity Both exceed 1.020, the highest and lowest urine specific gravity difference is less than 0.008;
2 The amount of urine is reduced, mostly below 1000ml per day;
3 urinary protein quantitative increase, the majority of glomeruli have been destroyed in the late stage, and urine protein is reduced;
4 urine sediment examination, leukocytosis in urine sediment (usually full of vision in the acute phase, 5 / high power field in the chronic phase), sometimes white blood cell cast;
5 urine bacteria examination: this method of nephritis is relatively simple, when the urine contains a lot of bacteria, due to urinary sediment coating for Gram staining, 90% can find bacteria. The positive result of the test is high.
X-ray inspection:
X-ray examination when the patient with nephritis repeated, or the patient's condition developed to the point of difficulty to control, at this time X-ray for nephritis examination, including abdominal X-ray, intravenous pyelography, urinary bladder urography. The purpose is to rule out the presence or absence of stones, congenital malformations of the urinary system, renal ptosis, and other pathological changes.
Diagnosis
Diagnosis and diagnosis of acute renal insufficiency
1, ARF is caused by a variety of reasons, the two kidney excretion function rapidly decreased in a short period of time, the average daily increase in serum creatinine 44.2umol / L.
2, further determined to be oliguria, non-oliguric, or high decomposition.
3, pay attention to the following two points: 1 the application of diuretics can increase the discharge of urinary sodium, so at this time can not rely on urine sodium discharge and sodium excretion score as a basis for diagnosis; 2 with proteinuria or diabetes and application of mannitol, dextran or angiography After the agent, the urine specific gravity and urine osmotic pressure can be increased, so it should not be used as a basis for diagnosis.
4, should also rule out chronic renal failure. The use of B-ultrasound to measure kidney size and nail creatinine determination helps identify acute and chronic renal failure. B-ultrasound is not small, and the thickness of the renal parenchyma is not thin to support acute renal failure. Nail creatinine represents the level of serum creatinine in the patient's serum 3 months ago, so the diagnosis of acute renal failure is supported if nail creatinine is normal.
5, the gold standard is the renal biopsy pathological diagnosis as soon as possible to carry out emergency renal biopsy to confirm the diagnosis.
