(精编)【医学教学课件】肾脏病理生理学.pptVIP

Hypertension ? Hypertension occurs in 80% to 90% of patients with renal insufficiency. Several factors contribute: a. Expansion of extracellular fluid volume; this may arise because of reduced ability of the kidney to excrete ingested sodium. b. Increased activity of the renin-angiotensin system is common; many patients with advanced renal failure have renin levels that are not completely suppressed by the elevated blood pressure. c. Dysfunction of the autonomic nervous system occurs with insensitive baroreceptor sensitive and with increased sympathetic tone. d. Possible diminished presence of vasodilators: there may be decreased renal generation of prostaglandins or of factors in the kallikrein-kinin system. 功能性肾衰和器质性肾衰（ATN）的鉴别 功能性肾衰 器质性肾衰 尿液性质 尿比重 尿渗透压 尿钠 尿肌酐/血肌酐 尿常规 治疗与反应 1.020 1.015 500mOsm/L 400mOsm/L 20mmol/L 40mmol/L 40 20 正常 蛋白尿、管型、红细胞、白细胞 应迅速补充血容量 需严格控制补液量 使肾血流恢复，GFR? 量出而入 补液后 尿量迅速增多 尿量持续减少 病情明显好转 甚至使病情恶化 Muddy Brown Cast Red Cell Cast White Cell Casts Diuretic phase As healing begins, improvement is reflected in the production of more than 400 ml of urine per day. Fluid and electrolyte abnormalities. Cr may still rise for 1-2 more days. Recovery phase ARF的主要机能代谢变化和临床表现 一 少尿期 1. 少尿、无尿 2. 氮质血症：指肾功能衰竭时，由于GFR下降，含氮的代谢产物如尿素、肌酐、尿酸等在体内蓄积，引起血中非蛋白氮的含量增加（＞28.6mmol/L，或＞40mg/dl）。 3. 水中毒：当肾排水功能障碍的情况下，一旦水摄入稍多，就易造成稀释性低钠血症，大量水份进入细胞内，引起脑水肿、肺水肿、心力衰竭。因此对少尿期ARF患者，要严格控制摄入水量。 4. 高血钾：主要由GFR降低和肾小管泌钾障碍引起，机体代谢分解增强使钾释放增多及酸中毒引起细胞内钾向细胞外转移，都能促使血钾进一步增高。严重高血钾可导致室颤和心跳骤停。高钾血症是ARF患者第一周死亡的最常见原因。 5. 代谢性酸中毒：主要由GFR降低、肾小管排酸保碱作用减退、体内分解代谢加强使固定酸产生过多等原因引起。 二 多尿期 经过少尿期后，当每天尿量大于400ml，说明病人已进入多尿期。进行性尿量增多是肾功能开始恢复的一个