ACUTE RENAL FAILURE 吳志仁 醫師 馬偕醫院 腎臟內科. Definition An increase Cr. ≧ 0.5...
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Transcript of ACUTE RENAL FAILURE 吳志仁 醫師 馬偕醫院 腎臟內科. Definition An increase Cr. ≧ 0.5...
DefinitionDefinition
An increase Cr. 0.5 mg/dl per day≧ An increase of more than 50 %
over baseline Cr. A reduction in calculated CCr
of 50% Decrease in renal function that
results in the need for dialysis
Main Categories of ARFMain Categories of ARF
P rerena l c aus es
I s c hemia
(50% )
T ox ins
(35% )
T ubular nec ros is Intrs t it ia l nephrit is
(10% )
A c ute glomerulonephrit is
(5% )
Intrins ic c aus es P os trena l c aus es
A c ute R ena l F a ilure
Acute Tubular NecrosisAcute Tubular Necrosis
ARF is not result of primary vascular, glomerular, or interstitial disorder has to been referred to as ATN.
Neither the incidence nor the mortality and morbidity rates with ATN decreased, despite ongoing improvement of supportive Rx and renal replacement therapy.
Pathophysiology of Ischemic Acute Renal Failure Pathophysiology of Ischemic Acute Renal Failure
Vascular Factors Medullary Hypoxia Tubular - Cell Injury Neutrophils and Reperfusion Injury Role of Growth Factors in Recovery f
rom Ischemic ARF
Vascular Factors and Therapy with VsodilatorsVascular Factors and Therapy with Vsodilators
Dopamine Calcium-Channel B
lockers Atrial Natriuretic P
eptides PGE1
Endothelin receptor antagonist
Adenosine antagonist
Nitric Oxide
Lassnigg A et al, J Am Soc Nephrol 11, 2000
0.5~2 mg/kg/min -- so call renal dose dopamine
In double blind, randomized, controlled studies showed no clear experimental or clinical support for renal protective effect of dopamine.
There are potential risks associated with even low dose dopamine. These include tachycardia, cardiac arrhythmias, AMI and ischemic bowel.
Renal protection effect of dopamine ?
Osmotic Agents and DiureticsOsmotic Agents and Diuretics
Loop diuretics can only increase urine output for fluid management.
There is little evidence that conversion from an oliguric to a nonoliguric state decreases the mortality rate.
Tepel M et al, NEJM 2000
Prevention of radiographic contrast agent induced reductionin renal function by ACETYLCYSTEINE
ConclusionsConclusions
The clinical Rx of ARF is still largely supportive.
Basic research has provided many, albeit still unproved, approaches to future therapies.
Additional experimental models better reflect the multifactorial causes of clinical ARF.
Single-drug will probably never be effective, and multiple agents may be need to improve outcome.