Download - 23160944-Insuficienta-Renala-Acuta
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Camelia IonescuCentrul de Medicina Interna – Nefrologie
Institutul Clinic Fundeni
INSUFICIENTA RENALA ACUTA
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IRA este un sindrom acut de pierdere partiala sau totala a functiilor renale, survenind cel mai adesea pe un parenchim sanatos si numai rareori pe o veche nefropatie.
IRA - Definitie
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IRA – Forme de IRA
IRA in comunitate IRA in spital IRA in ATI
Incidenta Scazuta Moderata (5%) Ridicata (10-20%)
Cauze O singura cauza Multiple MSOF
pre>post>renala pre>NAT>post MSOF+NAT
Evolutie Buna Mai putin buna Proasta
Supravietuire 70-90% 30-50% 10-30%Schrier and Gottschalk, Disease of the kidney, 2001
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Substrat morfologic
IRA functionale IRA organice
IRA – Clasificare
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Substrat etiologic
• IRA functionale• IRA excretorii• IRA toxice• IRA posttraumatice, postoperatorii• IRA prin necroza acuta corticala si CID• IRA din glomerulonefrite acute• IRA din vasculite
IRA – Clasificare
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Substrat etiopatogenic
• IRA functionala (prerenala)
• IRA renala (intriseca, organica)
• IRA postrenala (obstructiva, mecanica)
IRA – Clasificare
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Substrat etiopatogenic
• IRA functionala (prerenala) – 60 - 80%
• Hipovolemie• Scaderea debitului cardiac• Cresterea rezistentelor vasculare renale
IRA – Clasificare
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Substrat etiopatogenic
• IRA functionala (prerenala) – 60 - 80%
• Hipovolemie• Pierderi de lichide si electroliti
• Digestive: diaree, varsaturi• Renale: poliurie• Spatiu III: peritonita, ocluzie intestinala, statusuri
hipoalbuminemice
• Pierderi de sange• Traumatisme• Hemoragii digestive • Alte hemoragii
IRA – Clasificare
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Substrat etiopatogenic
• IRA functionala (prerenala)
• Scaderea debitului cardiac
IMA Embolie pulmonara Pericardita cu tamponada Tahicardii IC severa Chirurgie cardiaca
IRA – Clasificare
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Substrat etiopatogenic
• IRA functionala (prerenala)
• Cresterea rezistentelor vasculare renale
• Organica: embolii, tromboze, stenoze• Functionala
Anestezie SHR Consum AINS
IRA – Clasificare
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Substrat etiopatogenic
• IRA renala (intrinseca, organica) – 10 – 20%
• NTI acute (necroza tubulara acuta)• Nefrite interstitiale acute• Glomerulonefrite acute sau subacute• Nefropatii vasculare acute
IRA – Clasificare
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Substrat etiopatogenic
• IRA postrenala (obstructiva, mecanica) – < 10%
• Obstructia acuta a caii urinare localizata:
• Cale urinara comuna• Bilateral• Unilateral
• Rinichi unic morfologic (congenital, chirurgical)• Rinichi unic functional (rinichi contralateral lezat,
grefa)
IRA – Clasificare
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IRA – Patofiziologia IR ischemice
IRA ischemica
Anormalitati hemodinamice
Injurie tubulara
Contractie mezangiala
Vasoconstrictie
Congestie medulara
Obstructie tubulara
Back-leakage
Reducerea coeficientului de filtrare glomerulare
Reducerea fluxului plasmatic glomerular si a presiunii intraglomerulare
Reducerea eliberarii de O2 la nivelul medularei
Reducerea RFG Brady et al. ARF in Brenner and Rector; The kidney; US: Saunders Co, 2000: 1201-1262
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• 2 forme clinice• Forma oligurica• Forma non – oligurica
• Evolutie ciclica in 3 faze (ex: NTI acuta)• Faza preanurica• Faza anurica• Faza de reluare a diurezei• Faza de recuperare functionala renala
IRA – Clinica
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• Faza preanurica
• Durata 24 – 36h• Debut
• Brutal (soc traumatic, infectios, obstetrical, intoxicatii, accidente postransfuzionale) – 24h
• Insidios (toxice, medicamente, postchirurgical) – 5 – 7zile• Clinica: a bolii initiale, oligurie 400 – 600ml/24h• Biologic
• Probe urinare: volum urinar < 800ml, densitate variabila, proteinurie tubulara, hematurie, mioglobinurie, hemoglobinurie
• Probe sangvine: uree 50 – 80mg/dl, creatinina 1,2 – 1,4mg/dl
IRA – Clinica
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• Faza anurica
• Durata 24 – 36h 40zile (10 – 18zile, maxim 120zile)• Simptomatologia clinica
• Manifestari cutanate: paloare, echimoze, necroze
• Manifestari respiratorii: plaman uremic, pleurezie, infectii
• Manifestari cardio – vasculare: HTA / colaps, tulburari de ritm, IC, pericardita uremica
• Manifestari digestive: stomatita, gastrita, enterocolita uremica, HDS
IRA – Clinica
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• Faza anurica
• Durata 24 – 36h 40zile (10 – 18zile, maxim 120zile)• Simptomatologia clinica
• Afectare hepatica: citoliza, colestaza, insuficienta hepatica
• Pancreatita acuta
• Manifestari hematologice: anemie, leucocitoza, sd. Hemoragipar
• Manifestari neuro – psihice: encefalopatie, hemoragii, infectii
IRA – Clinica
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• Faza anurica
• Biologic
• Retentie azotata• ureea 15–30mg/dl/24h• creatinina 0,5-2mg/dl/24h
• Tulburari hidro – electrolitice: hipo/hiperNa, hiper/hipoK, acidoza metabolica
• Alte modificari: hiperglicemie, hipoproteinemie, TG
IRA – Clinica
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• Faza anurica
• Explorari imagistice
• Rx simpla• Ecografia renala simpla / doppler• UIV• Pielografia ascendenta• Arteriografia renala• Tomografia computerizata• Scintigrama renala• Punctia biopsie renala
IRA – Clinica
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• Faza de reluare a diurezei
• Simptomatologie clinica
• Poliurie volum urinar > 2000ml/24h
• Biologic
• Explorari urinare: densitate 1003 – 1009, proteinurie = 0,5g/24h, pierderi mari de Na, K, Ca, HCO3(> 200mEq/l)
• Sangvin: retentia azotata are o evolutie dinamica
IRA – Clinica
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• Faza de recuperare functionala renala
• Durata: pana la 6 – 12 luni• Simptomatologie clinica
• Poliurie persistenta: volum urinar > 2000ml/24h
• Biologic
• Recuperare completa: uree, creatinina normale• Recuperare incompleta: retentie azotata
IRA – Clinica
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• Criterii de diagnostic pozitiv
• Diureza < 500 ml/24h (< 30 ml/h)• Densitate urinara < 1015• Osmolaritate urinara < 600 mosm/l• Uree urinara < 10-15 g/l• Na u > 40 mEq/l• U osm / P osm = 1• Uree u / Uree p = 5-10• Test negativ la furosemid si manitol• Rx, Eco, TC: dimensiuni renale normale sau
crescute
IRA – Diagnostic pozitiv
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• Azotemia extrarenala
• Insuficienta renala cronica in stadiul uremic
• Acutizarea IRC
IRA – Diagnostic diferential
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• Infectiile
• Frecventa: 50 – 90% din cazuri• Localizare
• Bronho – pneumonie, septicemie, peritonite, de cateter, urinare
• Germeni implicati: Gram (-), Gram (+), fungi• Evolutie: spre deces in 30 – 70% din cazuri
IRA – Complicatii
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• Hemoragia digestiva superioara
• Evolutie: spre deces in 50% din cazuri (+ infectie)
• Complicatii cardio – vasculare
• Tulburari paroxistice de ritm• Insuficienta cardiaca• Emboliile
IRA – Complicatii
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• Mortalitate globala: 50%
• Factori de prognostic negativ• Leziuni renale preexistente• Varsta > 60 ani• Alte insuficiente de organ: plaman, ficat, inima• Forme hipercatabolice, oligo-anurice• Numarul si tipul complicatiilor• Asocierea CID• Aparitia unui al doilea episod de IRA
IRA – Evolutie. Prognostic
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• Revenire la normal • Frecventa: 40-50%
• Revenire clinica completa• Persista: scaderea capacitatii de concentrare,
a posibilitatii de acidifiere a urinii
• Sechele semnificative• Frecventa: 10%• Alterarea progresiva a functiei renale, HTA la
2-4%
• IRC in 1-5% (dializa cronica)
IRA – Prognosticul functiei renale
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• Obiective
• Restabilirea functiei renale
• Mentinerea functiilor vitale, a echilibrului hidro – electrolitic si acido - bazic
IRA – Tratament
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• Tratament etiologic
• Tratament patogenic
• Tratament simptomatic
• Tratamentul complicatiilorObiective
IRA – Tratament
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• Tratament etiologic
• Intoxicatii• Antidot specific• Epurare extrarenala: HD, HF, hemoperfuzie
• Infectii – sepsis• antibioticoterapie
IRA – Tratament
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• Tratament etiologic
• Corectarea deshidratarilor• Alimentatie po adecvata• Perfuzii adecvate
• Profilaxia IRA postoperatorii
IRA – Tratament
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• Managementul NAT - 1
• Diagnosticul si corectarea factorilor favorizanti pre si postrenali
• Revederea medicatiei si oprirea medicatiei nefrotoxice
• Optimizarea debitului cardiac si a fluxului plasmatic renal
• Restaurarea si/sau cresterea diurezei• Monitorizarea intrarilor/iesirilor zilnic si a greutatii
corporale (+/- 300mg/zi)
IRA – Tratament
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• Managementul NAT - 2
• Diagnosticul si corectarea complicatiilor acute (kiperkaliemia, hiponatremia, acidoza, hiperfosfatemia, edem pulmonar)
• Asigurarea precoce a suportului nutritional• Diagnosticul si tratamentul agresiv al infectiilor• Initierea precoce a dializei• Ajustarea dozelor medicamentelor conform
clearence-ului renal.
IRA – Tratament
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• Tratament patogenic
• Ameliorarea functiilor renale
• Diuretice osmotice: Manitol 20% 200-400ml/zi• Diuretice de ansa: Furosemid 20 fiole/zi• Vasodilatatoare: Dopamina 3-5 g/kgc/min, 3-5
zile
IRA – Tratament
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• Tratament patogenic
• Epurarea extrarenala. Indicatii
• Creatinina > 8 – 10 mg/dl, uree > 200 mg/dl
• Tulburari neurologice centrale: coma, convulsii, somnolenta, asterixis, fasciculatii neuro-musculare
• Tulburari digestive: greata, varsaturi, hemoragie
• Pericardita
IRA – Tratament
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• Tratament patogenic
• Epurarea extrarenala - indicatii
• Insuficienta respiratorie
• Tulburari cardio –vasculare: EPA, HTA, aritmii
• Anomalii metabolice
• Hiperpotasemie > 6,5 mEq/l• Hiponatremie < 120 sau hipernatremie > 160 mEq/l• Cloropenie < 80 mEq/l• Acidoza metabolica sau alcaloza EB > 15 – 20 mEq/l• Hiperuricemie > 15 mg/dl• Hipercatabolism proteic
IRA – Tratament
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• Tratament patogenic
• Epurarea extrarenala
• Terapia substitutiva renala continua• Hemofiltrare/hemodiafiltrare continua veno-venoasa
• Hemodializa zilnica (8-10h/zi)• SLEDD (Sustained low efficiency daily dialysis)
• Hemodializa intermitenta (la o zi alterna sau 2-3 zile)
• Dializa peritoneala
IRA – Tratament
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IRA – Tratament
TRSC in tratamentul IRA
Avantaje
Stabilizarea TA
Mai putine aritmii cardiace
Imbunatatirea suportului nutritional
Un mai bun schimb al gazelor respiratorii
Un mai bun control al fluidelor
Mai bun control biochimic
Spitalizare mai scurta
Dezavantaje
Cresterea complicatiilor legate de accesul vascular
Cresterea riscului de sangerare
Imobilizare prelungita
Risc mai mare de rupturi ale filtrului
Costuri crescute