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Insuficincia Renal

Edgar A F de Almeida
Cadeira de Fisiopatologia, FML Cadeira de Nefrologia, FML Servio de Nefrologia e Transplantao Renal, HSM

Funes do Rim
Funo depuradora (excretora)
Regulao da presso arterial Regulao do equilbrio cido-base Regulao do equilbrio hidro-electroltico Funo endcrina Funo metablica

Filtrao Glomerular

PAH

Inulina

Glucose

Determinantes do filtrado glomerular

Regulao do filtrado glomerular

Filtrado glomerular

Filtrado 180 litros/dia reabsoro 178 litros/dia

Urina 1,5 2 litros/dia

Filtrado glomerular

Filtrado 60 litros/dia Reabsoro 57 litros/dia

Urina 1,5 2 litros/dia

Funes tubulares

Reabsoro de solutos (glucose, aminocidos, etc.

Reabsoro de bicarbonato (regulao do equilbrio cido-base))

(dis)Funo tubular

(dis)Funo tubular

Acidose Tubular proximal (tipo 2)

(dis)Funo tubular

Funes tubulares
Produo de Renina (regulao da presso arterial)

Fisiopatologia da Insuficincia renal

FG = Kf * (Ph cg Ph B )

Kf coeficiente de ultrafiltrao cg capilar glomerular B cpsula de Bowman presso onctica (sangue)

Fisiopatologia da Insuficincia renal

FG = Kf * (Ph cg Ph B )

Fisiopatologia da Insuficincia renal

Leso renal aguda, pr-renal

Leso renal aguda, pr-renal

SRAA e Prostaglandinas na regulao do fluxo sangneo renal

Auto-regulao do FG

Auto-regulao do FG

Ecografia Renal

Fisiopatologia da Insuficincia renal

FG = Kf * (Ph cg Ph B )

Leso renal aguda, ps-renal

Ecografia Renal

Fisiopatologia da Insuficincia renal

FG = Kf * (Ph cg Ph B )

Leso renal aguda, intrnseca (renal, parenquimatosa)

Necrose tubular aguda

Necrose tubular aguda

NTA histria natural

Necrose tubular aguda

Nefrotocicidade de frmacos

Leso renal aguda


glomerulonefrite

crescntica

Leso renal aguda


septicmia

Schrier RW NEJM 351: 159-69, 2004

Leso renal aguda

Leso renal aguda

Leso renal aguda

Leso renal aguda classificao RIFLE

Indicadores de funo renal


creatininmia

Msculo

Creatinina

Sexo Idade Execcio fsico Frmacos

Glomrulo

Secreo tubular

Urina

Curvas de acumulao de produtos finais do metabolismo


creatinina

Fsforo, hidrognio, uratos

gua, sdio

Manifestaes da urmia Manifestaes


MJPP 8 7 6 5 4 3 2 1 0 0 50 100
meses

creat

150

200

250

Assintomtico

sintomas

Solutos urmicos

Consequncias da urmia
Hipertenso arterial / hipervolmia Anemia Hiperfosfatmia / hiperparatiroidismo secundrio / osteodistrofia Acidose metablica Hipercalimia Discrasia hemorrgica Neuropatia sensitiva Doena vascular aterosclertica

Prognstico da leso renal aguda

Opes teraputicas na urmia

Prerenal ARF I. Hypovolemia A. Increased extracellular fluid losses: hemorrhage B. Gastrointestinal fluid loss: vomiting, diarrhea, enterocutaneous fistula C. Renal fluid loss: diuretics, osmotic diuresis, hypoadrenalism, nephrogenic diabetes insipidus D. Extravascular sequestration: burns, pancreatitis, severe hypoalbuminemia (hypoproteinemia) E. Decreased intake: dehydration, altered mental status II. Altered renal hemodynamics resulting in hypoperfusion A. Low cardiac output state: diseases of the myocardium, valves, and pericardium (including tamponade); pulmonary hypertension or massive pulmonary embolism leading to right and left heart failure; impaired venous return (e.g., abdominal compartment syndrome or positive pressure ventilation) B. Systemic vasodilation: sepsis, antihypertensives, afterload reducers, anaphylaxis C. Renal vasoconstriction: hypercalcemia, catecholamines, calcineurin inhibitors, amphotericin B D. Impairment of renal autoregulatory responses: cyclooxygenase inhibitors (e.g., nonsteroidal anti-inflammatory drugs), angiotensinconverting enzyme inhibitors, or angiotensin II receptor blockers E. Hepatorenal syndrome Intrinsic ARF I. Renovascular obstruction (bilateral, or unilateral in the setting of one kidney) A. Renal artery obstruction: atherosclerotic plaque, thrombosis, embolism, dissection aneurysm, large vessel vasculitis B. Renal vein obstruction: thrombosis or compression II. Diseases of the glomeruli or vasculature A. Glomerulonephritis or vasculitis B. Other: thrombotic microangiopathy, malignant hypertension, collagen vascular diseases (systemic lupus erythematosus, scleroderma), disseminated intravascular coagulation, preeclampsia III. Acute tubular necrosis A. Ischemia: causes are the same as for prerenal ARF, but generally the insult is more severe and/or more prolonged B. Infection, with or without sepsis syndrome C. Toxins: 1. Exogenous: radiocontrast, calcineurin inhibitors, antibiotics (e.g., aminoglycosides), chemotherapy (e.g., cisplatin), antifungals (e.g., amphotericin B), ethylene glycol