lieberthal. kidney int 1997; 52: 1102-15 necrose tubular aguda
TRANSCRIPT
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Lieberthal. Kidney Int 1997; 52: 1102-15
Necrose Tubular Aguda
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Necrose Tubular Aguda - NO
Goligorsky et al.Kidney Int 2002; 61: 855-861
Aceptor de radicais livres
Inibidor de Apoptose
10 – 100 nmol/l
Ação pró-apoptótica
> 300 nmol/l
Peroxidação lipídica
Dano ao DNA
Aceptor de radicais livres
Anti-apoptose
Inibe NOs
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Thadhani et al. N Engl J Med 1996; 334(22):1448-60
Necrose Tubular Aguda
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Necrose Tubular Aguda
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Lesão à Célula Renal
Sub-letal Letal
Disfunção Tubular
Apoptose Necrose
Necrose Tubular Aguda
Edelstein et al. Kidney Int 1997; 51:1341-51
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NTA
Apoptose
Atlas of Kidney Disease 2001, HDCN.com
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Racusen-Nast Atlas Of Kidney Disease. HDCN.com,2002
Enrugamento da célula
Corpúsculos apoptóticos
Fragmentosfagocitados
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Epitélio normal
Lesão Sub-letal
Excesso de RGD
Noiri et al. Kidney Int 1995;48:1375-85
Necrose Tubular Aguda
RGD
Arginina
Glicina
Ácido Áspartico
Protéina Tamm-Hosfal
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Necrose Tubular Aguda
MECANISMO DE MORTE CELULAR
•Cálcio
•Radicais livres
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Malis et al. Am J Physiol 1983; 245:F735-F742
Necrose Tubular Aguda
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Necrose Tubular Aguda
[Ca] 10-7 [Ca] 10-3
Kidney Int 1997; 51: 1341-51
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Necrose Tubular Aguda
3.PAF
N Engl J Med 1985;312(3): 159-63
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ATP Ca
P-lipase A2
1-O-Alkylglicerofosfocolina
PAF
Ca
Necrose Tubular AgudaAgente TóxicoIsquêmico
Lopez-Novoa Kidney Int 1999;55: 1672-82
Xantina “D”
Xantina “O”
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Necrose Tubular Aguda
N Engl J Med 1985;312(3): 159-63
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Necrose Tubular Aguda
N Engl J Med 1985;312(3): 159-63
O2- + O2- + 4H ==== H2O2 + O2
H2O2 ======== H2O + O2
H2O2 + O2- ====== OH-
R CO
OH-RadicalHidroperóxido
SOD
G, C
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Edelstein et al. Kidney Int 1997; 51:1341-51
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Edelstein et al. Kidney Int 1997; 51:1341-51
Necrose Tubular Aguda
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Necrose Tubular Aguda
Thadhani et al. N Engl J Med 1996; 334(22):1448-60
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UTIBAIXORISCO
Necrose Tubular Aguda
Star RA Kidney Int 1997, 54: 1817-31
Ideal para melhorResposta ao tratamento
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0102030405060708090
0 1 2 3 4
INSUFICIÊNCIA RENAL AGUDA - EVOLUÇÃO
Mor
talid
ade
%
Falência de Órgãos
Arch Int Med 1995; 155: 24
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0 2 4 6 8 10 12
Falência Renal
Ulcera de stress
FalênciaHepática
FalênciaPulmonar
Sepsis
Situação temporal entre sepsis e falência de órgãos
Fry Arch Surg 1980; 115
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IRA/UTI
BALANÇO HÍDRICO
NUTRIÇÃO UREMIA
BALANÇO ELETROLÍTICO
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Tratamento
Aporte NutricionalCorreção da AcidoseFatores de CrescimentoFator Atrial NatriuréticoInibidores da iNOsDiuréticosDopaminaTratamento Dialítico
Necrose Tubular Aguda
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Tratamento Dialítico
SangramentosDescompensação Cardio-circulatóriaAlterações NeurológicasAcidose GraveHipercalemia
Necrose Tubular Aguda
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INSUFICIÊNCIA RENAL AGUDA
Terminologia em DiáliseHD Hemodiálise ClássicaUF Ultrafiltração IsoladaUF + HD Ultrafiltração Sequencial com HemodiáliseDPI Diálise Peritoneal Intermitente
UFLC Ultrafiltração Lenta ContínuaCAVHF Hemofiltração Artério-venosa ContínuaCVVHF Hemofiltração Veno-venosa ContínuaCAVHDF Hemodiafiltração Artério-venosa ContínuaCVVHDF Hemodiafiltração Veno-venosa ContínuaCEPD Diálise Peritoneal de Equilíbrio
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INSUFICIÊNCIA RENAL AGUDA
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Líquido de Diálise = 500 mL/minSangue = 200-250 mL/min
(UTI)
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HEMOFILTRAÇÃOVVHF
FILTRADO
LIQ.REP.
F.sangue = 50-100 mL/min
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15 mL/minF.sangue = 50-100 mL/min
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CAVHD
CAVHD
CAVHD
CAVHD
HD
HD
HD
HD
PESO PA MEDIA
UREIA BICARBONATO
Nephrol Dial Transplant 1994, 99(Sup4) : 201-9
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0
1
2
3
4
5
6
1 2 3 4 5
DIÁLISE PERITONEAL DE EQUILÍBRIOVolume de Ultrafiltração
Dias
Vol
ume
(litro
s)