Download to read offline
Uploaded byDr. Pandian M
Acute renal failure by Pandian M.
Acute renal failure (ARF) is defined as the kidneys' inability to maintain homeostasis, leading to a buildup of nitrogenous wastes, and it can occur due to pre-renal, intrinsic, or post-renal causes. Symptoms include weight gain, peripheral edema, hyperkalemia, and changes in urine output, while diagnostic tools focus on urinary indices, lab findings, and imaging studies. Management involves immediate treatment of complications, addressing the underlying cause, and may require dialysis to control symptoms and metabolic disturbances.
More Related Content
Similar to Acute renal failure by Pandian M.
More from Dr. Pandian M
Acute renal failure by Pandian M.
- 1. Pandian M Dept. ofPhysiology
- 2. Overview Definitions Classificationand causes Presentation Treatment
- 3. Definition Acute Renalfailure (ARF) Inability of kidney to maintain homeostasis leading to a buildup of nitrogenous wastes Different to renal insufficiency where kidney function is deranged but can still support life Exact biochemical/clinical definition not clear – 26 studies – no 2 used the same definition
- 4. ARF Occurs overhours/days Lab definition Increase in baseline creatinine of more than 50% Decrease in creatinine clearance of more than 50% Deterioration in renal function requiring dialysis
- 5. ARF definitions Anuria– no urine output or less than 100mls/24 hours Oliguria - <500mls urine output/24 hours or <20mls/hour Polyuria - >2.5L/24 hours
- 6. ARF Pre renal(functional) Renal-intrinsic (structural) Post renal (obstruction)
- 7. ARF Pirouz Daeihagh,M.D.Internal medicine/Nephrology Wake Forest University School of Medicine. Downloaded 4.6.09
- 8. Causes of ARF Pre-renal: Inadequate perfusion check volume status Renal: ARF despite perfusion & excretion check urinalysis, FBC & autoimmune screen Post-renal: Blocked outflow check bladder, catheter & ultrasound
- 9. Causes of ARF Pre-renalRenal Post-renal Absolute hypovolaemia Glomerular (RPGN) Pelvi-calyceal Relative hypovolaemia Tubular (ATN) Ureteric Reduced cardiac output Interstitial (AIN) VUJ-bladder Reno-vascular occlusion Vascular (atheroemboli) Bladder neck- urethra
- 10. ARF Pre renal Decreased renal perfusion without cellular injury 70% of community acquired cases 40% hospital acquired cases
- 11. ARF Intrinsic Acutetubular necrosis (ATN) Ischaemia Toxin Tubular factors Acute interstitial Necrosis (AIN) Inflammation oedema Glomerulonephritis (GN) Damage to filtering mechanisms Multiple causes as per previous presentation
- 12. ARF Post renal Post renal obstruction Obstruction to the urinary outflow tract Prostatic hypertrophy Blocked catheter Malignancy
- 13. Prerenal Failure 1 •Oftenrapidly reversible if we can identify this early. •The elderly at high risk because of their predisposition to hypovolemia and renal atherosclerotic disease. •This is by definition rapidly reversible upon the restoration of renal blood flow and glomerular perfusion pressure. •THE KIDNEYS ARE NORMAL. •This will accompany any disease that involves hypovolemia, low cardiac output, systemic dilation, or selective intrarenal vasoconstriction. ARF Anthony Mato MD Downloaded 5.8.09
- 14. Differential Diagnosis 2 Hypovolemia GI loss: Nausea, vomiting, diarrhea (hyponatraemia) Renal loss: diuresis, hypo adrenalism, osmotic diuresis (DM) Sequestration: pancreatitis, peritonitis,trauma, low albumin (third spacing). Hemorrhage, burns, dehydration (intravascular loss). ARF Anthony Mato MD Downloaded 5.8.09
- 15. Differential Diagnosis 3 Renal vasoconstriction: hypercalcaemia, adrenaline/noradrenaline, cyclosporin, tacrolimus, amphotericin B. Systemic vasodilation: sepsis, medications, anesthesia, anaphylaxis. Cirrhosis with ascites Hepato-renal syndrome Impairment of autoregulation: NSAIDs, ACE, ARBs. Hyperviscosity syndromes: Multiple Myeloma, Polycyaemia rubra vera
- 16. Differential Diagnosis 4 Low CO Myocardial diseases Valvular heart disease Pericardial disease Tamponade Pulmonary artery hypertension Pulmonary Embolus Positive pressure mechanical ventilation
- 17. The only organwith entry and exit arteries
- 18. Glomerular blood flow Afferentarteriole Efferent art Glomerular Capillaries & Mesangium Constrictors: endothelin, catecholamines, thromboxane Compensatory Constrictor: Angiotensin II Blocker: ACE-I Compensatory Dilators: Prostacyclin, NO Blocker: NSAID
- 19. Pre-Renal Azotemia Pathophysiology 7 Renal hypoperfusion Decreased renal blood flow and GFR Increased filtration fraction (GFR/RBF) Increased Na and H2O reabsorption Oliguria, high Uosm, low UNa Elevated BUN/Cr ratio Malcolm Cox
- 20. Acute Tubular Necrosis(ATN) Classification Ischemic Nephrotoxic
- 21. Acute Renal Failure NephrotoxicATN Endogenous Toxins Heme pigments (myoglobin, hemoglobin) Myeloma light chains Exogenous Toxins Antibiotics (e.g., aminoglycosides, amphotericin B) Radiocontrast agents Heavy metals (e.g., cis-platinum, mercury) Poisons (e.g., ethylene glycol)
- 22. Acute Interstitial Nephritis Causes Allergic interstitial nephritis Drugs Infections Bacterial Viral Sarcoidosis
- 23. Allergic Interstitial Nephritis(AIN) ClinicalCharacteristics Fever Rash Arthralgias Eosinophilia Urinalysis Microscopic hematuria Sterile pyuria Eosinophiluria
- 24. Contrast-Induced ARF Risk Factors Renal insufficiency Diabetes mellitus Multiple myeloma High osmolar (ionic) contrast media Contrast medium volume
- 25. Contrast-induced ARF Clinical Characteristics Onset - 24 to 48 hrs after exposure Duration - 5 to 7 days Non-oliguric (majority) Dialysis - rarely needed Urinary sediment - variable Low fractional excretion of Na
- 26. Pre-Procedure Prophylaxis 1. IVFluid (N/S) 1-1.5 ml/kg/hour x12 hours prior to procedure and 6-12 hours after 2. Mucomyst (N-acetylcysteine) Free radical scavenger; prevents oxidative tissue damage 600mg po bd x 4 doses (2 before procedure, 2 after) 3. Bicarbonate (JAMA 2004) Alkalinizing urine should reduce renal medullary damage 5% dextrose with 3 amps HCO3; bolus 3.5 mL/kg 1 hour preprocedure, then 1mL/kg/hour for 6 hours postprocedure 4. Possibly helpful? Fenoldopam, Dopamine 5. Not helpful! Diuretics, Mannitol
- 27. ARF Post-renal Causes1 Intra-renal Obstruction Acute uric acid nephropathy Drugs (e.g., acyclovir) Extra-renal Obstruction Renal pelvis or ureter (e.g., stones, clots, tumors, papillary necrosis, retroperitoneal fibrosis) Bladder (e.g., BPH, neuropathic bladder) Urethra (e.g., stricture)
- 28. Acute Renal Failure DiagnosticTools Urinary sediment Urinary indices Urine volume Urine electrolytes Radiologic studies
- 29. Urinary Sediment (1) Bland Pre-renal azotaemia Urinary outlet obstruction
- 30. Urinary Sediment (2) RBC casts or dysmorphic RBCs Acute glomerulonephritis Small vessel vasculitis
- 31. Red Blood CellCast
- 32. Red Blood Cells MonomorphicDysmorphic
- 33. Dysmorphic Red BloodCells
- 34. Urinary Sediment (3) WBC Cells and WBC Casts Acute interstitial nephritis Acute pyelonephritis
- 35.
- 36. Urinary Sediment (4) Renal Tubular Epithelial (RTE) cells, RTE cell casts, pigmented granular (“muddy brown”) casts Acute tubular necrosis
- 37. Renal Tubular EpithelialCell Cast
- 38.
- 39. Acute Renal Failure UrineVolume (1) Anuria (< 100 ml/24h) Acute bilateral arterial or venous occlusion Bilateral cortical necrosis Acute necrotizing glomerulonephritis Obstruction (complete) ATN (very rare)
- 40. Acute Renal Failure UrineVolume (2) Oliguria (<100 ml/24h) Pre-renal azotemia ATN Non-Oliguria (> 500 ml/24h) ATN Obstruction (partial)
- 41. ARF-Signs and Symptoms Weight gain Peripheral oedema Hypertension
- 42. ARF Signs andSymptoms Hyperkalemia Nausea/Vomiting Pulmonary edema Ascites Asterixis Encephalopathy
- 43. Lab findings Risingcreatinine and urea Rising potassium Decreasing Hb Acidosis Hyponatraemia Hypocalcaemia
- 44. Mx ARF Immediatetreatment of pulmonary edema and hyperkalaemia Remove offending cause or treat offending cause Dialysis as needed to control hyperkalaemia, pulmonary edema, metabolic acidosis, and uremic symptoms Adjustment of drug regimen Usually restriction of water, Na, and K intake, but provision of adequate protein Possibly phosphate binders and Na polystyrene sulfonate
- 45. Recognise the at-riskpatient Reduced renal reserve: Pre-existing CRF, age > 60, hypertension, diabetes Reduced intra-vascular volume: Diuretics, sepsis, cirrhosis, nephrosis Reduced renal compensation: ACE-I’s (ATII), NSAID’s (PG’s), CyA
- 46. Indications for acutedialysis AEIOU Acidosis (metabolic) Electrolytes (hyperkalemia) Ingestion of drugs/Ischemia Overload (fluid) Uremia
- 47.
- 48. CKD death Stages in Progressionof Chronic Kidney Disease and Therapeutic Strategies Complications Screening for CKD risk factors CKD risk reduction; Screening for CKD Diagnosis & treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis & transplant Normal Increased risk Kidney failure Damage GFR
- 49. Definition of CKD Structuralor functional abnormalities of the kidneys for >3 months, as manifested by either: 1. Kidney damage, with or without decreased GFR, as defined by pathologic abnormalities markers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests 2. GFR <60 ml/min/1.73 m2, with or without kidney damage
- 50. Clinical Practice Guidelinesfor the Detection, Evaluation and Management of CKD Stage Description GFR Evaluation Management At increased risk Test for CKD Risk factor management 1 Kidney damage with normal or GFR >90 Diagnosis Comorbid conditions CVD and CVD risk factors Specific therapy, based on diagnosis Management of comorbid conditions Treatment of CVD and CVD risk factors 2 Kidney damage with mild GFR 60-89 Rate of progression Slowing rate of loss of kidney function 1 3 Moderate GFR 30-59 Complications Prevention and treatment of complications 4 Severe GFR 15-29 Preparation for kidney replacement therapy Referral to Nephrologist 5 Kidney Failure <15 Kidney replacement therapy 1 Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors (ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot urine total protein-to-creatinine ratio of greater than 200 mg/g.
- 51. Classification of CKDby Diagnosis Diabetic Kidney Disease Glomerular diseases (autoimmune diseases, systemic infections, drugs, neoplasia) Vascular diseases (renal artery disease, hypertension, microangiopathy) Tubulointerstitial diseases (urinary tract infection, stones, obstruction, drug toxicity) Cystic diseases (polycystic kidney disease) Diseases in the transplant (Allograft nephropathy, drug toxicity, recurrent diseases, transplant glomerulopathy)
- 52. Objectives CKD Dialysis Access Eckel pearls Scenarios Kidney Failure Stages of Chronic Kidney Disease Definition and Classification of CKD • GFR • Proteinuria • Etiology Current use of ICD-9-CM codes for CKD Proposed changes to ICD-9-CM
- 53.
- 54. Types of dialysis 1.Hemodialysis (HD) 2. Ultrafiltration (UF) 3. Continuous Veno-Venous hemofiltration (CVVH) 4. Peritoneal Dialysis
- 55. Hemodialysis Semipermeable membrane Solute removal via passive diffusion Inversely proportional to the size (ie effective removal of K, urea, C; not of PO4)
- 57. Ultrafiltration use ofhydrostatic pressure gradient to induce convection (filtration of water) solvent drag (pulls dissolved solutes) across removal of excess fluid
- 58. CVVH highly permeablemembrane fluid and solute removal via ultrafiltration filtrate is discarded replacement fluid is infused similar to plasma (but no K, urea, Cr, PO4) used in ICU, runs 12-24h, through double lumen catheter less drastic fluid shifts
- 59. Peritoneal Dialysis peritoneal membrane= partially permeable membrane dextrose dialysate diffusion and osmosis until equilibrium 3-10 dwells per night with 2-2.5 L per dwell
- 60. Indications for Dialysis Acidosis Electrolytes Ingestions Overload Uremia
- 61. Access Arteriovenous fistula(AVF) Graft Tunneled catheter
- 62. Arteriovenous Fistula Highestpatency Lowest risk of infection Low risk of thrombus Maturation time (3-4mo) Steal syndrome (poor blood supply to the rest of the limb) Aneurysm formation
- 63. Arteriovenous Graft Easierto create Maturation time 3-6 weeks Poor patency (often requires thrombectomy or angioplasty) Infection Aneurysms Steal syndrome
- 64. Tunneled Catheter Immediateuse Bridge to AVF/AVG Poor flow (decreased HD efficiency) High infection risk Venous stenosis Thrombosis
- 65. Dialysis Rx: Time:2-5 hours Bath Blood flow rate: 400-450cc/min Dialysate flow rate: 500-800cc/min Anticoagulant Additives: ◦ Anemia (EPO, blood) ◦ Bone metabolism (vit D, calcitriol, etc) ◦ Meds (antibiotics)
- 66.
- 67.
- 68. Imaging in CKD Avoid contrast in CKD patients If you have to, prep ◦ volume expansion: isotonic IVFs 3 cc/kg x 1h before 1cc/kg x 6h after ◦ ? alkalinization: sodium bicarbonate ◦ ? acetylcysteine ◦ radiology can give you the protocol (treat empirically)