Acute Renal Failure
description
Transcript of Acute Renal Failure
Acute Renal Failure
Niroj Obeyesekere3rd year student notes
Definition
• Clinical syndrome characterised by rapid (over hours to weeks) decline in GFR, perturbation of extracellular fluid volume, electrolyte and acid base homeostasis, and accumulation of nitrogenous waste products from protein catabolism such as urea or creatinine.
RIFLE criteria
Why is it important
• 1. Common 5% of all hospital admissions and 5-30% in ICU admissions complicated by ARF.
• 2. Community acquired ARF does better than hospital acquired.
• 2. Major cause of in-hospital morbidity and mortality.
• 3. But, most cases are reversible.• 4. and, most cases can be prevented.
Diagnosis
• Serial measurement of urea and creatinine, but this has its limitations,
• 1. GFR may need to fall by 50% for Cr to be outside the “normal” level.
• 2. Reduced muscle mass.• 3. Pre-existing chronic renal insufficiency.• 4. Other substance e.g. drugs that interfere
with lab Cr measurements.
Aetiology
• 1. Prerenal – physiological response to hypoperfusion in which integrity of the renal parenchyma is preserved. Less than 48 hrs.
• 2. Renal – diseases of the renal parenchyma• 3. Postrenal – acute obstruction of the urinary
tract.• Prerenal most common. Prerenal and renal in
terms of ATN is a spectrum of hypoperfusion.
Causes of ARF
Causes of prerenal ARF
Pathophysiology of prerenal renal failure1. True intravacular hypovolaemia2. Decreased effceyive circulatory
volume3. Intrarenal vasoconstriction4. Renal artery disease and
borderline hypovolaemia
Pathophysiology
• Kidney function is maintained by – afferent arteriole vasodilatation by local myenteric reflex, increased PGs, kallikerin and kinins and preferential efferent arteriole constriction by angII.
• Afferent arteriole dilatation is maximal at mean BP of 80. Lesser degrees of hypotension can ARF in HT, DM and elderly.
• Very high Ang II causes both afferent and efferent constriction. Esp with pts with marked circulatory failure.
Pathophysiology
• 1. NSAIDS– reduce Pg production• 2. ACE inhibitors and ARBs- intraglomerular
pressure is dependent on efferent vasoconstriction.
• 3. Diuretics• 4. Nephrotoxics
Intrinsic renal failure
• 1. large renal vessels – artheroemboli, thromboemboli, thromobosis or dissection or vasculitis
• 2. microvasculature and glomeruli – GN, scleroderma, HT, TTP, HUS,
• 3. ischamic and nephrotoxic ATN• 4. tubulointerstitium – interstitial nephritis,
infections, infiltrative.
Post Renal
• Obstruction – only 5% of cases
Clinical approach
Clinical approach
• Some basic questions-• 1.Is it acute, acute on chronic or chronic• 2. is there obstruction• 3. evidence of true hypovolaemia• 4. has there been a major vascular occlusion• 5. is there parenchymal disease other than
ATN
Approach
• Usually blood tests but if not, anaemia, PO4, Ca, kidney size can help to differentiate between acute and chronic.
Clinical evaluation of volume status
Investigations• Urine output – relatively unhelpful in OP setting. If IP can
be useful.• Urine microscopy - useful • Hyaline casts or bland urine prerenal or obstruction.
(blood and pyuria in obstruction)• Muddy brown granular casts in ATN (can be absent in 20-
30%)• Dysmorphic red cells GN• Eosinophiluria – interstitial nephritis• Haemogloburia or myogloburia – haemolysis or rhabdo
Investigations
• Proteinuria – less than 1 g in prerenal or ATN• more than 1 g glomerular proteinuria• Pattern of Cr – Cr increases 24 to 48 hrs in renal
ischaemia, radiocontrast, and atheroembolism.• In contrast nephropathy peaks at 3- 5 days and
returns to normal in 5 to 7.• Normally ATN gets better 7 to 14 days post and
artheroembolic usually irreversible.• Gentamicin Cr increases 7 to 10 days.
Other lab findings
• Hyperkalemia - • Hyperphosphatemia• High K disproportionate might indicate
obstruction or type IV rneal tubular acidosis.• Severe anaemia – haemolysis, MM or TTP.• Thrombocytopenia, dysmorphic red cells in
blood film.
isomorphic
dysmorphic
Muddy casts
Urine microoscopy
Ix-Renal US
Other Ix
• CT KUB• Renal biopsy
Complications of ARF
Complications
• 1. Fluid overload• 2.Hyperkalemia – ECG changes • Peaked t waves• Prolongation of PR interval• Widening of QRS• Heart block, VT, VF asytole.
Complications
• 3. acid base balance- wide anon gap metabolic acidosis
• 4. uremia
Management
When you see a patient with ARF always think
Indications for dialysis