Acute renal failure - comed.uobaghdad.edu.iq
Transcript of Acute renal failure - comed.uobaghdad.edu.iq
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Acute renal failure
Dr.Nariman Fahmi
pediatric / 2013
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Objectives
• Introduction
• Defintion
• Classification
• management
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To function properly
kidneys require:
• Normal renal blood flow
• Functioning glomeruli and tubules
• Clear urinary outflow tract – for drainage and elimination of formed
urine from the body.
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ARF - definition
• An abrupt fall in GFR over a period of minutes to days with rapid & sustained rise in nitrogenous waste products in blood.
(Rate of production of metabolic waste exceeds the rate of renal excretion)
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definition
Sudden loss of the ability of the kidneys to excrete wastes,
concentrate urine and conserve electrolytes
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Definitions
• Oligurea
• Low urine output
• < 300 ml/m2/day
• Anurea
• No urine output
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Causes of AKF
• Prerenal : renal hypoperfusion
• Renal (Intrinsic) :
– Glomerular
– Tubular
– Vascular
– Interstitial
• Post renal: obstruction
injury
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Generalized or localized
reduction in RBF
Hypovolaemia Haemorrhage
Volume depletion
( vomiting,
diarrhoea,
burns)
Hypotension Cardiogenicshock
(sepsis,
anaphylaxis)
Oedema
states Cardiac failure
Hepatic cirrhosis
Nephrotic
syndrome
Renal
Hypoperfusion
NSAIDs
ACEI / ARBs
RAS /occlusion
Hepatorenal
syndrome
Reduced GFR
PRE-RENAL (Hemodynamic) AKI
PRERENAL AKI
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Renal / Intrinsic AKI
Tubular Glomerular Vascular Interstitial
ATN
Ischemia
Toxins
Ac. Interstitial
nephritis
Drug induced -
NSAIDs,
antibiotics
Infiltrative -
lymphoma
Granulomatous-
tuberculosis
Infection related -
post-infective,
pyelonephritis
Vascular
occlusions
-Renal artery
occlusion
-Renal vein
thrombosis
Ac.GN
post-infectious,
SLE,
ANCA associated,
Henoch-Schönlein purpura
,
Thrombotic microangiopathy
TTP
HUS
N Engl J Med 1996;334 (22):1448-60
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Principal POST-RENAL causes of AKI
Intra-luminal •Stone,
•Blood clots,
•Papillary
necrosis
•Pelvic
malignancies
•Retroperitonea
l fibrosis
Intrinsic
Intra-mural •Urethral stricture,
• Bladder tumour,
• Radiation fibrosis
Extrinsic
Post-renal Urinary outflow tract obstruction
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Careful history may aid in defining the cause of
renal failure
S.&S.
Oligurea or anuria
Fluid retention Ankle ,legs swelling
Changes in mental status
Drawsiness , lethargy, confuion ,coma
Seizures
Vomiting
hypertension
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Factors that suggest chronicity include –
Long duration of symptoms,
Nocturia,
Absence of acute illness, anaemia,
hyperphosphatemia, and hypocalcaemia,
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On examination : note state of
dehydration
Is the patient euvolaemic?
Pulse,
JVP/CVP,
blood pressure,
Fluid challenge
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Has obstruction been excluded?
Complete anuria
Palpable bladder
Renal ultrasound
Hilton et al, BMJ 2006;333;786-790
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What investigations are most useful in ARF?
Urinalysis:
Dipstick for blood, protein, or both - Suggests a
renal inflammatory process
Microscopy for cells, casts, crystals - Red cell casts
diagnostic in glomerulonephritis
Hilton et al, BMJ 2006;333;786-790
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RBCs
•Dysmorphic red blood cells suggest glomerular injury.
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Red blood cell cast
Marker of glomerular injury
Granular cast
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Biochemistry
Serial blood urea, creatinine, electrolytes,
Blood gas analysis, serum bicarbonate –
Important metabolic consequences of
ARF include hyperkalaemia, metabolic
acidosis, hypocalcaemia,
hyperphosphataemia
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• Radiology
• Renal ultrasonography
– For renal size, symmetry, evidence of
obstruction
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Treatment
The goal is to
• 1-identify any reversible causes
• 2- preventing excess accumulation of
fluids and wastes
Hospitalizations is required for treatment
and monitoring
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• Antibiotics may be used to treat infection
• Diuretics may be used to remove fluid
Control dangerous hyperkalemia
• S.k more than 6 meq/l
• 1- calcium gluconate 10% solution
• 2-sodium bicarbonate 7.5%solution
• 3-Glucose 50 % with insulin1unit/5 g glucose
• 4-B receptor agonist
• 5-Oral or rectal potassium exchange resine(kayexalate)
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• Hyponatremia is most commonly a dilutional disturbance
• Nacl (meq/L) required =0.6(BW Kg)x {125- serum sodium (meq/L)}
• Nutrition in acute renal failure
• sodium, potassium, and phosphorus should be restricted.
• Protein intake should be restricted
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Hypertension
Agent Dose Onset Action Complications
Hydralazine 0.2 to 15 mg/dose
• Nifedipine 0.25-0.5 mg/kg sublingual
• Frusemide 1-3mg/kg over 15min 0.1-1mg/kg/hr
Diazoxide 5 mg/kg (max 300) IV bolus 3-5 min
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• gastrointestinal bleeding
• Neurological symptoms
• anemia of ARF is generally mild
(hemoglobin 9–10 g/dL) and primarily
results from volume expansion
(hemodilution )
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dialysis
Used to remove excess waste and fluids
Indications
1- uncontrollable fluids overload or hypertension
2- uncontrollable acidosis
3- uncontrollable electrolyte disturbances
4-pericarditis
5- change in mental status
6-anuria
7-uncontrollable accumulations of nitrogen waste
products
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Thank you