Acute Renal Failure - WMH
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Transcript of Acute Renal Failure - WMH
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Acute Renal Failure
Dr Wong Mun Hoe
MBBS (IMU) M.Med (UM)Internal Medicine
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So True, So False?
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Outline
Definitions Acute Renal Failure (ARF) and
Acute Kidney Injury (AKI)
Etiology Pathogenesis
Investigations
Management
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Acute Renal Failure (ARF)
What does it mean?
A clinical syndrome characterized by
an abrupt decline in GFR and
accumulation of nitrogenous waste
products
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Lack of urine = ARF?
Urine volume can be normal (non-
oliguric)
Decreased (oliguric less than 400mls/24hours)
Absent (less than 100mls/ 24 hours)
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ARF to AKI
There is lack of standard definition for acute renal failure.
Therefore a group of experts have gathered around to formthe ACUTE DIALYSIS QUALITY INITIATIVE group (ADQI)
Measuring creatinine and urine output
The group has developed and published a set of consensus
criteria for classifying acute renal failure in 2002. Newterminology ACUTE KIDNEY INJURY (AKI) was introduced.
ACUTE KIDNEY INJURY NETWORK (AKIN)
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RIFLE Criteria
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RIFLE vs AKIN
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Incidence of AKI
Hospital admission : 2-7%
ICU admission : 5-25%
ICU admission with AKI requiring dialysis : 4%
Commonest cause for AKI - SEPSIS
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Acute Kidney
Injury
Pre-Renal
Glomerular
Intrinsic
Tubulo-interstitial
Post-Renal
AcuteTubularNecrosis
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Pre-Renal
Lack of blood supply to the kidneys: Inadequate blood volume
- massive blood loss eg trauma/ post
surgery- massive loss of fluidseg diarrhea, excessive use of diuretics
severe burns Adequate blood volume but poor cardiac
output- cardiogenic shock, large pericardial effusion
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Pre-Renal
Decreased effective blood volume:
Nephrotic Syndrome
Cirrhosis of the liver
Afferent arteriolar vasoconstriction
Drugs (NSAIDs, cyclosporine, amphotericin B,noradrenaline)
Hepatorenal Syndrome Radiocontrast agents,
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Pre-Renal
Efferent arteriolar vasodilatation
ACE-I, ARB
Systemic vasodilatation
Sepsis
Anaphylaxis
Anesthetics
Drug overdose
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Renal
Blood supply to the Kidney is adequate
No outflow tract obstruction
Cause of ARF lies within the kidneyInterstium
Glomeruli
Tubules
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Renal
Interstium InterstitialNephritis
Glomeruli AcuteGlomerulonephritis
Tubules TubularNecrosis
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Acute Interstitial Nephritis
Drug induced Infection related
Penicillins
Cephalosporins
SulfonamidesRifampin
Phenytoin
Bacterial
Viral
RickettsialTuberculosis
Frusemide
NSAIDs Malignancy
Idiopathic
Systemic diseases
SLE
Sarcoidosis
Sjogrens syndrome
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Drug induced acute interstitial nephritis
Fever
Eosinophilia
Rash
Renal biopsy
Inflammatory cells
including
Eosinophils in the
interstitium
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Urine examination
shows
Eosinophils
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Glomerular
Usually RPGN
- pauci immune eg wegeners
granulomatosis- Linear immune complex deposition eg
Good pastures syndrome
- Granular immune complex deposition eglupus nephritis, post infectious
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CRESCENTIC GN
Pathologic diagnosisextracapillary cell
proliferation within
Bowman space
The clinical manifestation
is the Rapidly Progressive
Glomerulonephritis (RPGN):
- active urine sediments- rapid rise in s.creatinine
- poor response to treatment
Many different aetiologies
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Urinary abnormalities in Acute
Glomerulonephritis
Urinary casts
RBC casts
Dysmorphic rbcs
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Acute Tubular Necrosis
Acute tubular necrosis
- common cause of Acute renal
failure in surgical / ICU setting- due to Ischaemic or toxins
Massive losses of blood
volume Any prolonged and severe
cause of renal hypoperfusion
Drugs eg Aminoglycosides
Toxins such as heavyMetals
Myoglobinuria
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Acute Tubular Necrosis
The term acute tubular necrosis refers to the
histology seen in this condition following
severe ischaemia or exposure to nephrotoxins
Acute tubular epithelial necrosis during the
acute phase of the illness
Evidence of tubular cell regeneration during
recovery
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Acute Tubular Necrosis
Damage mainly occurs in the outer medullary
segment (S3 segment of proximal tubule and
thick ascending limb of loop of Henle)
- lower basal blood flow
- higher oxygen requirement
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Post Renal
The blood supply to the kidneys is normaland the kidneys are normal
The cause is obstruction of the urinary
outflow tractsObstruction of both ureters rare occurrence
Obstruction of ureteric orifices Ca bladder, Ca
Cervix
Obstruction of urethra Prostatomegaly,Uretheral stricture
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Renal calculi
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Post Renal
NORMAL HYDRONEPHROSIS
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Approach to Renal Failure
Determine that there is renal failure
Detailed history
Blood tests
Urine output
What is the cause?
Acute vs chronic
Pre-renal, renal, post renal
When cause is established, instituteappropriate treatment
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Is it renal failure?
Elevated serum urea and creatinine
Oliguria/ anuria
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What is the cause?
Post renal obstructive; exclude with u/s
KUB
Pre-renal hypotension (from sepsis,
dehydration ,cardiac failure, blood loss)
Renal ATN, DRUGS, glomerulonephritis
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Investigations
Urine
Blood
X-rays (KUB)Ultrasound Kidney Ureter bladder (KUB)
Intravenous urography
CT urethrogram (CTU)Renal Biopsy
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Urine
Microscopy
Casts
RED - suggest glomerulonephritis/vasculitis
WHITE - a tubulointerstitial disease or acutepyelonephritis
Red and white cells
crystals
UrinalysisSpecific gravity, Protein, Glucose, Ketones, Nitrite,
pH
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Blood
Urea (BUN), Creatinine (Ratio of Urea:
creatinine 10-15:1)
Blood gasses Calcium/Phosphate
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X-rays
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Ultrasound KUB
Exclude obstructive uropathy
Polycystic kidneys
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Complications
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What does this ECG show?
Tall, Symmetrical, Tented T Waves
HYPERKALEMIA
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Metabolic acidosis
Severe acidosis may impair cardiac
contractility reduce cardiac output more
tissue hypoxia worsen lactic acidosis
NaHCO3 infusion NOT indicated in all cases
may cause more problems eg
Pulmonary edema (esp in anuric patients)
Hypernatremia
Metabolic alkalosis
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Metabolic acidosis
Primary aim of therapy reversal of
underlying disease
NaHCO3 only used in severe metabolic
acidosis eg pH
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Acute pulmonary edema
Breathless
Raised JVP
Bibasal crepitations
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Renal Replacement Therapy (RRT)
Volume overload not responding todiuretic
Hyperkalemia (K+ >6.5 or rising)
Severe metabolic acidosis
Symptomatic uremia (pericarditis,encephalopathy, bleeding dyscrasia,
nausea, vomiting, pruritus)
Uremia (BUN >100)
Method : intermittent HD or continuous RRT (CRRT)
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Summary
Definitions Acute Renal Failure (ARF) and
Acute Kidney Injury (AKI)
Etiology
Pathogenesis
Investigations
Management
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So True, So False?
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Thank You
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New dialysis patients, Malaysia 1980
to 2003.
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Patients dialyzing in Malaysia on
December 31, 1980 to 2003